中耳胆脂瘤并发真菌性外耳道炎及外耳湿疹 1 例

2019-10-11 杨野 晏文奇 孟祥明 临床皮肤科杂志

患者男, 35 岁, 因左外耳反复斑疹伴瘙痒 3 个月余, 于 2018 年 3 月 23 日来中国人民解放军 63600 部队医 院皮肤科门诊就诊。患者 3 个月前游泳后出现左侧外耳 道及耳前区皮肤瘙痒不适, 于掏耳及搔抓后症状加重, 时 伴左侧外耳道少量黄白色脓液流出,耳前区皮肤多形性 红斑, 上覆少量鳞屑, 当时未予重视及诊治。上述症状反 复发作且逐渐加重, 瘙痒症状严重影响正常工作学习,

1 病历摘要

患者男, 35 岁, 因左外耳反复斑疹伴瘙痒 3 个月余, 于 2018 年 3 月 23 日来中国人民解放军 63600 部队医 院皮肤科门诊就诊。患者 3 个月前游泳后出现左侧外耳 道及耳前区皮肤瘙痒不适, 于掏耳及搔抓后症状加重, 时 伴左侧外耳道少量黄白色脓液流出,耳前区皮肤多形性 红斑, 上覆少量鳞屑, 当时未予重视及诊治。上述症状反 复发作且逐渐加重, 瘙痒症状严重影响正常工作学习, 遂 就诊于当地医院耳鼻喉科,诊断为左外耳道炎,给予氧 氟沙星滴耳液、 头孢氨苄胶囊、氯雷他定片抗炎及抗组 胺治疗 2 周,外耳瘙痒症状较前有所改善,但仍有间断性左耳渗液,外耳斑疹未见明显消退。后遇病情加重时, 患者则自行购买氧氟沙星滴耳液、 复方醋酸地塞米松乳 膏、氯雷他定等药物治疗,上述症状有所改善但反复发 作。近 1周来患者左耳前无明显诱因出现瘙痒性斑疹。 患者既往体健,无药物、食物过敏史及其他慢性疾病 史,家族成员中无类似疾病患者。 体格检查:一般情况良好,系统检查无异常,全身 浅表淋巴结未触及增大。皮肤科检查: 左耳前区、 耳屏、 耳轮角、耳甲腔及外耳道前、中段可见多形性红斑,部 分融合,上覆糠秕状鳞屑,局部皮损糜烂、渗液,表面 可见淡黄色痂皮及多处搔抓痕迹。左耳道深部近鼓膜 处可见团块状物质, 鼓膜标志不清。右耳前区可见约指 甲盖大形状不规则红斑,上覆少量鳞屑,未见糜烂及 渗出,右侧外耳道通畅, 未见明显异常(图 1)。 实验室及辅助检查:患者左侧外耳道深部查见团块状新生物,遂请我院耳鼻喉科行电子纤维耳镜检查 示:左外耳道前、 中段可见红斑、 鳞屑、糜烂及少量淡黄 色渗液,外耳道深部可见黄白色绒毛状或絮状物生长, 鼓膜松弛部可见凹陷及黄色新生物,右外耳道及鼓膜 未见明显异常(图 2)。取左侧外耳道深部黄白色絮状生 长物送检,经棉蓝染色后镜检符合曲霉属镜下形态(图3)。分别取左侧外耳道前、 中部及耳前皮损处标本未检 出真菌。 诊断:①真菌性外耳道炎(左);②外耳湿疹(双);③ 中耳胆脂瘤(左)。 治疗:每日用适量温生理盐水行左侧外耳道冲 洗;3%硼酸洗液外耳道条状纱布湿敷收敛干燥,每日3 次;曲安奈德益康唑乳膏棉拭子左侧外耳道涂擦治 疗,每日 2 次,共 2 周;伊曲康唑 0.2 g,每日 2 次,间歇 冲击治疗2 个疗程。患者依从性较好, 每日坚持来我院 接受治疗, 2 周后复诊检查双侧外耳皮疹消退,口服伊 曲康唑2 个疗程后复查,左侧外耳道清洁,无渗出、糜 烂及渗液,真菌镜检及培养均阴性。针对左侧中耳胆脂 瘤转入耳鼻喉科进一步治疗。
 


A:右耳前皮损:右耳前见形状不规则红斑、上覆少量鳞屑,未见糜烂及渗出;B:左耳前皮损:左耳前、耳屏、 耳轮角、耳甲腔见大小不一形状不规则红斑,部分融合, 上覆糠秕状鳞屑,局部皮损糜烂、 渗液及淡黄色痂皮 图 1 中耳胆脂瘤并发真菌性外耳道炎及外耳湿疹患者皮损
 


