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耳鼻咽喉科学

郑州大学一附院
• 1. Secretory Otitis Media (分泌性中耳炎)
• 2. Acute suppurative otitis media
( 急性化脓性中耳炎)
• 3. Chronic suppurative otitis media
(慢性化脓性中耳炎)
• 4. The complications of the chronic suppurative otitis
media
(慢性化脓性中耳炎并发症 )
• 5.Idiopathic Facial Paralysis(Bell’ Palsy)
(面神经麻痹、面瘫)
• 6. Otosclerosis
(耳硬化症)

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Secretory Otitis
Media
(分泌性中耳炎)
Outline: The classification of middle ear
conditions connected with effusion varies a
great deal and terms such as ‘serous otitis
media’, ‘catarrhal otitis media’, ‘secretory otitis
media’ and ‘gule ear’ are often used as
synonyms. This confusion prevents accurate
assessment of clinical and epidemiological
studies and restricts the value of comparisons
between the clinical and laboratory data.

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1. Symptoms
• There is a felling of pressure and fullness in the
ear often accompanying an infection of the upper
airway and a considerable decrease in hearing on
one or both sides.
• Noises are heard in the ear on
yawning,swallowing,and sneering.
• The patients do not have pain .

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2. Pathogenesis
• Tubal incompetence and the resulting reduced
tympanic pressure are preeminent. Obstructive
processes of the nasopharynx, disorder of
tubalkinetics, especially incompetence of the
muscles opening the tube in cleft palate,and virus
infections are the most common underlying
mechanisms.
• Experimental infection of the middle ear of guinea-
pigs produces a section in less than 2 weeks,but in
humans the timing of the onset of the disease has
not been accurately defined.

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• The onset may be very insidious and not
precipitated by an acute inflammatory attack but
the possibility alwayas remains that the middle
ear process may have started at some time
during antibiotic treatment for an upper
respiratory illness during the subclinical stage of
acute otitis media.

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3. Diagnosis
• Otoscopy shows a markedly retracted tympanic
membrane with localized protrusion, an exudate
in the middle ear,and a dark discoloration behind
the tympanic membrane ( the so called “blue
drum”) with a blackish fluid level .
• There is a conductive deafness for the entire
frequency range of 40 to 50 dB.
• A typical impedance curve ( flat curve ) is found.

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• The primary cause shows chronic inflammation of
the
• adenoids, sinusitis, rhinitis,allergy,or tumor. The
nasopharygeal cancer is also a cause of the
disease,for it can obstruct the Eustachian tube.

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4.Treatment
• 1.Surgical restoration of tubal patency by adenoid-
ectomy or re-adenoidectomy under direct vision
and elimination of infection of sinuses.
• 2.Paracentesis and drainage of the middle ear.
• The tympanic membrane is incised in the
anteroinferior guadrant,under general anesthesia in
children and under local anesthesia in adults. The
middle ear effusion is aspirated out and long-term
drainage is provided for at least 6 months by
introduction of a drainage tube(or “grommet”).

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• 3.Laser treatment. Using the laser to make a
appoprate hole on the tympanic membrane , the
hole will heal in one month or more.
• 4. Using vasoconstrictor nose drops to relieve the
troublesome nasal obstruction.
• 5. Antibiotics shoud be used.

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Acute suppurative otitis
media
( 急性化脓性中耳炎)
一 . Symptoms
1. In the first phase of exudative inflammation
which lasts for 1 to 2 days, there is an increase of
temperature to 39° to 40° C, and in severe cases
,rigors, and occasionally meningismus in children.
The patient has a severe pulsating pain worse by
night than by day. There is a muffled noise in the
ear synchronous with the pulse, deafness, and
sensitivity of the mastoid process to press.
There is often no fever in older patients.

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• 2. The second phase of resistance and demarcation lasts 3
to 8 days . The pus and middle ear exuade usually
discharge spontaneously where upon the pain and fever
subside.This phase can be considerably shortened by early
application of an appropriate antibiotic, which also prevents
spontaneous perforation of the tympanic membrane.
• 3. In the third healing phase lasting 2 to 4 weeks, the aural
discharge dries up and the hearing return to normal.
• If the disease is not treated in time , it can occure the
serious complications.

