分泌性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)是以(yi)中(zhong)(zhong)耳積(ji)液及聽力(li)下降為(wei)特征的中(zhong)(zhong)耳非(fei)化膿性(xing)炎(yan)(yan)(yan)性(xing)疾病,又稱為(wei)滲出性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、非(fei)化膿性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、黏液性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、卡他性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、鼓室積(ji)液、漿(jiang)液性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、漿(jiang)液-黏液性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)、無菌性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)。為(wei)耳鼻喉(hou)常(chang)見疾病之一。兒童(tong)多見。在上呼(hu)吸道感染(ran)后以(yi)耳悶脹感和(he)(he)聽力(li)減退(tui)為(wei)主(zhu)要癥狀。由于耳痛不明顯,兒童(tong)主(zhu)訴不清,在小(xiao)兒聽力(li)受到影響時家長才(cai)發(fa)現就診(zhen),常(chang)常(chang)延誤診(zhen)斷(duan)和(he)(he)治(zhi)療。分泌性(xing)中(zhong)(zhong)耳炎(yan)(yan)(yan)可造成兒童(tong)的聽力(li)損失,影響語言發(fa)育,應(ying)高度(du)警(jing)惕和(he)(he)及時觀(guan)察治(zhi)療。對于成人單側病變者(zhe),應(ying)盡早明確病因,排除鼻咽部及其周(zhou)圍(wei)間隙的占位性(xing)腫(zhong)瘤,盡早緩解(jie)癥狀、改善(shan)生(sheng)活質量。
對于正常鼓(gu)(gu)(gu)膜患者,咽(yan)鼓(gu)(gu)(gu)管是中(zhong)(zhong)耳(er)與(yu)外界(jie)環境溝通(tong)(tong)的(de)惟(wei)一管道。咽(yan)鼓(gu)(gu)(gu)管阻塞是造成分泌性中(zhong)(zhong)耳(er)炎(yan)的(de)重要原(yuan)因(yin)(yin)。正常情況(kuang)下,中(zhong)(zhong)耳(er)內、外的(de)氣壓基本相等。當咽(yan)鼓(gu)(gu)(gu)管由于各(ge)種原(yuan)因(yin)(yin)出現通(tong)(tong)氣功(gong)能障(zhang)(zhang)礙(ai)時,中(zhong)(zhong)耳(er)的(de)氣體被黏(nian)膜吸(xi)收(shou),中(zhong)(zhong)耳(er)出現負壓從(cong)而導致中(zhong)(zhong)耳(er)黏(nian)膜的(de)靜(jing)脈(mo)擴(kuo)張(zhang),通(tong)(tong)透性增(zeng)加,血清(qing)漏出聚積于中(zhong)(zhong)耳(er),從(cong)而形成中(zhong)(zhong)耳(er)積液。咽(yan)鼓(gu)(gu)(gu)管通(tong)(tong)氣功(gong)能障(zhang)(zhang)礙(ai)又分為機械(xie)性功(gong)能障(zhang)(zhang)礙(ai)和功(gong)能性功(gong)能障(zhang)(zhang)礙(ai)兩種。
1.機械性阻塞
鼻(bi)(bi)咽(yan)(yan)(yan)部(bu)各種良性(xing)或惡性(xing)占位性(xing)病(bing)變(如:腺樣體肥大、鼻(bi)(bi)咽(yan)(yan)(yan)癌、鼻(bi)(bi)咽(yan)(yan)(yan)纖維血管(guan)瘤等),鼻(bi)(bi)腔和(he)鼻(bi)(bi)竇疾(ji)病(bing)(如:慢性(xing)鼻(bi)(bi)竇炎、巨(ju)大鼻(bi)(bi)息(xi)肉、肥厚性(xing)鼻(bi)(bi)炎、鼻(bi)(bi)中隔偏曲等),長期的鼻(bi)(bi)咽(yan)(yan)(yan)腔填(tian)塞(sai),咽(yan)(yan)(yan)鼓管(guan)咽(yan)(yan)(yan)口粘連(lian),代謝(xie)障(zhang)礙性(xing)疾(ji)病(bing)(如:甲狀腺功能減退等),以及很少(shao)見(jian)的鼻(bi)(bi)咽(yan)(yan)(yan)白喉、結核、梅毒(du)和(he)艾滋(zi)病(bing)等特(te)殊感染(ran)均可因(yin)直接(jie)壓(ya)迫、堵塞(sai)咽(yan)(yan)(yan)口或影響淋巴(ba)回流,造成咽(yan)(yan)(yan)鼓管(guan)管(guan)腔黏膜腫(zhong)脹等從而(er)引起(qi)本病(bing)。
2.功(gong)能性(xing)通氣功(gong)能障礙
小兒的腭(e)帆張肌(ji)(ji)、腭(e)帆提肌(ji)(ji)和咽(yan)(yan)鼓管(guan)(guan)(guan)咽(yan)(yan)肌(ji)(ji)等(deng)肌(ji)(ji)肉薄弱,收縮無力,加之咽(yan)(yan)鼓管(guan)(guan)(guan)軟(ruan)骨發(fa)育不夠(gou)成熟(shu),彈(dan)性(xing)(xing)較(jiao)差,當咽(yan)(yan)鼓管(guan)(guan)(guan)處于負壓狀態時,軟(ruan)骨段的管(guan)(guan)(guan)壁甚(shen)易發(fa)生(sheng)塌陷,導致(zhi)中耳負壓。細菌病毒感染、放射性(xing)(xing)損傷(shang)、先天(tian)性(xing)(xing)呼(hu)吸道黏(nian)膜(mo)纖毛運(yun)動(dong)不良、原發(fa)性(xing)(xing)纖毛運(yun)動(dong)障礙等(deng)原因(yin),引起咽(yan)(yan)鼓管(guan)(guan)(guan)表面活(huo)性(xing)(xing)物質減少,從而致(zhi)咽(yan)(yan)鼓管(guan)(guan)(guan)開放阻力加大,也被(bei)認為是分泌(mi)性(xing)(xing)耳炎(yan)的原因(yin)之一。此外Ⅰ、Ⅲ型變態反應均(jun)可(ke)能(neng)引起分泌(mi)性(xing)(xing)中耳炎(yan),可(ke)能(neng)與過(guo)敏引起的咽(yan)(yan)鼓管(guan)(guan)(guan)黏(nian)膜(mo)水腫,管(guan)(guan)(guan)腔閉(bi)塞有關。
