RU2570545C1 - Diagnostic technique for intracranial hypertension in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: dynamic position tympanometry with the use of a rotary table aims at recoding tympanograms to be transmitted to a computer. A first test procedure is performed in a vertical, and then horizontal position from two points of 90° and 0°. In each point, six tympanograms are recorded and then digitised; two 90°- and 0°-point tympanograms maximum displaced from each other are presented in Excel application. Each point of the vertical tympanogram are sequentially subtracted from respective horizontal values, and a curve derivative reflecting an acoustic compliance of a cochlear window is produced. If the acoustic compliance is 0.07-0.12 cm³, the absence of intracranial hypertension (ICH) is diagnosed; the values of 0.13-0.2 cm³ show a mild form of ICH; if the values are 0.21-0.3 cm³, the moderate form of ICH is diagnosed, whereas pronounced ICH is shown by the value of more than 0.3 cm³.

EFFECT: technique enables providing more reliable diagnosis that is ensured by recording the tympanograms in the declared mode and deriving the acoustic compliance of the cochlear window.

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Description

The invention relates to medicine, namely to neurology, neurosurgery, anesthesiology, resuscitation, and can be used for non-invasive determination of intracranial pressure (ICP) in pediatrics.

Intracranial hypertension syndrome (ICH) is one of the main problems in clinical neurology and neurosurgery. The main pathological conditions, such as intracranial volume processes, traumatic brain injury, subarachnoid hemorrhages, infectious meningitis, hydrocephalus, are often accompanied by a clinic of ICH syndrome up to irreversible dysfunctions of the central nervous system (Gasparyan S.S. Clinic, diagnosis and treatment of patients with the syndrome benign intracranial hypertension: thesis of a doctor of medical sciences. - Moscow, 1998, - 246 s).

Various types of sensors are used to monitor ICP: epidural, intraparenchymal, intraventricular. However, the use of these sensors is associated with a risk of bleeding, infection, and damage to brain matter. Ventricular drainage and insertion of a ventricular catheter are currently the gold standard for ICP monitoring, with which data obtained using other techniques are compared. Among its advantages include high measurement accuracy, the ability to remove cerebrospinal fluid to reduce high ICP, as well as relative simplicity and accessibility in clinical practice (Kovalev V.V., Gorbachev V.I. Intensive therapy of intracranial dislocation syndrome // Siberian Medical Journal. - 2009. - No. 3 (Issue 2). - S. 69-73).

A known method of intraventricular ICP measurement is a hydraulic system, the principle of which is based on the transmission of pressure of a column of cerebrospinal fluid to a special measuring device. After the installation of a ventricular catheter, a measuring system is attached to it (Petrikov S.S., Krylov V.V. Neuromonitoring in patients with intracranial hemorrhage. Part 2. Assessment of cerebral blood flow and neurophysiological monitoring // Neurosurgery. - 2010. - No. 1. - C. 5-9).

The disadvantage is the danger of the development of purulent-septic complications and a high probability of catheter blocking due to increasing compression of the ventricles and closure of the lumen by a blood clot.

A known method for measuring ICP is the Spiegelberg monitor, which is based on the installation of a special double-lumen ventricular catheter in the ventricle of the brain. At the end of the catheter is a canister connected to a measuring device. The second channel of the catheter is used to drain the CSF. After ventriculostomy, the monitor fills the can with air and determines the ICP by the degree of CSF pressure on the can wall. When using the device, manual calibration of the measuring device by atmospheric pressure is not required (Petrikov S.S., Krylov V.V. Neuromonitoring in patients with intracranial hemorrhage. Part 2. Assessment of cerebral blood flow and neurophysiological monitoring // Neurosurgery. - 2010. - No. 1 . - S. 5-9).

The disadvantage of the method of ventricular drainage is compression of the ventricular system, “slit-like” ventricles in case of cerebral edema, coagulopathy, cerebellar-tentorial dislocation (Kovalev V.V., Gorbachev V.I. Intensive therapy of intracranial dislocation syndrome // Siberian Medical Journal. - 2009. - No. 3 (issue 2). - S. 69-73).

