前言 5 1/4 5% 耳鳴之分類與造成原因 ( ) ( 國軍松山總醫院家庭醫學科總住院醫師 : tinnitus ) ( ) ( ) ( ) ( ) ( ) 1 2 耳鳴之臨床表現與評估方法 / / 90% 166 家庭醫學與基層醫療 第五期
表 1 造成耳鳴之原因感音神經性聽力損失 (sensorineural hearing loss): 老年性聽力障礙 (presbycusis) 遲發性先天性聽力損失 (late-onset congenital hearing loss) 噪音引起之聽力損失 (noise-induced hearing loss) 突發性耳聾 (sudden hearing loss, sudden deafness) 耳毒性 (ototoxicity) 自發性 (idiopathic) 血管功能不足 (vascular insufficiency): 小血管病變 (small vessel disease) 高凝血狀態 (hypercoagulable states) 高膽固醇血症 (hypercholesterolemia) 糖尿病血管病變 (diabetic vasculopathy) 高血壓 (hypertension) 鐮刀型血球貧血 (sickle cell anemia) 其他貧血 (other anemia) 骨頭疾病 (bone disease): 骨纖維發育不良 (fibrous dysplasia) 柏哲德氏症 (Paget s disease) 成骨不全症 (osteogenesis imperfecta) 耳硬化症 (otosclerosis) 中樞神經系統異常 (central nervous system anomalies): 類肉瘤病 (sarcoidosis) 假性腦瘤 (pseudotumor cerebri) 血管畸形 (vascular malformations) 腫瘤 (tumor), 如聽神經瘤 (acoustic neuroma) 鼻咽癌(nasopharyngeal carcinoma) 中風 (stroke) 多發性硬化症 (multiple sclerosis) 感染 (infections): 德國麻疹 (rubella) 第三期神經梅毒 (neurosyphilis) 萊姆病 (lyme disease) 腦膜炎 (meningitis) 慢性中耳炎 (chronic otitis media) 麻疹 (measles) 巨細胞病毒感染 (cytomegalovirus infection) 代謝性疾病 (metabolic disorders): 家庭醫學與基層醫療 第五期 167
表 1 續上頁 甲狀腺疾病 (thyroid disease) 糖尿病 (diabetes mellitus) 慢性腎功能衰竭 (chronic renal failure) 副甲狀腺機能亢進症 (hyperparathyroidism) 自身免疫性疾病 (autoimmune disease): 自體免疫內耳疾病 (autoimmune inner ear disease) 類風濕關節炎 (rheumatoid arthritis) 全身性紅斑狼瘡 (systemic lupus erythematosus) 耳蝸損傷 (cochlear injury): 藥物引起 : 如水楊酸 (salicylates) 抗生素(antibiotics) 利尿劑(loop diuretics) 鉑類為基礎的化療( 如 cisplatin) 梅尼爾氏症 (Meniere's syndrome) 外傷 (trauma) 藥物 (drugs): 請見表 2 資料來源 : 參考資料 1 表 2 可能引起耳鳴加劇的耳毒性藥物 藥物種類抗生素降血壓抗瘧疾安眠鎮靜止瀉抗癲癇化療止痛肌肉鬆弛劑射護腺肥大抗憂鬱藥 A 酸麻醉藥氫離子阻斷劑抗心律不整降血糖 藥物 aminoglycoside ( 如 gentamycin), clarithromycin, fluoroquinolone angiotensin converting enzyme inhibitors (ACEI), calcium channel blockers (CCB), loop diuretics, nitroprusside chloroquine, hydroxychloroquine benzodiazepines (BZD), chlordiazepoxide bismuth carbamazepine ( Tegretol), valproic acid ( Depakine) cisplatin salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), cox-2 inhibitors cyclobenzaprine doxazosin, prazosin tricyclic anti-depressants (TCA), sertraline (SSRI) isotretinoin lidocaine proton pump inhibitors (PPI) quinidine (class Ia anti-arrhythemic) tolbutamide ( 第一代 sulfonylurea) 資料來源 : 參考資料 1 168 家庭醫學與基層醫療 第五期
(Tinnitus Handicap Inventory) ( T i n n i t u s R e a c t i o n Questionnaire) ( ) 耳鳴之診斷 ( / / / ) ( ) (sensorineural hearing loss) (cochlear injury) ( M e n i e r e ' s d i s e a s e ) (idiopathic) ( ) X-ray MRI CT 危險性耳鳴之特徵與造成疾病簡介 1. 2. ( 2 ) 3. 4. (acoustic neuroma) (vestibular schwannoma) 50 90% 1. ( 95%) ( 61%) 2. ( 家庭醫學與基層醫療 第五期 169
17%) 3. ( 6%) (brainstem-evoked response audiometry, ABR) (brain MRI) (nasopharyngeal carcinoma, NPC) ( ) (sudden hearing loss, sudden deafness) 3 3 >30 5-20/100,000 40-60 ( ) 耳鳴之治療 ( ) ( c o g n i t i v e behavioral therapy) ( 2 ) ( xanax) ( meclizine) ( piracetam, pentoxifylline, ) ( B E) lidocaine ( dexamethasone) 170 家庭醫學與基層醫療 第五期
(biofeedback therapy) (tinnitus retraining t h e r a p y) 8 1-2 ( ) 1-2 結論 參考資料 1. Dinces EA, Deschler DG, Sokol HN: Etiology and diagnosis of tinnitus. UpToDate 2011. http:// 家庭醫學與基層醫療 第五期 171
www.uptodate.com/contents/etiology-anddiagnosis-of-tinnitus. 2. Dinces EA, Deschler DG, Sokol HN: Treatment of tinnitus. UpToDate 2011. http://www.uptodate. com/contents/treatment-of-tinnitus. 3. Wilson PH, Henry J, Bowen M, Haralambous G: Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. J Speech Hear Res 1991; 34:197. 4. Folmer RL, Griest SE, Meikle MB, Martin WH: Tinnitus severity, loudness, and depression. Otolaryngol Head Neck Surg 1999; 121:48. 5. Andersson G, Melin L, Hagnebo C, Scott B, Lindberg P: A review of psychological treatment approaches for patients suffering from tinnitus. Ann Behav Med 1995; 17:357. 6. Andersson G, Lyttkens L: A meta-analytic review of psychological treatments for tinnitus. Br J Audiol 1999; 33:201. 7. Phillips JS, McFerran D: Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev 2010; CD007330. 8. Vernon JA, Meikle MB: Masking devices and alprazolam treatment for tinnitus. Otolaryngol Clin North Am 2003; 36:307. 9. Hobson J, Chisholm E, El Refaie A: Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev 2010; 12:CD006371. 172 家庭醫學與基層醫療 第五期