嬰(ying)幼兒易患分泌性中(zhong)(zhong)(zhong)(zhong)耳炎與嬰(ying)幼兒特(te)殊的(de)解剖結構有(you)關。新(xin)(xin)生兒的(de)咽(yan)(yan)(yan)鼓(gu)管(guan)短、寬(kuan)而平(ping)直,鼻(bi)咽(yan)(yan)(yan)部的(de)分泌物(wu)易經咽(yan)(yan)(yan)鼓(gu)管(guan)進(jin)入中(zhong)(zhong)(zhong)(zhong)耳引(yin)起(qi)炎癥。分娩時(shi)難產、臀(tun)位、室息時(shi)作過人工呼吸的(de)新(xin)(xin)生兒,羊水常易進(jin)入中(zhong)(zhong)(zhong)(zhong)耳內。母體患妊娠(shen)中(zhong)(zhong)(zhong)(zhong)毒癥、先兆(zhao)子癇(xian)或產前(qian)出血者(zhe),羊水也易進(jin)入中(zhong)(zhong)(zhong)(zhong)耳發生感染引(yin)起(qi)中(zhong)(zhong)(zhong)(zhong)耳炎。新(xin)(xin)生兒哺乳不當容易逆乳,特(te)別是取平(ping)仰臥位用(yong)奶瓶人工哺養者(zhe),逆乳時(shi)乳汁潴積于鼻(bi)咽(yan)(yan)(yan)腔,經咽(yan)(yan)(yan)鼓(gu)管(guan)進(jin)入中(zhong)(zhong)(zhong)(zhong)耳引(yin)起(qi)中(zhong)(zhong)(zhong)(zhong)耳炎。
分泌性中耳(er)(er)炎的臨床表現(xian)主要(yao)為聽力(li)下降(jiang),可(ke)隨體位變化(hua)(hua)而變化(hua)(hua),輕(qing)微的耳(er)(er)痛、耳(er)(er)鳴、耳(er)(er)悶脹(zhang)和閉塞感,搖頭(tou)可(ke)聽見水(shui)聲。耳(er)(er)科(ke)專科(ke)檢查可(ke)見鼓膜(mo)內陷,呈琥珀(po)色或色澤發暗,亦(yi)可(ke)見氣液(ye)平面或氣泡,鼓膜(mo)活(huo)動(dong)度降(jiang)低。
嬰幼(you)兒則表現(xian)為(wei)對(dui)周圍聲音(yin)反(fan)應差(cha),抓耳(er),睡眠易醒,易激(ji)惹(re)。嬰兒對(dui)周圍的(de)聲音(yin)沒有(you)反(fan)應,不(bu)能(neng)將(jiang)頭準確地轉向聲源;即使(shi)患兒沒有(you)主訴聽(ting)力下降(jiang),家人(ren)則發現(xian)患兒漫不(bu)經心、行為(wei)改(gai)變、對(dui)正常對(dui)話(hua)無反(fan)應、在(zai)看電(dian)視或使(shi)用(yong)聽(ting)力設備時(shi)總是將(jiang)聲音(yin)開得很(hen)大;對(dui)于(yu)反(fan)復(fu)發作(zuo)的(de)急性(xing)(xing)中耳(er)炎(yan),應警惕在(zai)發作(zuo)間歇期可能(neng)持續(xu)的(de)分泌性(xing)(xing)中耳(er)炎(yan);學(xue)習(xi)成(cheng)績差(cha);平(ping)衡(heng)能(neng)力差(cha),不(bu)明原(yuan)因的(de)笨拙;語言發育遲緩。
1.鼓氣耳鏡(jing)檢(jian)查或顯微鏡(jing)檢(jian)查
鼓(gu)(gu)氣(qi)耳(er)鏡(jing)(jing)檢查(cha)方便(bian)易(yi)行,是(shi)(shi)分泌性中耳(er)炎的(de)主要診斷方法(fa)(fa),也是(shi)(shi)社區檢查(cha)鼓(gu)(gu)膜的(de)首選方法(fa)(fa)。它可以改變(bian)外(wai)耳(er)道的(de)氣(qi)壓,觀察鼓(gu)(gu)膜的(de)活動情況。如發現鼓(gu)(gu)膜動度減低,同時(shi)伴有鼓(gu)(gu)膜內陷、色澤由正常的(de)灰白(bai)色半(ban)透明狀改變(bian)為橘黃色或琥珀(po)色,見(jian)到氣(qi)液平面或氣(qi)泡即可診斷。與普通耳(er)鏡(jing)(jing)相比較,鼓(gu)(gu)氣(qi)耳(er)鏡(jing)(jing)有著更高的(de)敏感度和特異度。
2.聲導抗測試
聲(sheng)導(dao)抗(kang)(kang)測(ce)(ce)試是(shi)反映中耳功能的快速、有效的客觀測(ce)(ce)聽方法。由于(yu)鼓(gu)(gu)(gu)(gu)氣(qi)耳鏡對于(yu)2歲(sui)以(yi)下兒童的鼓(gu)(gu)(gu)(gu)膜和(he)中耳情況判斷困難,聲(sheng)導(dao)抗(kang)(kang)則提供了方便的測(ce)(ce)試。聲(sheng)導(dao)抗(kang)(kang)的鼓(gu)(gu)(gu)(gu)室壓(ya)(ya)圖可呈(cheng)B型(xing)和(he)C型(xing)。開始時咽鼓(gu)(gu)(gu)(gu)管(guan)功能不(bu)良(liang)或堵(du)塞(sai),中耳氣(qi)體被(bei)吸收形成負壓(ya)(ya),鼓(gu)(gu)(gu)(gu)膜內(nei)(nei)陷,鼓(gu)(gu)(gu)(gu)室壓(ya)(ya)峰(feng)壓(ya)(ya)點向負壓(ya)(ya)側位移,以(yi)C型(xing)曲線多見。當病變逐漸進(jin)展(zhan),鼓(gu)(gu)(gu)(gu)膜更(geng)加(jia)(jia)內(nei)(nei)陷,出現鼓(gu)(gu)(gu)(gu)室積液,傳音(yin)結構質量增(zeng)加(jia)(jia)而(er)使聲(sheng)導(dao)抗(kang)(kang)進(jin)一步增(zeng)加(jia)(jia),鼓(gu)(gu)(gu)(gu)室勁度加(jia)(jia)大,鼓(gu)(gu)(gu)(gu)膜和(he)聽骨(gu)鏈活動(dong)降低,峰(feng)壓(ya)(ya)點就越偏向負值(zhi),當聲(sheng)順減弱或無(wu)(wu)變化時則成為無(wu)(wu)峰(feng)的B型(xing)圖。
