皮肤恶性黑色素瘤(cutaneous malignant melanoma,CMM)是皮肤外科较为常见的一种高度恶性体表肿瘤,因传统诊断路径的早期确诊率和分期准确性不高,且单一外科手术治疗预后不佳,导致患者的5年生存率较低.多学科协作模式(multidisciplinary team,MDT)理念下将现有各学科的诊疗方法优化整合,实现CMM患者的全程、连续、个体化精准诊疗,逐渐发展为外科治疗CMM的国际新趋势.本文总结近年来CMM外科治疗的新进展,探讨多学科协作诊疗理念下CMM外科治疗的优势,并对未来建立和发展MDT提出思考.

目的 探讨儿童慢性化脓性中耳炎行鼓室成形术的疗效.方法 回顾性分析51例(51耳)行鼓室成形术的慢性化脓性中耳炎儿童年龄、手术方法、鼓膜愈合率、术后听力疗效.结果 51例患儿年龄7～17岁,平均12.98±3岁,51耳的鼓膜愈合率为90.2％(46/51);将患者分为≤13岁(26例)及>13岁(25例)两组,鼓膜愈合率分别为88.46％(23/26)、92.0％(23/25),差异无统计学意义(P>0.05);完成Ⅰ型鼓室成形术者35耳(68.63％),Ⅱ型鼓室成形术者16耳(31.37％),Ⅰ型和Ⅱ型鼓室成形术者术后术耳气骨导差较术前均有显著缩小(P<0.05);听力改善总有效率为78.43％(40/51),Ⅰ型和Ⅱ型鼓室成形术者听力改善的有效率分别为80％(28/35),75％(12/16).结论 7岁以上慢性化脓性中耳炎儿童的年龄可能不是影响鼓室成形术成功率的关键因素,但手术仍需谨慎.

目的 分析主观性耳鸣患者合并头痛的特点及其影响因素.方法 回顾性分析2019年12月至2020年5月就诊于西京医院耳鼻喉科门诊的361例主观性耳鸣患者的资料,记录所有患者详细的病史和耳鸣评估,包括:性别、年龄、耳鸣起病情况、耳鸣声性质、耳鸣侧别、病程、听力下降、是否伴头痛,其它伴发疾病或症状等,同时填写耳鸣残疾量表(timnitus handicap inventory,THI)、广泛性焦虑障碍量表(generalized anxiety disorder,GAD-7)、抑郁筛查量表(patient health questionnaire,PHQ-9)及匹兹堡睡眠质量指数量表(Pittsburgh sleep scale,PSQI)等量表,所有患者均接受纯音测听及耳鸣心理声学测试;根据是否合并头痛将患者分为头痛组(140例)、无头痛组(221例),并对两组患者间各相关因素进行统计学分析.结果 361例主观性耳鸣患者中140例(38.80％,140/361)合并头痛,女性患者合并头痛的比例(61.43％,86/156)显著高于男性(38.57％,54/205)(P<0.01),其中偏头痛62例(44.29％,62/140),紧张性头痛34例(24.29％,34/140),无法分类的头痛44例(31.42％,44/140).头痛组患者T H I评分(48.85±24.68分)显著高于无头痛组(37.55±24.30分),且中度以上耳鸣患者中合并头痛的比例(48.42％)显著高于轻度耳鸣患者(28.07％),头痛组听觉过敏、耳闷、头晕/眩晕、焦虑、抑郁及睡眠障碍发生率高于无头痛组(P<0.05).结论 主观性耳鸣患者常合并头痛,其中以偏头痛和紧张性头痛较为常见,合并头痛的患者耳鸣严重程度更高,更易合并听觉过敏、头晕/眩晕、焦虑、抑郁及睡眠障碍等.

