聲導(dǎo)抗基礎(chǔ)知識

聲導(dǎo)抗基礎(chǔ)知識培訓(xùn)TympanometryandAcousticReflexMeasurements鼓室聲導(dǎo)抗和聲反射測試+Infanttestrecommendations嬰兒測試的推薦方法目前一頁\總數(shù)三十三頁\編于十九點(diǎn)Soundtravel聲音傳導(dǎo)目前二頁\總數(shù)三十三頁\編于十九點(diǎn)Gettingsoundintoadifferentmedium

聲音在不同媒介中的傳導(dǎo)Mostofthesoundenergyisreflectedwhenconfrontingaanothermedium...大部分聲能在臨界面處被反射回來…becausedifferentmediaaremoreorlesseasytobringintomotion(impedance)因?yàn)椴煌浇榈穆曌杩故遣煌哪壳叭揬總數(shù)三十三頁\編于十九點(diǎn)Theroleofthemiddleear中耳的作用

目前四頁\總數(shù)三十三頁\編于十九點(diǎn)TheOssicles聽小骨Malleus錘骨Incus砧骨Stapes鐙骨Threesmallbonesformingachainbetweenthetympanicmembraneandtheinnerear聽骨鏈位于鼓膜和內(nèi)耳之間，由3塊聽小骨組成Airbornesoundwaveenergybecomesmechanicalvibration空氣傳導(dǎo)的聲波能量轉(zhuǎn)換為機(jī)械振動Compensatesfortheair-fluidimpedancedifference補(bǔ)償氣液相不同媒介的導(dǎo)抗差目前五頁\總數(shù)三十三頁\編于十九點(diǎn)TheMiddleearanatomy中耳解剖AirAirAirpressuremustbenearequalonbothsidesoftheeardruminordertooptimisemobilityofthewholesystem應(yīng)使鼓膜兩側(cè)氣壓接近，從而保證中耳傳聲系統(tǒng)的最佳活動性TheEustachiantube(ET)ventilatesthemiddleearandallowspressureequalisation咽鼓管是中耳的通氣管道，可保證中耳氣壓平衡TheETopenswhenswallowingoryawning吞咽和打哈欠時(shí)咽鼓管開放Innerearfluids內(nèi)淋巴目前六頁\總數(shù)三十三頁\編于十九點(diǎn)Gettingsoundintoadifferentmedium

聲音在不同媒介中的傳導(dǎo)The“stiletto”principle:圓錐效應(yīng)Forceiscollectedoveralargerareaandfocusedonasmallerarea(B)作用力在錐底收集后聚焦到錐尖目前七頁\總數(shù)三十三頁\編于十九點(diǎn)Howdowetestthemiddleear?

如何檢測中耳功能目前八頁\總數(shù)三十三頁\編于十九點(diǎn)中耳測試精密的中耳系統(tǒng)高精度的測試高質(zhì)量控制系統(tǒng)目前九頁\總數(shù)三十三頁\編于十九點(diǎn)Partoftheprobetoneisreflected,andsomeisadmittedintothemiddleear一部分探測音被反射回來，另一部分則進(jìn)入中耳Theadmittanceiscontinuouslymeasuredbyamicrophone聲導(dǎo)納通過麥克風(fēng)持續(xù)測量計(jì)算出來Admittance-lettingthesoundwavein

聲導(dǎo)納－將聲波導(dǎo)入目前十頁\總數(shù)三十三頁\編于十九點(diǎn)鼓室圖中耳–勁度TPP(=MEP?)AdmittancePressure目前十一頁\總數(shù)三十三頁\編于十九點(diǎn)Tympanometry鼓室聲導(dǎo)抗Admittance-200daPa200daPa0EarcanalpressureAdmittance聲導(dǎo)納-200daPa200daPa0Earcanalpressure外耳道壓強(qiáng)1&3:Pressurestiffensthetympanicmembranesotheprobetonebouncesback,andthesoundlevelinthemiddleeardecreases1和3：大壓強(qiáng)使鼓膜僵硬從而探測音多被反彈回來，進(jìn)入中耳的聲能減少2:Whenpressureisequalonbothsides,thesoundlevelinthemiddleearisatmaximum2：鼓膜兩側(cè)壓力相等時(shí)傳入中耳的聲能最大

