耳鸣中医辨证客观化的应用基础研究
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摘要
耳鸣指并无外界声刺激或电刺激时人体产生耳内或脑内的声音感觉,常伴随听力减退、失眠、烦躁、焦虑、忧郁等症状,对患者的生活质量造成重大影响。迄今为止,对耳鸣的发生机制依然未能得到满意的解释,因而临床上对于耳鸣患者虽有多种处理办法,但依然缺乏公认有确切疗效的治疗手段。耳鸣已经成为长期困扰着医生和患者的一种顽症,成为耳科三大难题(耳鸣、耳聋、眩晕)之首。
在治疗耳鸣的各种方法中,中医疗法具有一定的优势,但迄今为止,中医治疗耳鸣的疗效由于重复性差等原因尚未得到普遍公认。中医的精华在于辨证论治,辨证是论治的前提,辨证的准确与否对于疗效具有决定性的影响,因此,研究耳鸣的中医疗法,首先必须从辨证的研究入手。
鉴于临床上常常存在耳鸣“有症难辨”的难题,本研究选择使耳鸣的辨证客观化作为切入点。由于耳鸣的患者大多伴有不同程度的听力下降,对耳鸣病人进行各种听力学检测已成为临床的常规工作,纯音测听、阈上功能测试、声导抗测试、听性脑干反应等可为我们提供大量有用的信息,目前进行这类检查主要目的在于测试听敏度及鉴别中耳、耳蜗与蜗后病变,除此以外,其中是否还包含与中医辨证分型有关的信息呢?为此,本研究分两个阶段进行:
[第一阶段研究]
选择以主观性耳鸣为主要症状,根据中医辨证标准符合风热侵袭、肝火上扰、痰火郁结、脾胃虚弱、肾精亏损等五个证型中任何一型,年龄在14岁以上的患者为研究对象,排除传导性病变导致的耳鸣,或中医证候不典型(包括证候兼夹)以及各种原因不能配合完成系统的听力学检查者(包括听力损失>90dB者)。
对所有入选对象分别进行耳鸣程度分级、纯音测听、声导抗测试及电反应测听等多达52项指标的同步测试,将所有测试数据输入电脑,用SPSS11.0统计软件进行数据分析。
符合入选标准的病例共120例(165耳),其中男性73例,女性47例,年龄16～
Tinnitus is a sensation of sound in the ear or the head without an external stimulus of sound or electricity, which usually accompanied by some symptoms such as hearing loss , insomnia, dysphoria, anxious, melancholy,etc, and the life quality can be strongly affected. Up till now, we still do not know clearly the mechanism of tinnitus.Although there are many means to treat the cases of tinnitus,but there is no definite therapy that can cure it. Tinnitus has become a stubborn illness that puzzles physician and sufferer over a long period of time, and become the first of three difficult problems (tinnitus,deafness, dizziness) in otology.The treatment of TCM has some superiority in all different means to treat tinnitus, but the curative effect is still not universally acknowledged as the poor repeatability. The essence of TCM is Determination of Treatment Based on the Syndrome Differentiation, the Syndrome Differentiation is the base of the treatment. So in order to study the TCM therapy of tinnitus, we must study the Syndrome Differentiation first.That Syndrome of tinnitus hard to differentiate is usually a difficult problem in the clinic, so we selected the Objective Syndrome Differentiation of tinnitus as a study point. The tinnitus sufferer usually accompanied by different degree of hearing loss, and the audiometry for the tinnitus sufferer has become a clinical rule work. Audiometry, such as pure tone, superthreshold, acoustic immittance and auditory brainstem response (ABR),etc, can supply great number of useful messages for us. The main purpose of these kinds of examination is to test auditory acuity and discriminates pathological changes in the middle
ear, cochlea and behind cochlea. Except for this, dose it still embody the messages to differentiate the syndrome of tinnitus? For this reason, The whole research includes two stages:[First Stage Research]The cases in research have the symptom of tinnitus and accord with one of the five types according to the standard of Syndrome Differentiation, such as the Invasion of Wind-heat, the Liver-fire Up-stirring, the Stagnation of phlegm-fire, the Weakness of Spleen-stomach, and the Kidney-essence Deficiency. The cases of tinnitus due to conductive hearing loss were excluded, so as to the cases of age below 14 years old, the cases of TCM Syndrome not clear, the cases of hearing loss more than 90dBHL.All the cases in research were classified by the tinnitus degree, and 52 indexes of audiometry of pure tone test, acoustic immittance and electric response audiometry (ERA) were synchronized. AH test datas were inputed to the computer and analyzed by SPSS statistics software (11.0 type ).There were 120 cases (165 ears) in research, and the male were 73, the female was 47. The ages were from 16 to 77 years old, the mean age was 40.5 years old. The courses of disease were from 1 day to 20 years, the mean course of disease was 1.51 years. There were 16 cases(17 ears) of the Invasion of Wind-heat, 27 cases(40 ears) of the the