RU2713139C1 - Method for surgical sanitation of pretympanum cholesteatoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to otorhinolaryngology. Surgical sanitation of the middle ear cholesteatoma is followed by resection of cholesteatoma from the tympanum ear of the auditory tube and an additional attic ventilation path is created. At first atticotomy is performed, anvil is removed, hammer head, transverse comb and front attic tooth cog. Then, the handle of the hammer together with the metatympanic flap is displaced laterally. After removal of the bone wall between the auditory tube and the tensor tympani muscle semi-channel, the pretympanum widen by complete removal of the musculo-tubular bone canal from the bottom to the spoon-shaped process and from the top to the above-tubal pocket. Protiniculum is removed to a carotid canal. After the tensor tympani muscle removing, a bone canopy of the lateral wall of the pretympanum is smoothened from above from the articular fossa to the drum ring. Cholesteatoma is resected from the pretympanum from the tympanum ostium of the auditory tube. Lateral wall is repaired with a chondroperichondral flap.

EFFECT: invention provides a reduced risk of developing residual and / or recurrent middle ear cholesteatoma in patients with middle ear cholesteatoma and simultaneous improvement of patient's hearing by creating wide access to pretympanum, to a tympanic ostium of the auditory tube and creating an additional aeration path of middle ear and mastoid process.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in performing sanitizing operations in patients with a cholesteatoma located in the protimpanum, with narrowing of the tympanic orifice of the auditory tube.

The location of the cholesteatoma in the protimpanum involving the tympanic part of the auditory tube in the pathological process is one of the hard-to-reach sections of the middle ear when performing the sanitizing stage of the operation and a functionally significant structure when performing the hearing-improving stage of surgical treatment.

Protimpanum cholesteatoma is more common in the following pathologies: a congenital form of the disease (congenital middle ear cholesteatoma), in the presence of an anterior epitympanal cholesteatoma with an underdeveloped muscle fold straining the eardrum, with an aggressive form of mesotympanum cholesteatoma.

Protimpanum is the anterior space of the tympanic cavity and its main part is occupied by the tympanal niche of the auditory tube. Outside, the space is covered by a drum ring, limited by the walls of the muscular-tubal canal, the slope of the labyrinth wall and the carotid canal.

The use of angled endoscopes in otosurgery made it possible to detail the micro-topographic anatomy of the protimpanum, where the following boundaries are distinguished.

Upper: the roof of the tympanic cavity, the muscular-tubal canal, merging anteriorly with the supratubular pocket, if present, and with a fold of muscle straining the eardrum. The presence of the supratubular pocket and the variability of its size depends on the orientation of the location of the folds of the muscles straining the eardrum. Also in the literature there is a description of the subtar pocket, which is a pneumatized area located lower medially of the half-channel of the muscle straining the eardrum.

Lower: protiniculum (a constant bone ridge that delimits the hypothympanum), with the possible presence of cellular cells of the protimpanum and a complex of cells of the hypothympanum.

Anterior: tympanic orifice of the auditory tube merging with the connective tissue, and then with the cartilaginous portion of the auditory tube.

Back: transition to a mesotympanum.

Medial: the lateral wall of the carotid canal, including the carotid-cochlear pocket in front, carotid-tympanic vessels and nerves containing the anterior branches of the Jacobson nerve.

Lateral: a bone wall that delimits the space above the articular fossa and extends to the anterior tympanic ring, from the bottom from the protiniculum level to the tympanic notch (Rivini) in front. Medially from the drum ring there is a short and smooth pocket, which is called a pre-tympanic pocket.

The tympanic mouth occupies the upper third or upper half of the anterior wall of the tympanic cavity and plays an important role in regulating intrathimpanic pressure. Changing the ventilation conditions of the middle ear creates the prerequisites for starting in this zone of fibrosis, the formation of granulations and cholesteatoma.

The size and shape of the tympanum mouth, the conditions of its aeration depend on the height of the ridges located at its bottom, on the position of the carotid artery channel, and also on the degree of development of the half-channel of the muscle straining the eardrum. The funnel-shaped and slit-shaped forms, which are more often characteristic of the anatomically low mouth, covered by ridges and overhanging muscle half-channel, worsen the conditions for aeration of the protimpanum. Peritubular cells and Usuras in the walls of the canal contribute to prolonged inflammation in the tympanic cavity and in the half-channel of the muscle straining the eardrum, which for years has supported the dysfunction of the auditory tube.

Despite the existing possibilities of using modern surgical equipment, modern diagnostic research methods, the risk of developing residual and / or recurrent middle ear cholesteatoma in patients with tympanic obstruction of the auditory tube in the presence of cholesteatoma in the protimpanum and simultaneous hearing improvement in this category of patients remains relevant .

