非耳疾就診患者的聽(tīng)力篩查意愿與篩查結(jié)果分析*

蘇俊波，駱文龍，王德平，郝亞寧

(重慶醫(yī)科大學(xué)附屬第二醫(yī)院耳鼻咽喉頭頸外科 400010)

論著·臨床研究

非耳疾就診患者的聽(tīng)力篩查意愿與篩查結(jié)果分析*

蘇俊波，駱文龍△，王德平，郝亞寧

(重慶醫(yī)科大學(xué)附屬第二醫(yī)院耳鼻咽喉頭頸外科 400010)

目的 調(diào)查非耳疾就診患者的聽(tīng)力篩查意愿及分析篩查結(jié)果，提高醫(yī)護(hù)人員與患者對(duì)聽(tīng)力健康的重視程度，盡可能避免可控因素致聽(tīng)力損害。方法 記錄參與調(diào)查患者的臨床資料，對(duì)其中愿意行聽(tīng)力篩查者行純音聽(tīng)閾測(cè)定并分析結(jié)果；對(duì)拒絕行聽(tīng)力篩查者完成問(wèn)卷以明確其拒絕原因。結(jié)果 280例參與調(diào)查的患者中，72例愿意行聽(tīng)力篩查，208例拒絕聽(tīng)力篩查；拒絕篩查的主要原因?yàn)樽杂X(jué)聽(tīng)力正常、自覺(jué)聽(tīng)力與本次就診疾病無(wú)關(guān)；年齡大于或等于60歲、家屬或身邊重要人士有聽(tīng)力疾患者較對(duì)照組更愿意接受聽(tīng)力篩查(均P<0.05)；約40.00%長(zhǎng)期服藥患者存在聽(tīng)力障礙，較對(duì)照組更多(P<0.05)；自覺(jué)聽(tīng)力狀況與純音聽(tīng)閾測(cè)定結(jié)果之間差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 聽(tīng)力障礙在非耳疾就診患者中有極高的患病率，高齡、長(zhǎng)期服藥等患者應(yīng)特別重視聽(tīng)力健康狀況；自覺(jué)聽(tīng)力正常者仍應(yīng)警惕潛在的聽(tīng)力障礙。

聽(tīng)力篩查；主觀意愿；聽(tīng)力障礙

聽(tīng)力障礙是全球范圍內(nèi)的沉重醫(yī)療負(fù)擔(dān)。根據(jù)最新流行病學(xué)資料顯示，全球聽(tīng)力殘疾人數(shù)已達(dá)3.6億，其中成年人約3.28億，男性多于女性。根據(jù)我國(guó)流行病學(xué)調(diào)研數(shù)據(jù)推算，我國(guó)聽(tīng)力減退患病率約為11.7%[1]。然而，聽(tīng)力減退實(shí)際就診率卻遠(yuǎn)低于患病率，大量的聽(tīng)力障礙患者隱藏在人群中。人體是一有機(jī)整體，聽(tīng)力疾病與全身其他系統(tǒng)疾病密切相關(guān)；年齡、耳毒性藥物使用、噪聲刺激等多種因素均可導(dǎo)致聽(tīng)力下降。迄今為止，針對(duì)成年人的聽(tīng)力篩查依然缺乏足夠的重視，尤其是對(duì)非耳疾就診患者的聽(tīng)力健康狀況依然缺乏醫(yī)護(hù)人員以及患者自身的重視，本研究旨在調(diào)查非耳疾就診患者的聽(tīng)力篩查意愿以及分析篩查結(jié)果，提高醫(yī)護(hù)人員與患者對(duì)聽(tīng)力健康的重視程度，盡可能避免可控因素致聽(tīng)力損害。

1 資料與方法

1.1 一般資料 收集2015年12月1日至30日就診于本科的非耳疾患者280例。見(jiàn)表1。其中，男133例，女147例；年齡18～83歲，60歲及以上者占33.93%(95例)，平均年齡(51.35±13.50)歲，中位數(shù)年齡為51歲；長(zhǎng)期居住于城市的患者占55.36%(155例)，農(nóng)村患者為44.64%(125例)；患者家屬或身邊重要人士有聽(tīng)力疾病者占43.93% (123例)；因慢性病需長(zhǎng)期服藥者41.79%(117例)；自訴噪音暴露史者38.57%(108例)。