目的 探讨慢性耳鸣患者中焦虑和抑郁的伴发情况及其影响因素.方法 以2018年1月到2019年11月就诊于空军军医大学第一附属医院耳鼻喉科门诊并诊断为慢性耳鸣的278例患者为研究对象,所有患者均进行详细的病史询问和评估,接受纯音测听、耳鸣心理声学检测,填写耳鸣病史调查表、耳鸣残疾量表(tinnitus handi-cap inventory,T HI)、焦虑自评量表(self-rating anxiety scale,SAS)、抑郁自评量表(self-rating depression scale,SDS)、匹兹堡睡眠质量指数量表(Pittsburgh sleep scale,PSQI)和D型人格量表(type D personality scale-14,DS-14),分析慢性耳鸣患者中焦虑和抑郁的发生情况及可能的影响因素.结果 278例慢性耳鸣患者,平均SAS评分为43.66±8.71分,平均SDS评分为45.38±9.96分,均高于正常常模得分(30分);其中合并焦虑73例(26.26％),合并抑郁91例(32.73％),同时合并焦虑及抑郁51例(18.35％).Logistic回归分结果显示,性别(男性OR=0.29)、THI评分(OR=1.03)、PSQI评分(OR=1.31)及D型人格(OR=5.34)与焦虑相关,而THI评分(OR=1.03)、PSQI评分(OR=1.32)及D型人格(OR=4.75)与抑郁相关.结论 焦虑和抑郁是慢性耳鸣患者常见的合并心理障碍,而耳鸣的严重程度、睡眠障碍及D型人格是其危险因素,其中以D型人格最为突出,在慢性耳鸣合并焦虑或抑郁患者的诊治过程中应予以关注.

目的 分析后天原发性紧张部内陷袋性胆脂瘤的分期、临床特点以及手术疗效.方法 回顾性分析33例(33耳)经手术证实为紧张部内陷袋性胆脂瘤患者的临床资料,对患者术前鼓膜形态、胆脂瘤分期(2017 EAO-NO/JOS版)、病变侵及范围、听骨链受累情况、手术方式和听骨链重建方法以及术后并发症进行分析,比较手术前后患者的平均气导听阈、骨导听阈及气骨导差.结果 33例患者中,17例表现为鼓膜紧张部后上方内陷袋形成,10例为鼓膜紧张部后上方内陷伴穿孔,6例为整个鼓膜紧张部内陷伴或不伴穿孔.胆脂瘤分期为工期4例,Ⅱ期29例;病变累及鼓室腔33例,鼓室窦26例,上鼓室11例,鼓窦乳突区6例,砧骨受累29例,镫骨受累16例.16例行鼓室成形术,15例行上鼓室切开重建+鼓室成形术,2例行开放式乳突切开+鼓室成形术;行听骨链重建者32例,其中选择部分听骨赝复体(partial ossicular replacement prosthesis,PORP)7例,全听骨赝复体(total ossicular replacement prothesis,TORP)5例,自体砧骨搭桥3例,软骨加高镫骨10例,皮质骨小柱7例.患者术后平均随访12.7个月,术后鼓膜紧张部穿孔2例,胆脂瘤残留或复发1例.术后气导听阈(43.2±14.0 dB HL)较术前(50.1±11.4 dB HL)显著降低(P＜0.05),术后气骨导差(25.8±11.3 dB)较术前(33.1±9.3 dB)显著缩小(P＜0.05),而手术前后骨导听阈差异无统计学意义(P＞0.05).结论 紧张部内陷袋性胆脂瘤多源于紧张部后上方内陷袋,易侵犯砧骨和镫骨,听力下降出现早且较重;多数病变未超出中鼓室和上鼓室,可以经耳道完成胆脂瘤切除,选择合适的听骨链重建方法可提高患者听力.

To analysis the data of the patients with parotid tumors, clarify the contributing factors of Frey syndrome, and to evaluate the role of soft tissues membrane SIS in prevention of Frey syndrome after parotidectomy. The data of 95 patients who suffered from parotid tumors and underwent parotidectomy were included in this study. The relationship between the patients' age, sex, tumor location ,tumor size, disease pathology, type of resection, SIS application and the incidence of Frey syndrome were statistically analyzed . The incidence of Frey syndrome after parotidectomy for 95 patients was 25.3%. Age, sex, tumor location and size, disease pathology, type of resection did not appear to be associated with development of Frey syndrome（>0.05）. SIS application was the only statistically significant factor（<0.01）, and SIS could prevent Frey syndrome after parotidectomy. Frey syndrome is one of the common complicationsafter parotidectomy. Implantation of SIS is an effective method for prevention of Frey syndrome after parotidectomy.