A known method of surgical debridement of cholesteatoma of the protimpanum together with the attic cholesteatoma, including the use of microscopic and endoscopic techniques (see Endoscopic approach to tensor fold in patients with attic cholesteatoma / D. Marchioni [et al.] // Acta Oto-Laryngologica. - 2009. - Vol. 129. - No. 4. - P. 946-954).

When implementing this method, a classic behind-the-ear section is performed. The periosteal flap is raised anteriorly to identify spina Henle. Under the control of an operating microscope, a posterior tympanomeatal flap is formed from above from 1 hour down to 6 hours. The tympanomeatal flap is separated and displaced down. Next, transcanal atticotomy is performed. Under endoscopic control, using the 3 mm 30 ° and 45 ° endoscopes, the boundaries of the cholesteatomic sac are determined. When the cholesteatoma spreads to the medial wall of the posterior epitympanic space, the anvil body and the head of the malleus are removed. When the cholesteatoma spreads posterior to the entrance to the antrum, a wide posterior atticotomy is performed. Under the control of a 3 mm 45 ° endoscope inserted into the protimpanum, examine the lower surface of the folds of muscle, straining the membrane, the mouth of the auditory tube. The fold of the muscle straining the eardrum is resected. A 45 ° endoscope is inserted into the anterior epitympanic space, while the endoscope is turned down to visualize its lower sections. After removal of the cholesteatoma, the defect of the tympanic membrane and attic wall is closed with a combined chondroperichondral flap. The reconstruction of the ossicular chain is carried out autonomously.

The disadvantages of this method are the possibility of manipulation with only one hand, the loss of depth of perception and at a number of stages of binocular vision. The use of sufficiently large diameter (3 mm) endoscopes makes it difficult to work in a limited space, and the rapid misting prevents the use of equipment of a smaller diameter.

In the presence of even minor bleeding, the use of endoscopes becomes difficult, and sometimes almost impossible. In this case, there is a need to switch to the traditional otomicroscopic technique, which can cause frustration to the surgeon.

This method of surgical debridement of the cholesteatoma of the protimpanum does not solve the problem of restoring patency of the tympanic orifice of the auditory tube, which is often found in this category of patients. Since, due to the development of the cholesteatomic process in the protimpanum, the tympanic niche of the auditory tube undergoes ossification, the growth of granulation tissue, which is then replaced by scar connective tissue, the formation of polyps with the subsequent development of auditory tube dysfunction, and in the presence of an anatomically narrowed tympanic part of the auditory tube, the above phenomena are more acute .

There is also known a method of surgical debridement of protimpanum cholesteatoma in case of obstruction of the tympanic orifice of the auditory tube in patients with chronic purulent otitis media (see K. Murata, F. Ohta, "Reconstruction of the Eustachian tube and the anterior tympanum: planned staged tubo-tympanoplasty", Laryngoscope Vol. 95 (3), 1985, p. 330-4).

When performing this method, radical mastodectomy is necessarily performed, pathological tissue is removed from the tympanic orifice of the auditory tube and a T-shaped silicone tube 0.2-0.5 mm thick and 20 mm long is placed in its lumen; Gelfoam is placed around the proximal part of the silicone tube for reducing the growth of granulation tissue in the protimpanum. In this case, the antrum and the tympanic cavity lead openly for up to 6 months or until the trepanation cavity is completely epidermized, then proceed to the removal of the T-shaped silicone tube and reconstructive surgery on the middle ear.

The disadvantage of this method is its radicality with respect to the structures of the middle ear, the need for repeated surgery to remove the silicone tube and reconstructive surgery on the middle ear, using the epidermal and mucous lining for these purposes.

The closest in technical essence to the claimed solution is a method of surgical debridement of the middle ear with restoration of patency of the auditory tube with cicatricial narrowing of its tympanic anastomosis in patients with chronic purulent otitis media (see patent RU No. 2219884, IPC A61F 11/00, 2003).

This access is carried out through the behind-the-ear incision, the tympanic or trepanation cavity is opened and the sanitizing stage of the operation is performed. From the tympanic orifice of the auditory tube, the scar tissue is maximally excised, then the bony septum between the auditory tube and the half-channel of the muscle that stretches the tympanic membrane is removed with a microarray. The muscle that stretches the eardrum, or its remnants are also removed due to the lack of functional value of the latter in the postoperative period. After that check the patency of the auditory tube by injection of sterile saline. Then the operation is continued in the usual way: ossiculo- and myringoplasty are performed, and in patients who have undergone radical surgery on the ear earlier, also full or partial mastoidoplasty. A thin iodine-oil swab is placed in the external auditory meatus, the behind-the-ear wound is sutured in layers.

