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慢性中耳炎

著者: 小森学 聖マリアンナ医科大学 耳鼻咽喉科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2022/05/25
参考ガイドライン:
  1. 日本耳科学会:用語委員会で中耳慢性炎症性疾患の用語整理中
患者向け説明資料

概要・推奨   

  1. すでに疾患定義のコンセンサスが得られている急性中耳炎、中耳真珠腫、ANCA関連血管炎性中耳炎以外の中耳慢性炎症性疾患(癒着性中耳炎、慢性穿孔性中耳炎、鼓室硬化症、コレステリン肉芽腫、滲出性中耳炎、アテレクターシス)の用語定義に関して整理している。2022〜2023年に公開予定である。
 
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小森学 : 特に申告事項無し[2022年]
監修:森山寛 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い新たな治療法としてリティンパ、聴力改善の手段として人工聴覚器について言及した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 慢性中耳炎は広義には中耳真珠腫や癒着性中耳炎、コレステリン肉芽腫なども含めるが、一般には慢性穿孔性(化膿性)中耳炎を指す。
  1. 慢性中耳炎は幼少時の急性中耳炎の遷延化や反復により、鼓膜に永久穿孔が生じて発症する。
  1. 急性中耳炎の起炎菌の種類や薬剤耐性、鼻副鼻腔炎の存在、不完全治療、耳管機能などが遷延化に関係する。
  1. 鼓室・耳管・乳突洞・乳突蜂巣の粘膜や骨膜、骨組織の慢性炎症が本症の病態である。
  1. 感冒時などの活動期は膿粘性耳漏が主症状であるが、非活動期の耳内は乾燥していて難聴のみが症状である。
  1. 急性中耳炎が非穿孔性の滲出性中耳炎に、そして中耳真珠腫や癒着性中耳炎に移行するものもある。
問診・診察のポイント  
  1. 難聴の有無・程度、耳漏の有無・回数・性状、耳鳴・めまいの有無・経緯、幼少時の中耳炎罹患。

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文献 

M Sakagami, A Maeda, M Node, M Sone, Y Mishiro
Long-term observation on hearing change in patients with chronic otitis media.
Auris Nasus Larynx. 2000 Apr;27(2):117-20.
Abstract/Text OBJECTIVE: Very few reports are available in the literature to clarify the natural long course of hearing change in an individual patient with chronic otitis media (COM). We reviewed hearing change in patients suffering from perforated COM without an operation.
METHODS: Eighty-seven ears of 70 patients had COM with tympanic perforation and were observed without an operation. The mean follow-up period was 10.7 years (5-22 years) and the mean age at the first examination was 51.3 years. To minimize the effect of aging, 23 patients with normal ear drums on the other side were further analyzed.
RESULTS: All 87 ears tended to show deterioration of hearing gradually under long observation. In 23 patients, hearing deterioration was 0.13 dB/year in the control side and 0.61 dB/year in the COM side (P < 0.02). Although elevation of bone conduction hearing level tended to be larger at high frequencies than at low and middle frequencies, there was no significant difference between COM and normal ears.
CONCLUSIONS: Air conduction hearing levels deteriorated with the passage of time and surgery is recommended at the early stage of COM to prevent progress of hearing loss.

PMID 10733138
M Sakagami, R Yuasa, Y Yuasa
Simple underlay myringoplasty.
J Laryngol Otol. 2007 Sep;121(9):840-4. doi: 10.1017/S0022215106005561. Epub 2006 Dec 14.
Abstract/Text OBJECTIVE: To introduce simple underlay myringoplasty which is widely performed in Japan.
PATIENTS: 391 ears with perforated eardrum underwent simple underlay myringoplasty from 2000 to 2004, and which were followed up for more than six months after surgery.
METHODS: After removing the margin of the perforation by a transcanal approach under local anaesthesia, a connective tissue graft was inserted through the perforation and lifted to contact the edge. Fibrin glue was dropped on the contact area. There was no packing in the canal or in the middle-ear cavity. If the perforation remained, re-closure was attempted using the patient's frozen tissue.
RESULTS: The rate of closure after the initial attempt was 304/391 (77.7 per cent), and that after re-closure for unsuccessful cases was 70/87 (80.5 per cent). The overall rate was 374/391 (95.7 per cent). There were no serious complications such as sensorineural hearing loss.
CONCLUSIONS: Simple underlay myringoplasty is a simple and minimally invasive procedure employing fibrin glue and has led to a high closure rate of the eardrum.

PMID 17166327
Y Mishiro, M Sakagami, Y Takahashi, T Kitahara, H Kajikawa, T Kubo
Tympanoplasty with and without mastoidectomy for non-cholesteatomatous chronic otitis media.
Eur Arch Otorhinolaryngol. 2001 Jan;258(1):13-5.
Abstract/Text OBJECTIVES: Cases of non-cholesteatomatous chronic otits media (COM) were reviewed to determine whether mastoidectomy is helpful when combined with tympanoplasty for these conditions.
STUDY DESIGN: A retrospective analysis of 251 ears with non-cholesteatomatous COM operated on by one surgeon (Y.M.) in an 11-year period was conducted.
METHODS: Patients in group A (n = 147) were treated by tympanoplasty with mastoidectomy. Patients in group B (n = 104) were operated on without mastoidectomy.
RESULTS: Graft success rates were 90.5% in group A and 93.3% in group B. There was no statistically significant difference. Graft success rates of discharging ears were 90.0% in group A and 85.7% in group B. Graft success rates of dry ears were 90.7% in group A and 94.4% in group B. There was no statistically significant difference between discharging ears and dry ears. The rates of the postoperative air-bone gap within 20dB were 81.6% in group A and 90.4% in group B, without a statistically significant difference.
CONCLUSIONS: Mastoidectomy is not helpful in tympanoplasty for non-cholesteatomatous COM, even if the ear is discharging.