目的 探讨慢性化脓性中耳炎患者耳鸣的发生率、特点及可能的影响因素.方法 以2016年3月～2017年9月在空军军医大学西京医院耳鼻咽喉头颈外科住院并接受手术治疗的慢性化脓性中耳炎或中耳胆脂瘤患者393例为研究对象,根据患者是否有耳鸣将患者分为耳鸣组和非耳鸣组,伴耳鸣患者均填写耳鸣病史调查表、耳鸣残疾量表(tinnitus handicap index,THI)和耳鸣严重程度评估量表(index of tinnitus serious,ITS),分析不同性别、年龄、病程、病变侧别、病变类型、手术次数、术前气骨导听阈、气骨导差、术中所见鼓室内病变及咽鼓管鼓口病变等因素与耳鸣发生的关系;采用Logistic回归分析可能导致耳鸣的危险因素.结果 在393例患者中有149例(37.91％)患者伴发耳鸣,其中135例患者完成THI和ITS量表,结果显示耳鸣严重程度多较轻,以Ⅰ、Ⅱ级为主(THI分级Ⅰ、Ⅱ级占69.63％,ITS分级Ⅰ、Ⅱ级占70.37％),极重度患者少(THI分级Ⅴ级占1.48％,ITS分级Ⅴ级占2.22％).耳鸣平均音调匹配为1224±373.6 Hz,响度为2.57±0.43 dB HL(0～10 dB HL).咽鼓管鼓口病变患者耳鸣的发生率显著高于鼓口正常的患者(χ2=25.321,P<0.001);Logistic回归分析显示咽鼓管鼓口病变是慢性中耳炎患者发生耳鸣的危险因素(P<0.001,OR=3.339).结论 慢性中耳炎患者伴发耳鸣的程度多较轻,咽鼓管鼓口病变是慢性化脓性中耳炎患者发生耳鸣的可能危险因素.

Objective: To discuss the therapeutic scheme of petrous bone cholesteatoma(PBC) and the technique of facial nerve reconstruction. Method: The data of 28 patients who underwent surgery for PBC in our center were analyzed retrospectively. All patients were diagnosed radiologically with PBCs and reconfirmed pathologically after surgery. The surgical approach was discussed basing Sanna's classification of PBCs, and the facial nerve outcomes were analyzed moreover. Result: PBC cases 11 were supralabyrinthine, 4 infralabyrinthine, 3 infralabyrinthine-apical, 10 massive and none apical. The facial nerve was involved in 50% of the cases. The translabyrinthine approach were used in 3 cases. The transotic approach was used in 7 cases in this series.The transcochlear approach type was applied in 12 cases. The Infratemporal fossa type B approach and subtotal petrosectomy were employed in 2 cases and 4 cases respectively. Active management of the nerve(rerouting, anastomosis, or grafting) was required in 14 cases, postoperative facial nerve function were inproved in 10 cases(71.43%). Conclusion: The appropriate surgery approach was vitally important to radical disease clearance in PBCs. The facial nerve preservation was preceded hearing preservation. Active facial nerve management were beneficial to facial nerve recovery..

