RU2484777C1 - Method of covering bone defect of middle cranial fossa bottom in patients with oto-liqorrhea by transmeatal or transmastoid approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to otolaryngology. Essence of method lies in the following: under endotracheal anesthesia after installation of lumbar drainage planum mastoideumis exposed, antrum is opened, aditus is extended, zone of bone defect of middle cranial fossa and liquorrhea is determined. After detachment of dura mater from bone defect edges in open lumbar drainage, cartilage transplant is intracranially brought at the defect edges. Then, from the side of middle ear transplant is covered with autofascia, which is fixed to it with fibrin-thrombin glue. Depending on the defect zone, antrum and (or) attic is additionally tamponed with adipose tissue, fixed to fascia with fibrin-thrombin glue. After that, wound behind ear is sutured.

EFFECT: application of said invention makes it possible to increase efficiency of surgical treatment of patients with oto-liquorrhea, resulting from defect of bone wall of middle cranial fossa, formed as a result of inflammatory or traumatic destructive changes, to reduce operation risk and reduce surgery volume.

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Description

The invention relates to medicine, namely to otorhinolaryngology.

Known methods for treating otoliquorrhea by closing defects in the bone wall of the middle cranial fossa with an intracranial (neurosurgical) approach. In this case, various biological metallized materials and their combinations are used. The disadvantages of the intracranial approach are the high risk of surgery and its large volume with the formation of a new defect in the bone wall of the skull, depending on the surgical approach (in the occipital or temporal bone). In addition, intracranial access in Russia is the prerogative of neurosurgeons.

The prototypes of this invention are the "Method of surgical treatment of ear liquorrhea with temporal-parietal surgical access" (Potapov A.A., Okhlopkov V.A., Likhterman L.B., Kravchuk A.D. "Post-traumatic basal liquorrhea", Moscow, "Antidor ", 1997), characterized in that the visualization and plastic surgery of the cerebrospinal fluid fistula is carried out by the intracranial approach using autotissues and fibrothrombin glue; “A method for the surgical treatment of nasal liquorrhea” (Kuznetsova G.V., Ismagilova S.T., Angelovich M.S., RF patent No. 2346667 dated 07.07.2006), characterized by endonasal excision of tissues in the area of the cerebrospinal fistula of the base of the skull and exposure high-intensity laser radiation on the mucous membrane of this zone before autologous fistula plastic surgery; as well as a transnasal approach (without opening the cranial cavity) to the cerebrospinal fluid fistula of the skull base using an endoscope with plastic fistula autotissues and the use of fibrothrombin glue (Kapitanov D.N., Lopatin A.S. “Endoscopic diagnosis and treatment of nasal liquorrhea and encepholocoel of the anterior base skulls ”, Bulletin of Otolaryngology, 2000, No. 6).

The purpose of the invention is to increase the efficiency of surgical treatment of patients with ear cerebrospinal fluid caused by a defect in the bone wall of the bottom of the middle cranial fossa, resulting from inflammatory or traumatic destructive changes, using the transmeatal or transmastoid approach.

The technique of the operation is as follows. Under endotracheal anesthesia after the lumbar drainage is installed, the site of the mastoid process (Shipo triangle) is exposed by the transmastoid approach. With the help of a surgical bur, the antrum is opened and the entrance to it (aditus) is expanded to review the upper wall of the middle ear from the front of the attic to the antrum. Then, using the operating microscope, the area of the bone defect of the middle cranial fossa and liquorrhea is determined. Auto-cartilaginous and autofascial, auto-fat grafts are prepared according to the size of their defect. After detachment of the dura mater from the edges of the bone defect with open lumbar drainage, the cartilage graft is introduced intracranially beyond the edges of the defect, it is covered by autofascia on the side of the middle ear and fixed with fibrothrombin glue to it. Depending on the defect zone, the antrum and (or) attic are tamped with adipose tissue, also fixed to the fascia with fibrothrombin glue. The behind-the-ear wound is sutured in layers. Lumbar drainage continues to function after surgery and is removed for 5-7 days.

In chronic otitis media after a previously performed general cavity surgery on the middle ear, as well as in post-traumatic otoliquorrhea, both transmastoid and transmeatal approaches are possible, depending on the localization zone of the cerebrospinal fluid. The fistula is determined using high-resolution computed tomography (CT) scan of the temporal bones with a scan step of 1-2 mm. The operation ends with laying on the cavity walls of rubber or silicone strips and tamponade gelatin sponge with antibiotic for 12-14 days.

The method was applied in 15 patients (9 men and 6 women aged 4 to 74 years) with a diagnosis of otoliquorrhea of various origins. The cause of liquorrhea was traumatic damage to the structures of the middle and inner ear - 12 patients; previous sanitizing operations on the middle ear (chronic suppurative otitis media) - 3. The duration of the disease ranged from 6 months to 27 years. After surgery, persistent cessation of cerebrospinal fluid was observed in 14 patients. Relapse of liquorrhea was observed in one case: in a patient with an extensive bone defect in the atticoantral region, medially extending to the posterior surface of the pyramid. This patient underwent repeated fistula surgery with intracranial neurosurgical access.

As an illustration of the effectiveness of the applied method for closing bone defects of the middle cranial fossa in patients with otoliquoria, we present two observations.

Patient D., 69 years old, was admitted to the department with a diagnosis of chronic right-sided purulent otitis media, condition after a sanitizing operation on the right ear, otoliquorrhea. Upon admission, the patient complained of hearing loss in the right ear, transparent, copious discharge from the right ear. From the anamnesis it is known that a patient from childhood suffered from chronic right-sided purulent otitis media with frequent exacerbations. In 1996, she underwent a debridement operation on her right ear of the “open type”. In November 2007, when an otolaryngologist conducted an ear lavatory in a clinic, abundant transparent discharge appeared from it. Prior to this, the patient noted periodically occurring transparent discharge from the ear, which independently stopped within 1-2 days.