PMID 11271427
Toshihiko Mutoh, Osamu Adachi, Kojiro Tsuji, Mieko Okunaka, Masafumi Sakagami
Efficacy of mastoidectomy on MRSA-infected chronic otitis media with tympanic membrane perforation.
Auris Nasus Larynx. 2007 Mar;34(1):9-13. doi: 10.1016/j.anl.2006.05.017. Epub 2006 Aug 21.
Abstract/Text OBJECTIVES: To retrospectively evaluate the efficacy of mastoidectomy on methicillin-resistant Staphylococcus aureus (MRSA)-infected chronic otitis media in comparison with methicillin-susceptible Staphylococcus aureus (MSSA)-infected otitis media.
METHODS: Between January 1998 and October 2003, 18 ears underwent surgery for MRSA-infected chronic otitis media with tympanic membrane perforation at the Department of Otolaryngology, Hyogo College of Medicine. Another 33 ears underwent surgery for MSSA-infected chronic otitis media with tympanic membrane perforation during the same period. The postoperative results of graft success rate, hearing results and other complications were compared between MRSA-infected and MSSA-infected ears with or without mastoidectomy, and discharging or dry ears.
RESULTS: In MRSA, the mastoidectomy group tended to have a better graft success rate than the non-mastoidectomy group. In MSSA, there were almost the same graft success rate and hearing results between the mastoidectomy and non-mastoidectomy groups regardless of the presence of discharge. In MRSA-infected discharging ears, the rate of postoperative complications (ear drum perforation, persistent otorrhea, and dehiscence of skin incision) were significantly lower in the mastoidectomy group than in the non-mastoidectomy group (p=0.046).
CONCLUSION: Mastoidectomy had significantly better results concerning postoperative complications in discharging ears with MRSA-infected chronic otitis media. We recommend performing tympanoplasty with mastoidectomy in MRSA-infected chronic otitis media.

PMID 16920308
M Sakagami, Y Mishiro, K Tsuzuki, T Seo, M Sone
Bilateral same day surgery for bilateral perforated chronic otitis media.
Auris Nasus Larynx. 2000 Jan;27(1):35-8.
Abstract/Text OBJECTIVE: Bilateral same day surgery has been performed rarely because of the risk of postoperative sensorineural hearing loss following conventional myringoplasty or tympanoplasty (CMT). Simple underlay myringoplasty (SUM) through the ear canal has been developed by Yuasa R, Saijo S, Tomioka Y, et al. Office closure of eardrum perforation with fibrin glue (in Japanese), Otolaryngol Head Neck Surg (Tokyo) 1989;61:1117-1122, which has little risk of sensorineural hearing loss. We tried bilateral same day surgery using this technique and evaluated its outcome.
METHODS: Of 86 cases with bilateral perforated chronic otitis media that we treated between 1995-1997, 25 cases underwent bilateral same day surgery. Bilateral SUMs was performed on seven patients, SUM and CMT on 16 patients, and bilateral CMTs on two patients.
RESULTS: Closure of perforation was successful in 18 patients (72%) on both sides and in seven patients (28%) on one side. Postoperative air-bone gap of less than 20 dB was achieved in 15 cases (60%) on both sides and in 23 cases (92%) on one side.
CONCLUSION: Bilateral same day surgery for bilateral perforated chronic otitis media is possible if the operative indications are considered.

PMID 10648066
M Sakagsami, T Muto, O Adachi, Y Mishiro, K Fukazawa
Surgical management of only hearing ears with positive indications.
J Laryngol Otol. 2006 Nov;120(11):972-5. doi: 10.1017/S0022215106002556. Epub 2006 Aug 15.
Abstract/Text Positive surgical indications for an only hearing ear were evaluated in order to improve patients' quality of life. Fifteen cases of surgery involving an only hearing ear over the past eight years were retrospectively reviewed. Of eight perforated chronic otitis media cases, seven underwent type one tympanoplasty and one underwent simple underlay myringoplasty regardless of otorrhoea at the time of surgery. Of six cholesteatoma cases, two received the canal wall up method and four received the canal wall down method. Ossiculoplasty was carefully performed in six cases. Hearing was improved in seven cases, whereas it remained unchanged in seven cases and deteriorated in one case. Of nine patients, two did not need a hearing aid after surgery. Five patients with severe combined hearing loss (>90 dB) were able to communicate with a hearing aid, alleviating their anxiety regarding hearing loss. Only hearing ears with chronic otitis media and cholesteatoma can be successfully treated by tympanoplasty with or without ossiculoplasty.

PMID 17040591

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