RU2526978C2 - Method for old radical cavity repair with tympanoplasty following open-type sanitating eardrum surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, otosurgery. A mastoid segment of a trephine cavity is inspected and de-epidermised, and bone walls are polished. A back wall of an external acoustic meatus is repaired with Alloplant costal cartilage placed into formed spur grooves. A mastoid process cavity is filled rectangular fragments of Alloplant costal cartilage. That is combined with the tympanoplasty.

EFFECT: method enables eliminating the trephine cavity completely, repairing the natural architectonics of the external acoustic meatus, its resonant characteristics, restoring the eardrum integrity, recreating the air eardrum limited from the ambient medium, as well as eliminating the additional surgical injury accompanying an autograft sampling.

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Description

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

Chronic purulent otitis media (HCHO) today remains one of the urgent problems of otorhinolaryngology. A special place among patients with HGSO is occupied by patients who underwent radical surgery (sanitizing open surgery) on the middle ear.

The presence of a trepanation cavity “obliges” patients to observe the following conditions all their lives: keep the operated ear away from water and periodically (1 time in 6 months) visit the otolaryngologist to carry out the toilet of the cavity. Failure to comply with these conditions even in the presence of a very good epidermal cavity can lead to infection and periodic otorrhea. In addition, in a number of patients, the sanitizing effect after radical surgery (RO) is unstable, and they still have complaints of hearing loss, discharge from the ear, ear noise, headache, and vestibular disorders. This set of symptoms is similar to the symptoms of the most chronic purulent otitis media, which indicates the imperfection of RO, which is essentially an amputation of the middle ear (Tolstov Yu.P. On the clinical significance of the state of a trepanation cavity in patients undergoing radical surgery on the middle ear / Tolstov Yu .P., Anikin I.A. // Bulletin of Otorhinolaryngology. - 1999. - No. 1. - P.44-46; Nikiforova G.N. Combined treatment of patients with a lack of epidermization of the trepanation cavity after sanitizing operations on the ear. G.N .Nikiforova, E. M.Khon, V.M. Svistushkin, A.Yu. Ovchinnikov // Russian Otorhinolaryngology. 2005.- No. 5 (18) .- P.115-117, Eremeeva KV Surgical rehabilitation of patients undergoing general cavity surgery on the ear : Abstract of thesis .... Candidate of Medical Sciences / K.V. Eremeeva. - Moscow, 2010. -24 p.).

According to Kuzovkova V.E., patients with HGSO have a significant decrease in the quality of life in comparison with a healthy population of working age, the more pronounced the symptoms of the disease, the lower the quality of life of patients. The lowest quality of life indicators have patients suffering from operated ear disease (BOU), lower quality of life indicators were found in patients with meso- and epithympanitis (Kuzovkov V.E. Assessment of the quality of life of patients with chronic purulent otitis media: Abstract. Dis .... Candidate of Medical Sciences / V.E. Kuzovkov. - St. Petersburg, 2003 .-- 22 p.).

The tactics of treating this condition still causes heated debate. Until recently, a conservative approach was considered priority, which often did not allow achieving stable remission. While the costs associated with it, according to Domhoffer J.L. (2008) “stunning”, taking into account the frequent visits to the doctor for an ear lavatory, the use of a large number of topical medications for treatment, periods of temporary disability, sometimes inpatient treatment, restrictions on the choice of profession, a decrease in “quality of life”, and in some cases and patient disability.

Repeated surgical intervention with BOC was most often treated as a step of despair, and if it was carried out, it was limited and was reduced, as a rule, to the removal of polyps, granulations, cholesteatomas, etc. Today, the attitude towards the reoperation has begun to change dramatically (Fedoseev V.I. et al., 1999; Aabd N.A., 2000; Anikin I.A., 2000; Bance, M., 2005; Eremeeva K.V., 2010 ) However, there is still no consensus among otosurgeons regarding the indications and tactics of surgical rehabilitation of patients with operated ear disease.

The reconstruction technique of the “old radical cavity” after the open type sanitizing operation on the middle ear is aimed at restoring the natural architectonics of the external auditory canal (NSC), 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, it is possible to achieve complete rehabilitation of this category of patients.

Reconstruction of the “old radical cavity” involves revision, epidermization of the mastoid segment with resurfacing of the bone walls, restoration of the posterior wall of the NSP, obliteration of the mastoid segment of the postoperative cavity, and tympanoplasty.

For reconstruction of the posterior wall of the ear canal, the most popular materials are autogenous cartilage of the tragus (Tos M. din 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. Guideline 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 )

Various materials are used for obliteration of the mastoid process: muscle flaps (Shpotin V.P., Proskurin A.I .; RF patent “Method of mastoidoplasty” No. 2007116778A, 2007; muscle flap according to Palva is especially popular among otosurgeons), ear and tragus autocartilage (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 (Toe M. Guidelines for middle ear surgery. In 4t. T.2. Surgery of co process and reconstructive operations: Translated from English by A.V. Davydov / Edited by A.V. Starokhi. - Tomsk, Sib. GMU, 2005. - 436 p.).

