RU2428155C1 - Method of carrying out closed versions of sanitating operations on middle ear in patients with chronic purulent epitympanitis with cholesteatoma - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to otorhinolaryngology. Method lies in mastoidectomy with ablation of posterior wall of external acoustic meatus (EAM), reconstruction of EAM posterior wall with application of cutaneous-periosteal fascial flap, closing tympanic membrane perforation with free fragment of temporal muscle fascia. Reconstruction of EAM posterior wall is performed with fragment of rib autocartilage. Preliminarily autocartilage is "wrapped" in cutaneous-periosteal fascial flap. After that, remaining edge of flap is bent into mastoidal cavity. The latter is also filled with rib autocartilage fragments. ^ EFFECT: application of claimed invention makes it possible to increase reliability of restored external acoustic meatus, ensure preservation of natural architectonics of acoustic meatus, its resonance characteristics. ^ 1 ex, 4 dwg

Description

The present invention relates to medicine, namely to otorhinolaryngology (otosurgery).

It is generally accepted today that with epitympanitis the main treatment method is surgical. In the presence of cholesteatoma, indications for sanitizing surgery become absolute. However, the otosurgeons do not have unity in the question of choosing the method of sanitizing surgery (open or closed version of the operation). The accumulated experience of otosurgery has shown a higher level of cholesteatoma recurrence when using closed methods of sanitizing operations compared to open methods. Relapse of cholesteatoma with a closed procedure for sanitizing operations is, according to different authors, 2-41% (Abdulmuslimov K.D. Clinical evaluation of some modern options for closed methods of treating chronic purulent otitis media: Abstract of thesis ... Candidate of Medical Sciences / K. D. Abdulmuslimov. - Novokuznetsk, 1988. - 24 p.), With an open methodology - 6-11% (Tarasov D.I. Diseases of the middle ear / D.I. Tarasov, O.K. Fedorova, V.P. Bykova . - M .: Medicine, 1988. - 288 p.).

Thus, in the presence of a cholesteatoma with chronic purulent epithympanitis, an open version of the sanitizing operation, due to providing wide access to deeply located lesions and great visualization of the structures of the middle ear, allows for greater reliability of complete debridement in case of cholesteatoma. Performing a sanitizing operation of the open type involves the formation of an epidermal trepanation cavity in the mastoid process. But even with a good morphological result, after a sanitizing open surgery, the patient has certain limitations: the patient is forced to protect his ear from water and periodically (1 time in 6 months) visit the otolaryngologist to carry out the toilet cavity. These restrictions, of course, reduce the quality of life of this category of patients.

The method of reconstructing the posterior wall of the external auditory canal (NSC) after performing the open surgery type bone stage is aimed at combining the advantages of the open technique (better visualization of all structures of the middle ear and greater reliability of debridement in case of cholesteatoma) and the unconditional "advantages" of closed surgery (preserving the natural architectonics of the auditory meatus, its resonant characteristics). In addition, when combined with tympanoplasty, it is possible to achieve a good functional result and remove restrictions on showering and bathing. Thus, complete rehabilitation of this category of patients is achieved.

When performing a sanitizing operation with reconstruction of the posterior wall of the auditory meatus, the mastoid cavity can be ventilated or obliterated. Various materials are used for obliteration of the mastoid process: muscle flaps (Palva muscle flap is especially popular among otosurgeons), auricular and trageloid auto-cartilage (Heermann, 1963), allogeneic cartilage of the nasal septum (Jansen, 1963, Preobrazhensky N.A., 1977), knee (Wehrs, 1972), ribs (Cole. 1992; Zini, 1994; Kozlyuk A.S., 1992 (patent No. 2074688, 1997)), autogenous cortical bone of the mastoid process, biocompatible materials (Tos M. Guidelines for secondary surgery In 4 volumes of T. 2. Surgery of the mastoid process and reconstructive operations: Translated from English by A.V. Davydov / Po . Ed. A.V.Starohi - Tomsk, Siberian State Medical University, 2005 -. 436)..

For reconstruction of the posterior wall of the ear canal, the most popular materials are autogenous cartilage of the tragus (Tos M. Clin Otolaryngol. 1978; 3: 263-268), auricle (Mukhamedov I.T .; patent No. 2371105, 2009), as well autologous bone (Portmann, 1966; Magnan at al., 1991), allogeneic knee cartilage and nasal septum cartilage (Tos M. Manual for middle ear surgery. In 4 vol. T.2. Surgery of the mastoid process and reconstructive surgery: Trans. English A.V. Davydova / Under the editorship of A.V. Starokhi - Tomsk, Siberian State Medical University, 2005 .-- 436 p.). There is also evidence of the use of biocompatible materials: titanium nickelide (K. Borisova; patent of the Russian Federation “Prosthesis of the ear canal wall” No. 1634272A1, 1991), hydroxyapatite (Black B. Am. J Otol. 1991; 12: 426-428 )