A:右外耳道及鼓膜未见明显异常;B:左外耳道深部可见黄白色绒毛状或絮状物生长,鼓膜松弛部可见凹陷及黄色新生物 图 2 中耳胆脂瘤并发真菌性外耳道炎及外耳湿疹患者电子纤维耳镜像



A:患者外耳道深部送检标本经马铃薯葡萄糖琼脂培养基培养 48 h 后,菌落可见绒毛状或絮状白色边 缘,中央为浅绿色粉末状;B:左外耳道标本真菌涂片镜检示:培养物镜下可见菌丝体、短柱形分生孢 子头和球形分生孢子,顶囊为烧瓶状,符合曲霉属显微镜下形态( 棉蓝染色 ×400) 图 3 中耳胆脂瘤合并真菌性外耳道炎及外耳湿疹患者标本菌落培养及真菌图片镜检像
 
2 讨 论
 
真菌性外耳道炎及外耳湿疹是常见疾病,患者多 因耳部不适就诊于耳鼻喉科,但部分患者同时表现外 耳瘙痒性皮疹而首诊于皮肤科。浅部真菌病为常见的 皮肤黏膜感染,可表现为多种皮肤真菌病,外耳道真菌 感染同属于浅部真菌病范畴,也在皮肤科诊治范围之 内[1]。本例患者由于游泳或频繁掏耳致耳内积水及外耳 道炎症,引起局部皮肤屏障功能障碍[2],未给予规范诊 治,反复多次自行予以广谱抗生素滴耳液及激素类药 物治疗,引起局部环境菌群失调[3],而真菌性外耳道炎 是真菌侵入外耳道或外耳道的条件致病菌,从而导致 外耳道炎症病变。外耳湿疹为累及外耳道、耳廓及外耳 周围皮肤由多种内外因素引起的变态反应性多形性皮 炎,局部皮肤屏障功能障碍为外耳湿疹的主要因素[4],同时外耳道真菌团块的刺激可有外耳道分泌物渗出, 刺激或加重外耳湿疹。该患者行电子显微耳镜检查时 发现鼓膜松弛部凹陷及黄色新生物,耳鼻喉科会诊诊 断:中耳胆脂瘤(左)。该病由 Cruveilhier 于 1828 年描 述为早期肿瘤的胆脂瘤并非真性肿瘤,而以囊内壁为 复层鳞状上皮,囊外以一层厚薄不一的纤维组织与邻 近的骨壁或组织相连的囊性结构[5],伴有慢性化脓性 中耳炎者可有耳流脓,但在不伴感染的胆脂瘤早期可 无任何症状[6]。追问患者病史,自诉近 3 个月来左耳间 断性流脓,且每次予氧氟沙星滴耳液后症状有所好 转,考虑该患者合并慢性化脓性中耳炎的可能性,且 流出的脓液浸泡会刺激外耳皮肤及局部微环境变化, 引起或加重真菌性外耳道炎及外耳湿疹。该患者诊断 明确,主要以保持外耳干燥清洁,恢复局部皮肤屏障, 积极抗真菌为治疗原则。用适量温生理盐水行外耳道 冲洗,清除外耳道内污物,3%硼酸洗液外耳道条状纱 布湿敷收敛干燥清洁,考虑真菌性外耳道炎并发外耳 湿疹,给予曲安奈德益康唑乳膏外耳道涂擦抗炎及抗 真菌治疗[7-9]。根据何平等相关文献报道[10-13],由于真菌 性耳道炎复发率高,如不及时治疗或多次局部用药治 疗无效可发展为难治性复发性真菌性外耳道炎等其 他耳部疾病,给予伊曲康唑间歇冲击疗法 2~3 个疗程后能够取得满意疗效。本例患者口服伊曲康唑 2 个疗 程后来院复诊,耳内窥镜下见左侧外耳道清洁,无充血 和糜烂,复送真菌镜检及培养均阴性,已达临床痊愈。 由于我院周边及地方研究机构条件有限,未能行分子 检测鉴定, 病原微生物室镜检符合曲霉属形态。针对中 耳胆脂瘤于耳鼻喉科进一步治疗。

参考文献略。

原始出处:

杨 野,晏文奇,孟祥明,李元珠等,中耳胆脂瘤并发真菌性外耳道炎及外耳湿疹 1 例[J],临床皮肤科杂志,2019,48(8):490-493.

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    2019-10-13 zhaojie88
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