The disadvantage of this method is the inability to perform a complete resection of the cholesteatoma matrix from the protimpanum due to the lack of revision of its pockets, which can lead to the development of residual and / or recurrent cholesteatoma of the middle ear. Also, despite the expansion of the tympanic orifice of the auditory tube, there is no surgical debridement of the supratubular space, which subsequently can lead to retraction of the tympanic membrane in the postoperative period.

The technical result of the proposed solution is to reduce the risk of residual and / or recurrent cholesteatoma of the middle ear in patients with cholesteatoma in the protimpanum and at the same time improve the hearing of patients by creating wide access to the protimpanum, in particular to the tympanic orifice of the auditory tube, and creating an additional aeration path for the middle ear and mastoid process.

To achieve the specified technical result in the method of surgical debridement of the cholesteatoma of the protimpanum, including access by the ear, opening the tympanic cavity and sanitizing the middle ear, removing the bony septum between the auditory tube and the half-channel of the muscle that stretches the tympanic membrane, as well as removing the specified muscle, performing ossicle myringoplasty, according to the invention, simultaneously with surgical debridement of the middle ear cholesteatoma resection of the cholesteatoma from the tympanum of the mouth hearing the new tube and create an additional ventilation path for the attic, at first an atticotomy is performed, the anvil, the head of the malleus, transverse crest and cog tooth of the anterior attic are removed, then the handle of the malleus, together with the meatotympanic flap, is laterally displaced, and after removal of the bony septum between the auditory tube and the semicanal muscle , stretching the tympanic membrane, expand the protimpanum due to the complete removal of the muscular-tubal bone channel from below to the spoon-shaped process and from above to the supratubular pocket, remove p rotiniculum to the carotid canal, and after removing the muscle that stretches the tympanic membrane, the bony canopy of the lateral wall of the protimpanum is smoothed from the top of the articular fossa to the tympanic ring, the cholesteatoma is resected from the protimpanum, from the tympanum of the auditory tube, and the plastic of the lateral wall is chondroperichondral flap.

Also according to the invention, before the plastic of the lateral wall, a control audit of the tympanic orifice of the auditory tube and pockets of the protimpanum is performed.

Also according to the invention, after the plastic surgery of the lateral wall, a solution of diprospan is introduced into the tympanic mouth of the auditory tube.

The inventive method of surgical debridement of cholesteatoma protimpanum is intended for patients with a congenital form of cholesteatoma of the middle ear; with chronic purulent otitis media complicated by cholesteatoma of the anterior epitympanic space; with an aggressive form of mesotympanum cholesteatoma, complicated by the spread of cholesteatoma into the scarred or anatomically narrowed tympanic part of the auditory tube.

Performing such actions as: atticotomies, removal of the anvil, hammerhead, transverse crest and cog tooth of the front attic, as well as the lateral displacement of the hammer handle together with the meatotympanic flap, allows the protimpanum and attic to be widely opened for further manipulations on surgical debridement of the cholesteatoma from the protimpanum.

Removal of elements such as: the muscular-tubal bone canal from the bottom to the spoon-shaped process and from above to the supratubular pocket, protiniculum to the carotid canal, the muscle straining the tympanic membrane, and also the smoothing of the bone canopy of the lateral wall of the protimpanum from above the articular fossa to the tympanic ring allows the tympanum to expand the auditory tube to prevent retraction of the non-tympanic membrane in the postoperative period and to provide access to the pockets of the protimpanum (supubaric, subtaric, pretimpanic cue, carotid-cochlear) for their subsequent rehabilitation.

Performing plastic surgery of the lateral wall with a chondroperichondral flap allows the walls of the attic and external auditory canal to be formed.

The introduction of diprospan solution into the tympanic orifice of the auditory tube reduces the risk of development of the scar-adhesions in the protimpanum and in the tympanic orifice of the auditory tube, which affects the restoration of patency of the latter.

Thus, this method allows you to create wide access to the tympanic orifice of the auditory tube and additional aeration paths of the middle ear and mastoid process, and as a result, reduce the risk of residual and / or recurrent protimpanum cholesteatoma and at the same time improve the patient’s hearing.

From the above it follows that the introduced distinguishing features affect the specified technical result, are with him in a causal relationship.