Objective:To compare the efficacy and safety between Bondy modified radical mastoidectomy (BMRM) and atticotomy for stage Ⅰ epitympanic cholesteatoma. Method:A retrospective analysis of 36 cases with stage Ⅰ epitympanic cholesteatoma was performed. According to different surgery methods, the cases were divided into the atticotomy group (21 cases) and the BMRM group (15 cases). Hearing function, the dry ear ratio after two months of the surgery, and the epithelial time were observed. The complications for the retraction of tympanic membrane, residual or recurrence of cholesteatoma, and otorrhea were analyzed. Result:There was no significant difference between the two groups in average air-bone gaps (ABG) and ABG gain before and after surgery (P>0.05). The preoperative hearing was preserved both in the atticotomy group and the BMRM group. However, more surgery time, lower ratio of the dry ear after two months of the surgery, and longer epithelial time were observed in the BMRM group than those in the atticotomy group(P<0.05). No cholesteatoma residual or recurrence was observed in both groups. Conclusion:For stage Ⅰ epitympanic cholesteatoma lateral to an intact ossicular chain, atticotomy has the advantage of complete removal of the cholesteatoma matrix, avoiding big mastoidal cavity, keeping normal anatomical structure of external auditory canal, better hearing preservation, and faster healing. Therefore, atticotomy has better clinical and practical value.

目的 观察采用耳甲软骨行Ⅱ型鼓室成形术后听力改善的情况,并分析可能的影响因素.方法 回顾分析自2008年9月至2016年7月在空军军医大学第一附属医院耳鼻咽喉头颈外科行耳甲软骨Ⅱ型鼓室成形(鼓膜-软骨-镫骨连接)的患者,包括:单纯鼓室成形术,上鼓室切开+鼓室成形,开放式乳突切开+鼓室成形术患者共52例.所有患者于术前及术后2月,6月,1年及2年进行纯音测听,分别计算术前术后的气导听阈(AC),骨导听阈(BC)及气骨导差(ABG),分析术前术后听力的变化,并根据术后ABG将患者分成ABG>20dB,ABG≤20dB两组,比较两组患者年龄,性别,病程,术前听力,鼓室内粘膜情况及咽鼓管鼓口情况与术后听力改善的关系.结果 52例患者中行单纯鼓室成形13例,上鼓室切开+鼓室成形12例,开放式乳突切开+鼓室成形27例.术后随访期内1例患者术后2月出现外耳道深部闭锁,再次手术后恢复.1例患者术后5月出现外耳道霉菌感染,予局部处理后恢复,余患者恢复好,未见穿孔及胆脂瘤复发.术后患者的气导听阈较术前显著降低(t=4.006,P<0.05),气骨导差较术前明显缩小(t=3.926,P<0.05),而术前术后患者的骨导听力无显著统计学差异(t=0.47,P>0.05);咽鼓管鼓口病变在ABG>20dB,ABG≤20dB两组之间有显著差异(χ2=5.04,P<0.05).结论 本研究初步研究了耳甲软骨Ⅱ型鼓室成形术后的听力效果及可能的影响因素,结果显示患者术后听力改善明显,而咽鼓管鼓口病变与听力改善有显著相关性.因此术中评估咽鼓管鼓口的状态并做相应处理,有利于预测和改善术后听力.

临床教学是高等医学院校教育教学工作的重要环节,临床教学查房又是临床教学的重要组成部分.将整合医学理念贯穿于耳鼻喉科临床教学查房,有利于医学生全面、系统的理解和掌握耳鼻喉科相关疾病,做到医学知识的融会贯通,对医学生临床思维的培养具有重要意义,可有效提高耳鼻喉科的临床教学质量.

This article reviews the history and current status of endoscopic ear surgery,and describes in detail as-sociated technical difficulties. Based on otological techniques used and equipment requirements, various approaches to categorize endoscopic ear surgery are proposed, including categorization based on utilization of otoendoscopic devices as a tool or based on the location, approach and technical requirement of the surgery. Finally, two evaluation indexes of minimally invasive capability for endoscopic ear surgery are proposed. The objective of this article is to, through illus-trating classification of endoscopic ear surgery, provide assistance or guidance to institutions or individuals involved in utilization of the endoscopic technique.