1.2 方法 對(duì)患者進(jìn)行詳細(xì)的聽(tīng)力篩查講解，對(duì)其中愿意行聽(tīng)力篩查的患者行純音聽(tīng)閾測(cè)定，并記錄其性別、年齡、長(zhǎng)期居住地、耳聾患者接觸史、長(zhǎng)期服藥史、噪音刺激史、自覺(jué)聽(tīng)力狀況，進(jìn)行統(tǒng)計(jì)分析；對(duì)拒絕聽(tīng)力篩查但愿意行問(wèn)卷調(diào)查的患者進(jìn)行詳細(xì)的問(wèn)卷調(diào)查解說(shuō)并完成問(wèn)卷。其中，耳聾患者接觸史為患者親人或身邊重要人士是否有聽(tīng)力障礙疾?。婚L(zhǎng)期服藥史為患者就診時(shí)已服藥1個(gè)月及以上、就診后需繼續(xù)長(zhǎng)時(shí)間服藥的情況。依據(jù)WHO聽(tīng)力減退分級(jí)依據(jù)，對(duì)純音聽(tīng)閾測(cè)定測(cè)定結(jié)果中，任一耳0.5、1.0、2.0、4.0 kHz平均聽(tīng)閾大于25 dB認(rèn)定為聽(tīng)力異常，如以上頻率雙耳平均聽(tīng)閾均不大于25 dB則認(rèn)定為聽(tīng)力正常。

1.3 統(tǒng)計(jì)學(xué)處理 采用SPSS 19.0軟件對(duì)收集的數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析，依據(jù)是否愿意行聽(tīng)力篩查分組后，組內(nèi)依性別、年齡、長(zhǎng)期居住地、耳聾患者接觸史、長(zhǎng)期服藥史、噪音刺激史等分亞組，進(jìn)行χ2檢驗(yàn)；對(duì)拒絕行聽(tīng)力篩查的患者，依據(jù)其一般特征與拒絕原因，進(jìn)行卡方檢驗(yàn)；對(duì)進(jìn)行聽(tīng)力篩查的患者，依據(jù)篩查結(jié)果正常與否進(jìn)行分組，再依據(jù)性別、年齡、長(zhǎng)期居住地、耳聾患者接觸史、長(zhǎng)期服藥史、噪音刺激史、自覺(jué)聽(tīng)力狀況等分亞組，進(jìn)行卡方檢驗(yàn)；以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

2.1 280例患者聽(tīng)力篩查意愿與患者主要特征的關(guān)系 280例非耳疾就診患者中，僅72例(占25.71%)愿意行聽(tīng)力篩查。依據(jù)患者聽(tīng)力篩查意愿及性別、年齡、長(zhǎng)期居住地、耳聾患者接觸史、長(zhǎng)期服藥史、噪音刺激史等分別分組進(jìn)行統(tǒng)計(jì)學(xué)分析后發(fā)現(xiàn)，年齡大于或等于60歲的患者較年齡小于60歲者更愿意行聽(tīng)力篩查(P=0.000)；患者家屬或身邊重要人士有聽(tīng)力疾患者，更容易接受聽(tīng)力篩查(P=0.013)，見(jiàn)表1。

2.2 208例拒絕聽(tīng)力篩查人員主要特征及其拒絕原因分析 對(duì)208例拒絕性聽(tīng)力篩查的患者進(jìn)行問(wèn)卷調(diào)查，根據(jù)其選擇的拒絕聽(tīng)力篩查的主要原因與其主要特征分組比較發(fā)現(xiàn)，拒絕篩查的主要原因?yàn)樽杂X(jué)聽(tīng)力正常、自覺(jué)聽(tīng)力與本次就診疾病無(wú)關(guān)。年齡小于60歲者較大于或等于60歲者更多地認(rèn)為“自覺(jué)聽(tīng)力正?！倍芙^行聽(tīng)力篩查(P=0.004)；年齡大于或等于60歲者較小于60歲者更多地因主觀認(rèn)為“聽(tīng)力不重要”、“經(jīng)濟(jì)原因”以及“害怕檢查出聽(tīng)力問(wèn)題”而拒絕行聽(tīng)力篩查，P分別為0.003、0.021、0.038；長(zhǎng)期居住于城市者較農(nóng)村患者更多地認(rèn)為“自覺(jué)聽(tīng)力正?！倍芙^行聽(tīng)力篩查(P=0.000)，而農(nóng)村患者較城市患者更多地因“本次就診疾病與聽(tīng)力無(wú)關(guān)”而拒絕行聽(tīng)力篩查(P=0.000)；其余組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見(jiàn)表2。