A known method for the diagnosis of intracranial hypertension in pediatrics by performing transcranial dopplerography, when at values of the velocity of blood flow through the basal veins more than 22 cm / s and the speed of blood flow through the direct sinus of more than 34 cm / s is diagnosed with increased intracranial pressure (RF Patent No. 2171631).

A known method for the diagnosis of intracranial hypertension, according to which indicators of heart rate variability are determined: normalized power in the low frequency range, mode amplitude, maximum cardio interval in the sample. The values of the coefficients F1 and F2 are calculated according to the formulas: F1 = -13.46 + 35.1 × x1-8.04 × x 2 + 7.48 × x3; F2 = -12.17 + 27.97 × x1 + 4.41 × x2 + 7.76 × x3; where x1 - LFnorm - normalized power in the low frequency range; x2 - AMo - the amplitude of the mode (the proportion of cardio intervals corresponding to the value of the mode); x3 - max. - maximum cardio interval in the sample. When F2 is greater than F1, the presence of intracranial hypertension greater than 20 mm Hg is diagnosed. Art., and with F1 greater than F2 - its absence (RF Patent No. 2428925).

The disadvantage of this method is the dependence of heart rate variability on the state of the autonomic nervous system. The method requires certain conditions: in a quiet, calm room with constant temperature and humidity, before the study, the patient needs to adapt to the conditions (Yabluchansky NI, Martynenko A.V. Heart rate variability to help a practitioner. - Kharkov. - 2010. - S.42), which is difficult in pediatric practice, especially in younger patients.

Otoacoustic methods for assessing ICP are based on the presence of a reliable close anatomical and physiological connection between the inner ear and intracranial structures, as well as on experimentally established patterns of the relationship between cerebrospinal fluid dynamics and inner ear function.

A known method for displacement of the eardrum during the stapedi reflex, according to which the normal ICP leads to bilateral displacement of the eardrum during the implementation of the acoustic stapedi reflex, while with increased ICP its displacement inside. When the intracranial pressure is low, contraction of the stapedial muscle leads to the displacement of the eardrum outside. Eardrum displacement is measured using the Marchbanks measurement system (MMS) (Ayache D., Nengsu Tchuente Α., Plouin-Gaudon I. et al. Assessment of perilymphatic pressure using the MMS-10 tympanic membrane displacement analyzer (Marchbanks ′ test) in patients with Meniere's disease: preliminary report // Ann Otolaryngol Chir Cervicofac. - 2000. - Vol. 117 (3). - P. 183-188).

A known method for determining changes in intracranial pressure, including installing the insert in the external ear canal to form a sealed chamber in it, creating air pressure in it using an air pump, supplying an audible tone, while the air pressure in the chamber is changed in a dosed manner, the sound tone is produced continuously, register two tympanograms with an interval of time between measurements, find the relative change in the magnitude of the acoustic compliance of the eardrum according to the formula:

, $${\text{C}}_{\text{2}}\left({\text{P}}_{\text{0}}{}^{\text{2}}\right)$$

- величины акустической податливости барабанной перепонки в первом и втором измерениях соответственно; $${\text{P}}_{\text{0}}{}^{\text{1}}$$

, $${\text{P}}_{\text{0}}{}^{\text{2}}$$

- величины давления воздуха в полости среднего уха пациента в первом и втором измерениях соответственно, а значение величины ΔC_1,2 является мерой изменения величины внутричерепного давления (Бохов Б.Б., Патент РФ №2163090, 2001 г.).where ΔС _1,2 is the relative change in the magnitude of the acoustic compliance of the eardrum in the time interval between the first and second measurements; $${\text{C}}_{\text{one}}\left({\text{<figure-callout id="0" label="P" filenames="00000011.png" state="{{state}}">P</figure-callout>}}_{\text{0}}{}^{\text{one}}\right)$$