Liver-fire Up-stirring, 25 cases(37 ears) of the Stagnation of phlegm-fire, 27 cases (36 ears) of the Weakness of Spleen-stomach, and 25 cases(35 ear) of the kidney-essence deficiency. The statistics analysis indicated that the group of Invasion of Wind-heat wind-heat has the briefest course of disease (the means was 8.7days),compared with the other groups, the difference was significant(P< 0.01), and the age of group of the Kidney-essence Deficiency was the oldest (P< 0.05). The sex was no significant difference in all groups( P>0.05).The single factor analysis result indicated that in 52 items of audiometry of pure tone test, acoustic immittance and ERA, there were 22 items of audiometry which had significant difference in the five groups(P<0.05). After utilized the multivariate stepwise discriminant analysis, we screened out 17 distinctive items, such as the degree of tinnitus, frequency of tinnitus, the type of audiogram(even,steep drop,marked drop), the SISI score
of 4kHz, the TD grade of 4kHz, ipsilateral acoustic reflex threshold (0.5kHz> 1kHz, 2kHz> 4kHz), contralateral Metz (0.5kHz% lkHz> 4kHz), the click hearing threshold, the time of ABR I -III wave, 0.5kHz respons threshold of 40Hz auditory event related potential (40Hz AERP), and so on. We found that the different items had different distinguish value for different Syndrome. Based on these, the multivariate stepwise discriminant analysis was used to set up multivariate discriminant functions of the five Syndromes. Further study verified that the discriminating accurate rate in the goup of the Invasion of Wind-heat was the highest (reach 91.8%, in the other hand, the discriminating accurate rate in other two groups of the Liver-fire Up-stirring and the Stagnation of phlegm-fire were relatively lower (76.3% and 77.4%), the discriminating mean accurate rate in five groups attained 83.5%.[Second Stage Research!The research result of the first stage was verified on the foreseeability from two different angles. The cases of tinnitus were divided into two groups according to whether accompanied by typical Syndrome of TCM.The first group included the cases of tinnitus accompanied by typical Syndrome of TCM. After a series audiometry Objective Syndrome Differentiation was carried on according to the multivariate discriminant functions resulted in the first stage, which compared with traditional Syndrome Differentiation. It included 52 cases, 33 male and 19 female, the age from 20 to 73 years old, the mean age was 41.2 years old. There were 10 of the Invasion of Wind-heat, 6 of the the Liver-fire Up-stirring, 7 of the Stagnation of phlegm-fire, 13 of he Weakness of Spleen-stomach and 16 of the kidney-essence deficiency. The foreseeability was verified that the discriminating mean accurate rate in the five discriminant functions attained 79.6%, which was close to the test itself. The discriminant function of the Invasion of Wind-heat had the higher sensitivity, specificity and accuracy, which approached the test itself and indicated the higher repeatability. The discriminant function of the the Liver-fire Up-stirring had the lower sensitivity than the test itself, but the specificity and the accuracy approached the test itself, which indicated the relatively higher repeatability. The discriminant function of the Stagnation of phlegm-fire had lower sensitivity and higher specificity than the test itself, but the accuracy approached the test