2.3 72例患者主要特征與聽(tīng)力篩查結(jié)果分析 對(duì)所有72例愿意行聽(tīng)力篩查的患者進(jìn)行純音聽(tīng)閾測(cè)定后發(fā)現(xiàn)，≥60歲者約35.56%存在聽(tīng)力異常，較年齡小于60歲為多(P=0.028)；因慢性疾病長(zhǎng)期服藥患者中，約40.00%存在聽(tīng)力異常，較無(wú)長(zhǎng)期服藥病史者更多，差異有統(tǒng)計(jì)學(xué)意義(P=0.016)；5例自覺(jué)聽(tīng)力正常患者篩查出聽(tīng)力下降，而1名自覺(jué)聽(tīng)力異?；颊?，經(jīng)純音聽(tīng)閾測(cè)定，未發(fā)現(xiàn)聽(tīng)閾改變，自覺(jué)聽(tīng)力狀況與純音聽(tīng)閾測(cè)定結(jié)果之間差異有統(tǒng)計(jì)學(xué)意義(P=0.000)，見(jiàn)表3。

表1 280例患者聽(tīng)力篩查意愿與患者主要特征的關(guān)系(n)

表2 208例拒絕聽(tīng)力篩查人員主要特征及其拒絕原因分析(n)

表3 72例患者主要特征與聽(tīng)力篩查結(jié)果分析(n)

3 討 論

目前，我國(guó)已經(jīng)廣泛開(kāi)展新生兒聽(tīng)力篩查，但對(duì)成人的聽(tīng)力篩查重視程度依然十分欠缺。大多數(shù)體檢并未將純音聽(tīng)閾測(cè)定等較為準(zhǔn)確的聽(tīng)力測(cè)定作為體檢手段。本研究中，僅25.71%非耳疾就診患者在聽(tīng)取醫(yī)務(wù)人員詳細(xì)的聽(tīng)力篩查宣講后選擇行聽(tīng)力篩查，拒絕篩查的主要原因?yàn)樽杂X(jué)聽(tīng)力正常、自覺(jué)聽(tīng)力與本次就診疾病無(wú)關(guān)，尤其是年齡小于60歲者較大于或等于60歲者更多地認(rèn)為“自覺(jué)聽(tīng)力正?！倍芙^行聽(tīng)力篩查，城市患者較農(nóng)村患者更多地認(rèn)為“自覺(jué)聽(tīng)力正?！倍芙^行聽(tīng)力篩查。然而，對(duì)72例純音聽(tīng)閾測(cè)定結(jié)果分析發(fā)現(xiàn)，自覺(jué)聽(tīng)力正常與純音聽(tīng)閾測(cè)定結(jié)果并不一致，主觀感覺(jué)并不可靠。國(guó)外研究發(fā)現(xiàn)，聽(tīng)力相關(guān)癥狀、自我感覺(jué)的聽(tīng)力損失并不能很好地預(yù)測(cè)噪音性耳聾，常規(guī)的聽(tīng)力檢查對(duì)防治噪音性耳聾極為重要[2]。這一結(jié)論與本研究吻合，開(kāi)展成年人的聽(tīng)力篩查對(duì)防治耳聾極為重要而迫切。

在本研究中，聽(tīng)力障礙有極高的患病率，大于或等于60歲者，約35.56%存在聽(tīng)力異常，較年齡小于60歲為多。雖然聽(tīng)力障礙與年齡關(guān)系密切，高齡人群比年輕人群有更高的聽(tīng)力障礙患病率，但年齡絕非聽(tīng)力下降的唯一因素，環(huán)境因素、生活習(xí)慣等多種因素均與聽(tīng)力下降的發(fā)生密切相關(guān)[3-5]。