, $${\text{C}}_{\text{2}}\left({\text{<figure-callout id="0" label="P" filenames="00000011.png" state="{{state}}">P</figure-callout>}}_{\text{0}}{}^{\text{2}}\right)$$

- the magnitude of the acoustic compliance of the eardrum in the first and second dimensions, respectively; $${\text{<figure-callout id="0" label="P" filenames="00000011.png" state="{{state}}">P</figure-callout>}}_{\text{0}}{}^{\text{one}}$$

, $${\text{<figure-callout id="0" label="P" filenames="00000011.png" state="{{state}}">P</figure-callout>}}_{\text{0}}{}^{\text{2}}$$

- the air pressure in the middle ear cavity of the patient in the first and second measurements, respectively, and the value of ΔC _1.2 is a measure of the change in the value of intracranial pressure (Bokhov BB, RF Patent No. 2163090, 2001).

There is a known otoacoustic method for diagnosing intracranial hypertension by the method of positional tympanometry, based on the fact that the ICP and perilymph pressure when deviating from the vertical by changing the membrane resistance of the round window changes the stiffness of the middle ear conduction system, increasing it, which contributes to the displacement of the eardrum outside. The method consists in isolating from the standard tympanogram a component related to the inner ear and having a high sensitivity to changes in intracranial pressure (Bokhov B. B. Change in the flexibility of the inner ear when the body deviates from the vertical // Herald of Otorhinolaryngology. - 2007. - No. 5. - C . 14-19).

Tympanometry as a method of measuring intracranial pressure is best suited for measuring intracranial pressure precisely in children with hydrocephalus, benign intracranial hypertension, after a traumatic brain injury, since in this age group the deviation of the tympanic membrane most accurately correlates with a change in the intracranial pressure due to good patency of the cochlea’s water supply ( Reid Α., Marchbanks RJ, Bateman DE et al. The relationship between intracranial pressure and tympanic membrane displacement // Br J Audiol. - 1990. - Vol. 24. - P. 123-129).

A known method of measuring ICP by the method of dynamic positional tympanometry. The study is carried out on a standard impedance meter "GSI-61" (USA) with a sounding sound frequency of 226 Hz and an intensity of 85.5 dB. The rate of compliance measurement is 5 measurements per second with a time interval of 0.2 s. A rotary table was used for stepwise deviation from the vertical. The table rotation speed was 5 deg / s. The first test was carried out in a horizontal position, then the turntable was installed vertically. The tilt angle was counted from the horizontal. A total of 9 positions were used: 90 ° 75 °, 60 °, 45 °, 30 ° 15 °, 0 °. Tympanograms were taken immediately after stopping the table in each of the 9 listed positions and transferred to a computer in digital form. The total examination time was about 10 minutes for each ear. The method allowed to identify the features of the transformed tympanometric curve during the hydrops of the labyrinth. For this, the shape of the tympanometric curve was compared in patients with labyrinth hydrops, confirmed by psychoacoustic methods and electrocochleography, and in normally hearing volunteers. In patients with hydrops in areas corresponding to high pressure in the external auditory meatus, compliance did not change much, resembling a tympanogram, as with exudative otitis media. It indicated a delay in the reaction of the inner ear due to increased pressure of fluids in response to a decrease in pressure in the external auditory canal. Thus, using dynamic tympanometry, it is possible to non-invasively confirm the presence of ICH and endolymphatic hydrops (Eremeeva N.V. Kokhleovestibular disturbances in patients with altered cerebrospinal fluid dynamics: Abstract of thesis, Candidate of Medical Sciences. - Moscow, 2011. - 26 p.).

The disadvantage of this method is the use of 9 positions of the turntable for measuring tympanograms, which is hardly tolerated by children, especially young children, and also lengthens the study time. In intermediate positions of 75-15 °, the effect of cerebrospinal fluid pressure and perilymph on the middle ear structures is less pronounced, and the acoustic compliance of the tympanic membrane may not reach its maximum change.