一般認為,如鼓(gu)(gu)(gu)室導(dao)抗圖(tu)為B型,結合臨床可(ke)診斷(duan)為分(fen)泌(mi)性中(zhong)(zhong)(zhong)耳(er)(er)炎。但是(shi),新生(sheng)(sheng)兒(er)(er)和(he)(he)嬰(ying)兒(er)(er)出(chu)生(sheng)(sheng)后外(wai)耳(er)(er)和(he)(he)中(zhong)(zhong)(zhong)耳(er)(er)結構(gou)發生(sheng)(sheng)了一系列的(de)(de)改(gai)(gai)變,如1歲以內嬰(ying)兒(er)(er)外(wai)耳(er)(er)道大(da)小和(he)(he)直徑的(de)(de)增加(jia)(jia)(jia),使(shi)(shi)(shi)其順(shun)(shun)應(ying)性也發生(sheng)(sheng)變化(hua),導(dao)致外(wai)耳(er)(er)道共(gong)振增益和(he)(he)共(gong)振頻率發生(sheng)(sheng)改(gai)(gai)變;隨著生(sheng)(sheng)后6個(ge)月(yue)內鼓(gu)(gu)(gu)膜(mo)(mo)到鐙骨底板(ban)距(ju)離的(de)(de)增長(chang),增加(jia)(jia)(jia)了中(zhong)(zhong)(zhong)耳(er)(er)含氣腔,擴大(da)了中(zhong)(zhong)(zhong)耳(er)(er)腔的(de)(de)容積,此(ci)時乳突氣化(hua)也增加(jia)(jia)(jia),中(zhong)(zhong)(zhong)耳(er)(er)腔容積增加(jia)(jia)(jia)使(shi)(shi)(shi)鼓(gu)(gu)(gu)膜(mo)(mo)的(de)(de)順(shun)(shun)應(ying)性和(he)(he)控制低頻傳導(dao)方(fang)面受(shou)到重要(yao)影響;此(ci)外(wai),中(zhong)(zhong)(zhong)耳(er)(er)腔中(zhong)(zhong)(zhong)存在(zai)的(de)(de)羊水和(he)(he)間葉細(xi)胞逐漸(jian)消失(可(ke)持續到生(sheng)(sheng)后5個(ge)月(yue)),也使(shi)(shi)(shi)得中(zhong)(zhong)(zhong)耳(er)(er)總質量(liang)減(jian)(jian)少;鐙骨密(mi)度(du)降低,質量(liang)減(jian)(jian)少;聽(ting)骨鏈關(guan)節之間和(he)(he)鐙骨底板(ban)附著到卵圓窗上(shang)的(de)(de)緊(jin)密(mi)程度(du)也在(zai)改(gai)(gai)變,這些都減(jian)(jian)少了抵抗成分(fen)。因此(ci),常(chang)規的(de)(de)226Hz探測(ce)音測(ce)試的(de)(de)鼓(gu)(gu)(gu)室圖(tu)不能真實(shi)地反映6個(ge)月(yue)以內嬰(ying)幼兒(er)(er)中(zhong)(zhong)(zhong)耳(er)(er)有無病(bing)變和(he)(he)中(zhong)(zhong)(zhong)耳(er)(er)功能。因此(ci)大(da)于4個(ge)月(yue)患兒(er)(er)使(shi)(shi)(shi)用(yong)(yong)226HZ的(de)(de)探測(ce)音,小于4個(ge)月(yue)的(de)(de)患兒(er)(er)使(shi)(shi)(shi)用(yong)(yong)高頻率的(de)(de)探測(ce)音(1000Hz)。這樣可(ke)使(shi)(shi)(shi)檢查結果更加(jia)(jia)(jia)準確。
3.鼓膜穿刺或鼓膜切(qie)開術
在耳顯微鏡或(huo)(huo)內鏡下(xia),于鼓膜前下(xia)方進行(xing)穿刺(ci)或(huo)(huo)切(qie)開,若有(you)漿液樣或(huo)(huo)黏液樣液體流(liu)出則(ze)可證實分(fen)泌性(xing)中(zhong)耳炎(yan)的存(cun)在。其為一(yi)種有(you)創性(xing)診(zhen)斷方式,不但可以明確診(zhen)斷,同時(shi)可以達到(dao)治療目(mu)的。
4.鼻咽部檢查
成人患者(zhe),用鼻(bi)內(nei)鏡或多功能纖維鼻(bi)咽(yan)鏡直接(jie)觀察鼻(bi)咽(yan)部及咽(yan)鼓管咽(yan)口情況(kuang)。排(pai)除鼻(bi)咽(yan)部占位性病變。
5.顳(nie)骨高分辨率薄層CT
單(dan)側頑固性分泌性中(zhong)耳炎,經過治(zhi)療無(wu)效,應警惕黏(nian)膜下型鼻(bi)咽(yan)癌累及咽(yan)旁(pang)間(jian)隙(xi),壓迫咽(yan)鼓管(guan)。如鑒別診斷需要(yao),或需要(yao)排(pai)除鼻(bi)咽(yan)部和咽(yan)旁(pang)間(jian)隙(xi)占位者,顳骨高分辨率(lv)薄層CT可了解中(zhong)耳情況,將CT片調(diao)到軟組織窗時可觀(guan)察咽(yan)旁(pang)間(jian)隙(xi)有無(wu)占位。必要(yao)時需進行增強掃描。