123目前十二頁\總數(shù)三十三頁\編于十九點(diǎn)TheTympanogramcurve,ECVandTPP

鼓室導(dǎo)抗圖形，等效外耳道容積和峰壓點(diǎn)TheTPPapproximatesthemiddleearpressure峰壓點(diǎn)近似于鼓膜內(nèi)側(cè)的中耳壓力ECVTotalAdmittanceoftheearcanalandthemiddleear外耳道和中耳的聲導(dǎo)納總值TPPPressuresweepThe226Hzadmittanceoftheairintheearcanalisdirectlyproportionaltothevolumeofthatair.ThatgivesustheEquivalentEarCanalVolume,ECV以226Hz為探測音，測試探頭與鼓膜之間的空氣導(dǎo)納值為外耳道容積，即等效外耳道容積目前十三頁\總數(shù)三十三頁\編于十九點(diǎn)ECVTotalAdmittanceSATPPSATPPTheTympanogramcurveandbaselinecompensation鼓室導(dǎo)抗圖形和基線補(bǔ)償SubtractionoftheECVcontributiongivesusabaselinecompensatedtympanogram去除外耳道容積成分后的鼓室圖稱為基線補(bǔ)償鼓室導(dǎo)抗圖PeakadmittancebecomesStaticAdmittance,SA該圖峰值處的聲導(dǎo)納稱為靜態(tài)聲導(dǎo)納(SA)TheSAistheadmittanceofthemiddleearalone.Nowwecanusethenormativedata!SA等于中耳的聲導(dǎo)納值目前十四頁\總數(shù)三十三頁\編于十九點(diǎn)-2002000TypeAd:OssiculardiscontinuityoragerelatedhypermobilityAd型：聽骨鏈中斷或鼓膜松弛-2002000TypeA:NormalA型：正常-2002000TypeB:“Flat”-EffusionorperforatedeardrumdependingonECVvalueB型：平坦型。鼓室積液或鼓膜穿孔，根據(jù)ECV值區(qū)分-2002000TypeAs:PossibleeffusionorotosclerosisAs型：鼓室積液可能或耳硬化癥-2002000TypeC:AbnormalpressureC型：負(fù)壓型TheTympanogramcurveclassification,Type鼓室導(dǎo)抗圖形分類目前十五頁\總數(shù)三十三頁\編于十九點(diǎn)SATWSA/2PressureAdmittanceTheTympanogramcurveandTympanometricWidth

鼓室導(dǎo)抗圖形與鼓室圖寬度（TW）TympanometricWidthquantifythesteepnessofthetympanogramTW決定鼓室導(dǎo)抗圖的坡度Normativedataexistfordifferentagegroups不同年齡組標(biāo)準(zhǔn)化值不同TWandSAarethecriteriausedintheASHAtympanometricscreeningprotocol美國社會衛(wèi)生學(xué)會的鼓室聲導(dǎo)抗篩查方案把TW和SA作為診斷指標(biāo)目前十六頁\總數(shù)三十三頁\編于十九點(diǎn)226Hz:Differentconfigurationsoftympanometricresults

