呂攀攀，董榮芝，劉芳，王娜娜，徐沖鋒，邴衛(wèi)衛(wèi)，耿立蒙

高危兒聽(tīng)力篩查及隨訪(fǎng)研究①

呂攀攀，董榮芝，劉芳，王娜娜，徐沖鋒，邴衛(wèi)衛(wèi)，耿立蒙

目的探索高危兒聽(tīng)力篩查情況及聽(tīng)力障礙的發(fā)生、變化及轉(zhuǎn)歸。方法2015年3月～2016年3月，采用耳聲發(fā)射(OAE)、聽(tīng)性腦干反應(yīng)(ABR)及腦干聽(tīng)覺(jué)誘發(fā)電位(BAEP)的方法，對(duì)336例高危兒分別于生后0～1、3、6、12個(gè)月進(jìn)行聽(tīng)力監(jiān)測(cè)。結(jié)果336例高危兒中，0～1個(gè)月內(nèi)初檢時(shí)29例未通過(guò)；3月齡復(fù)檢時(shí)37例聽(tīng)力未通過(guò)；6月齡27例恢復(fù)正常；12月齡復(fù)檢7例恢復(fù)正常，3例(0.89%)確診耳聾。結(jié)論OAE、ABR結(jié)合BAEP檢查高危兒聽(tīng)力損傷可獲得較全面的診斷，連續(xù)聽(tīng)力監(jiān)測(cè)可有效動(dòng)態(tài)觀察高危兒聽(tīng)力損傷的發(fā)生、變化及轉(zhuǎn)歸。

高危兒；聽(tīng)力篩查；耳聲發(fā)射；聽(tīng)性腦干反應(yīng)；腦干聽(tīng)覺(jué)誘發(fā)電位；隨訪(fǎng)

[本文著錄格式]呂攀攀，董榮芝，劉芳，等.高危兒聽(tīng)力篩查及隨訪(fǎng)研究[J].中國(guó)康復(fù)理論與實(shí)踐,2016,22(12):1459-1461.

CITED AS:LüPP,Dong RZ,Liu F,etal.Hearing screening and follow-up of high risk infant[J].Zhongguo Kangfu Lilun Yu Shijian, 2016,22(12):1459-1461.

新生兒及嬰幼兒聽(tīng)力篩查在許多發(fā)達(dá)國(guó)家已成為常規(guī)制度[1-2]，在我國(guó)發(fā)達(dá)地區(qū)也已列入常規(guī)。新生兒及嬰幼兒聽(tīng)力篩查，特別是高危新生兒的聽(tīng)力追蹤評(píng)估非常重要。國(guó)內(nèi)外報(bào)道均顯示，高危新生兒聽(tīng)力障礙的發(fā)生率為2%～4%，遠(yuǎn)高于正常新生兒，是聽(tīng)力損傷的高發(fā)人群[3-5]。高危兒聽(tīng)力障礙既可能是疾病本身所造成，也可能是由于出生后治療引起。為探索本院就診高危兒聽(tīng)力損傷情況，我們對(duì)2015年3月～2016年3月本院新生兒科及產(chǎn)科出院的高危新生兒進(jìn)行連續(xù)聽(tīng)力監(jiān)測(cè)，以進(jìn)一步了解高危兒聽(tīng)力障礙的發(fā)生、變化及轉(zhuǎn)歸情況。

1 資料與方法

1.1 一般資料

收集本院新生兒科及產(chǎn)科2015年3月～2016年3月出院的新生兒，符合下列指征之一者均為監(jiān)測(cè)對(duì)象：羊水異常；胎盤(pán)異常；妊娠期高血壓；妊娠期糖尿??；足月小樣兒；早產(chǎn)；低出生體質(zhì)量；過(guò)期產(chǎn)；新生兒高膽紅素血癥；新生兒黃疸；新生兒缺氧缺血性腦病，符合韓玉昆等新生兒缺氧缺血性腦病診斷分度標(biāo)準(zhǔn)[6]；新生兒肺炎。排除標(biāo)準(zhǔn)：先天性并發(fā)癥；先天性畸形；其母孕期耳毒性藥物使用史及肝腎疾病史；耳聾及其他遺傳性疾病家庭史。符合指征作為檢測(cè)對(duì)象的高危新生兒共336例。