Upon admission to the department, the general condition of the patient is satisfactory. On examination - nose, pharynx, larynx without visible changes. With otomicroscopy of the right ear, the ear canal is wide. The eardrum is a non-tympanic membrane. The mastoid cavity is contoured, almost completely epidermized, with the exception of the upper sections, where a soft-tissue formation covered by the epidermis with a point defect through which a clear fluid comes in with pulsation is determined in the area of the roof of the atticoantral region. With CT of the right temporal bone, a postoperative cavity is determined, in the roof area of which in the area of the antrum there is a bone defect of 0.3 cm in size that opens into the middle cranial fossa. The patient was diagnosed with chronic right-sided otitis media, condition after a sanitizing operation on the right ear, otoliquorrhea.

07/10/2003, the patient underwent surgery on the right ear - revision of the postoperative cavity with plastic of the cerebrospinal fluid fistula. After endotracheal anesthesia, the transmastoid approach, after preliminary preparation of the muscular-fascial flap, opened the postoperative cavity, the skin lining covering the walls of the cavity was separated. In the upper parts of the cavity, a soft tissue formation filled with a clear liquid (meningocele) was found. After isolating the formation, a bone defect in the roof of the antrum measuring 0.3 × 0.3 cm and a defect in the dura mater through which cerebrospinal fluid enters were detected. Soft tissues were excised in the region of the edges of the defect, the dura mater was separated from the edges of the defect. After the lumbar drainage is opened, the cartilaginous plate from the patient’s auricle, which exceeds the defect size by 2 mm, is placed intracranially in the area of the defect. From the side of the tympanic cavity, the autofascation pre-coated with fibrothrombin glue, significantly (0.5-0.7 cm) overlapping its bone edges, is laid on the defect. The plastic zone is closed by a displaced behind-the-ear muscular-fascial flap. The postoperative cavity is lined with silicone strips, swabbed with a gelatin sponge and cotton swabs with an antibiotic. The behind-the-ear wound is sutured in layers. The postoperative period was uneventful. Tampons from the cavity were removed on the 10th day, lumbar drainage - on the 5th day. When observing the patient for 5 years, recurrence of otoliquorrhea was not observed. The postoperative cavity was completely epidermal.

Patient Yu., 33 years old, was admitted to the department with a diagnosis of post-traumatic right-sided adhesive otitis media, fracture of the pyramid of the right temporal bone, otoliquorrhea. Upon admission, the patient complained of deafness in the right ear, periodically appearing clear discharge from the right half of the nose when the head was tilted forward, a sensation of dripping of fluid along the back of the throat. The above complaints arose after a closed head injury in 2003. Twice (in January and May 2004), the patient developed meningitis, after which he underwent CT of the temporal bones in two projections. According to CT of the temporal bones, a transverse fracture of the pyramid of the right temporal bone was revealed, coming through its front face, the inner auditory meatus, the cochlear apical and basal curls, the cochlear window and the hypothympanum. In the tympanic cavity and cells of the mastoid process, fluid levels were clearly defined.

Upon admission to the ward, the general condition of the patient is satisfactory. On examination - nose, pharynx, larynx without visible changes. With otomicroscopy, the ear canals are wide, without detachable. The left eardrum is thin, mobile, with identification points. The right tympanic membrane is thickened, turbid, mobile, fluid is visualized in the tympanic cavity. An endoscopic examination of the nasopharynx determines the release of clear fluid from the pharyngeal mouth of the right auditory tube.

Patency of the auditory tubes is preserved on both sides. According to tonal threshold audiometry, hearing in the left ear corresponds to the age norm, deafness is determined in the right ear.

Based on the examination data and the clinical picture, the patient was diagnosed with a fracture of the pyramid of the right temporal bone, post-traumatic otoliquorrhea on the right, deafness of the right ear.

05/31/2005, the patient underwent surgery on the right ear - transmeatal revision of the tympanic cavity with plastic surgery of the cerebrospinal fluid fistula of the tympanic cavity. After endotracheal anesthesia after the installation of lumbar drainage, a transmeatal approach detached a meatotympanic flap. The drum cavity is filled with scar tissue, after removal of which a fracture line is defined, passing from the vestibule window along the medial wall of the tympanic cavity through the niche of the cochlear window 0.4 × 0.1 cm in size, through which a transparent fluid enters. Separated mucous membrane along the edge of the fracture line. Lumbar drainage is open. The fracture area is closed by fibrinthrombin glue-covered autofascia of the temporal muscle, overlapping the edges of the defect. On autofasion, adipose tissue is placed up to the level of the handle of the malleus, also covered on the fascia with fibrothrombin glue. The meatotympanal flap is in place. The postoperative period was uneventful. Tampons from the external auditory meatus were removed on the 10th day, lumbar drainage - on the 5th day. When observing the patient for 7 years, recurrence of otoliquorrhea was not observed.

Claims (1)

A method of treating patients with otoliquorrhea due to a bone defect in the bottom of the middle cranial fossa, characterized in that under the endotracheal anesthesia after installing the lumbar drainage, the area of the mastoid process is exposed, the antrum is opened, the aditus is expanded, the area of the bone defect of the middle cranial fossa and cerebrospinal fluid is determined, after the detachment of the dura mater from the edges of the bone defect with open lumbar drainage, the cartilage graft is introduced intracranially beyond the edges of the defect, autophasia is covered from the side of the middle ear Which is fixed thereto fibrintrombinovym adhesive, further depending from the defect zone and antrum (or) adipose tissue tamponiruyut attic, latched to the fascia fibrintrombinovym adhesive BTE wound sutured by layers.