226Hz鼓室聲導(dǎo)抗測試結(jié)果與疾病的關(guān)系Tympanometryisaninvaluablediagnostictoolwhencombinedwithotheraudiologicaltests鼓室聲導(dǎo)抗與其它聽力學(xué)測試結(jié)合是不可替代的診斷工具疾病早期中耳積液中耳積液聽骨鏈中斷鼓膜病變耳硬化癥錘骨固定咽鼓管阻塞鼓膜置管鼓膜穿孔耵聹栓塞、探頭叩堵塞目前十七頁\總數(shù)三十三頁\編于十九點(diǎn)Thetwomiddleearmuscles中耳肌121:Tensormuscle鼓膜張肌2:StapediusMuscle鐙骨肌Themusclesarebelievedtostabilisethemechanicalsystemandprotectthecochleafromexcessivelowfrequencyvibration中耳肌可穩(wěn)定中耳機(jī)械系統(tǒng)，并保護(hù)耳蝸免受低頻強(qiáng)聲損傷目前十八頁\總數(shù)三十三頁\編于十九點(diǎn)TheAcousticReflex聲反射Loudsoundsmakethestapediusmusclecontract.Thismakesthemiddleearsystemstiffer...強(qiáng)聲刺激可使鐙骨肌收縮，從而增加中耳傳聲系統(tǒng)的勁度…andlesslowfrequencysoundcangetthroughthemiddleear因而進(jìn)入中耳的低頻聲波減少目前十九頁\總數(shù)三十三頁\編于十九點(diǎn)Stapediusmusclecontrolledbyfacialnerve(CNVII)鐙骨肌由第七對顱神經(jīng)－面神經(jīng)支配Networkinbrainstemconsistsofipsilateralandcontralateralpaths腦干層面由同側(cè)和對側(cè)神經(jīng)通路組成Reflexactivatedonbothears,evenwhenstimulationonlyoccursinoneear一側(cè)耳受到刺激時(shí)，雙側(cè)鐙骨肌都會收縮Comparisonofipsilateralvs.contralateralacousticreflexeshelpstodeterminesiteoflesion對比同側(cè)和對側(cè)聲反射有助于判斷病變部位TheMiddleear-Immittancetests中耳聲導(dǎo)納測試Acousticreflexthreshold聲反射閾目前二十頁\總數(shù)三十三頁\編于十九點(diǎn)聲反射AdmittanceTimeDeflection0.02蹬骨肌目前二十一頁\總數(shù)三十三頁\編于十九點(diǎn)0.000.0280dBHL0.000.0285dBHL0.000.0295dBHL0.000.0290dBHLDeflectioncriterion聲導(dǎo)納偏移標(biāo)準(zhǔn)Itisusefultostudythegrowthwithintensitytoconfirmareflexthreshold繼續(xù)增加聲強(qiáng)觀察偏移變化有助于進(jìn)一步明確聲反射閾?!AcousticReflexThresholds聲反射閾Loudstimuliarepresented,whilsttheadmittanceismeasured強(qiáng)聲刺激出現(xiàn)時(shí)，可測試出聲導(dǎo)納值的變化目前二十二頁\總數(shù)三十三頁\編于十九點(diǎn)聲反射測試–高精度的挑戰(zhàn)鼓膜處壓力為TPP值時(shí)中耳蹬骨肌反射狀況最佳正確的聲反射是刺激音引起導(dǎo)納在TPP處的變化耳道或中耳壓力的改變導(dǎo)致錯(cuò)誤的聲反射對于鼓膜活動度過大可進(jìn)行TPP補(bǔ)償目前二十三頁\總數(shù)三十三頁\編于十九點(diǎn)Threshold+10dB,10secondsstimulustime聲反射閾上10dB給聲，刺激時(shí)程10s0510secondsAdmittancechangeHalf-LifeTime(HLT),thetimeafterstimulusonsetwhentheadmittancedeflectionhasdecreasedby50%.半衰期是指聲反射振幅減少50％的時(shí)程Ahalf-lifetimevalue<5secondsisindicativeoftumour半衰期小于5秒提示蝸后病變，常見的疾病是聽神經(jīng)瘤Noreflexdecaypresent陰性AdmittancechangeMax50%ofMaxHLT0510secondsReflexdecaypresent!陽性AcousticReflexDecay聲反射衰減目前二十四頁\總數(shù)三十三頁\編于十九點(diǎn)Thereflexshouldbeactivatedinbothearsevenifstimulatedinonlyoneear單耳刺激聲可激活雙耳聲反射Theuppernormalintensitylimitforreflexthresholdsinadultsis95-100dBHL正常成人聲反射閾上限是95－100dBHLReflexthresholdscannotbedeterminedifthereisaproblemwiththemiddleear