1.2 方法

檢查在聽(tīng)力篩查室由專(zhuān)門(mén)人員進(jìn)行，采用耳聲發(fā)射(otoacoustic em issions,OAE)、聽(tīng)性腦干反應(yīng)(auditory brainstem response,AABR)及腦干聽(tīng)覺(jué)誘發(fā)電位(brainstem auditory evoked potential,BAEP)三種方法。OAE采用CD-RW Vser Cuide測(cè)定儀(丹麥)，AABR使用MB11快速聽(tīng)性腦干反應(yīng)測(cè)試儀(德國(guó)MAIKO)。BAEP使用丹迪全功能肌電誘發(fā)電位儀KEYPOINT(丹麥)。OAE用于出生后1個(gè)月內(nèi)聽(tīng)力初篩，AABR用于復(fù)查，BAEP用于聽(tīng)力障礙患兒確診。所有高危兒均在生后0～1、3、6、12個(gè)月各聽(tīng)力測(cè)查1次。

1.3 統(tǒng)計(jì)學(xué)分析

應(yīng)用M icrosoft Excel2000進(jìn)行數(shù)據(jù)錄入和統(tǒng)計(jì)學(xué)分析。

2 結(jié)果

336例(672耳)1個(gè)月內(nèi)篩查未通過(guò)者34耳，初篩未通過(guò)率5.06%，其中雙耳未通過(guò)5例，未通過(guò)率1.49%。3個(gè)月AABR復(fù)查未通過(guò)者50耳，復(fù)查未通過(guò)率7.44%，其中雙耳未通過(guò)13例，未通過(guò)率3.87%。6個(gè)月復(fù)查AABR和BAEP未通過(guò)者14耳，復(fù)查未通過(guò)率2.08%，其中雙耳未通過(guò)4例，未通過(guò)率1.19%。12個(gè)月AABR和BAEP復(fù)查雙耳未通過(guò)者3例，復(fù)查未通過(guò)率0.89%。說(shuō)明本研究中聽(tīng)力損傷兒6個(gè)月后恢復(fù)正常，0.89%確診耳聾患兒，轉(zhuǎn)為耳鼻喉診治。見(jiàn)表1。

表1 高危兒聽(tīng)力篩查情況(n)

回顧分析高危因素，最后確診聽(tīng)力障礙患兒3例中，1例為新生兒缺氧缺血性腦病，1例為早產(chǎn)低出生體質(zhì)量，1例為高膽紅素血癥。

3 討論

聽(tīng)力障礙是常見(jiàn)的出生缺陷。據(jù)國(guó)內(nèi)外報(bào)道，高危新生兒聽(tīng)力障礙的發(fā)生率遠(yuǎn)高于正常新生兒[3-5]。正常新生兒中雙側(cè)聽(tīng)力障礙的發(fā)生率約0.1%～0.3%[7-8]。高危新生兒的聽(tīng)力障礙可能由宮內(nèi)感染、低出生體質(zhì)量、窒息、缺氧缺血性腦損傷、肺部疾病、顱內(nèi)出血、高膽紅素血癥等疾病引起[9-11]，特別是早產(chǎn)兒[12]。也存在遺傳因素[13]。各種高危因素導(dǎo)致高危兒的聽(tīng)力損失多為中樞性的[14]，臨床上應(yīng)用OAE、AABR及其他相關(guān)專(zhuān)業(yè)的檢查如BAEP可以確診[15-17]，大部分損傷是可逆的[18-19]。但是有部分高危新生兒聽(tīng)力損傷具有獲得性或進(jìn)展性的特點(diǎn)，遲發(fā)型聽(tīng)力損傷的發(fā)病年齡最早可出現(xiàn)在8～12個(gè)月[20]，最晚為4～5歲及以后[21-22]，故對(duì)該人群聽(tīng)力進(jìn)行定期聽(tīng)力監(jiān)測(cè)和隨訪(fǎng)，顯得尤為重要[23-24]。