There is a method of an open version of a sanitizing operation on the middle ear (Kamalova Z. Z. et al. Modification of the method of plastic surgery in the postoperative cavity for sanitizing operations on the ear. Otorhinolaryngology Bulletin, 2007, No. 2, p. 48-50), including mastoidectomy with removal of the posterior wall external auditory meatus, mastoid plastic surgery using a skin-periosteal-fascial flap, closure of the perforation of the tympanic membrane with a free fragment of the fascia of the temporal muscle. This method is taken as a prototype. The disadvantage of this method is the formation of an open postoperative cavity that differs from the normal structure of the external auditory canal. In the future, throughout life, patients are forced to observe the following conditions: protect the operated ear from water and visit the otolaryngologist every 6 months to carry out an ear lavatory. The restrictions imposed certainly reduce the quality of life of this category of patients.

EFFECT: increased reliability of the restored external auditory canal due to delimitation of the reconstructed posterior wall of the nasal cavity and the mastoid cavity from the skin of the nasal cavity and preservation of blood supply to the underlying tissues, preservation of the natural architectonics of the auditory meatus, its resonant characteristics.

The specified technical result is achieved by the fact that in the method of sanitizing surgery on the middle ear in patients with chronic purulent epithympanitis with cholesteatoma, including mastoidectomy with removal of the posterior wall of the external auditory canal (NSP), reconstruction of the posterior wall of the NSP using a skin-periosteal fascial flap, closing of perforation the eardrum with a free fragment of the fascia of the temporal muscle, according to the invention, the reconstruction of the posterior wall of the NSP is carried out by a fragment of the costal auto-cartilage, which is a preliminary But they "wrap" the skin-periosteal-fascial flap, the remaining edge of the flap is wrapped in a mastoid cavity, which is filled with fragments of the costal auto-cartilage.

The proposed method is illustrated by the following figures: figure 1 presents a photogram of the initial stage of the operation on the left ear. A periosteal-fascial flap was formed with a base on the skin of the posterior wall of the external auditory meatus; figure 2 is a photogram of the next stage of the operation. The bone phase of the operation is completed. In the “groove” on the “spur” there is a fragment of the costal auto-cartilage, previously “wrapped” in a skin-periosteal-fascial flap; figure 3 is a photogram of the final stage of the operation. The mastoid cavity behind the reconstructed posterior wall of the auditory meatus is filled with fragments of the costal auto-cartilage; figure 4 is an endophotogram of the otoscopic picture of patient X. at the control examination after 2 months. The external auditory meatus has a normal contour, the attic cavity is epidermized, the eardrum is intact.

The proposed method of operation is as follows. Under general anesthesia, a perichondrium fragment of the cartilage of the VII rib is taken on the right with a size of 1 × 3 cm (without violating the integrity of the rib itself). An intrarameal incision is made in the skin of the lower wall of the external auditory meatus, 4 mm indent from the annulus tympanicus with a transition to the posterior and upper walls to the perforation of the tympanic membrane. Separate the skin of the posterior, upper walls of the external auditory meatus in the bone section to annulus tympanicus, and perform a typanotomy.

A layer-by-layer incision is made of the skin and soft tissues in the behind-the-ear area along the transitional fold to the periosteum. The periosteum is separated from the soft tissues, the temporal muscle is covered with fascia. The periosteal-fascial flap with the base on the skin of the posterior wall of the ear canal is cut out (Fig. 1), it is isolated and temporarily placed under the jaw of the retractor. The bone stage of the sanitizing operation is performed (the posterior wall of the NSP is demolished). According to the “pattern” template, a fragment is cut from the costal cartilage for reconstruction of the posterior wall of the auditory meatus. On the "spur" with a small bur, a "groove" is formed, into which the formed posterior wall of the auditory meatus from the costal cartilage is adapted (Fig. 2). Immediately before installation, the reconstructed posterior wall is “wrapped” with a skin-periosteal-fascial flap, which is wrapped in a mastoid cavity. The use of a skin-periosteal-fascial flap allows maintaining blood supply to the underlying bone (bone tissue is supplied by the periosteum), since the periosteum is the phylogenetically closest tissue. The mastoid cavity is filled with rectangular fragments of the costal cartilage (figure 3). Perforation of the tympanic membrane is closed with a free fragment of the fascia of the temporal muscle according to the underlay method (the fascia is placed under the tympanic membrane on the wall of the attic and the reconstructed wall of the ear canal, according to indications, ossiculoplasty elements are performed). Thus, the attic is open and becomes part of the external auditory meatus. A tympanomeatal flap is placed on top. Rubber "circles" are placed on the eardrum, a strip of glove rubber is placed on the area of the intrameatal incision. The external auditory meatus is swabbed with a cotton “wick” with an antibiotic. Layered stitches in the ear region.

