2 突发性感音神经性聋的诊断
因突聋治疗早晚与预后有关,临床应及时明确诊断。尽早找出病因,了解发病时环境、耳聋性质、排除外伤、糖尿病、代谢疾病及免疫疾病史,与患者交待和讨论疾病危害、治疗效果及预后,积极治疗疾病,对听力无改善者进行听力康复,密切随访,以早期发现引起突聋的潜在疾病。注意耳部检查,有无瘘管征,了解小脑功能及眼震情况。眼震电图检查可用于伴有眩晕患者,但不必作为常规检查方法。氨基糖甙类抗生素耳中毒者,冷热试验检查,双侧前庭功能减退。影像学检查排除听神经瘤。双耳发病,特别是起病急,或惟一听力耳发病,或同时有全身免疫系统疾病,提示发病与免疫因素有关。
3 突发性感音神经性聋的治疗
由于突聋病因不明,目前无有效治疗方法,各种治疗方法疗效均在65%左右。某些病因明确的病例,对病因治疗有效,如停用耳毒性药物、修补外淋巴瘘、抗病毒治疗等。对病因不明病例,治疗仍有争议,主要是根据所推测的血管或感染病因,使用改善内耳微循环和提高血氧浓度的药物和方法。目前临床上多采用综合疗法,即同时使用多种药物,包括右旋糖酐、组胺、泛影葡胺、利尿剂、激素、血管扩张剂、都可喜、抗凝剂、神经营养药物和卡波金( carbogen, 5%二氧化碳和95%氧气的混合气体)吸入等。决定内耳的血氧供应主要有3个因素:即动脉氧分压、动脉二氧化碳分压及全身血压。研究证实,血中二氧化碳浓度对耳蜗血流有较强的刺激作用,因此,临床治疗使用卡波金优于纯氧治疗[ 19 ] 。
尽管在治疗药物上有较大争议,但激素的使用,对炎症或自身免疫所致突聋治疗有效。Jackson等[ 20 ]研究表明,对于口服激素治疗失败的突聋患者可进行鼓室内注射以改善预后。Horn等[ 21 ]对9例正规激素治疗失败的突聋患者进行高压氧治疗,结果表明对激素治疗失败的突聋患者进行后续高压氧治疗有助于改善其听力。
4 突发性感音神经性聋的预后
由于突发性聋病因众多,预后差异较大。尽管许多学者对突聋预后进行了多因素分析,但决定预后的因素尚不能肯定, 2 /3患者不经治疗症状可以改善。一般认为,突聋恢复大多始于发病后2周,症状持续时间越长,预后越差,有15%患者就诊后症状可进行性加重。突聋早期治疗,预后较好,不合并眩晕、耳聋较轻或听力图为上升型曲线者,预后好,反之经治疗2周,症状无改善,或耳聋严重、听力曲线为下降型或伴有眩晕则预后差。Shah等[ 22 ]对103例突聋患者预后行统计学分析表明,听力完全恢复或明显恢复多出现在病后1～2周, 1个月内基本固定;而部分恢复者听力改善多在病后2周开始, 1个月左右基本停止;经积极治疗1个月听力无变化者,则治疗无效,这时原发疾病已基本治愈,但造成的听力损害可能无法恢复。故对病因不明的突聋患者应在发病后1个月之内进行积极治疗,才能获得较好效果。
影响突聋的预后因素很多,包括年龄、性别、有无眩晕病史、高血压史、糖尿病、冠状动脉疾病、脑卒中、初始听力曲线、发病到治疗的时间、血浆三酸甘油脂和胆固醇水平、血红蛋白水平、血沉等[ 23 ] 。
总之,突发性耳聋是一种多因素疾病,未来应致力于它的病因研究,以制定更有针对性的治疗方案,改善患者的预后。
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