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摘要: 目的 本研究旨在分析总结结核性中耳炎的临床特征、诊断方法，以丰富结核性中耳炎的临床实践诊疗经验，减少漏诊误诊，以利于患者得到及时有效的治疗，改善患者的预后。方法 本研究回顾性分析2008至2022年在我院耳科住院并接受手术治疗的结核性中耳炎患者的临床资料，记录并分析总结其临床特征、影像学表现、术中所见及治疗效果。结果 23例(26耳)结核性中耳炎病例纳入此回顾性分析。本研究中结核性中耳炎最常见的临床症状为耳溢液(稀薄无臭味性液)(100%)及传导性听力下降(100%)；伴较高的面瘫发生率(23.1%)；部分患者用常规抗生素(如左氧氟沙星)局部治疗可短暂减轻或控制症状(有效率仅为50%)，且症状在停药后很快复发。术中可见灰白质韧的肉芽组织增生(100%)伴干酪样坏死(23.1%)。手术治疗目的为清除病变，减少流脓感染复发率，酌情功能修复(听力重建或面神经减压)，并可明确诊断以利于进一步治疗。术中送检的肉芽组织病变，石蜡病理回报为典型的肉芽肿性炎以及干酪样坏死，抗酸染色阳性，符合结核。结论 结核性中耳炎由于其临床特征的不典型性，很容易被漏诊或误诊。当耳部局部表现严重程度与病程长短明显不匹配；病程早期即出现面瘫或感音神经性听力损失；常规抗生素治疗不能长期有效地控制局部症状；颞骨CT呈现中耳及乳突腔内广泛弥漫性的病变；术中发现广泛的苍白质韧的肉芽增生，伴或不伴干酪样坏死或死骨形成，都应该高度警惕疑似结核性中耳炎。组织病理切片抗酸染色检出阳性抗酸杆菌可明确诊断，同时应尽早综合多种实验室检查手段(如T-spot，PCR)来协助支持诊断。明确诊断后应及早进行全身抗痨治疗。Abstract: Objective The purpose of this study was to analyze and summarize the clinical characteristics and diagnostic methods of tuberculous otitis media(TOM), to enrich clinical experience in diagnosis and treatment of tuberculous otitis media, so as to reduce missed diagnosis and misdiagnosis, and facilitate timely and effective therapy for better prognosis.Methods This study retrospectively analyzed the clinical data of patients with tuberculous otitis media who were hospitalized in the Ear ward of our hospital and received surgical treatment from 2008 to 2022. The data of patients' clinical characteristics, radiological examination, intraoperative findings and therapeutic strategies were recorded and summarized.Results A total of 23 cases (26 ears) of tuberculous otitis media were included in this retrospective study. The most common clinical symptoms were otorrhea(thin odorless fluid)(100%) and conductive hearing loss(100%), with a high incidence of facial paralysis(23.1%). It was not sensitive to traditional antibiotic treatment, eg. Levofloxacin (50% effective rate only), and relapsed soon after drug withdrawal. It was revealed that all the surgical views had gray and white tough granulation tissue hyperplasia(100%), and 23.1% with caseous necrosis. The purpose of surgery was to clear the lesion, reduce the recurrence rate of suppurative infection, and repair the function (hearing reconstruction or facial nerve decompression) as appropriate. The paraffin pathology of granulation tissue were reported as typical granulomatous inflammation and caseous necrosis with positive acid-fast staining, which was consistent with tuberculosis.Conclusion It was easily confused by the clinical manifestations of tuberculous otitis media and common chronic suppurative otitis media. When met with the following conditions, we should pay highly attention to suspect tuberculous otitis media: The severity of local manifestations did not match with the length of the disease; with poor tympanic membrane at the early stage with no obvious cholesteatomas, with facial paralysis or hearing loss early onset; insensitive to traditional antibiotic treatment; with extensive granulation appeared in the tympanum and or mastoid cavity, with or without caseous necrosis or dead bone in the early days. The diagnosis should be confirmed based on the acid-fast staining of the histopathological section to detect positive acid-fast bacilli. Meanwhile, multiple laboratory examination methods(such as T-spot and PCR) should be integrated synchronously to help support the diagnosis.