The method we have chosen as a prototype.

The objective of the invention is to develop a method for the diagnosis of intracranial hypertension in children.

The technical result aimed at solving the problem is the maximum non-invasiveness and simplicity of the method.

The essence of the method of positional tympanometry, adapted for pediatric practice, is that the study is carried out on a standard impedance meter "AT-235" (Denmark) with a sounding sound frequency of 226 Hz and an intensity of 85.5 dB. The measurement speed is 5 measurements per second with a time interval of 0.2 seconds. To deviate from the vertical, use a rotary table. Table rotation speed is 5 deg / s. The tilt angle is counted from the horizontal, while using 2 positions: 90 ° and 0 °, in each of which six tympanograms are recorded. The tympanograms in digital form are transmitted to a computer. The total examination time is about 5 minutes for each ear. Using the Excel program, two tympanograms of the 90 ° and 0 ° positions that are maximally offset from each other are distinguished, and each point of the tympanogram of the vertical position is sequentially subtracted from the corresponding values of the tympanogram of the horizontal position. The result is a derivative curve reflecting the acoustic compliance of the round window of a water pipe in a cochlea.

Acoustic compliance in the range of 0.07-0.12 cm ³ reflects the normal ICP, acoustic compliance of 0.13-0.2 cm ³ corresponds to light ICH, acoustic compliance in the range of 0.21-0.3 cm ³ corresponds to moderate ICG, and an indicator above 0.3 cm ^{3 is} regarded as a pronounced ICH.

Clinical examples of the method.

Example 1. Girl Ya., 16 years old, came to the Scientific Research Institute of NIHT on 04.24.2014 with complaints of frequent headaches accompanied by nausea. A history of concussion four years ago. When examining the fundus of the pathology, no pathology was detected, while conducting transcranial dopplerography, slight difficulty in the venous outflow. The child underwent positional tympanometry using a standard AT-235 impedance meter (Denmark) with a sounding sound frequency of 226 Hz and an intensity of 85.5 dB. The measurement speed is 5 measurements per second with a time interval of 0.2 seconds. To deviate from the vertical used a turntable. The table rotation speed was 5 deg / s. The tilt angle was counted from the horizontal, and 2 positions were used: 90 ° and 0 °, in each of which six tympanograms were recorded. The tympanograms in digital form were transmitted to a computer. The total examination time was about 5 minutes for each ear. Using the Excel program, two tympanograms of the 90 ° and 0 ° positions, maximally offset from each other, were isolated, and each point of the tympanogram of the vertical position was sequentially subtracted from the corresponding values of the tympanogram of the horizontal position. The result was a derivative curve reflecting the acoustic compliance of a round snail water pipe window. The maximum acoustic compliance is 0.16 cm ³ , which is regarded as a mild form of intracranial hypertension (Fig. 1). Neurologist prescribed treatment. When re-examined on 06/18/2014, the maximum acoustic compliance was 0.07 cm ³ (Fig. 2). There are no complaints, headaches do not bother.

Example 2. Girl A., 11 years old, turned to the Scientific Research Institute of NDHiT 09/26/2013, with complaints of headaches with nausea and repeated vomiting, which brings relief. On MRI, endosuprasellar pituitary microadenoma was revealed, while fundus examination revealed angiopathy of the retinal vessels, during transcranial dopplerography - moderate venous outflow obstruction. The child underwent positional tympanometry using a standard AT-235 impedance meter (Denmark) with a sounding sound frequency of 226 Hz and an intensity of 85.5 dB. The measurement speed is 5 measurements per second with a time interval of 0.2 seconds. To deviate from the vertical used a turntable. The table rotation speed was 5 deg / s. The tilt angle was counted from the horizontal, and 2 positions were used: 90 ° and 0 °, in each of which six tympanograms were recorded. The tympanograms in digital form were transmitted to a computer. The total examination time was about 5 minutes for each ear. Using the Excel program, two tympanograms of the 90 ° and 0 ° positions, maximally offset from each other, were isolated, and each point of the tympanogram of the vertical position was sequentially subtracted from the corresponding values of the tympanogram of the horizontal position. The result was a derivative curve reflecting the acoustic compliance of a round snail water pipe window. The maximum acoustic compliance is 0.26 cm ³ , which is regarded as moderate intracranial hypertension (Fig. 3). Neurologist prescribed treatment. When re-examined on 06/28/2014, the maximum acoustic compliance of 0.14 cm ³ was regarded as mild intracranial hypertension (Fig. 4). There are no complaints, headaches do not bother.