根(gen)據病史及專科(ke)檢查(cha),結合鼓室導抗圖和聲反射(she)、耳顯(xian)微鏡或內鏡檢查(cha),鼓膜穿(chuan)刺或切開術等(deng)可以(yi)明確(que)診(zhen)斷(duan)。
1.急性中耳炎
嬰幼(you)兒及兒童(tong)分(fen)(fen)(fen)泌(mi)性(xing)(xing)(xing)中(zhong)耳(er)(er)炎(yan)(yan)(yan)應與急性(xing)(xing)(xing)中(zhong)耳(er)(er)炎(yan)(yan)(yan)相(xiang)鑒(jian)別。急性(xing)(xing)(xing)中(zhong)耳(er)(er)炎(yan)(yan)(yan)治療(liao)不徹底或遷延(yan)不愈可(ke)(ke)轉換為(wei)分(fen)(fen)(fen)泌(mi)性(xing)(xing)(xing)中(zhong)耳(er)(er)炎(yan)(yan)(yan)。多病程較短,患者可(ke)(ke)有劇烈(lie)耳(er)(er)痛(tong)(tong)、耳(er)(er)流膿等癥狀,分(fen)(fen)(fen)泌(mi)性(xing)(xing)(xing)中(zhong)耳(er)(er)炎(yan)(yan)(yan)多病程較長,多以耳(er)(er)悶為(wei)主要(yao)癥狀,耳(er)(er)痛(tong)(tong)呈間斷性(xing)(xing)(xing),較輕,甚至無耳(er)(er)痛(tong)(tong)表(biao)現(xian)。
2.鼻咽癌或鼻咽部(bu)占位(wei)性(xing)病(bing)變
典型(xing)的鼻咽癌早期(qi)癥(zheng)狀(zhuang)可為涕中帶血、頸(jing)部包塊。但有(you)些患者(zhe)耳部癥(zheng)狀(zhuang)先于上述癥(zheng)狀(zhuang),癌腫在鼻咽部的黏(nian)膜下潛行,鼻內鏡檢查在早期(qi)不易發現。對(dui)于單耳分泌性中耳炎,特(te)殊(shu)地區患者(zhe),應(ying)高度警(jing)惕。
3.慢性(xing)化膿性(xing)中(zhong)耳(er)炎(yan)合并(bing)中(zhong)耳(er)膽脂瘤
松弛部穿(chuan)孔被痂皮覆蓋,耳鼓膜緊(jin)張部顯(xian)示鼓室積液(ye),此類患者應仔細檢查松弛部,必(bi)要時行顳骨的高分(fen)辨率CT,以除外(wai)中耳膽脂瘤。
4.粘連性(xing)中(zhong)耳(er)炎
主訴為聽力減退和(he)悶(men)脹(zhang)感,檢(jian)查鼓膜與(yu)鼓岬粘連(lian)以資鑒別(bie)。
5.鼓室硬化
屬慢性中耳炎(yan)的后遺病變。主訴聽力下(xia)降和耳悶脹(zhang)感。一般病史較長,有(you)中耳炎(yan)病史。鼓膜可以完整,鼓室內大量(liang)硬化癥(zheng)包(bao)裹聽骨鏈(lian),影響聲能傳(chuan)導(dao)。顳骨CT或手(shou)術探(tan)查(cha)可以明確診斷(duan)。
6.膽固醇肉芽腫
患者主訴聽(ting)力減退和耳悶脹感。但耳科檢查(cha)可(ke)見鼓膜呈藍色,顳(nie)骨CT提示鼓竇入(ru)口狹窄,可(ke)有骨質破壞(huai)。手術探查(cha)及病例檢查(cha)可(ke)以(yi)明確診斷。
7.先天性(xing)或后天性(xing)中耳膽脂瘤(liu)
對于鼓(gu)(gu)膜(mo)(mo)完(wan)整的中耳膽脂瘤,主訴聽(ting)力下降,檢(jian)查(cha)鼓(gu)(gu)膜(mo)(mo)完(wan)整,透(tou)光度差,聽(ting)力圖顯(xian)(xian)示為(wei)傳導性(xing)聽(ting)力損失,容易混淆(xiao)。但鼓(gu)(gu)室(shi)積液征不(bu)明顯(xian)(xian),鼓(gu)(gu)膜(mo)(mo)透(tou)光度差,可透(tou)過(guo)鼓(gu)(gu)膜(mo)(mo)見到白色的實性(xing)團塊樣物位于鼓(gu)(gu)膜(mo)(mo)內側的鼓(gu)(gu)室(shi)內。
8.自發性或外傷性腦脊(ji)液耳漏
可主訴患側反復發生(sheng)腦(nao)膜炎(yan),檢查(cha)(cha)顯示鼓室內液體(ti)積聚。年(nian)輕患者,根據病史、查(cha)(cha)體(ti)及影像學(xue)檢查(cha)(cha)可以(yi)確(que)診(zhen)。外(wai)傷性者則有明確(que)的外(wai)傷史。
9.外淋巴漏
兩窗(chuang)破裂和先天性裂隙,造(zao)成(cheng)外淋巴(ba)液漏至中耳(er)鼓室腔(qiang)。可表現為(wei)鼓室積液,但患(huan)者(zhe)有眩(xuan)(xuan)暈(yun)病史,遇(yu)強聲刺激可誘發眩(xuan)(xuan)暈(yun)。聽力圖(tu)提示感(gan)音神(shen)經性耳(er)聾。
10.Wergerner肉芽腫
雖然屬于少(shao)見(jian)病(bing)(bing),但疾病(bing)(bing)初(chu)期容易誤診為分(fen)泌性(xing)中耳炎(yan)。雙耳發病(bing)(bing),病(bing)(bing)程遷延和(he)頑(wan)固,伴有(you)全身發熱(re)、肺(fei)部及腎臟(zang)病(bing)(bing)變,ANCA等抗體陽性(xing),對(dui)糖(tang)皮(pi)質(zhi)激素(su)治療有(you)效,應(ying)高(gao)度警(jing)惕該病(bing)(bing)。
11.其他
當咽(yan)鼓(gu)管(guan)功(gong)能不良或(huo)耳(er)硬化癥,聽(ting)力曲線為(wei)(wei)傳(chuan)導性聾(long)(long),另外,內耳(er)的(de)病變如梅(mei)尼埃病、上半規管(guan)裂綜合征等,可表現為(wei)(wei)耳(er)悶脹感(gan),尤其是聽(ting)力曲線上顯(xian)(xian)示有骨氣導間距時(shi)則容易混淆。但鼓(gu)膜檢查無(wu)積液征,聲導抗圖(tu)顯(xian)(xian)示為(wei)(wei)A型(xing)圖(tu)或(huo)C型(xing)圖(tu),而非B型(xing)圖(tu);內耳(er)病變以感(gan)音(yin)神經性聾(long)(long)為(wei)(wei)其主要特征,以資鑒別。