Objective To analyze the rehabilitation outcomes of auditory and speech ability for older pre-lingual hearing-impaired patients at one year after Nurotron cochlear implantation.Methods 18 pre-lingual hearing-impaired patients who underwent Nurotron cochlear implantation participated in this study. Auditory and speech abilities were evaluated by the Auditory Ability Assessment Criteria and Methods, the Categories of Auditory Performance(CAP), the Meaningful Auditory Integration Scale(MAIS), the Speech Intelligibility Rating(SIR) and the Meaningful Use of Speech Scale (MUSS) at pre-operation, 2 months, 6 months and 12 months after operation. The results were statistically analyzed.Results There were no significant differences in Vowels, consonants,short sentence recognition rate,listen and find the associated picture , thematic dialogue and the Speech Intelligibility Rating(SIR) between pre- cochlear implantation and after cochlear implantation at all time points.there was a significant difference in two-syllable recognition between 12 months after operation and pre-operation and 6 months after operation (P<0.05).The CAP questionnaire showed there were significant differences between preoperative and each postoperative time point (P<0.05). MAIS scores showed there were significant differences(P<0.05) between preoperative and each postoperative time point, and MUSS scores showed significant differences(P<0.05)except for 2 months after operation and got the highest score in 6 months after operation.Conclusion The auditory ability of the pre-lingual hearing-impaired patients was improved to different degrees after one year of rehabilitation, especially in the basic sound perception and recognition. Although their speech abilities did not improve substantially, their awareness and skills of language application were still better.

Retroperitoneal fibrosis (RPF), is a rare fibro-inflammatory disease that develops around the abdominal aorta and the iliac arteries, and extends into the adjacent retroperitoneum, where it causes ureteral obstruction and renal failure frequently.Most RPF occurs in the middle aged, and the male/female ratio is 3∶1~2∶1.Diagnosis depends on the abdomen ultrasound, CT and MRI, while, retroperitoneal mass biopsy can identify clear pathological types.In clinical practice, the aims of treatment are to relieve urinary obstruction and promote disease reversal.Glucocorticoids are recommended for first-line treatment.In this paper, we reported a case of retroperitoneal fibrosis in a 83-year-old male.

目的:探讨巴曲酶与血管扩张剂治疗突发性耳聋的临床疗效及安全性.方法:将96例突发性耳聋患者随机分为观察组与对照组,观察组48例给予巴曲酶治疗,对照组48例给予血管扩张剂治疗,对比两组患者治疗临床疗效,治疗前后血浆纤维蛋白原(Fg)、凝血酶时间(TT)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)等,并观察两组患者不良反应发生情况.结果:与对照组相比,观察组总有效率明显升高(P<0.05);与治疗前比较,治疗后观察组与对照组患者的FG水平明显降低,TT、PT及APTT明显延长,且观察组较对照组各指标变化更显著(P<0.05);与对照组比较,观察组患者眩晕、耳鸣及听力缓解时间均明显缩短(P<0.05).结论:巴曲酶较血管扩张剂治疗突发性耳聋疗效更显著,且能改善患者凝血功能状态.

Objective To evaluate the effects of modified overlay tympanoplasty treating in chronic suppurative otitis media (CSOM) patients with difficult exposure of the perforation.Methods This study was a retropective review of 45 patients who underwent modified overlay tympanoplasty.The changes in the airbone gap (ABG) at the end of follow-up were compared with preoperative hearing ABG.The effects and the postoperative complications were also documented.Results The preoperative mean ABG was 29.78±10.06 dB HL and the postoperative was 22.94±11.75 dB HL,There were significant differences between the two(P＜0.05).The postoperative complications included graft lateralization (3/45,6.7％),tympanic membrane reperforation (1/45,2.2％) and external auditory canal stenosis (1/45,2.2％).Conclusions Modified overlay tympanoplasty is an effective technique for the difficult exposure of the perforation.The main complication in our cases is graft lateralization.

