伴有横窦狭窄的搏动性耳鸣患者诊治策略探索

Clinical management strategies of pulsatile tinnitus with transverse sinus stenosis

目的:探索伴有横窦狭窄的静脉相关血管性搏动性耳鸣患者的临床诊治策略。方法:收集首都医科大学附属北京友谊医院2015年1月至2019年8月因静脉相关血管性搏动性耳鸣收入院且数字减影血管造影检查显示横窦狭窄患者的临床资料。以2019年12月为末次随访时间,分析入组患者临床特点、CT血管造影及数字减影血管造影检查结果,腰椎穿刺压力和脑脊液成分,其他辅助检查结果(纯音听阈、眼底检查、颈动脉B超、骨密度、内分泌六项),耳鸣残疾量表评分,以及治疗方案的选择和随访结果。应用SPSS13.0软件进行统计学分析。结果:共83例患者入组,其中女性74例(89.2%),男性9例(10.8%);右侧耳鸣54例(65.1%),左侧耳鸣26例(31.3%),双侧耳鸣3例(3.6%);静脉优势回流右侧56例(67.5%),左侧16例(19.3%),双侧均衡型11例(13.3%);双侧横窦狭窄46例(55.4%),单侧横窦狭窄37例(44.6%);体质量指数(BMI)超重及肥胖者41例(49.4%);耳鸣残疾量表评分3级及以上者66例(79.5%)。最终33例患者选择观察(39.8%),选择乙状窦相关手术、介入手术及导静脉封闭的患者分别为40例(48.2%),8例(9.6%)及2例(2.4%)。74例随访患者平均随访时间为26.2个月。对48例手术患者的分析显示,乙状窦相关手术后耳鸣消失又复发的患者,其静脉窦内压力差高的比例较大;介入手术若同期植入支架则治疗效果好;导静脉封闭患者术后效果不佳。对26位腰椎穿刺患者分析发现,正常颅压8例、颅高压18例,两组患者静脉窦内压力差比较,差异有统计学意义(P=0.025),而发病年龄、伴随症状、BMI、空蝶鞍及视乳头水肿比例等指标比较,差异均无统计学意义(P值均>0.05)。结论:伴有横窦狭窄的静脉相关血管性搏动性耳鸣患者的评估需要规范的流程,视乳头水肿不能作为早期颅高压患者的敏感检测指标,静脉窦内压力差可能是提示颅高压的指标之一。减轻体重可以作为观察期的保守治疗方法,静脉窦明显狭窄是乙状窦手术患者复发的风险因素,介入支架手术是治疗继发于横窦狭窄的耳鸣患者的有效方法。

Objective To study the clinical diagnosis and treatment strategies for vein-related pulsatile tinnitus patients with transverse sinus stenosis.Methods The clinical data of patients with vein-related pulsatile tinnitus,from January 2015 to August 2019,were collected,whose digital subtraction angiography showing transverse sinus stenosis.Taking December 2019 as the last follow-up time,we analyzed the clinical characteristics,CT angiography and digital subtraction angiography results,lumbar puncture pressure and cerebrospinal fluid composition,and other auxiliary examination results(pure tone audiometry,fundus examination of papilledema,carotid ultrasonography,bone density screening,endocrinous test),as well as tinnitus handicap inventory,treatment options and follow-up results.Results 83 patients were enrolled with female of 89.2%(74/83)and male of 10.8%(9/83);65.1%(54/83)with right tinnitus,31.3%(26/83)with left tinnitus,and 3.6%(3/83)with bilateral tinnitus;67.5%(56/83)with right dominant sinus,19.3%(16/83)with left dominant sinus,13.3%(11/83)with bilateral equalization;Bilateral and ipsilateral stenosis accounted for 55.4%and 44.6%respectively;BMI was overweight or obese in 41 cases(49.4%,41/83).Patients with tinnitus handicap inventory level three or above accounted for 79.5%(66/83).Eventually,33 patients chose conservative observation(39.8%,33/83),40 patients(48.2%),8 patients(9.6%)and 2 patients(2.4%)received sigmoid sinus-related surgery,interventional surgery,or emissary vein occlusion respectively.The mean follow-up time of 74 patients was 26.2 months.The data of 48 surgery patients showed that the pressure differences of venous sinus among the recurrent patients were more obvious;Interventional surgery with simultaneous stenting placement was effective.Tinnitus did not decrease in two patients with emissary vein occlusion.Analysis of 26 patients with lumbar puncture revealed eight cases of normal cranial pressure and 18 cases of high cranial pressure.The sinus pressure difference between the two groups was different(P=0.025),but the difference of age of onset,concomitant symptoms,BMI,proportion of empty sella or papilledema was not statistically significant(P>0.05).Conclusions The evaluation of patients with vein-related pulsatile tinnitus requires a standardized procedure.Papilledema cannot be used as a sensitive indicator in patients with early intracranial hypertension.Venous sinus pressure difference may be one of the indicators of intracranial hypertension,and the lumbar puncture is the gold standard for the diagnosis.Weight loss can be used as a conservative treatment during the observation period.Significant sinus stenosis is a risk factor for recurrence in patients undergoing sigmoid sinus surgery.Interventional stenting is an effective treatment for tinnitus secondary to transverse sinus stenosis.