分泌性中(zhong)耳(er)炎可發(fa)展為粘連性中(zhong)耳(er)炎、鼓(gu)(gu)室硬化癥、膽固醇(chun)肉芽腫和后(hou)天(tian)原發(fa)性膽脂瘤等(deng),這些病變如不(bu)及時治療(liao),可引起嚴重聽力減退和引起一系列并發(fa)癥。長期(qi)鼓(gu)(gu)室置管可能遺留鼓(gu)(gu)膜穿孔,等(deng)待觀(guan)察至成年后(hou)可考慮鼓(gu)(gu)膜修補手術。
治療原(yuan)則為積極治療原(yuan)發(fa)病及(ji)鄰近病灶,去(qu)除(chu)病因,改善咽鼓(gu)(gu)管的通(tong)氣功能,平衡(heng)和消除(chu)中耳鼓(gu)(gu)室內的負壓狀況,通(tong)暢引流鼓(gu)(gu)室內的積液,防止(zhi)鼓(gu)(gu)室粘連和中耳膽脂瘤及(ji)膽固(gu)醇肉芽腫(zhong)的發(fa)生(sheng)。
1.成(cheng)人分泌性中耳炎(yan)的治療
(1)保守治療(liao)①鼻(bi)(bi)(bi)腔收縮劑(ji) 改善(shan)咽鼓(gu)管(guan)(guan)通(tong)氣功能,常用(yong)(yong)藥(yao)物(wu)(wu)(wu)為麻(ma)黃素(su)(su)(su)制劑(ji)、鹽酸(suan)羥甲唑(zuo)啉等藥(yao)物(wu)(wu)(wu),但(dan)是使用(yong)(yong)此藥(yao)物(wu)(wu)(wu)要注(zhu)意防止藥(yao)物(wu)(wu)(wu)依賴(lai),一般療(liao)程不(bu)超過(guo)1周,若頻(pin)繁過(guo)量(liang)使用(yong)(yong)易引(yin)起藥(yao)物(wu)(wu)(wu)性(xing)鼻(bi)(bi)(bi)炎(yan)。麻(ma)黃素(su)(su)(su)類(lei)鼻(bi)(bi)(bi)腔收縮劑(ji)可升高血壓,老(lao)年人用(yong)(yong)藥(yao)后應觀察血壓變化(hua)。②黏液促排劑(ji) 可調節咽鼓(gu)管(guan)(guan)及鼓(gu)室內(nei)(nei)黏膜生(sheng)理功能,促進鼓(gu)室內(nei)(nei)積液排除(chu),改善(shan)黏膜黏液毯的(de)清理作(zuo)用(yong)(yong),常用(yong)(yong)藥(yao)物(wu)(wu)(wu)有(you):鹽酸(suan)氨溴索等藥(yao)物(wu)(wu)(wu)。③抗生(sheng)素(su)(su)(su) 在急性(xing)期(qi)(qi)內(nei)(nei),可短(duan)期(qi)(qi)內(nei)(nei)使用(yong)(yong)敏感(gan)抗生(sheng)素(su)(su)(su)。④口(kou)服糖(tang)(tang)皮(pi)(pi)質(zhi)激(ji)素(su)(su)(su) 對于無糖(tang)(tang)尿病等禁忌(ji)證(zheng)的(de)患者,可使用(yong)(yong)糖(tang)(tang)皮(pi)(pi)質(zhi)激(ji)素(su)(su)(su)類(lei)藥(yao)物(wu)(wu)(wu)如潑(po)尼松(song)等口(kou)服,但(dan)只可作(zuo)短(duan)期(qi)(qi)治療(liao),不(bu)宜長期(qi)(qi)使用(yong)(yong)。⑤鼻(bi)(bi)(bi)用(yong)(yong)糖(tang)(tang)皮(pi)(pi)質(zhi)激(ji)素(su)(su)(su) 改善(shan)鼻(bi)(bi)(bi)腔炎(yan)癥(zheng)狀(zhuang)態,消除(chu)炎(yan)癥(zheng)介質(zhi),且相對口(kou)服糖(tang)(tang)皮(pi)(pi)質(zhi)激(ji)素(su)(su)(su)更為安全,局部作(zuo)用(yong)(yong)于鼻(bi)(bi)(bi)腔、鼻(bi)(bi)(bi)咽、咽鼓(gu)管(guan)(guan),全身副作(zuo)用(yong)(yong)小(xiao)。⑥咽鼓(gu)管(guan)(guan)吹(chui)張 可采用(yong)(yong)咽鼓(gu)管(guan)(guan)吹(chui)張器、捏鼻(bi)(bi)(bi)鼓(gu)氣法(fa)、波氏球法(fa)或導(dao)管(guan)(guan)法(fa)促使咽鼓(gu)管(guan)(guan)通(tong)暢,還可經(jing)導(dao)管(guan)(guan)向咽鼓(gu)管(guan)(guan)咽口(kou)吹(chui)入潑(po)尼松(song)龍(long),達到(dao)通(tong)暢和引(yin)流的(de)目的(de)。但(dan)應用(yong)(yong)此方(fang)法(fa)時須注(zhu)意鼻(bi)(bi)(bi)腔不(bu)能有(you)鼻(bi)(bi)(bi)涕,不(bu)然(ran)容易將鼻(bi)(bi)(bi)涕吹(chui)入鼓(gu)室,引(yin)起急性(xing)化(hua)膿性(xing)中耳炎(yan)。
(2)手術(shu)(shu)治(zhi)療(liao)①鼓(gu)(gu)(gu)(gu)(gu)膜穿(chuan)刺(ci)(ci)抽(chou)液(ye) 可(ke)(ke)同(tong)(tong)時(shi)作為(wei)診斷(duan)方(fang)法及(ji)治(zhi)療(liao)方(fang)法,可(ke)(ke)有(you)效清除中(zhong)耳積液(ye),改善(shan)中(zhong)耳通(tong)(tong)(tong)氣(qi)。必要(yao)時(shi)可(ke)(ke)重復穿(chuan)刺(ci)(ci),或抽(chou)液(ye)后注(zhu)入糖皮質激素(su)類(lei)藥物。②鼓(gu)(gu)(gu)(gu)(gu)膜切開(kai)術(shu)(shu) 適用(yong)(yong)(yong)于分(fen)(fen)(fen)泌(mi)的(de)(de)液(ye)體(ti)較黏稠,鼓(gu)(gu)(gu)(gu)(gu)膜穿(chuan)刺(ci)(ci)不能吸(xi)盡者。