聽(tīng)力下降與全身疾病的關(guān)系越來(lái)越引起國(guó)內(nèi)外耳科醫(yī)生的重視。Hong等[6]通過(guò)對(duì)9 786例成年韓國(guó)人的研究發(fā)現(xiàn)，聽(tīng)力下降與蛋白尿有關(guān)，Moon等[7]研究認(rèn)為，血液中過(guò)高濃度的高密度脂蛋白、尿酸、總膽紅素等增加罹患老年性聾的風(fēng)險(xiǎn)，大量研究證明糖尿病與耳聾密切相關(guān)，風(fēng)濕性關(guān)節(jié)炎患者更容易出現(xiàn)聽(tīng)力損失[8-9]。而諸如上述眾多疾病的首要表現(xiàn)并非耳聾，如高尿酸血癥者表現(xiàn)為痛風(fēng)，高膽紅素者表現(xiàn)為黃疸等，且此類疾病通常需長(zhǎng)期藥物治療。越來(lái)越多的藥物甚至其他治療被證實(shí)與聽(tīng)力損失有關(guān)[10]。Thirumala等[11]發(fā)現(xiàn)，三叉神經(jīng)痛、膝狀神經(jīng)節(jié)痛、舌咽神經(jīng)痛等經(jīng)微血管解壓治療后可能出現(xiàn)高頻聽(tīng)力損失。在本研究中，因慢性疾病長(zhǎng)期服藥患者中，約40.00%存在聽(tīng)力異常，較無(wú)長(zhǎng)期服藥病史者更多，差異有統(tǒng)計(jì)學(xué)意義；農(nóng)村患者較城市患者更多地因“本次就診疾病與聽(tīng)力無(wú)關(guān)”而拒絕行聽(tīng)力篩查；如患者、醫(yī)護(hù)人員缺乏對(duì)患者聽(tīng)力的重視，缺乏對(duì)治療與聽(tīng)力損失之間的認(rèn)識(shí)，將極大地增加患者醫(yī)源性聽(tīng)力損失的潛在危險(xiǎn)。

人體是一有機(jī)的整體，全身疾病會(huì)影響聽(tīng)力，而聽(tīng)力同樣會(huì)影響全身疾病。研究發(fā)現(xiàn)，聽(tīng)力障礙會(huì)導(dǎo)致認(rèn)知力下降[12]，聽(tīng)力下降者更容易得阿爾茲海默病[13]，每提高一個(gè)標(biāo)準(zhǔn)差的聽(tīng)力損失將會(huì)增加約0.23%的癡呆表現(xiàn)[14]，聽(tīng)力下降影響生活質(zhì)量已基本得到業(yè)界公認(rèn)[15]。而且聽(tīng)力下降的老年人較無(wú)聽(tīng)力下降者有更高的住院率[16]。而在本研究中，年齡大于或等于60歲者較小于60歲者更多地因主觀認(rèn)為“聽(tīng)力不重要”而拒絕行聽(tīng)力篩查。在臨床工作中，存在大量人群無(wú)視聽(tīng)力的重要性，加強(qiáng)聽(tīng)力知識(shí)普及，提高人們對(duì)聽(tīng)力的重視程度，才能更好地防治耳聾，防治因耳聾導(dǎo)致其他疾病的發(fā)生。

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Willingness to hearing screening of non hearing disease patients and the result of hearing screening*

SuJunbo,LuoWenlong△，WangDeping，HaoYaning

(DepartmentofOtorhinolaryngology,HeadandNeckSurgery,theSecondAffiliatedHospitalofChongqingMedicalUniversity,Chongqing400010,China)

Objective To investigate the willingness of hearing screening of non-hearing disease patients and analysis the hearing test result,in order to make people pay more attention to auditory healthy.Methods Patients clinical data including the willingness of hearing screening,gender,age,residence,hearing disease of someone important,long-term medicine usage,noise exposure were collected.Pure tone audiometry testing were conducted for those who were willing to hearing screening;and a questionaire were conducted to those not.Results Among the 280 interviewers,only 72 patients were willing to hearing screening;frequent reason for refusing hearing screening were no self reported hearing loss and coming to doctor for non-hearing disease;60 years old or elders and have someone important were hearing diseases patients were more willing to hearing screening (P<0.05);40.00% long-term medicine usage patients were suffering hearing loss(P<0.05);self reported hearing loss was not the same as the test result (P<0.05).Conclusion Hearing loss is common in patient who came to doctor for non-hearing diseases.More attention should be paid to those patients who are old,long-term medicine usage,people have no self reported hearing loss should pay attention to hearing loss.

hearing screening；willingness；hearing loss

10.3969/j.issn.1671-8348.2017.08.024

重慶市教委科學(xué)技術(shù)研究項(xiàng)目(KJ1600219)。 作者簡(jiǎn)介：蘇俊波(1977-)，碩士，講師，主要從事耳鼻咽喉頭頸外科臨床及教育教學(xué)研究?！?/p>

，E-mail：luowenlong163@163.com。

R764.5

A

1671-8348(2017)08-1082-03

2016-10-20

2016-12-12)