RU2758242C1 - Method for formation and placement of fascial autograft during tympanoplasty in patients with chronic purulent otitis media with localization of perforation in the anterior quadrants of the tympanic membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely to otorhinolaryngology, otiatrics. The fascia of the temporal muscle is taken, cleaned and dried. Initially, the autograft is given the shape of an oval, then with the help of scissors it is brought to the shape in the form of “8”, and “8” has larger and smaller parts in accordance with Figure 1. After that, the formed autograft is laid in such a way that the defect of the tympanic membrane is mostly covered, and the smaller part is laid out on the front wall of the external auditory canal. The autograft is placed under the tympanic meatal flap, including the fibrous ring, and above the supporting cartilaginous autograft.

EFFECT: method makes it possible to perform surgical correction of the tympanic membrane defect and avoid secondary fibrous atresia of the anterior angle between the tympanic membrane and the anterior wall of the external auditory canal in the postoperative period.

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Description

The invention relates to medicine, in particular to otorhinolaryngology, otiatrics, and can be used in the surgical treatment of patients with chronic suppurative otitis media (CHS), with the localization of a defect in the tympanic membrane (PD) in the anterior-lower and anterior-upper quadrants.

The relevance of competent surgical treatment of patients with CHS remains a problem of modern otosurgery, given the high prevalence of this disease and its danger to the patient's life. Thus, according to the literature, the efficiency of primary surgical reconstruction of PD with autotissue grafts varies from 76% to 97.9% (Mouna B. et al., 2017; Nemade S. et al., 2018). At the same time, the effectiveness of repeated surgical intervention is 90.2% (Lesinskas E., Stankeviciute V., 2011).

Currently, the most used auto-tissue grafts are the cartilage with the perichondrium taken from the auricle and the fascia of the temporalis muscle. The main advantages of these materials are the topical proximity to the operation area and ease of collection. According to the literature, the effectiveness of their use is 76% (Mouna B. et al., 2017). Also, there was no negative effect on the sound transmission of these materials (Callioglu E. et al., 2013).

If we evaluate the technical complexity of the surgical closure of perforations, then the most difficult operation is when the perforation is localized in the anterior quadrants of the PD. The complexity is due to the presence of an acute angle between the tympanic membrane and the anterior wall of the external auditory canal (anterior angle), low visualization of this zone, weak blood supply in this area and the proximity of the mouth of the auditory tube, which contribute to sluggish regeneration and retraction of the graft into the tympanic cavity. Despite the use of various absorbable materials (collagen sponge, purified gelatin foam sponge) as a support, there is a high probability of failure of the graft flap in this area in the postoperative period.

In order to increase the efficiency of surgical treatment of patients with chronic hepatitis B, characterized by the presence of a PD defect in the anterior quadrants of the stretched PD part, a method for the formation and placement of a fascial autograft (FA) was developed.

The prototype of the proposed method is the technique of laying autografts "underlay" in order to reduce the risks of reperforation in the early and late postoperative period (Tos M., 2004).

The main disadvantage of the prototype is the insufficient number of anchorage points for grafts. In the case of PA laying in the form of an oval or a circle, the location of its anterior edge on the anterior wall of the external auditory canal (EAC) becomes either insufficient to create adequate support, or may lead to a smoothing of the anterior angle. And if in the first case a possible undesirable consequence is the recurrence of the defect, then in the second case an atresia of the anterior angle can be formed.

The uniqueness of the proposed method lies in giving a special shape to the FA - in the form of "8", which allows you to fold and lay it both on the front wall of the NSP and under the annulus fibrosus, overlapping the PD defect. At the same time, the original shape allows for adequate tamponade of the ear canal in order to prevent the formation of secondary fibrous atresia in this area.

The technical result of the claimed method is the high-quality performance of surgical correction of the tympanic membrane defect and the prevention of secondary fibrous atresia of the anterior angle between the tympanic membrane and the anterior wall of the external auditory canal in the postoperative period.