itself, which indicates a higher rate of missed diagnosis and the lower rate of wrong diagnosis if you used the function to distinguish the cases of tinnitus with the Stagnation of phlegm-foe. The discriminant function of the Weakness of Spleen-stomach had the similar tendency to the Stagnation of phlegm-fire. The discriminant function of the kidney-essence deficiency had the highest specificity and the lowest sensitivity in the five discriminant functions, the accuracy rate attained 73.1%, thus if you used the function to distinguish the tinnitus with the kidney-essence deficiency, there were a large number of missed cases, and if you had distinguished the cases of the kidney-essence deficiency, it is almost true.The second group were the cases of tinnitus who had not typical Syndrom of TCM so as hard to Differentiated according to traditional method. The cases were divided at random into two groups: experimental group and control group. The cases of experimental group were treated in Chinese medicine based on the objective Syndrom Differentiation according to the discriminant functions after a series audiometry. The cases of control group were treated in Chinese medicine based on the kidney-essence deficiency according to the theory that the kidney of TCM is related to the ear and the clinical custom. The curative effect was evaluated after taking a month of medicine.There were 51 cases which include 30 cases of experimental group and 21 cases of control group. The experimental group had 17 male and 13 femal, and the age from 18 to 78 years old, the mean age 40.13 years old, the course of disease between 0.5 months and 12 years, the mean course of disease was 23.69 months. According to the objective Syndrom Differentiation, there were 1 case of the Invasion of Wind-heat, 9 cases of the Liver-fire Up-stirring, 5 cases of the phlegm-fire syndrome, 7 cases of the Weakness of Spleen-stomach, and 8 cases of the kidney-essence deficiency. The control group included 12 male and 9 femal, the age from 20 to 71 years old, the mean age 42.38 years old, the course of disease between 0.7 months and 10 years, the mean course of disease 36.41 months. The sex, age, course and degree of tinnitus in two groups have no significant difference (P>0.05).The result indicated that the score of tinnitus degree in two groups droped after treatment, paired-samples T test showed the significant difference (P<0.01), which
在治疗耳鸣的各种方法中,中医疗法具有一定的优势,但迄今为止,中医治疗耳鸣的疗效由于重复性差等原因尚未得到普遍公认。中医的精华在于辨证论治,辨证是论治的前提,辨证的准确与否对于疗效具有决定性的影响,因此,研究耳鸣的中医疗法,首先必须从辨证的研究入手。
鉴于临床上常常存在耳鸣“有症难辨”的难题,本研究选择使耳鸣的辨证客观化作为切入点。由于耳鸣的患者大多伴有不同程度的听力下降,对耳鸣病人进行各种听力学检测已成为临床的常规工作,纯音测听、阈上功能测试、声导抗测试、听性脑干反应等可为我们提供大量有用的信息,目前进行这类检查主要目的在于测试听敏度及鉴别中耳、耳蜗与蜗后病变,除此以外,其中是否还包含与中医辨证分型有关的信息呢?为此,本研究分两个阶段进行:
[第一阶段研究]
选择以主观性耳鸣为主要症状,根据中医辨证标准符合风热侵袭、肝火上扰、痰火郁结、脾胃虚弱、肾精亏损等五个证型中任何一型,年龄在14岁以上的患者为研究对象,排除传导性病变导致的耳鸣,或中医证候不典型(包括证候兼夹)以及各种原因不能配合完成系统的听力学检查者(包括听力损失>90dB者)。
对所有入选对象分别进行耳鸣程度分级、纯音测听、声导抗测试及电反应测听等多达52项指标的同步测试,将所有测试数据输入电脑,用SPSS11.0统计软件进行数据分析。
符合入选标准的病例共120例(165耳),其中男性73例,女性47例,年龄16～
Tinnitus is a sensation of sound in the ear or the head without an external stimulus of sound or electricity, which usually accompanied by some symptoms such as hearing loss , insomnia, dysphoria, anxious, melancholy,etc, and the life quality can be strongly affected. Up till now, we still do not know clearly the mechanism of tinnitus.Although there are many means to treat the cases of tinnitus,but there is no definite therapy that can cure it. Tinnitus has become a stubborn illness that puzzles physician and sufferer over a long period of time, and become the first of three difficult problems (tinnitus,deafness, dizziness) in otology.The treatment of TCM has some superiority in all different means to treat tinnitus, but the curative effect is still not universally acknowledged as the poor repeatability. The essence of TCM is Determination of Treatment Based on the Syndrome Differentiation, the Syndrome Differentiation is the base of the treatment. So in order to study the TCM therapy of tinnitus, we must study the Syndrome Differentiation first.That Syndrome of tinnitus hard to differentiate is usually a difficult problem in the clinic, so we selected the Objective Syndrome Differentiation of tinnitus as a study point. The tinnitus sufferer usually accompanied by different degree of hearing loss, and the audiometry for the tinnitus sufferer has become a clinical rule work. Audiometry, such as pure tone, superthreshold, acoustic immittance and auditory brainstem response (ABR),etc, can supply great number of useful messages for us. The main purpose of these kinds of examination is to test auditory acuity and discriminates pathological changes in the middle