The method is illustrated by drawings, where:

- in FIG. 1 shows a tympanic cavity after an atticotomy has been performed;

- in FIG. 2 shows the tympanic cavity and attic, after removal of the anvil, the head of the malleus, transverse crest, cog tooth of the front attic, the displacement of the handle of the malleus with a meatotympanic flap;

- in FIG. Figure 3 schematically shows the operation stage, expansion of the protimpanum by removing the half-channel of the muscle straining the eardrum, protiniculum to the carotid canal, smoothing the bone canopy of the lateral wall of the protimpanum from above to the tympanic ring;

- in FIG. Figure 4 schematically shows the stage of the operation; the lateral wall of the attic is plastic.

The following positions are used in the drawing: 1 - anvil; 2 - the head of the malleus; 3 - transverse ridge; 4 - cog of the front attic; 5 - stirrup; 6 - a window of a snail; 7 - the handle of the malleus; 8 - the meatotympanal flap; 9 - cholesteatoma protimpanum; 10 - tympanic orifice of the auditory tube; 11 - a half-channel of the muscle straining the eardrum; 12 - a spoon-shaped process; 13 - an overtubular pocket; 14 - a subtarb pocket; 15 - protiniculum; 16 - carotid channel; 17 - carotid - snail pocket; 18 - a drum ring; 19 - pre-tympanic pocket; 20 - chondroperichondral flap.

The method is as follows.

The method is carried out under conditions of multicomponent anesthesia with tracheal intubation and under the control of facial nerve monitoring. A behind-the-ear incision is performed from level 1. temporalis to the apex of the mastoid process. Separate soft tissue to visualize the site of the mastoid process, spina Henle and posterior wall of the bony section of the external auditory meatus. A fascial graft and auto-cartilage are prepared from the ear cup.

Under the control of an operating microscope, a tympanomeatal flap is formed. The tympanic cavity is opened and a sanitizing stage of the operation is performed. Cutting bores with a diameter of 3-4 mm remove the lateral wall of the attic to visualize the anvil 1, the head of the malleus 2, the transverse ridge 3 and the cog of the front attic 4. Boron smooths the back wall of the external auditory meatus to visualize the stapes 5 and the niche of the cochlea round window 6 (Fig. 1 )

With a microneedle and a round knife, the anvil-stirrup and / or anvil-hammer joint is de-articulated, after which the anvil 1 (or its remains) is removed. The head of the malleus 2 is resected with a guillotine. Using a microthorax or boron of 2 mm, the transverse ridge 3 and cog of the anterior attic are removed 4. A fold of muscle straining the tympanic membrane is dissected with a microneedle. With a round knife or micro scissors, the tendon of the muscle straining the eardrum is resected. After the micro-raspator, the handle of the malleus 7 together with the meatotympanal flap 8 is laterally displaced and a good overview of the cholesteatoma of the protimpanum 9 and its pockets is obtained (Fig. 2).

With a microfolore or boron with a diameter of 1.5-1 mm at low revs, remove the bony septum between the tympanum orifice of the auditory tube 10 and the half-channel of the muscle straining the eardrum 11. Extend the protimpanum by removing the diamond boron with a diameter of 2 mm at small speeds of the half-channel of the muscle straining the tympanic membrane 11 from the bottom to the spoon-shaped process 12 under the monitoring of the facial nerve, from above to the supratubular pocket 13 and from the bottom to the subtubular pocket 14.

Eliminate the muscle straining the eardrum using a radio knife. Protiniculum 15 is removed with a diamond boron with a diameter of 2 mm at low revolutions or microarray to the carotid channel 16 with the opening of the carotid-cochlear pocket 17.

A cutting canopy of the lateral wall of the protimpanum is smoothed with a cutting boron with a diameter of 4 mm from the articular fossa to the tympanic ring 18 with the opening of the pre-tympanic pocket 19.

The cholesteatoma and pathologically altered mucous membrane are resected from the protimpanum, in particular from the tympanum orifice of the auditory tube 10 and the pockets of the protimpanum (supubar 13, subtar 14, pretimpanic 19, carotid-cochlear 17).

A control audit of the tympanic orifice of the auditory tube 10 and the pockets of the protimpanum (supratubular 13, subtubar 14, pretympanic 19, carotid-cochlear 17) is performed.

The operation is continued in the usual way: ossiculo- and myringoplasty are performed by autofasion. Plastic surgery of the lateral wall is performed with a chondroperichondral flap 20. A diprospan solution of 1 ml is injected into the tympanal mouth of the auditory tube 10. The external auditory meatus is plugged with hemostatic material. The behind-the-ear wound is sutured in layers. Apply an aseptic dressing.

The method is illustrated by the following example.