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二 . Pathogenesis
The effects of the acute inflammtion on anatomy and physiology
explain the clinical presentation and natural history of the
condition.The normal function of the middle ear has an
impedance matching mechanism requires it to be filled with air at
atmospheric pressure. However, oxygen is being continually
absorbed from the middle ear spaces by the blood vessels in its
mucosa. To correct this developing negative intratympanic
pressure, the Eustachian tube is opened periodically to allow
aeration and pressure equalization.
The tube is shorter,wider and more horizontal in infant.

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• A disturbance in the normal aeration of the middle ear
may cause a pathological sequence of events leading
to acute suppurative otitis media.
• Route of infection: The tubal route is the most
common .
• Hematogenous infection is unusual and occurs in
measles, scarlet fever,typhus,and septicemia.
Exogenous infection requires rupture of the tympanic
membrane or preceding perforation allowing peneration
of bath water or dirt duringirrigation of the ear.
Incorrect methods for the removal of a foreign body
from the external meatus are also another a cause.

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三 . Organism

• The infecting organisms in decreasing order of


frequency are: streptococci in
adults,pneumococci in children,Hemophilus
influenzae, staphylococci and coliforms.

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四 . Diagnosis

• 1. Otoscopy shows hyperemia,then moist infiltration and opacity of


the surface of the tympantic membrane. The contours of the handl of
the malleus and its short process disappear.
• 2.Hemorrhagic bullae form on the tympanic membrane.
• The patient has a conductive deafness. The mastoid process is
tender to pressure as a result of the accompanying mastoiditis.
• 3.Before spontaneous rupture,a pinhole-size fistula forms.
• This discharges a pulsating ,thin,fluid,odorless pus.

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五 . Differential diagnosis

• One must consider otitis externa. In the latter


disease, there is pain on pressure on the
tragus,the exudate is not pulsating,is usually
fetid,and is never mucoid. There is little or no
deafness.

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六 Treatment

• 1.Systemic antibiotics in high dosages are given,not


only until the symptoms abate but for a further 10
days.Penicillin and other broad-spectrum
penicillins are indicated;
• 2. Nasal drops(1% 麻黄素) are given to decongest
the mucosa of the nasopharynx around the opening of
the tube;
• 3.Culture and sensitivity tests are performed and
appropriate antibiotics given if the tympanic
membrane perforates.

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• Paracentesis in the following circumstances:
• 1.Marked bulging of the tympanic membrane;
• 2.Persisting high fever and sever pain ;
• 3.Unsatisfactory spontaneous perforation with
incomplete differentiation of the tympanic
membrane.

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Chronic suppurative otitis
media
(慢性化脓性中耳炎)
• 一、 Chronic mucosal inflammation
• 1.Concept: Chronic mucosal inflammation is a form
of chronic otitis media in which the inflammation is
mainly confined to the mucosa. It usually does not
cause progressive bone destruction and therefore is
free of complication,but runs a protracted course.
• 2.Symptoms:
• (1) There is a chronic discharge of mucoid, purulent,
odorless exudate. The otitis demonstrates periods of
complete freedom from symptoms, alternating with
acute exacerbation. The exudate may be creamy and
purulent in acute phase and then becomes mucoid and

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• stringy as the infection resolves.It is, however, always odoreless;
• (2) Hearing. The patient has a conductive deafness;
• (3) Pain. The pain is absent,and the general condition is good.
• 3.Pathgenesis. This is not a disease with a unique cause, but it
is the end result of several different primary disease processes.
The inflammation remains confined to the mucosa but in certain
patients lead in time to a rarifying osteitis,I.e., a chronic
inflammatory destruction of the ossicles,e.g., the long process of
the incus( 砧骨 ).

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• In contrast to cholesteatoma, this destructive process of
bone is unusual and less likely to extentd and progress.
• 4.Pathogenetic factors.
• (1) Constitutional reduced mucosal(immunological)
competence;
• (2) Type, pathogenicity,virulence, and resistance of the
bacterial organisms;
• (3) Anatomic conditions of the middle ear such as
pneumatization, and the connections between the attic,
antrum, middle ear cavity,and eustachiantube;

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• (4) Disordered function of the eustachian
tube,I.e., in patients with cleft palate;
• (5) Generalized diseases such as allergy,immune
defects,cachexia,and diabets.
• 5.Diagnosis
• (1) The history shows a chronic recurrent
aural discharge with reduced hearing;
• (2) The otoscopic findings include a central defect
of the tympanic membrane, scarring of the pars
tensa, and occasionally aural polys due to
mucosal hyper plasia in acute exacerbations.