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Key words:
- tuberculous otitis media /
- clinical characteristics /
- diagnosis /
- acid-fast staining
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表 1 TOM患者的基本流行病学及临床资料
临床表现 例数(患耳数) 占所有耳比例/% 听力下降 23(26) 100.0 耳流脓 23(26) 100.0 稀薄 19(22) 黏稠 4(4) 伴臭味 8(8) 不伴臭味 15(18) 耳痛 4(4) 15.4 面瘫 6(6) 23.1 耳闷 6(6) 23.1 耳鸣 3(5) 19.2 眩晕 2(2) 7.7 局部冷脓肿 0 0 既往抗生素治疗有效 11(13) 50.0 鼓膜穿孔 无 5(5) 19.2 单发 15(18) 69.2 多发 3(3) 11.5 
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表 2 TOM术中所见及手术方式
术中所见 例耳(%) 描述 肉芽肿样增生 26(100.0) 乳突、鼓窦入口及鼓窦内可见苍白肉芽组织增生，鼓岬黏膜为肉芽所覆盖 干酪样坏死物 19(73.1) 鼓室内增生肉芽组织表面可见干酪样物 死骨的形成 17(65.4) 鼓室和(或)乳突腔内有死骨的形成 听小骨破坏 21(80.8) 肉芽组织包绕听小骨，14例锤砧关节、11例锤骨头、21砧骨长脚不同程度破坏，6例镫骨缺失、足板为肉芽所覆盖 面神经受累 6(23.1) 6例面神经水平段、1例垂直段骨管、1例膝状神经节处骨质破坏，神经实质裸露伴水肿，鞘膜尚完整 水平段 6(23.1) 垂直段 1(3.8) 膝状神经节 1(3.8) 面隐窝 2(7.7) 2例面隐窝内可见肉芽增生；1例耳蜗、后外半规管破坏；1例水平半规管破坏 耳蜗 1(3.8) 半规管受累 2(7.7) 其他(坏死、脓液) 26(100.0) 几乎所有病例均伴有炎性肿胀黏膜，5例鼓室内可见坏死组织，8例鼓室及乳突内可见潴留囊肿，6例局部可见脓性分泌物 手术方式 乳突根治术 病变累及乳突、鼓窦、鼓室 开放式 1(4.2) 弥漫性，外耳道后壁受累 完壁式 19(70.8) 局限性，外耳道后壁未受累 鼓室成形术 病变仅累及鼓室 Ⅰb型 3(12.5) 病变未累及听骨，或虽包绕听骨，但听骨链完整且活动好 Ⅲa型 13(54.2) 病变累及并破坏听骨链，镫骨完整，足板完整活动好 Ⅲb型 9(29.2) 病变破坏听骨链，镫骨缺失，足板完整活动好 颞骨次全切术 1(4.2) 病变广泛累及乳突、鼓窦、鼓室、诸段面神经、耳蜗及后外半规管 面神经减压术 6(23.1) 面神经诸段被肉芽组织包绕，骨管缺损，实质裸露水肿
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[1] Organization WH. Global tuberculosis report 2020[R]. Geneva: WHO, 2020.
[2] Gupta N, Dass A, Goel N, et al. Tuberculous Otitis Media Leading to Sequentialib Bilateral Facial Nerve Paralysis[J]. Iran J Otorhinolaryngol, 2015, 27(80): 231-237.
[3] Fain O, Lortholary O, Lascaux VV, et al. Extrapulmonary tuberculosis in the northeastern suburbs of Paris: 141 cases[J]. Eur J Intern Med, 2000, 11(3): 145-150. doi: 10.1016/S0953-6205(00)00076-5
[4] 王晋龙, 王峰, 罗锋, 等. 西藏地区44例男性附睾结核回顾性分析[J]. 临床泌尿外科杂志, 2020, 35(9): 725-728.
[5] Richardus RA, Jansen JC, Steens SC, et al. Two immigrants with tuberculosis of the ear, nose, and throat region with skull base and cranial nerve involvement[J]. Case Rep Med, 2011, 2011(1): 675807.
[6] Guan M, Zhang J, Jia Y, et al. Primary bilateral tuberculous otitis media with peripheral facial paralysis: a case report and literature review[J]. Int J Clin Exp Pathol, 2021, 14(3): 304-313.