ear, cochlea and behind cochlea. Except for this, dose it still embody the messages to differentiate the syndrome of tinnitus? For this reason, The whole research includes two stages:[First Stage Research]The cases in research have the symptom of tinnitus and accord with one of the five types according to the standard of Syndrome Differentiation, such as the Invasion of Wind-heat, the Liver-fire Up-stirring, the Stagnation of phlegm-fire, the Weakness of Spleen-stomach, and the Kidney-essence Deficiency. The cases of tinnitus due to conductive hearing loss were excluded, so as to the cases of age below 14 years old, the cases of TCM Syndrome not clear, the cases of hearing loss more than 90dBHL.All the cases in research were classified by the tinnitus degree, and 52 indexes of audiometry of pure tone test, acoustic immittance and electric response audiometry (ERA) were synchronized. AH test datas were inputed to the computer and analyzed by SPSS statistics software (11.0 type ).There were 120 cases (165 ears) in research, and the male were 73, the female was 47. The ages were from 16 to 77 years old, the mean age was 40.5 years old. The courses of disease were from 1 day to 20 years, the mean course of disease was 1.51 years. There were 16 cases(17 ears) of the Invasion of Wind-heat, 27 cases(40 ears) of the the Liver-fire Up-stirring, 25 cases(37 ears) of the Stagnation of phlegm-fire, 27 cases (36 ears) of the Weakness of Spleen-stomach, and 25 cases(35 ear) of the kidney-essence deficiency. The statistics analysis indicated that the group of Invasion of Wind-heat wind-heat has the briefest course of disease (the means was 8.7days),compared with the other groups, the difference was significant(P< 0.01), and the age of group of the Kidney-essence Deficiency was the oldest (P< 0.05). The sex was no significant difference in all groups( P>0.05).The single factor analysis result indicated that in 52 items of audiometry of pure tone test, acoustic immittance and ERA, there were 22 items of audiometry which had significant difference in the five groups(P<0.05). After utilized the multivariate stepwise discriminant analysis, we screened out 17 distinctive items, such as the degree of tinnitus, frequency of tinnitus, the type of audiogram(even,steep drop,marked drop), the SISI score
of 4kHz, the TD grade of 4kHz, ipsilateral acoustic reflex threshold (0.5kHz> 1kHz, 2kHz> 4kHz), contralateral Metz (0.5kHz% lkHz> 4kHz), the click hearing threshold, the time of ABR I -III wave, 0.5kHz respons threshold of 40Hz auditory event related potential (40Hz AERP), and so on. We found that the different items had different distinguish value for different Syndrome. Based on these, the multivariate stepwise discriminant analysis was used to set up multivariate discriminant functions of the five Syndromes. Further study verified that the discriminating accurate rate in the goup of the Invasion of Wind-heat was the highest (reach 91.8%, in the other hand, the discriminating accurate rate in other two groups of the Liver-fire Up-stirring and the Stagnation of phlegm-fire were relatively lower (76.3% and 77.4%), the discriminating mean accurate rate in five groups attained 83.5%.