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• (3) Radiographs.
• CT shows either reduced pneumatization or opacity of the
cell system,if it is well pneumatized, and occasionally
signs of bony destruction .This is regarted as the signs of
chronic mastoiditis.
• (4) Hearing. The audiogram shows a conductive deafness.
• 6.Differential diagnosis.
• (1) Acquired cholesteatoma of the middle ear;
• (2) Aural tuberculosis ;
• (3) Middle ear carcinoma.

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• 7.Treatment
• 1.Conservative measures to dry up the middle ear.
• The external meatus is cleaned periodically.
• Pus is taken for culture and sensitivity tests,and the
appropriate systemic and local antibiotics(3% hydrogen
peroxide solution;0.3% ofloxacim, 氧氟沙星 ) are given,
• One must take car not to use ototoxic drugs(gentamycin
solution).
• Aural polys shoud be removed. Chronic infections of the
nasopharynx and paranasal sinuses must be looked for.

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• 2. Mastoidectomy may be carried out to
eliminate the foci of infection in the temporal
bone and the middle ear cavity.
• A tympanoplasty may be carried out to
reconstruct the sound –conducting
apparatus,i.e., the tympanic membrane and the
ossicular chain.

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Acquired cholesteatoma of the
middle ear (胆脂瘤性中耳炎)

• 1. Symptoms.
• (1) Fetid otorrhea which is sometimes minimal or
completely absent,when present always
purulent,and never mucoid;
• (2) Progressive deafness, possibly dizziness;
• (3) Otalgia and fever in acute exacerbations;

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(4) Dull headaches or a felling of pressure in the head.

2. Pathogenesis

An acquired middle ear cholesteatoma is not a tumor but a chronic inflammation which, unlike
• chronic mucosal inflammation,causes progressive destruction of the bony structures.
3.Promoting factors.

1. Disordered ventilation and drainabe of the middle ear(chronic reduction of pressure) with
• hypopneumatization;
2. Displaced squamous epithelium as a result of the capacity for growth of the meatal skin in
• the upper

to be continued

– capacity for growth of the meatal skin in the upper part of the anulus tympanicus ( the papillary ingrowths form the later matrix
either as a result of invagination of the pars flaccida or by formation of a retention pocket in the pars tensa);
– 3. An increased proliferative tendency of the stratum germinativum caused by the stimulus of inflammation;
– 4. Incompletely resolved embryonal hyperplastic mesenchymal remnaats n the submucosa of the middle ear which later form the
perimatrix.

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• part of the anulus tympanicus (the papillary
ingrowths form the later matrix either as a result
of invagination of the pars flaccida or by
formation of a retention pocket in the pars tensa);
• 3. An increased proliferative tendency of the
stratum germinativum caused by the stimulus of
inflammation;
• 4. Incompletely resolved embryonal hyperplastic
mesenchymal remnants the submucosa of the
middle ear which later form the perimatrix.

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• 4. Histopathgenesis
• A cholesteatoma may form a compact sac of
desquamated lamellae arranged like the layers of an
onion and connected with a fairly thick pedicle to its
site of origin from the tympanic membrane.
Alternatively,it consists of a widely fanned-out
cholesteatoma matrix lining the antrum and mastoid
cavity and sending off shoots into the furthest bony
niches of the bony process. The bone destruction is
caused first by enzymes (e.g., collagenase ) formed
in the perimatrix and second by osteoclastic
destruction of bony tissue,I.e., a chronic osteomyelitis.

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• 5. Diagnosis
(1) Fetid otorrhea;

(2) Radiography: The CT of the temporal bone is now recognized


as the most useful and versatil procedure for demonstrating bone
destruction in the petrous pyramid, soft-tissue abnormalities in
the middle ear, and extention of the cholesteatoma into the
cranial cavity;

(3) Audiometry: The audiogram shows a conductive deafness


possibly combined with sensorineural deafness;

(4) Facial nerve: The disease may cause facial paralysis.

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• 6. Treatment
• The disease should be treated by surgery as soon as possible ,
because the disease may at any time develop the life-
threatening complications.
• Perpose of the operation:
• 1.Radical removal of the cholesteatoma with its matrix and
perimatrix;
• 2.Reconstruction of the sound pressure protection of the round
window and of the sound pressure transformation between the
tympanic membrane and the oval window by means of:

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(1) Closure of the perforation of the tympanic membrane
with fascia or perichondrium;
(2) Reconstruction of the direct connection between the
tympanic membrane and stapes footplate if the ossicular
chain is defective, i. e.,construction of acolumella to
bridge the defect using a bone, cartilage,or synthetic
prosthesis;
(3) Separation of the middle ear cavity from the external
meatus by reconstruction of the posterior meatal and
lateral attic walls by bony or cartilaginous graft or
preservation of the intact bony meatal wall.