Example 3. Girl Z., 16 years old, was admitted to the Scientific Research Institute of NDChT 03/19/2013 with a diagnosis of occlusive hydrocephalus with severe headache, repeated vomiting, dizziness. On the fundus congestion. The child underwent positional tympanometry using a standard AT-235 impedance meter (Denmark) with a sounding sound frequency of 226 Hz and an intensity of 85.5 dB. The measurement speed is 5 measurements per second with a time interval of 0.2 seconds. To deviate from the vertical used a turntable. The table rotation speed was 5 deg / s. The tilt angle is counted from the horizontal, using 2 positions: 90 ° and 0 °, in each of which six tympanograms were recorded. The tympanograms in digital form were transferred to a computer. The total examination time was about 5 minutes for each ear. Using the Excel program, two tympanograms of the 90 ° and 0 ° positions, maximally offset from each other, were isolated, and each point of the tympanogram of the vertical position was sequentially subtracted from the corresponding values of the tympanogram of the horizontal position. The result was a derivative curve that reflects the acoustic compliance of a round snail water window. The maximum acoustic compliance was 1.02 cm ³ (Fig. 5), which is regarded as a pronounced ICH. Ventriculoperitoneal bypass surgery was performed on an emergency basis. On examination, 03/21/2013, the girl is feeling well, there are no complaints. Positional tympanometry showed an acoustic compliance of 0.37 cm ³ (Fig. 6).

By way of positional tympanometry, 93 children aged 4 to 18 years were examined at the Scientific Research Institute for Nuclear Chemistry and Technology. The obtained results were compared with the results of other non-invasive techniques: TCD, neurophthalmological examination, phase contrast MRI in liquorodynamics mode. The specificity of the method was 82% and the sensitivity was 80%. The diagnostic effectiveness of the method is 82% with mandatory anatomical safety and the absence of inflammatory changes in the structures of the middle and inner ear of the examined children.

The method can be used in neurology, neurosurgery, otoneurology for non-invasive determination of intracranial pressure when examining children with suspected ICH in an outpatient and inpatient setting. The method does not require expensive equipment and can be applied an unlimited number of times.

The results of the study can be used to diagnose intracranial hypertension on an outpatient basis and for a dynamic study of intracranial pressure during treatment of patients.

Claims (1)

A method for diagnosing intracranial hypertension in children by the method of dynamic positional tympanometry using a rotary table, the tympanograms are taken immediately after the table stops and transferred to the computer in digital form, characterized in that the first test is carried out in an upright position, then the turntable is installed horizontally, the tympanograms are removed immediately after table stops, for measurements use 2 positions: 90 ° and 0 °, examination time - 5 minutes, in each position register tympanograms, tympanograms are digitized and, using the Excel program, two tympanograms of 90 ° and 0 ° positions, maximally offset from each other, are extracted and each point of the tympanogram of vertical position is sequentially subtracted from the corresponding values of the tympanogram of horizontal position, a derived curve is obtained that reflects the acoustic flexibility of a round windows of the water supply of the cochlea, and at values of acoustic compliance of 0.07-0.12 cm ³ diagnose the absence of ICH, at values of 0.13-0.2 cm ³ diagnostician mild form of ICH, with values of 0.21-0.3 cm ³ - moderate form of ICH, and an indicator above 0.3 cm ^{3 is} regarded as a pronounced form of ICH.

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