不合作的(de)(de)小兒可(ke)(ke)于全麻下進行(xing)。需要(yao)注(zhu)意保護鼓(gu)(gu)(gu)(gu)(gu)室內壁黏膜,鼓(gu)(gu)(gu)(gu)(gu)膜切開(kai)后應(ying)將鼓(gu)(gu)(gu)(gu)(gu)室內液(ye)體(ti)全部(bu)吸(xi)盡。③鼓(gu)(gu)(gu)(gu)(gu)室置管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)術(shu)(shu) 適用(yong)(yong)(yong)于病(bing)情遷延不愈(yu),或反(fan)復發(fa)作,頭(tou)部(bu)放療(liao)后,咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)功(gong)(gong)能短期內難以(yi)恢(hui)復正常者,目(mu)的(de)(de)是改善(shan)通(tong)(tong)(tong)氣(qi)引流,促使咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)恢(hui)復功(gong)(gong)能。通(tong)(tong)(tong)氣(qi)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)留置時(shi)間(jian)一般(ban)為(wei)3~6個月,最長可(ke)(ke)達6個月~1年。可(ke)(ke)在咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)功(gong)(gong)能恢(hui)復后取出通(tong)(tong)(tong)氣(qi)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan),有(you)部(bu)分(fen)(fen)(fen)患者可(ke)(ke)自行(xing)將通(tong)(tong)(tong)氣(qi)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)排出于外(wai)耳道(dao)內。④對(dui)于頑固性(xing)(xing)分(fen)(fen)(fen)泌(mi)性(xing)(xing)中(zhong)耳炎(yan)一直缺乏有(you)效的(de)(de)治(zhi)療(liao)措施,目(mu)前咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)激光(guang)(guang)成形(xing)術(shu)(shu)和(he)咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)球囊(nang)擴(kuo)(kuo)張術(shu)(shu)為(wei)該(gai)(gai)類(lei)患者帶來一線希望。對(dui)于反(fan)復發(fa)作的(de)(de),病(bing)程大于3個月以(yi)上的(de)(de)慢(man)性(xing)(xing)分(fen)(fen)(fen)泌(mi)性(xing)(xing)中(zhong)耳炎(yan)患者,可(ke)(ke)采用(yong)(yong)(yong)此類(lei)方(fang)法,改善(shan)咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)通(tong)(tong)(tong)氣(qi)功(gong)(gong)能。⑤激光(guang)(guang)咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)成形(xing)術(shu)(shu) 應(ying)用(yong)(yong)(yong)半導體(ti)激光(guang)(guang)、CO2光(guang)(guang)纖激光(guang)(guang)、KTP激光(guang)(guang)燈等軟管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)激光(guang)(guang),對(dui)咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)圓枕(zhen)后唇部(bu)分(fen)(fen)(fen)進行(xing)消融,國外(wai)在近兩年的(de)(de)臨(lin)床研究發(fa)現其有(you)效率達到(dao)90%以(yi)上。球囊(nang)擴(kuo)(kuo)張咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)成形(xing)術(shu)(shu):應(ying)用(yong)(yong)(yong)球囊(nang)置入咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)咽(yan)口,對(dui)咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)軟骨部(bu)進行(xing)擴(kuo)(kuo)張,提高咽(yan)鼓(gu)(gu)(gu)(gu)(gu)管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)軟骨部(bu)開(kai)放功(gong)(gong)能,達到(dao)治(zhi)療(liao)分(fen)(fen)(fen)泌(mi)性(xing)(xing)中(zhong)耳炎(yan)的(de)(de)目(mu)的(de)(de)。⑥懷疑鼓(gu)(gu)(gu)(gu)(gu)峽(xia)阻(zu)塞、鼓(gu)(gu)(gu)(gu)(gu)竇入口有(you)肉芽組織阻(zu)塞的(de)(de)頑固性(xing)(xing)分(fen)(fen)(fen)泌(mi)性(xing)(xing)中(zhong)耳炎(yan)患者 可(ke)(ke)考慮(lv)單(dan)純乳(ru)突切開(kai)術(shu)(shu)及(ji)鼓(gu)(gu)(gu)(gu)(gu)室探查手術(shu)(shu),同(tong)(tong)時(shi)行(xing)鼓(gu)(gu)(gu)(gu)(gu)膜置管(guan)(guan)(guan)(guan)(guan)(guan)(guan)(guan)術(shu)(shu)。對(dui)將要(yao)發(fa)生粘(zhan)連(lian)性(xing)(xing)中(zhong)耳炎(yan)及(ji)內陷囊(nang)袋(dai)者,應(ying)該(gai)(gai)盡早進行(xing)手術(shu)(shu)治(zhi)療(liao),以(yi)防(fang)止并(bing)發(fa)癥(zheng)。