Brief description of the drawings.

Figure 1. Fascial autograft (the dotted line indicates the cut line of the original form of FA)

1 - most of the PA,

2 - smaller part of FA

Figure 2. Laying of the fascial autograft with support on the underlying autocartilage and the anterior wall of the external auditory canal.

1 - most of the PA,

2 - smaller part of FA,

3 - autocartilage,

4 - hammer handle,

5 - drum string,

6 - round window.

Figure 3. Otoendoscopy (before surgery): tympanic membrane defect in the anterior quadrant of the right ear.

Figure 4. Otoendoscopy (21st day after surgery): the state of the nontympanic membrane after the removal of tampons and protectors (the front angle is indicated by the dotted line).

Implementation of the method.

After local infiltration anesthesia with a solution of 2% lidocaine, a skin incision of 2.0-2.5 cm is performed, 0.5 cm retreat dorsally from the fold behind the ear, above the NSP level. A blunt method is used to isolate the fascia of the temporal muscle 1.5x3.0 cm in size and take it out. Adequate hemostasis and layer-by-layer wound closure are performed. Next, the autograft is placed on a glass slide and cleaned of fatty inclusions and hemorrhagic clots. Cutting out FA is performed after drying it on a glass slide. The use of dried fascia has no negative impact on the engraftment process (Jiang Z., Lou Z., 2017). First, with the help of a scalpel or scissors, the shape of an oval is cut out, then with the help of scissors it is brought to the original shape - in the form of "8", and "8" has a larger and smaller part. The size of the parts is selected depending on the anatomical features of the structure of the patient's ear and the size of the defect (figure 1). This shape is most convenient for bending and angling. If the flap is laid in the same way without losing its original shape, then the edges of the fascia in the fold zone will form folds that can lead to the formation of secondary fibrous atresia. Cartilage autograft collection is performed according to the classical technique, the description of which can be found in literature manuals.

After completing the main stages of tympanoplasty: refreshing the edges of the perforation, incision, isolation of the flap, annulus fibrosus, revision of the tympanic cavity and scalping of the hammer handle, the autografts are placed. An intrameatal incision is made with an indentation of at least 5 mm from the anteroposterior quadrant of the BP in order to create a bone site for the PA. The autocartilage half-plate is placed on the hammer handle by the posterior section, and fragments of a collagen or gelatin sponge are used to support the anterior quadrant. The flap is straightened to adequately match the perforation margins with the folded autocartilage. Next, the formed autograft is inserted in such a way that the greater part of the "8" covers the defect in the LB, and the smaller part is laid out on the anterior wall of the NSP, forming the anterior angle between the tympanic membrane and the anterior wall of the NSP and completely covering the defect (Fig. 2). In this case, the autograft is placed under the meatotympanic flap, including the annulus fibrosus, and over the supporting cartilaginous autograft. Next, a meato-tympanic flap is laid out, the edges of the defect are compared with the grafts. The final stage is tamponade of the postoperative area.

This method was applied in 11 patients. In the postoperative period, all patients (100%) achieved a positive result of surgical treatment - closure of the PD defect, while none of the patients developed secondary fibrous atresia of the anterior angle. At the same time, the time spent on the formation of the necessary form of PA does not significantly affect the total time of the operation and is comparable to the time for the pattern of the PA of the generally accepted form.

Clinical example

Patient K., 35 years old, was admitted to the otorhinolaryngological department No. 2 of the N.N. L.I. Sverzhevsky "DZM, with complaints of hearing loss in the right ear, separated from the right ear. From the anamnesis it is known that he suffers from chronic otitis media in the right ear from the age of eight. Up to the age of 15, otitis media recurred no more than 1 time per year, then there were no exacerbations. I went to the Institute for surgical treatment. Otomicroscopy revealed perforation of the right ear PD in the antero-inferior quadrant (Fig. 3). There is no detachable. The auditory tube is passable with the Valsalva maneuver. Whisper speech 1 m, colloquial speech 3 m. Samples of Rinne, Lewis-Federici are negative. Lateralization of sound during Weber's test to the right. The results of tonal threshold audiometry: right-sided conductive hearing loss of 1 degree.

