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罕見之膽脂瘤併發症-Bezold氏膿瘍合併內頸靜脈栓塞

A Rare Complication of Cholesteatoma-Bezold's Abscess and Internal Jugular Vein Thrombosis

摘要


Bezold氏膿瘍(Bezold's abscess)是慢性中耳炎的罕見併發症,在抗生素普及之後更爲少見。由於初期並沒有明顯之症狀,通常被發現的時間較晚。內頸靜脈栓塞是一罕見但可能致命的疾病,常肇因於外傷、腫瘤以及感染。Bezold氏膿瘍併發頭內靜脈血栓形成更是一種極爲罕見的疾病表現,在文獻上相關之案例討論甚少。本文提出1名19歲的男性案例:病人因暈眩、嘔吐4日入急診,亦有耳漏、耳痛持續2日。理學檢查爲發燒併左耳持續性耳漏、耳痛、左頭部壓痛,病人有慢性中耳炎併膽脂瘤病史,故診斷爲左側中耳炎併膽脂瘤急性發炎,建議病人住院接受廣效性抗生素及暈眩治療,並擇期手術。患者於住院第4天曾安排電腦斷層檢查,檢查結果爲左側中耳炎以及乳突炎併骨侵蝕,無明顯頸部膿瘍。病人後因臨床症狀並無改善,且伴有耳後區域劇烈疼痛以及日漸嚴重的左側頸部轉動疼痛,於住院第7天緊急安排接受左側乳突切除術以根除乳突病灶。另因在術中發現乳突下方內側時有大量膿液流出,懷疑有Bezold's abscess可能,因而併作經乳突引流膿瘍及頸部探查手術。術後頸部壓痛雖有減輕但依然持續,而以超音波掃描殘留膿瘍時,赫然發現左側內頸靜脈完全阻塞。核磁共振血管攝影(MRV)發現左側內頸靜脈栓塞,無乙狀竇栓塞。因栓塞部位過於廣泛,故只採觀察方式而未使用抗凝血劑治療,最後病情仍然得到控制。術後5個月後以核磁共振血管攝影追蹤,栓塞仍然存在,並發現有左側乙狀竇栓塞,但無任何後遺症,患者至今追蹤3年,病況穩定。此罕見病例的治療重點首重感染來源之外科清除,至於文獻上對於廣泛內頸靜脈栓塞是否使用抗凝血劑治療,尚無確切之定論。

並列摘要


After the introduction of antibiotics, Bezold's abscess became a rare complication of otits media after the era of antibiotics. It is usually seen at a late stage because there is no specific presentation initially and this results in a failure to consider it as part of the differential diagnosis. Internal jugular vein thrombosis is an uncommon problem that has potentially lethal sequelae. It manifests in diverse clinical scenarios including after traumatic injury, during neoplastic disease and during infection. Bezold's abscess complicated with internal jugular Vein thrombosis is very rare and to our knowledge this is the first reported case. Treatment of Bezold's abscess focuses on the eradication of the infectious origin of the disease. Herein we present a 19 year-old male who developed Bezold's abscess and then suffered from a subsequent internal jugular vein thrombosis. The abscess was evacuated by modifited radical mastoidectomy. Anticoagulant was not used with this patient and no further sequalae were noted during the subsequent three years of follow-up. Aggressive surgical treatment was mandatory in order to obtain better clinical outcome and the timing of use of an anticoagulant still remained to be determined.

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