Objective:To analyze the clinical effect of 54 cases with chronic otitis media prepared for staging tympanoplasty and 19 cases finished staging ossicular reconstruction surgery, evaluate the advantages of different surgery technique.Method:Fifty-four cases with chronic otitis media were planned for staging tympanoplasty surgery and had been received the first stage surgery. Silicagel plates were placed in the tympanic cavity in order to prevent adhesions. Among them, 19 cases had received the second stage ossicular reconstruction, including 10 cases with TORPs and 9 cases with PORPs. The average air bone gaps (ABG) were measured at four frequencies: 500, 1 000, 2 000 and 4 000 Hz.Result:Among the 54 cases, 45 cases had swollen mucosa in the tympanic cavity and eustachian tube, 18 cases had tympanic fibrous adhesions, and 12 cases had fixed or sclerotic stapes. The preoperative ABG of the 54 cases were (38.26±7.88)dB. As for the 19 cases finished the second stage surgery, their preoperative ABG in the first stage were (39.21±7.05)dB, the preoperative ABG in the second stage were (38.82±11.43)dB, and the postoperative ABG after the second stage were (21.77±11.92)dB. The hearing function after staging tympanoplasty was significantly improved compared with the preoperative hearing in the first and the second stage operation (P< 0.01). In addition, the second stage surgery of three cases was postponed because of a good postoperative hearing with (10.42±10.63)dB ABG after the first stage surgery. Up to now, none of the 54 cases suffered from facial palsy, infection and other complications after surgery.Conclusion:Staging tympanoplasty is an important technique to improving hearing and reducing the complications, especially for the cases with chronic otitis media unsuitable for one stage reconstruction of ossicular chain.

目的 评估语前聋人工耳蜗植入患者的听觉言语康复效果,分析康复效果的相关影响因素.方法 采用听觉行为分级标准(categories of auditory performance,CAP)和言语可懂度分级标准(speech intelligibility rating,SIR),对50例语前聋人工耳蜗植入患者术后1年的听觉能力和言语能力进行分级评估;分析CAP和SIR结果与植入年龄、性别、侧别、术前助听时间、术后配戴方式、耳蜗是否畸形、康复模式、性格、康复时间等9个因素的关系.结果 植入年龄、术前助听时间、康复模式、性格、耳蜗畸形、康复时间对CAP有显著影响;植入年龄、术前助听时间、康复模式、康复时间、性格对SIR有显著影响;性别、术后配戴方式、侧别对CAP和SIR均无显著影响.结论 术前及早进行听力补偿及康复训练,有利于术后听觉言语能力的提高;家庭参与及教养方式对患儿康复效果有很大影响.

全科医学专业旨在培养具有全科医学知识及技能的综合型医学卫生专门人才.我国全科医学教育起步较晚,临床教学方法值得探索.老年病以慢病、多系统疾病为主,是全科医学生教育的重要环节.发挥问题对学习过程的指导作用是PBL教学法的精髓,从而调动学生学习的积极性和主动性,整体提升学生的综合素质和能力,适用于全科医学生的老年病科教学.在老年病科的临床见习过程中,带教老师将“认识问题、提出问题、分析问题和解决问题”四个步骤贯穿于整个教学,以任务为主线、以学员为主体进行引导,取得了很好的教学效果.通过应用PBL教学法,有效提升了学员自学能力、创新能力、沟通协作能力,以及学习、思考的积极性,培养了学员的分析问题、解决问题的技能,并养成其综合性整体的临床思维方式,值得全科医学生临床教学推广应用.

Objective To investigate the types and incidences of the connexin 26 gene(GJB2) mutations among patients with non-syndromic hearing loss in Shaanxi province.Methods Genomic DNAs of 800 patients with non-syndromic hearing loss and 104 normal-hearing controls were obtained from peripheral blood. The whole coding region of GJB2 gene was amplified by polymerase chain reaction (PCR) and sequenced. The GJB2 gene sequences of the patients were compared with NCBI’s reference sequences.Results Twenty-nine GJB2 gene mutations were identified, including 5 polymorphic changes, 19 pathologic mutations and 5 novel ones. The frequencies of 235delC and 299_300delAT mutations were significantly higher in patient group than those in normal control group. One hundred and fifty-three patients were homozygotes or compound heterozygotes.Conclusion It is concluded that 235 delC, 299_300delAT and 176-191del16 are the three most common GJB2 mutations among patients with non-syndromic hearing loss in Shaanxi province.