2.兒童及(ji)嬰幼兒分泌性中耳炎(yan)的治療
(1)密切觀察和隨診 因(yin)(yin)為(wei)(wei)分(fen)(fen)泌(mi)(mi)性(xing)(xing)中(zhong)耳炎(yan)為(wei)(wei)自限性(xing)(xing)疾病,有(you)一定(ding)的(de)自愈率(lv),在(zai)(zai)(zai)給(gei)予有(you)創治療前患(huan)者(zhe)應該嚴密觀察3個月(yue)。分(fen)(fen)泌(mi)(mi)性(xing)(xing)中(zhong)耳炎(yan)是(shi)否自愈取決于(yu)病因(yin)(yin)及積液時(shi)(shi)間的(de)長短(duan)。由急(ji)性(xing)(xing)中(zhong)耳炎(yan)遺(yi)留的(de)分(fen)(fen)泌(mi)(mi)性(xing)(xing)中(zhong)耳炎(yan)患(huan)者(zhe),約(yue)75%~90%在(zai)(zai)(zai)3個月(yue)時(shi)(shi)可(ke)以自愈,鼓(gu)室壓圖由B轉為(wei)(wei)A、C型(xing)。約(yue)55%分(fen)(fen)泌(mi)(mi)性(xing)(xing)中(zhong)耳炎(yan)患(huan)者(zhe)可(ke)在(zai)(zai)(zai)3個月(yue)時(shi)(shi)自愈,但是(shi),約(yue)1/3的(de)患(huan)兒可(ke)能加重。在(zai)(zai)(zai)起病時(shi)(shi)間不祥(xiang)的(de)2~4歲的(de)患(huan)兒中(zhong),約(yue)25%的(de)患(huan)兒自愈時(shi)(shi)間為(wei)(wei)3個月(yue)。嬰兒和小小兒的(de)自愈率(lv)更高。2歲以上(shang)雙耳分(fen)(fen)泌(mi)(mi)性(xing)(xing)中(zhong)耳炎(yan)、病程在(zai)(zai)(zai)3月(yue)以上(shang)患(huan)兒,在(zai)(zai)(zai)6~l2個月(yue)時(shi)(shi)其自愈者(zhe)約(yue)為(wei)(wei)30%。
對(dui)于處(chu)(chu)于觀察階(jie)段的(de)非(fei)高危患兒(er),無論是(shi)(shi)藥物還是(shi)(shi)手術干預則百(bai)害而(er)無一利(li),而(er)觀察等(deng)待對(dui)非(fei)高危患兒(er)則無害處(chu)(chu);需要告知家人患兒(er)聽力差,尤其是(shi)(shi)雙耳分(fen)泌性中耳炎(yan)患者;制定(ding)改(gai)善(shan)患兒(er)聆(ling)聽和學(xue)習環境的(de)措施和方案;定(ding)期復查(cha),并進行(xing)氣(qi)壓耳鏡和鼓室壓圖檢查(cha)。
改善聆聽環(huan)境(jing)的(de)措施(shi)包括:說話時在(zai)3英尺內;將周圍干擾(rao)的(de)聲響關掉如電視機、音(yin)(yin)樂;面對(dui)患(huan)兒說話時,做到口(kou)齒(chi)清(qing)晰,并應用手勢和圖片(pian)等(deng)視覺(jue)方式作為輔助;降低語速、提高音(yin)(yin)量、言語清(qing)晰;與患(huan)兒一起閱(yue)讀和講述、解(jie)釋圖片(pian)或提出(chu)問題;注意重復單詞、詞組或句子;安排患(huan)兒坐在(zai)距離老(lao)師較近(jin)的(de)位(wei)置(zhi)上(shang);在(zai)教室里使用可(ke)調節音(yin)(yin)量的(de)擴音(yin)(yin)設備等(deng)。
(2)藥物(wu)治(zhi)療(liao)(liao)(liao) 對于兒童,藥物(wu)療(liao)(liao)(liao)效短暫而有限,副作(zuo)用多,不推薦使(shi)用。不主張(zhang)長期使(shi)用抗生素(su)(su)治(zhi)療(liao)(liao)(liao)分(fen)泌性中耳(er)炎,鼓(gu)(gu)膜充血不應該(gai)成為抗生素(su)(su)應用的(de)指征,不主張(zhang)聯合使(shi)用抗組胺藥及減充血劑,因為他們的(de)副作(zuo)用明顯(xian)。也不主張(zhang)普遍地長期使(shi)用口服(fu)激素(su)(su)治(zhi)療(liao)(liao)(liao),除非個別病例。尚無證據支持咽鼓(gu)(gu)管通氣、口服(fu)或鼓(gu)(gu)室內注射黏液促排劑及其他藥物(wu)的(de)治(zhi)療(liao)(liao)(liao)作(zuo)用。
(3)手(shou)術(shu)治療 選擇手(shou)術(shu)時應該(gai)考慮的因(yin)(yin)素(su)為(wei)聽(ting)力(li)水(shui)(shui)平(ping)及伴隨癥(zheng)狀;是否存在(zai)影響(xiang)(言語(yu)語(yu)言)發(fa)育的高危因(yin)(yin)素(su);分泌性(xing)(xing)中耳(er)炎(yan)(yan)自(zi)愈的可(ke)能性(xing)(xing)。手(shou)術(shu)指(zhi)征為(wei)分泌性(xing)(xing)中耳(er)炎(yan)(yan)持續在(zai)4月以上伴有聽(ting)力(li)減(jian)退和(he)其他癥(zheng)狀;持續或復發(fa)性(xing)(xing)分泌性(xing)(xing)中耳(er)炎(yan)(yan),伴有高危因(yin)(yin)素(su)存在(zai)(只要是高危患(huan)兒,無(wu)論積(ji)液(ye)時間長短(duan),都(dou)應該(gai)盡早手(shou)術(shu));鼓膜(mo)或中耳(er)結構損害。