[Second Stage Research!The research result of the first stage was verified on the foreseeability from two different angles. The cases of tinnitus were divided into two groups according to whether accompanied by typical Syndrome of TCM.The first group included the cases of tinnitus accompanied by typical Syndrome of TCM. After a series audiometry Objective Syndrome Differentiation was carried on according to the multivariate discriminant functions resulted in the first stage, which compared with traditional Syndrome Differentiation. It included 52 cases, 33 male and 19 female, the age from 20 to 73 years old, the mean age was 41.2 years old. There were 10 of the Invasion of Wind-heat, 6 of the the Liver-fire Up-stirring, 7 of the Stagnation of phlegm-fire, 13 of he Weakness of Spleen-stomach and 16 of the kidney-essence deficiency. The foreseeability was verified that the discriminating mean accurate rate in the five discriminant functions attained 79.6%, which was close to the test itself. The discriminant function of the Invasion of Wind-heat had the higher sensitivity, specificity and accuracy, which approached the test itself and indicated the higher repeatability. The discriminant function of the the Liver-fire Up-stirring had the lower sensitivity than the test itself, but the specificity and the accuracy approached the test itself, which indicated the relatively higher repeatability. The discriminant function of the Stagnation of phlegm-fire had lower sensitivity and higher specificity than the test itself, but the accuracy approached the test
itself, which indicates a higher rate of missed diagnosis and the lower rate of wrong diagnosis if you used the function to distinguish the cases of tinnitus with the Stagnation of phlegm-foe. The discriminant function of the Weakness of Spleen-stomach had the similar tendency to the Stagnation of phlegm-fire. The discriminant function of the kidney-essence deficiency had the highest specificity and the lowest sensitivity in the five discriminant functions, the accuracy rate attained 73.1%, thus if you used the function to distinguish the tinnitus with the kidney-essence deficiency, there were a large number of missed cases, and if you had distinguished the cases of the kidney-essence deficiency, it is almost true.The second group were the cases of tinnitus who had not typical Syndrom of TCM so as hard to Differentiated according to traditional method. The cases were divided at random into two groups: experimental group and control group. The cases of experimental group were treated in Chinese medicine based on the objective Syndrom Differentiation according to the discriminant functions after a series audiometry. The cases of control group were treated in Chinese medicine based on the kidney-essence deficiency according to the theory that the kidney of TCM is related to the ear and the clinical custom. The curative effect was evaluated after taking a month of medicine.There were 51 cases which include 30 cases of experimental group and 21 cases of control group. The experimental group had 17 male and 13 femal, and the age from 18 to 78 years old, the mean age 40.13 years old, the course of disease between 0.5 months and 12 years, the mean course of disease was 23.69 months. According to the objective Syndrom Differentiation, there were 1 case of the Invasion of Wind-heat, 9 cases of the Liver-fire Up-stirring, 5 cases of the phlegm-fire syndrome, 7 cases of the Weakness of Spleen-stomach, and 8 cases of the kidney-essence deficiency. The control group included 12 male and 9 femal, the age from 20 to 71 years old, the mean age 42.38 years old, the course of disease between 0.7 months and 10 years, the mean course of disease 36.41 months. The sex, age, course and degree of tinnitus in two groups have no significant difference (P>0.05).The result indicated that the score of tinnitus degree in two groups droped after treatment, paired-samples T test showed the significant difference (P<0.01), which
引文
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