[7] 徐明芳, 沈敏, 万俐佳, 等. 以鼓室积液为首发表现的结核性中耳炎1例[J]. 临床耳鼻咽喉头颈外科杂志, 2019, 33(9): 889-891. https://lceh.whuhzzs.com/article/doi/10.13201/j.issn.1001-1781.2019.09.022
[8] Hwang GH, Jung JY, Yum G, et al. Tuberculous otitis media with facial paralysis combined with labyrinthitis[J]. Korean J Audiol, 2013, 17(1): 27-29. doi: 10.7874/kja.2013.17.1.27
[9] Meher R, Singh I, Yadav SP, et al. Tubercular otitis media in children[J]. Otolaryngol Head Neck Surg, 2006, 135(4): 650-652. doi: 10.1016/j.otohns.2005.06.027
[10] Bhatkar D, Utpat K, Desai U, et al. Bilateral tuberculous otitis media: An unique presentation[J]. Indian J Tuberc, 2017, 64(4): 334-336. doi: 10.1016/j.ijtb.2016.10.005
[11] Kameswaran M, Natarajan K, Parthiban M, et al. Tuberculous otitis media: a resurgence?[J]. J Laryngol Otol, 2017, 131(9): 785-792. doi: 10.1017/S0022215117001281
[12] Meher R, Singh I, Yadav SP, et al. Tubercular otitis media in children[J]. Otolaryngol Head Neck Surg, 2006, 135(4): 650-652. doi: 10.1016/j.otohns.2005.06.027
[13] Apostol A, Grigoreanu E, Fetica B, et al. Bilateral Tuberculous Otitis: A Furtive Middle Ear Infection[J]. J Craniofac Surg, 2020, 31(6): e552-e553. doi: 10.1097/SCS.0000000000006478
[14] Sebastian SK, Singhal A, Sharma A, et al. Tuberculous otitis media-series of 10 cases[J]. J Otol, 2020, 15(3): 95-98. doi: 10.1016/j.joto.2019.12.001
[15] Kryukov AI, Garov EV, Ivoilov AY, et al. [The clinical manifestations and diagnostics of otitis media caused by tuberculosis][J]. Vestn Otorinolaringol, 2015, 80(3): 28-34. doi: 10.17116/otorino201580328-34
[16] Malinvaud D, Shenouda K, Laccourreye L, et al. Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data[J]. Eur Ann Otorhinolaryngol Head Neck Dis, 2022, 139(6): 343-349. doi: 10.1016/j.anorl.2022.05.005
[17] Chirch LM, Ahmad K, Spinner W, et al. Tuberculous otitis media: report of 2 cases on Long Island, N.Y., and a review of all cases reported in the United States from 1990 through 2003[J]. Ear Nose Throat J, 2005, 84(8): 488-490, 492. doi: 10.1177/014556130508400811
[18] Wang B, Dai CF, Chi FL. Etiological factor analysis of facial nerve paralysis due to chronic inflammation of middle ear[J]. Chinese J of OHN, 2007, 42(12): 889-892.
[19] Kamesawaran M, Natarajan K, Parthiban M, et al. Tuberculous otitis media: a resurgence?[J]. J Laryngol Otol, 2017, 131(9): 785-792. doi: 10.1017/S0022215117001281
[20] Lima AF, Moreira FC, Costa IE, et al. Multiple perforations of the tympanic membrane: what to suspect[J]. BMJ Case Rep, 2020, 13(12): e235989. doi: 10.1136/bcr-2020-235989
[21] Migliori GB, Zellweger JP, Abubakar I, et al. European union standards for tuberculosis care[J]. Eur Respir J, 2012, 39(1): 807-819.
[22] Liktor B, Liktor B, Liktor B Jr, et al. Primary tuberculosis of the middle ear cleft: diagnostic and therapeutic considerations[J]. Eur Arch Otorhinolaryngol, 2014, 271(7): 2083-2809. doi: 10.1007/s00405-014-2977-7
[23] Doan HTH, Hoang PT, Tran TPC. Tuberculous otitis media in Vietnam: Clinical features and diagnostic difficulties[J]. Eur Ann Otorhinolaryngol Head Neck Dis, 2021, 138(6): 467-469. doi: 10.1016/j.anorl.2021.05.009
[24] Cho YS, Lee HS, Kim SW, et al. Tuberculous otitis media: a clinical and radiologic analysis of 52 patients[J]. Laryngoscope, 2006, 116(6): 921-927. doi: 10.1097/01.mlg.0000214861.87933.00
[25] Aremu SK, Alabi BS. tuberculous otitis media: a case presentation and review of the literature[J]. BMJ Case Rep, 2010, 2010(1): bcr0220102721.
[26] Xu TT, Lai Q, Qu N, et al. Diagnostic Values of Peripheral Blood T-Cell Spot Test for Tuberculosis(T-SPOT. TB)for Spinal Tuberculosis[J]. Surg Infect(Larchmt), 2023, 24(6): 534-540. doi: 10.1089/sur.2023.089
[27] Fakhreddine M, Khalid K, Othman D, et al. Rapid detection of Mycobacterium tuberculosis complex by real time polymerase chain reaction(PCR)in pulmonary and extrapulmonary samples in Casablanca, Morocco[J]. Pan Afr Med J, 2020, 36(1): 134.
[28] Petrucci R, Lombardi G, Corsini I, et al. Quantiferon-TB Gold In-Tube Improves Tuberculosis Diagnosis in Children[J]. Pediatr Infect Dis J, 2017, 36(1): 44-49. doi: 10.1097/INF.0000000000001350
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