医学咽喉带状疱疹.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,*,Click to edit Master title style,Click to edit 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style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,咽喉带状疱疹,Pharyngolaryngeal Involvement byVaricella-Zoster Virus,Journal of Voice Volume 27,Issue 5,September 2013,Pages 636641,咽喉带状疱疹,水痘,-,带状疮疹病毒,初次感染后，病毒在神经节内潜伏；常在部位：三叉神经节和背根神经节或自主神经节,病毒重新被激活，在神经分布区产生疱疹，为带状疱疹，老年人或免疫力降低时易得病,颅神经中，最多见的是三叉神经眼支,(herpes zoster ophthalmicus),和面神经,(herpes zoster oticus).,耳鼻喉科最常见的为耳带状疱疹,其他颅神经受累较少，咽喉带状疱疹很少,瑞士,Nisa,从,MEDLINE,中收集,2012,年,1,月以前的文献，得,54,例咽喉带状疱疹，其中,83%,并有其它颅神经受累，,VII(48%),VIII(44%),V(18%),XI(15%),XII(10%),VI(5%),III(4%),and IV(2%).,咽反射,72%,病例有治疗记录，其中,77%,抗病毒,(acyclovir,valacyclovir,or famciclovir).57%Prednisone,治疗,(2/3,病例联合抗病毒,18%,未治,63%,病例有随访，随访期,5.6 5.5,月,(2,周,28,月,).,(1),多与,VII,、,VIII,颅神经病伴随发生,;,(2),最早的表现为吞咽痛和发音困难,;,(3),症状偏侧，软颚及咽喉轻偏瘫及偏侧感觉缺失，为恒定特征症状，不一定有疱疹,;,(4),血清学是可靠的诊断工具，大多数病例放射学检查正常,;,(5),完全恢复率低,(26%),，很多病人长期留有神经功能障碍,有的病例只有单侧咽部疱疹，有的病例伴,IIIXII,颅神经病损。,1/3,病例有前驱耳痛症状，但未发展为耳带状疱疹。耳痛可以是反射性的，也可以是外耳神经,(CN V,、,VII),受累,CN VII,膝状神经节是,VZV,最常潜伏的部位，亲神经性病毒 有沿,CN VII and CN V,CN VIII,CN IX,and CN X,神经间吻合扩展的潜能。,34%,病例没有疱疹,，,肯定诊断需靠血清或脑脊液证明,VZV,感染。,VZV,感染的,IgG,绝对值缺乏特异性，发病后,3,周最高，在可疑病例，比较,2-to 3,周间隔的两次检查值，如有升高就有意义,公认疱疹出现,72,小时内用抗病毒剂可减轻疼痛。,本文收集的病例，用与不用抗病毒剂的效果，无统计学差异，激素治疗,VZV,感染是个争议的问题,Case 1,55,岁，女，喉痛伴左耳痛、声嘶、吞咽困难,5,天，耳部及口腔无疱疹，喉镜见左下咽、杓会厌襞、杓状软骨、会厌黏膜肿胀、红色糜烂,.,左软腭运动力弱，发,“Ah”,声偏右，伸舌偏左，左声带固定在旁中央位，提示,9,、,10,、,12,颅神经麻痹,实验室检查：白细胞,4520/mm3,、,72.4%,中性,、,13.5%,淋巴、,12.8%,单核，,C-,反应蛋白明显升高,5.9 0.3 mg/dL,，血沉,25 20 mm/h.,最初,VZV,血清免疫球蛋白,IgM,（,-,）、,IgG10.80 negative 0.80 index.,随访,VZV IgM 3.46 negative 0.80 index,VZV IgG,升至,11.29 negative 0.80 index.,颈部增强,CT,未见肿物,静脉注,acyclovir,口服,prednisone 0.5 mg/kg,，,2,次,/,日,7,天，减半量,7,天,再减半量,7,天,全程,10,天,acyclovir,，,21,天激素治疗,入院,2,天后，发现左面瘫，,House-Brackmann(HB)grade IV,治疗后喉痛和黏膜病变好转。,6,个月后，面瘫,grade III,，吞咽明显改善，声带麻痹在代償中,Case 2,30,岁女性吞咽困难声嘶,4,天，诊断会厌炎，广谱抗生素应用后反加重，入院,2,天后诉右耳痛，鼓膜充血；右软腭力弱，下咽、杓会厌襞、会厌右侧肿胀，右声带麻痹；入院第,4,天，发生眩晕，右前庭功能减退，右低频听力下降,；静脉用,acyclovir,和激素，情况改善,最初,VZV IgM,抗体（,-,），,VZV IgG 10.37 negative 0.80 index.3,天后，,VZV IgM 0.95 negative 0.80 index.VZV IgG 9.62 negative 0.80 index.,5,天后，听力改善，,1,周后，声门上黏膜肿胀、外耳道炎症消退,VZV,感染,IgM,抗体出现在皮肤或黏膜病损后,8 to 10,天，,IgG,抗体出现在皮肤或黏膜病损后,4 to 6,天，,3,周后达高峰,50%to 84%,的带状疱疹病例可检测出,VZVIgM,反应,早期启动抗病毒治疗是良好预后的关键,神经解剖,舌咽、迷走组成咽神经从，提,供口咽、喉咽感觉神经支配，并提供除茎突咽肌外的所有咽肌运动纤维，茎突咽肌由舌咽神经直接支配。,软腭运动由咽从和面神经的分支，腭小神经双层支配,颈静脉球瘤,瘤,鼻咽癌,Fig.2,50-year-old man with NPC with parapharyngeal extension(T2).Axial contrast T1 shows NPC(,white arrows,)with left parapharyngeal extension and involvement of parapharyngeal fat space.Note normal levator palatini muscle(,red arrow,),tensor palatini muscle(,blue arrow,),pharyngobasilar fascia(,black arrow,),and fat space(,yellow arrow,)on normal right side,