Computed tomography of the temporal bones showed no decrease in pneumatization of the middle ear cavities.

Surgical treatment was performed under local anesthesia with 2% lidocaine solution. After sampling of autografts, the edges of the PD defect were refreshed using an intrameatal approach, tympanotomy and revision of the tympanic cavity were performed. After removing the handle of the malleus, a cartilaginous autograft was placed with support on the handle of the malleus and fragments of a collagen sponge in the hypo- and mesotympanum. The FA was laid according to the declared method. The operation was completed by tamponade of the NSP with a microporous sponge made of oxycellulose.

In the early postoperative period, the patient received antibacterial and analgesic therapy. Discharge on the second day after surgery with recommendations for further outpatient follow-up.

Removal of stitches was performed on the seventh day after surgery on an outpatient basis. On the twenty-first day, tampons and latex protectors from the NSP were removed. When otomicroscopy: the nontympanic membrane is well-formed, vascularized (Fig. 4), when performing the Valsalva test, it is mobile. The anterior angle is sharp, correctly formed.

Used Books.

1. Mouna B., Khalifa M., Ghammem M., Limam M., Meherzi A., Kermani W., Abdelkefi M. Cartilage and fascia graft in type 1 tympanoplasty: comparison of anatomical and audological results. J Craniofac Surg. 2019; 30 (4): e297-e300. doi: 10.1097 / SCS.0000000000005278.

2. Nemade S., Shinde K., Sampate P. Comparison between clinical and audiological results of tympanoplasty with double layer graft (modified sandwich fascia) technique and single layer graft (underlay fascia and underlay cartilage) technique. Auris Nasus Larynx. 2018; 45 (3): 440-446. doi: 10.1016 / j.anl.2017.08.006.

3. Lesinskas E., Stankeviciute V. Results of revision tympanoplasty for chronic non-cholesteatomatous otitis media. Auris Nasus Larynx. 2011; 38 (2): 196-202. doi: 10.1016 / j.anl.2010.07.010.

4. Callioglu E., Ceylan B., Kuran G., Demirci S., Tulaci K., Caylan R. Cartilage graft or fascia in tympanoplasty in patients with low middle ear risk index (anatomical and audological results). Eur Arch Otorhinolaryngol. 2013; 270 (11): 2833-2837.

5. Tos M. Guide to middle ear surgery: in 4 volumes. Vol. 1: Approaches, myringoplasty, ossiculoplasty and tympanoplasty / Per. from English, ed. A.V. Oldokhs. - Tomsk: Sib. state honey. un-t, 2004.412 p.

6. Jiang Z., Lou Z., Impact of the nature of the temporalis fascia graft on the outcome of type I underlay tympanoplasty. J Laryngol Otol. 2017; 131 (6): 472-475.

Claims (1)

A method of forming and laying a fascial autograft in tympanoplasty in patients with chronic purulent otitis media with localization of perforation in the anterior quadrants of the tympanic membrane, including the collection of the fascia of the temporal muscle, its cleaning and drying, characterized in that at first the autograft is given the shape of an oval, then with the help of scissors it is brought to forms in the form of "8", and "8" has a larger and smaller part in accordance with figure 1, after which the formed autograft is placed in such a way that the defect of the tympanic membrane is mostly covered, and the smaller part is laid out on the front wall of the external auditory canal, forming the anterior angle between the tympanic membrane and the anterior wall of the external auditory canal, while the autograft is placed under the meatotympanic flap, including the annulus fibrosus, and over the supporting cartilaginous autograft.

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