The well-known technique of Sitnikov V.P. surgical treatment of patients with "operated ear disease", which consists in the fact that they undergo a revision, epidermization of the mastoid segment of the trepanation cavity, the posterior wall of the external auditory meatus is restored by the septum-cartilage, and the mastoid cavity behind the restored posterior wall is filled with a muscle-periosteal flap on the vascular pedicle (Sit .P. Reconstructive mastoidoplasty in individuals suffering from "operated ear disease". / Materials of the Russian scientific-practical conference of otorinol ringologists. Orenburg, 2002). This method is taken as a prototype. The disadvantages of this method are the need for additional surgical trauma during the sampling of a fragment of the auto-cartilage of the nasal septum, increasing the duration of the operation. In addition, almost all soft-tissue flaps sclerosize over time, decreasing in size and forming cavities (Tos M. Manual for middle ear surgery. In 4t. T.2. Mastoid surgery and reconstructive surgery: Translated from English by A.V. Davydova / Under the editorship of A.V. Starokhi. - Tomsk, Sib. GMU, 2005 .-- 436 p.).

The technical result is the restoration of the natural architectonics of the external auditory canal, its resonant characteristics, the integrity of the eardrum, the reconstruction of the air drum cavity delimited from the external environment.

The specified technical result is achieved by the fact that in the method of reconstruction of the "old radical cavity" after a debridement surgery of the open type on the middle ear, including revision, epidermization of the mastoid segment of the trepanation cavity with polishing of the bone walls, restoration of the posterior wall of the external auditory canal, filling the cavity of the mastoid process behind the restored the posterior wall, according to the invention, the posterior wall of the external auditory meatus is restored by the Alloplant costal cartilage, which is installed poured into the formed grooves on the "spur", and the cavity of the mastoid process is filled with rectangular fragments of the costal cartilage "Alloplant", additionally simultaneously perform tympanoplasty.

The proposed method is illustrated by the following figures: figure 1 presents a photogram of the initial stage of surgery on the right ear. A skin incision was made along the behind-the-ear fold; further - photograms of the subsequent stages. In Fig.2 - parallel to the spur 4 cm from it, an incision was made of the epidermal lining of the mastoid segment to the bone; figure 3 - grinding the bone walls of the mastoid segment; figure 4 - in the "groove" on the "spur" is a template made of packaging from suture material. Figure 5 - a fragment of the costal cartilage "Alloplant" is installed in the corresponding "groove; in Fig.6, the cavity of the mastoid process behind the reconstructed posterior wall of the ear canal is filled with fragments of costal cartilage "Alloplant"; Fig.7 is a photogram of the final stage of the operation. Stitches are applied to the skin; Fig. 8 is an endophotogram of the otoscopic picture of patient C. during follow-up examination 1.5 months after surgery. 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 skin incision is made along the behind-the-ear fold. 3-4 mm apart from the “spur” parallel to the last scalpel, an incision of the epidermal lining to the bone is performed. Separate the skin adjacent to the "spur" (it will become the source of the skin lining of the reconstructed posterior wall of the NSP). 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 anterior wall perpendicular to the previous incision. Separate the skin of the lower, anterior walls of the external auditory meatus in the bone section to annulus tympanicus, and perform a typanotomy. A free fragment of the fascia of the temporal muscle of sufficient size (at least 20 × 30 mm) is taken.

The mastoid segment is revised with thorough epidermalization of the cavity under the control of an operating microscope, smoothing the edges and grinding the bone wound with a drill. According to the “pattern” template, a fragment is cut out from the Alloplant 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 Alloplant cartilage is adapted (Fig. 5). The cavity of the mastoid process is filled with rectangular fragments of the costal cartilage "Alloplant" (Fig.6). 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 is performed). The epidermal lining of the mastoid wound segment adjacent to the spur is adapted to the posterior wall of the NSP formed from Alloplant (a fragment of the free fascia of the temporal muscle is preliminarily laid between them). A tympanomeatal flap is placed on top. Silicone protectors are placed on the eardrum, a strip of silicone is placed on the area of the intrameatal incision. The external auditory meatus is plugged with an antibiotic merocel sponge. Layered stitches in the ear region. The Alloplant costal cartilage is a stable inert material that does not change in volume, that is, is devoid of this significant drawback characteristic of soft-tissue flaps.

In the available scientific, medical and patent literature, no information was found about the popularity of the method of reconstructing the “old radical cavity” after an open-type sanitizing operation on the middle ear, including revision, epidermization of the mastoid segment with resurfacing of the bone walls, restoration of the posterior wall of the external auditory canal with Alloplant cartilage ", Filling the cavity of the mastoid process behind the restored posterior wall with Alloplant cartilage fragments, closing the perforation of the tympanic membrane with free fr an agent of fascia of the temporal muscle. Thus, the claimed invention meets the criterion of "novelty."