應該(gai)綜合基層醫(yi)生、耳(er)鼻咽喉(hou)科醫(yi)生和(he)家人的意(yi)見,權衡手(shou)術(shu)利弊。隨訪患(huan)兒的手(shou)術(shu)指(zhi)征為(wei):較好耳(er)的聽(ting)力(li)水(shui)(shui)平(ping)達到40dB或以上;長期分泌性(xing)(xing)中耳(er)炎(yan)(yan)并出現了耳(er)痛、不明原因(yin)(yin)的睡(shui)眠障礙和(he)合并急性(xing)(xing)中耳(er)炎(yan)(yan)反(fan)復發(fa)作(zuo);鼓膜(mo)后(hou)上方內陷(xian)囊袋;聽(ting)骨爛(lan)蝕;內陷(xian)粘連和(he)內陷(xian)囊袋內角化物的積(ji)存。
手術術式包括首選鼓(gu)(gu)膜置(zhi)管術(可使(shi)中耳(er)通氣狀態保持12~14個月);有鼻堵、慢性(xing)鼻竇(dou)炎、慢性(xing)腺樣(yang)體(ti)炎等指征時同(tong)時行腺樣(yang)體(ti)切除(chu)術,不(bu)建議4歲以下患兒行腺樣(yang)體(ti)切除(chu)術;再(zai)次手術時可行腺樣(yang)體(ti)切除(chu)術和鼓(gu)(gu)膜切開(kai)術,同(tong)時行鼓(gu)(gu)膜置(zhi)管或不(bu)置(zhi)管;不(bu)建議單獨行鼓(gu)(gu)膜切開(kai)術(使(shi)中耳(er)通氣僅僅保持幾天(tian),激(ji)光(guang)輔助鼓(gu)(gu)膜切開(kai)也只(zhi)使(shi)中耳(er)通氣保持幾周)或單獨行扁桃體(ti)切除(chu)術治療(liao)分泌性(xing)中耳(er)炎(無確切療(liao)效(xiao))。
再次手術問題:在鼓膜置管脫管的患兒中,20%~50%的患兒分泌性中耳炎復發,需要再次手術。建議再次手術時,無論腺樣體大小,都應該行腺樣體切除術(但是腭裂或黏膜下腭裂除外)。因為它使再次手術率降低50%。再次手術的療效好(對于2歲兒童的再手術療效明顯,而對于3歲兒童的再手術療效最明顯)。術式采用鼓膜切開+腺樣體切除(>4歲);鼓膜置管+腺樣體切除(<4歲)。再次手術時,鼓膜置管尤其適合于高危患兒并且必須根治分泌性中耳炎患兒和鼓膜、中耳黏膜有明顯炎癥的患者。
手術(shu)并發癥(zheng):急診手術(shu)中麻醉的死(si)亡率(lv)為1:50000或(huo)(huo)更低;小(xiao)兒(er)在(zai)麻醉中較成人更易出現喉(hou)頭和氣管的痙攣;鼓(gu)膜穿孔的發生率(lv)為2%~17%,需要修補;腺(xian)樣體(ti)切(qie)除術(shu)的出血(xue)率(lv)為0.2%~0.5%,腭帆功能(neng)障礙為2%,還有鼻咽部閉鎖或(huo)(huo)持續腭帆功能(neng)障礙(適應證選擇和手術(shu)技(ji)巧)。
應該權衡是觀(guan)(guan)察隨(sui)訪還是手術所帶來的風險(xian),并建議每3~6月或更短(duan)間(jian)期復查(cha)(cha)一次。在觀(guan)(guan)察階段不(bu)宜繼續觀(guan)(guan)察等待的患(huan)(huan)者(zhe)有:不(bu)能定期復查(cha)(cha)的患(huan)(huan)者(zhe);高危患(huan)(huan)者(zhe)或并發有其他(ta)疾病的患(huan)(huan)兒。
3.其他(ta)補充(chong)治療(liao)手段
(1)補(bu)充或替(ti)代(dai)性治療(liao) 常(chang)見的補(bu)充及替(ti)代(dai)療(liao)法包括推(tui)拿按摩、微(wei)波、限(xian)制(zhi)飲食(如限(xian)制(zhi)奶(nai)制(zhi)品)、中草藥、補(bu)品、針(zhen)灸、中藥等療(liao)法。
(2)抗(kang)過敏治(zhi)療(liao) 據報道,分泌(mi)性(xing)(xing)中(zhong)(zhong)耳炎患者(zhe)中(zhong)(zhong)存在過敏者(zhe)為10%~80%不(bu)等(deng)。長(chang)期以(yi)來一直懷疑(yi)分泌(mi)性(xing)(xing)中(zhong)(zhong)耳炎和過敏因素兩者(zhe)間存在著某種(zhong)關系,但循證(zheng)(zheng)醫學研(yan)究認為抗(kang)過敏治(zhi)療(liao)分泌(mi)性(xing)(xing)中(zhong)(zhong)耳炎的(de)(de)研(yan)究資料缺(que)乏前瞻性(xing)(xing)、對照(zhao)研(yan)究和足夠的(de)(de)證(zheng)(zheng)據。
加強(qiang)鍛煉,增強(qiang)體質,預防(fang)感冒;避免(mian)辛辣刺激性(xing)食(shi)物(wu)和(he)(he)煙酒刺激,避免(mian)接觸(chu)(chu)煙霧(wu)等不良氣(qi)體刺激呼吸(xi)道(dao),保護和(he)(he)增強(qiang)上呼吸(xi)道(dao)黏膜的(de)抵抗(kang)力(li);預防(fang)和(he)(he)治療過(guo)敏(min)性(xing)疾病(bing),避免(mian)接觸(chu)(chu)過(guo)敏(min)原,飲食(shi)上應避免(mian)引(yin)發個體過(guo)敏(min)的(de)食(shi)物(wu),如海(hai)鮮(xian)食(shi)品等;擤鼻(bi)(bi)涕(ti)時勿雙手同(tong)時捏緊前鼻(bi)(bi)孔用力(li)擤鼻(bi)(bi)涕(ti),應該按壓(ya)一側(ce)鼻(bi)(bi)孔輕(qing)輕(qing)清理鼻(bi)(bi)腔的(de)分泌物(wu);嬰(ying)幼兒喂奶時應注意(yi)不要頭(tou)部太低;鼓(gu)膜置管(guan)期間應避免(mian)耳道(dao)進(jin)水,以(yi)防(fang)引(yin)發急(ji)性(xing)化(hua)膿性(xing)中耳炎(yan)。