Ahmed Miraj, Mishra Anupam, Sawlani Kamal Kumar, Verma Veerendra, Garg Rajiv, Singh Hitendra Prakash, Kumar Sunil
Departments of Otolaryngology and Head and Neck Surgery, King George Medical University, Shahmeena Road, Lucknow, India.
Departments of Internal Medicine, King George Medical University, Lucknow, India.
Indian J Otolaryngol Head Neck Surg. 2016 Sep;68(3):359-66. doi: 10.1007/s12070-015-0949-x. Epub 2015 Dec 19.
The Global tuberculosis control is challenged with a growing resistance to antitubercular treatment (ATT) culminating in resistant (MDR/XDR) strains; an important factor being premature withdrawal of streptomycin owing to its morbidity particularly nephrotoxicity and cochleotoxicity as guidelines for their prevention exist. An attempt is made here to address the least recognized and most debilitating vestibular toxic effects of streptomycin and defining a vestibular-protocol for its early detection and progression. Thirty two prospective patients (treatment-failures, relapse and default cases) undergoing ATT (24 shots of IM streptomycin 15-20 mg/kg over 8 weeks) underwent complete vestibular workup including vestibulo-ocular and vestibulo-spinal reflex assessment with an attempt to closely follow them. Four categories (I: No-, II: Occult-, III: Delayed-Manifest- and IV: Manifest-vestibulotoxicity) were defined. The DHI and casual gait abnormality clearly differentiated III/IV from I/II. The occilopsia and head thrust tests significantly differentiated II from I. Rotation and bithermal calorics significantly differentiated I from II and II from III/IV. The Fukuda, Rhomberg, Tandem-Rhomberg and CTSIB were significant in differentiating I from II and II from III/IV. Dix-Hallpike and Positional tests were of no significance in the entire study. The Occilopsia and Head-Thrust tests that showed 100 % positivity for II to IV are more likely to better predict 'manifest' or 'occult' -vestibulotoxicity while DHI and casual gait assessment may be carried out by a paramedic at a peripheral center to suspect vestibulotoxicity. Since we found absolute compliance with our series we feel that vestibulotoxicity may not be a deciding factor for termination of streptomycin provided an in-built mechanism for patient support/counseling be incorporated in management schedule.
全球结核病控制面临着对抗结核治疗（ATT）耐药性不断增加的挑战，最终导致耐药（耐多药/广泛耐药）菌株的出现；一个重要因素是由于链霉素的发病率，特别是肾毒性和耳毒性，导致链霉素过早停用，而预防这些毒性的指南已经存在。本文试图解决链霉素最不为人知且最具致残性的前庭毒性作用，并制定一项前庭方案以早期发现和监测其进展。32例接受抗结核治疗（8周内肌肉注射24次链霉素，剂量为15 - 20mg/kg）的前瞻性患者（治疗失败、复发和违约病例）接受了全面的前庭检查，包括前庭眼反射和前庭脊髓反射评估，并试图密切跟踪他们。定义了四类（I：无、II：隐匿、III：延迟显现和IV：明显前庭毒性）。DHI和随意步态异常清楚地将III/IV与I/II区分开来。视动性眼震试验和摇头试验显著地将II与I区分开来。旋转试验和冷热试验显著地将I与II区分开来，也将II与III/IV区分开来。福田试验、罗姆伯格试验、串联罗姆伯格试验和感觉组织试验在区分I与II以及II与III/IV方面具有显著意义。在整个研究中， Dix-Hallpike试验和位置试验没有意义。对视动性眼震试验和摇头试验，II至IV的阳性率为100%，更有可能更好地预测“明显”或“隐匿”前庭毒性，而DHI和随意步态评估可由外周中心的护理人员进行，以怀疑前庭毒性。由于我们发现我们的系列研究中患者完全依从，我们认为前庭毒性可能不是终止链霉素治疗的决定性因素，前提是在管理计划中纳入患者支持/咨询的内置机制。