The authors found that reconstruction of the "old radical cavity" after a debridement surgery of the open type on the middle ear, including revision, epidermization of the mastoid segment with resurfacing of the bone walls, restoration of the posterior wall of the external auditory canal with Alloplant cartilage, filling of the mastoid cavity behind the restored posterior wall Alloplant cartilage fragments, closing the perforation of the tympanic membrane with a free fragment of the fascia of the temporal muscle, provides restoration of eating the natural architectonics of the external auditory canal, its resonant characteristics, the integrity of the tympanic membrane, and the reconstruction of the airy drum cavity delimited from the external environment. Thus, the claimed invention meets the criterion of "inventive step".

According to the proposed method, 7 patients who underwent a previously sanitizing open surgery on the middle ear were operated on.

We give an example of clinical use of the proposed method. Patient S. v. O., 34 years old (medical history No. 2012/21207). Diagnosis: Right-sided chronic purulent otitis media. Illness of the operated ear. Osl .: Right-sided mixed hearing loss II degree.

Received in the ENT department of the Republican Clinical Hospital named after G.G. Kuvatova 09/26/2012 with complaints of periodic suppuration from the right ear, hearing loss. According to the patient, she’s been sick since childhood, at the age of 5 (1983) she underwent radical surgery on her right ear. After the operation, the patient had pronounced vestibular phenomena up to the inability to stand up, which gradually subsided over 2 weeks. After surgery, otorrhea periodically resumed, hearing was poor. Repeatedly received inpatient treatment, under the microscope, an audit of the postoperative cavity was performed, during which systemic dizziness was also disturbing.

Somatic status without features. The nasopharynx is free, the larynx is free of pathology. Otoscopically: on the right there is a cavity after a radical operation, in the closure region there is a site without epidermis, small granulations, traces of pus. The stretched portion of the tympanic membrane is partially preserved. Hearing at admission: ШР AD / AS - Adc / 6м, РР AD / AS - 2,5 м /> 6 м.

09/29/2012, under the general anesthesia, the reconstruction of the “old radical cavity” on the right ear was performed with tympanoplasty type III with the TORP prosthesis from Kurz. Operational findings: during the audit of the mastoid segment, granulations were found and removed, the entire epidermal lining was carefully dissected. The mucous membrane of the tympanic cavity is moderately edematous, the stretched part of the tympanic membrane is mostly preserved. Under the control of an operating microscope, "drilling with otosclerosis" was performed, the retrotymbanum and the front pocket were opened. It was found that the oval window is closed by a soft-tissue membrane (there is no foot plate of the stirrup!). In the tympanic cavity (hypothympanum), the hammer (lies removed) lies freely. Reconstruction of the posterior wall of the external auditory meatus by the Allopant costal cartilage was performed, and the mastoid cavity was obliterated by Alloplant cartilage strips. After measuring the distance to the oval window membrane, a total Kurz TORP prosthesis of 3.5 mm length was installed, the “plate” of which was previously hemmed to the auto-cartilage plate. Produced plastic perforation b / n fragment of autofascia of the temporal muscle. The skin flap of the posterior wall of the NSP formed from the epidermal lining is adapted to the cartilaginous posterior wall (practically without diastases), free fascial flaps are laid between it and the skin. The auditory meatus is lined with strips of silicone, plugged with pieces of Merocele with an antibiotic. Sutures on the skin behind the ear.

The postoperative period was uneventful, no vestibular events were observed in the postoperative period. Healing with the normal contour of the external auditory canal and restoration of the integrity of the tympanic membrane occurred on the 22nd day after the operation. Hearing at discharge: AD / AS -4.5 m / 6 m, PP AD / AS 6 m /> 6 m. The average thresholds for airborne sound conduction at speech frequencies (500, 1000, 2000, 4000 Hz) during discharge were 21, 25 dB, the bone-air interval was 7.5 dB. Follow-up examination 1.5 months after the operation: the external auditory meatus has a normal contour, the attic cavity is epidermized, the eardrum is whole (the contour of the cartilage covering the prosthesis is visible through the eardrum). Hearing: SR AD / AS -5 m / 6 m, PP AD / AS> 6 m /> 6 m. The otoscopic picture is presented in Fig. 8.

Thus, this technique can be used by otosurgeons for reconstruction of the “old radical cavity” with tympanoplasty in patients who underwent radical (sanitizing open type) surgery on the middle ear. 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)

The method of reconstruction of the "old radical cavity" after a debridement surgery of the open type on the middle ear, including revision, epidermization of the mastoid segment of the trepanation cavity with grinding of the bone walls, restoration of the posterior wall of the external auditory canal, filling the cavity of the mastoid process behind the restored posterior wall, characterized in that the posterior the wall of the external auditory meatus is restored by the Alloplant costal cartilage, which is installed in the formed grooves on the spur, and the cavity the mastoid process is filled with rectangular fragments of the Alloplant costal cartilage; additionally, tympanoplasty is performed simultaneously.

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