In the available scientific, medical and patent literature, no information was found on the popularity of the method of sanitizing surgery on the middle ear in patients with chronic purulent epithympanitis with cholesteatoma, including reconstruction of the posterior wall of the NSP with a fragment of the costal auto-cartilage, which was previously “wrapped” with a skin-periosteal-fascial flap, after whereby the remaining edge of the flap is wrapped in a mastoid cavity, which is filled with fragments of the costal auto-cartilage. Thus, the claimed invention meets the criterion of "novelty."

The authors found that reconstruction of the posterior wall of the NSP with a fragment of the costal autochondral cartilage, which is previously “wrapped” with a skin-periosteal-fascial flap, after which the remaining edge of the flap is wrapped in a mastoid cavity, and the mastoid cavity is filled with fragments of the costal auto-cartilage during sanitizing surgery in the middle ear chronic purulent epithympanitis with cholesteatoma delimits the reconstructed posterior wall of the NSP and the mastoid cavity from the skin of the NSP, provides trophic underlying tissues. Thus, the claimed invention meets the criterion of "inventive step".

According to the proposed method, 3 patients with chronic purulent epitympanitis with cholesteatoma were operated on.

We give an example of clinical use of the proposed method.

Patient X-va R., 29 years old (medical history No. 2010/00626). Diagnosis: Left-sided chronic purulent epithympanitis with cholesteatoma. Osl .: Left-sided mixed hearing loss of I degree.

Received in the ENT department of the Clinical Hospital named after G.G. Kuvatova 01/12/2010, with complaints of suppuration from the left ear, a gradual hearing loss. According to the patient, she’s been ill for about five years, the last year the suppuration of their ear did not stop. Somatic status without features. The nasopharynx is free, the larynx is free of pathology. Otoscopically: on the left there is a defect of the eardrum in the relaxed part, pus with a ichorous odor, cholesteatomic masses. The stretched part of the eardrum is saved. Hearing at admission: ШР AD / AS - 6 m / 2 m, РР AD / AS -> 6 m / 5 m.

On January 14, 2010, under a general anesthesia, a sanitizing operation was performed on the left ear with reconstruction of the posterior wall of the external auditory meatus, obliteration of the mastoid process with costal autochondral cartilage, and type III tympanoplasty. Operational findings: a cholesteatoma in the attic covered the auditory ossicles, penetrated into the aditus, spread into the tympanum in the front pocket, in the antrum there were granulations, mucopurulent discharge. An anvil is destroyed by a carious process (a small fragment has been preserved). The mucous membrane of the tympanic cavity is swollen. Under the control of an operating microscope, “drilling with otosclerosis” was performed, the retrotymbanum and the front pocket were opened, granulation was removed from the antrum, cholesteatoma from the attic, and the tympanic cavity. Anvil removed, hammer head. The stretched part of the eardrum with the handle of the malleus is saved. Reconstruction of the posterior wall of the external auditory meatus was performed with an autogenous costal cartilage wrapped in a skin-periosteal-fascial flap and obliteration of the mastoid cavity with rib cartilage strips. Type III tympanoplasty was performed by autophasis of the temporal muscle. The postoperative period was uneventful. Healing with the normal contour of the external auditory canal and restoration of the integrity of the tympanic membrane occurred on the 16th day after the operation. Hearing at discharge: SR AD / AS - 6 m / 4 m, PP AD / AS> 6 m / 6 m. The average bone-air gap in the audiogram during discharge was 22.5 dB at speech frequencies. Control examination after 2 months (figure 4): the external auditory meatus has a normal contour, the attic cavity is epidermized, the tympanic membrane is intact. Hearing: SR AD / AS - 6 m / 4.5 m, PP AD / AS> 6 m /> 6 m. The average bone-air gap in the control audiogram after 2 months was 17.5 dB at speech frequencies.

Thus, this technique can be used by otosurgeons when performing sanitizing operations in patients with chronic purulent epithympanitis with cholesteatoma. The technique allows you to restore the natural architectonics of the outer ear, relieve patients from the need to be under the constant supervision of an otolaryngologist, improves hearing and reduces the length of the patient’s hospital stay.

The proposed method is reproducible in a hospital environment and when it is used, the indicated technical result is achieved. Thus, the claimed invention meets the criterion of "industrial applicability".

Claims (1)

A method for sanitizing surgery in the middle ear in patients with chronic purulent epithympanitis with cholesteatoma, including mastidectomy with removal of the posterior wall of the external auditory meatus (NSP), reconstruction of the posterior wall of the NSP using a cutaneous-periosteal fascial flap, closure of perforation of the tympanic membrane with a free fragment of the fascia of the temporal muscle, characterized in that the reconstruction of the posterior wall of the NSP is carried out with a fragment of the costal autochondral cartilage, which is previously “wrapped” in the skin-periosteal-fascial gloss that the remaining edge of the flap is wrapped in mastoidalnuyu cavity, which is filled with fragments of rib autocartilage.

Images