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The complications of the chronic
suppurative otitis media
(慢性化脓性中耳炎并发症 )

• 一 .Labyrinthitis
• 1. Symptoms: Dizziness,nausea,vomiting,whistling
noises in the ears,and deafness develop within a brief
period. The patient has no fever and no pain.
• 2.Treatment: Intravenous antibiotics are administered
in high doses by continuous infusion. The middle ear
should be drained ,and a mastoidecomy may need to
be carried out immediately.

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• 二 .Epidural empyema( 硬膜外脓肿 )
• 1.Symptoms:
• Dull pulsating pain in the head, otorrhea ,and
subfebrile temperature occur. There is no
completely characteristic pattern of symptoms.
• 2.Treatment:
• Immediate mastoidectomy with wide exposure of
the dura,drainage,and antibiotics are indicated.

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• 三 .Otogenic meningitis( 耳源性脑膜炎 )
• 1. Symptoms:
• Headaches,stiffness of the neck,scaphoid
abdomen, increasing loss consciousness,
photophobia, restlessness,tonicclonic
convulsions,and facial paralysis.
• Typically there is bounding pulse,irregular
breathing,and a fever of 39 º to 40º C.
• 2.Treatment:
• Antibiotics are given intravenously in high
dosages determined by sensitivity tests,
Immediate mastoidectomy

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• shoud be carried out immediately.

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• 四 Otogenic sinus thrombosis( 乙状窦血栓性静脉炎)
• 1.Symptoms:
• Chills, a spiking temperature chart,with several peaks on the
same day, increased pulse rate, headaches,
vomiting,somnolence,neck stiffness,dyspnea due to septic lung
metastases or pneumonia.
• 2.Treatment:
• Immediate surgical excision of the primary inflammatory focus
in the mastoid and sigmoid sinus by cortical or by
mastoidecomy for cholesteatoma is performed.

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• 五 Otitic hydrocephalus( 耳源性脑积
水)
• 1.Symptoms:
• Failing vision,vomiting, double vision, jacksonian
epilepsy, pareses and disorders of sensation.
• 2.Treatment:
• Mastoidectomy and antibiotics are given
intravenously in high dosages determined by
sensitivity tests .

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• 六 Otogenic brain abscess
• (耳源性脑脓肿)
• 1.Symptoms:
• (1) Initial stage:
Meningismus,nausea,headache,psychological changes,fever;
• (2)Latent stage:
• Epileptiform attacke,neurologic signs;
• (3)Manifest stage:
• Papilledema,psychological changes,focal signs of aphasia,

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• alexia,agraphia,hemiplegia,epileptic attacks,and ataxia in
cerebellar abscess. Symptoms due to spread to neighboring
organs include cranial nerve paralysis,visual field
defects,disorders of the oculomotor system and of posture.
• (4) Terminal stage:
• Stupor,coma,conjugated deviation to the side of the lesion,
bradycardia,and Cheyne-Stokes respiration (潮式呼吸) .
• 2.Treatment:
• Mastoidectomy,removal of the brain abscess,antibiotic.

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• In a word,the complications of
the chronic suppurative otitis
media was usual before,but
nowdays,it is usually controlled
by antibiotics and has therefore
become rare.

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Idiopathic Facial Paralysis(Bell’
Palsy)
(面神经麻痹、面瘫)
• The incidence of the most common form of
intratemporal facial palsy,i.e. Bell’ palsy ,varies in
Europe between 11.5 and 18.8 patients per 100000 per
year.Higher figures are reported from countries like
Egypt,Columbia and India.
• In order of frequency the most common forms of
intratemporal facial palsy are:
• (1) idiopathic or Bell’ palsy (39.7%);
• (2) trauma (24.7%);
• (3) tumours (12.5 %);
• (4) herpes zoster oticus (6.8%)( 耳带状疱疹 );
• (5) acute and chronic otitis media (5.5%).

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• Bell’ palsy are evenly distributed in children and
adults.Palsies due to acute middle ear infections predominate
in children,whereas herpetis lesions characteristically occur in
the adult. Tumours originating from the facial nerve
(neurinomas,haemangiomas) or involving the seventh nerve
(glomus jugulare tumours,meningiomas, epidermoids) are
mostly found in adults.
• 1.Cause:
• It may be a disturbance of the microscirculation leading to a
serous inflammation with the formation of edema.