國(guó)內(nèi)報(bào)道正常新生兒聽(tīng)力障礙發(fā)生率為0.3%；經(jīng)重癥監(jiān)護(hù)病房搶救的新生兒，聽(tīng)力障礙發(fā)生率高達(dá)22.6%[25]。本組高危兒最后確診耳聾3例，發(fā)生率為0.89%，顯示高危兒聽(tīng)力障礙發(fā)生率比正常新生兒高，但其聽(tīng)力損傷多為可逆性，故其最終耳聾發(fā)生率與正常新生兒基本一致。

本研究表明，應(yīng)用OAE初篩有部分高危兒漏診，復(fù)檢采用AABR監(jiān)測(cè)為陽(yáng)性，進(jìn)一步采用BAEP確診，故采用OAE、AABR和BAEP可獲得較全面的診斷。對(duì)出生時(shí)通過(guò)篩查的高危兒應(yīng)提高警惕，因?yàn)樗麄円嘤锌赡馨l(fā)生遲發(fā)性或獲得性聽(tīng)力損傷，所以連續(xù)的聽(tīng)力檢測(cè)尤為重要[26-27]。

及時(shí)發(fā)現(xiàn)，早期干預(yù)，可以改善患兒聽(tīng)力，刺激言語(yǔ)功能的發(fā)育，最終達(dá)到減少聾啞發(fā)病率的目的[28-30]。

高危兒聽(tīng)力損傷后有一段恢復(fù)期，不要過(guò)早下結(jié)論，造成家長(zhǎng)思想負(fù)擔(dān)過(guò)重，因?yàn)椴糠指呶嚎苫謴?fù)正常。本研究結(jié)果表明，通過(guò)實(shí)行聽(tīng)力監(jiān)測(cè)可有效動(dòng)態(tài)觀察到高危兒聽(tīng)力障礙的發(fā)生、變化及轉(zhuǎn)歸，同時(shí)使有聽(tīng)力障礙高危兒及早得到干預(yù)，有效得到康復(fù)治療，故建議在建立新生兒聽(tīng)力篩查同時(shí)，對(duì)高危兒要實(shí)施聽(tīng)力監(jiān)測(cè)。

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Hearing Screening and Follow-up of High Risk Infant

LüPan-pan,DONGRong-zhi,LIU Fang,WANGNa-na,XU Chong-feng,BINGWei-wei,GENG Li-meng
Departmentof Pediatrics,TheA ffiliated Hospitalof Binzhou MedicalUniversity,Binzhou,Shandong 256603,China

ObjectiveTo explore the hearing screening,and the change and outcome of hearing impairmentof high risk infants.MethodsFrom March,2015 to March,2016,336 high risk infantswere screened w ith otoacoustic emissions(OAE),auditory brainstem response (ABR)and brainstem auditory evoked-potential(BAEP)0-1,3,6,12months after born,respectively.ResultsAmong the 336 high risk infants,29 failed theexam inationsw ithin the1stmonth,37 cases failed in the3rdmonth,27 cases recovered in the9thmonth,and 7 cases recovered in the 12thmonth,3 caseswere finally diagnosed as deafness(0.89%).ConclusionOAE,ABR combining with BAEPexamination may obtain com prehensive diagnosis of hearing impairment for high risk infants,continuous listening com prehensionmonitoring can effectively dynam ically observe thehearing impairment,changesand outcomeof high risk infants.

high risk infants;hearing screening;otoacoustic emissions;auditory brainstem response;brainstem auditory-evoked potential;follow-up

10.3969/j.issn.1006-9771.2016.12.021

R246.81

B

1006-9771(2016)12-1459-03

2016-08-24

2016-09-05)

濱州市科技發(fā)展計(jì)劃項(xiàng)目(No.2014ZC0155)。

濱州醫(yī)學(xué)院附屬醫(yī)院兒科，山東濱州市256603。作者簡(jiǎn)介：呂攀攀(1985-)，女，漢族，山東淄博市人，碩士，醫(yī)師，主要研究方向：高危兒篩查及早期干預(yù)。E-mail:lvpanpan163@163.com。