中耳疾病時(shí)不能測出聲反射閾BroadBandNoiseprovokesareflexatabout10-15dBlowerthanpuretonestimuli寬帶噪聲聲反射閾較純音刺激聲低10－15dBDeterminestypeofhearinglosswhencomparedwiththeaudiogram聲反射閾與聽力圖比較可幫助判斷耳聾類型Decayswithneuralfatigue(typically8thnervetumour)

衰減提示聽神經(jīng)疲勞，是聽神經(jīng)腫瘤的典型表現(xiàn)AcousticReflexfeatures聲反射特征目前二十五頁\總數(shù)三十三頁\編于十九點(diǎn)DifferentconfigurationsofAcousticReflexresults聲反射結(jié)果與疾病的關(guān)系Usingthiskindoftablemakesreflexinterpretationeasier使用該表格有助于判斷聲反射的臨床意義病變部位/患耳中耳/右中耳/左耳蝸/右耳蝸/左聽神經(jīng)/右聽神經(jīng)/左面神經(jīng)/右面神經(jīng)/左腦干/右腦干/左腦干/中線目前二十六頁\總數(shù)三十三頁\編于十九點(diǎn)226Hzprobetone:Normaltympanograminabnormalear!226Hz探測音：異常中耳顯示正常鼓室導(dǎo)抗圖Tympanometryininfantsyoungerthan4-7months4－7個(gè)月以下嬰兒的鼓室聲導(dǎo)抗226HzprobetoneTheinfantouterandmiddleearsarestilldeveloping,anddonotvibratewithsoundthesamewayadultearsdo.嬰兒外耳和中耳正處于發(fā)育期，與成人的聲波振動方式不同Use1000Hzprobetoneininfants推薦使用1KHz探測音目前二十七頁\總數(shù)三十三頁\編于十九點(diǎn)Tympanometryininfants嬰兒鼓室聲導(dǎo)抗1000Hztympanometryclearlyindicatesabnormalmiddleearfunction!1kHz鼓室聲導(dǎo)抗明確顯示中耳功能異常Normal226Hztympanogramsforbothears!226Hz鼓室聲導(dǎo)抗顯示雙耳正常Acousticreflexesconfirmahealthyrightsidemiddleear.聲反射證實(shí)右側(cè)中耳功能正常目前二十八頁\總數(shù)三十三頁\編于十九點(diǎn)HoweasilycanImovethisme－chanicalsystem?怎樣輕而易舉的推動這個(gè)機(jī)械系統(tǒng)？Traditionaladmittancemagnitudetympanometry

傳統(tǒng)鼓室聲導(dǎo)抗中聲導(dǎo)納的成分目前二十九頁\總數(shù)三十三頁\編于十九點(diǎn)B/Gcomponenttympanogram聲納/聲導(dǎo)成分鼓室導(dǎo)抗圖B:Susceptance聲納G:Conductance聲導(dǎo)目前三十頁\總數(shù)三十三頁\編于十九點(diǎn)NowIcanseenotonlyhoweasilyIcanmovethesystem,butIcanactuallyfindoutwhy!現(xiàn)在我不僅能輕而易舉的推動它，而且還明白了其中的原因！SusceptanceandConductancemagnitude

tympanometry聲導(dǎo)與聲納目前三十一頁\總數(shù)三十三頁\編于十九點(diǎn)TraditionalbaselinecompensationEarcanal