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• The bony canal is unyielding( 不易扩张 ) ,and
compression of the nerve leads to ischemia and
venous congestion so that a vicious circle is set up. A
virus infection may also be responsible.
• 2. Clinical picture
• Idiopathic palsy is the most common form of
isolated facial palsy. It is of sudden onset and occurs
at any age,particularly in healthy adults of 20-35
years and children of 6-12years of age. Exposure to
cold, emotional stress, and pain over the mastoid
may precede the onset of the lesion.

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• Bilateral idiopathic facial palsy has been noted to
occur in 1.5-2% of all Bell’s palsies and must be
differentiated from alternating or recurrent Bell’s
palsy which are more common.
• 3 Diagnosis:
• In a peripheral paralysis all three branches are
affected. The secretion of tears and the sensitivity
for taste are affected, and hyperacusis may occur
due to disruption of the stapedius reflex.
• The topographical diagnosis of peripheral lesions
of the facial nerve should be made.

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• (1) Taste test: The anterior two-thirds of the tongue
is innervated by the chorda tympani. The test
stimulus is 20% sugar,10% saline, or 5% citric acid
solution;
• (2) Schirmer’s test: The reduction of the secretion of
tears due to interruption of the lacrimal
anastomosis in the greater superfical petrosal nerve
is measured on the paralyzed side;
• (3) The stapedius reflex test: is measured by
impedance audiometry;
• (4) the severity and prognosis of a paralysis can
only be determined by electrodiagnosis.

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• 4.Treatment
• The treatment includes injection of steroids,
stellate ganglion block, and low-molecular-weight
intravenous infusion of dextran.
• Schedule for prednisone in the treatment of
idiopathic facial paralysis: 60 mg for 4 days
reducing by 5 mg daily to 5 mg on the 15th
day,followed by intermittent dosage of 5 mg for 10
days.
• Immediate decompression of the nerve should be
undertaken for progressive denervation after
careful assessment of the indication.

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• The principle of treatment is to decompress the
nerve fibers by exposure of the nerve and slitting
of its sheath.

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Otosclerosis
(耳硬化症)

• Otosclerosis is a localized disease of the bony


labyrinthine capsule,the cause of which has still
not been explained.
• 1.Symptoms: Depending on the site of the
otosclerotic focus,the symptoms include:
• (1) Conductive deafness of the middle ear type in
about 80% of patients;
• (2) Mixed conductive and sensorineural deafness
in about 15% of patients;
• (3) Pure sensorineural deafness in about 5% of
patients.

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• The disease declares itself subjectively by:
• (1) A slowly progressive hearing loss which initially
usually affects one ear, but later affects both ears in
most patients;
• (2) Constant, progressive tinnitus.
• The disease never causes otalgia, otorrhea,dizzness, or
disorders of balance.
• 2. Pathogenesis:
• The disease appears to have a multifactorial
cause,which the following being the most important:

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• (1) Heredity and Constitution;
• (2) Disorders of hormone and bone metabolism;
• Otosclerosis is due to an extremely localized disorder of
mineral or bone metabolism with an abnomal increase of
enzyme activity of the mesenchymal cells of the
labyrinthine capsule mainly by genetics but also by
hormonal disturbances. The newly reformed bone fixed
the stapes footplate in the oval window.
• 3.Diagnosis
• There is often a positive family history.
• Otoscopy occasionally shows hyperemia of the promontory
shining through the tympanic membrane

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• (Schwartze’s sign).
• Functional symptoms include middle ear deafness,
occasionally with an inner ear companent.
• Gelle’s test is abnormal.
• A pure-tone audiogram usually shows a pure middle ear
deafness, occasionaly a mixed deafness, and exceptionally
a pure sensorineural deafness with positive recruitment.
• There is often a characteristic notch of the bone
conduction curve at 2,000 Hz (the carhart notch).
• Impedence audiometry usually shows a normal curve at

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• normal pressure. However ,the stapedius reflex is
often suppresed due to otosclerosic fixation of the
footplate.
• Radiography usually shows very good
pneumatization of the temporal bone
• 4.Treatment:
• Stapedectomy is performed.

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be to continued

• 6. Differential diagnosis:
• (1) Carcinoma of the middle ear or external
meatus;
• (2) Tuberculosis of the middle ear.

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