Patient K., 47 years old, was admitted to the adult surgical department of FBSU "St. Petersburg Research Institute of Ear, Throat, Nose and Speech" with a diagnosis of Right-sided chronic otitis media, relapse of cholesteatoma. Condition after tympanoplasty on AD from 2016, 2017. Right-sided chronic conductive hearing loss, II degree.

Upon admission, the patient complained of hearing loss in the right ear, periodic purulent discharge from the right external auditory canal. From the anamnesis it is known that he suffers from chronic otitis media from early childhood. In 2016, an antrotomy was performed on the right ear; in 2017, tympanoplasty was performed on the right ear.

On examination: the nose - the mucous membrane is pink, wet. The septum of the nose is in the midline. The nasal passages and nasopharyngeal arch are free. Nasal breathing is free. The mucous membrane of the pharynx is pink, moist. The mucous membrane of the larynx is pink, moist. The vocal folds are white, the edges are even, with full phonation during phonation. The interfold clearance is wide. The voice is clear, breathing is free.

Facial nerve function corresponded to grade I (normal) according to the House-Brackmann classification.

When conducting otomicroscopy: AS - the external auditory meatus is wide, free. The eardrum is gray, contoured. Whispering speech - 6 m, colloquial speech - more than 6 m; AD: the external auditory meatus is wide, free, in a non-tympanic membrane perforation filled with cholesteatom masses. Whispering 0 m, conversational 0.6 m.

Data from additional examination methods.

Tonal audiometry: right-sided conductive hearing loss of the II degree. Computed tomography (hereinafter referred to as CT) of the temporal bones: AD is the sclerotic structure of the mastoid process. The antrum cavity and tympanic cavity are filled with pathological soft tissue contents. A typically located auditory ossicle prosthesis is visualized. The bone bed of the sigmoid sinus, the upper face of the pyramid, the bone capsule of the labyrinth without destruction.

The patient underwent surgery on his right ear.

Surgical intervention was performed under conditions of multicomponent anesthesia with tracheal intubation and monitoring of the facial nerve.

An incision was made in the behind-the-ear area on the right side of the scar. Autofascia was taken from the behind-the-ear incision, and auto-cartilage was taken from the tragus of the auricle.

An antrum cavity was opened, filled with a soft-tissue formation of white color (cholesteatoma) spreading through the attic into the tympanic cavity.

They opened the tympanic cavity and performed the sanitizing stage of the operation: removed the cholesteatoma from the antrum, from the attic, aditus ad antrum, from the mesotympanum.

Cutting burs with a diameter of 3 mm removed the lateral wall of the attic before visualizing the anvil, smoothing the back wall of the external auditory meatus before visualizing the pyramidal elevation and the niche of the round window. Found the lack of contact carious modified long leg of the anvil with the head of the stapes. An anvil-stirrup articulation was performed with a microneedle, after which the anvil was removed.

The guillotine resected the epidermis-affected head of the malleus. Boron with a diameter of up to 2 mm removed the transverse ridge and cog of the anterior attic. Eliminated cholesteatoma from the anterior epitympanic space. A microneedle dissected a fold of muscle straining the eardrum. Microscissors resected the tendon of the muscle, straining the eardrum.

After that, the handle of the malleus, together with the meatotympanal flap, was displaced laterally with the micro-raspator and the protimpanum filled with cholesteatoma was visualized. They removed the cholesteatoma from the visible areas of the protimpanum. The scar tissue of the tympanic orifice of the auditory tube was excised together with a single polyp.

The microflora removed the bony septum between the auditory tube and the half-channel of the muscle that stretches the eardrum. The bone ridges of the protimpanum were removed from the top of the drum cavity with a diamond bur of 2 mm in diameter at low speeds. The microtubular neatly removed the muscular-tubal bone canal from below to the spoon-shaped process, taking into account the location of the cranked ganglion of the facial nerve, and from above to the supratubular pocket. Using a radio knife at low power, the muscle that stretches the eardrum was completely eliminated. With a diamond bur up to 2 mm in diameter at low speeds, the protiniculum was removed as accurately as possible to the carotid canal. A cutting canopy of the lateral wall of the protimpanum from the articular fossa to the tympanic ring with the opening of the pre-tympanic pocket was smoothed with a cutting bur of 4 mm in diameter.

The remnants of the cholesteatoma and pathologically altered mucous membrane from the protimpanum, from the tympanic mouth of the auditory tube were completely resected. A control audit was made of the tympanic orifice of the auditory tube, pockets of the protimpanum (supubaric, subtaric, pretimpanic, carotid-cochlear pockets) with the removal of epidermis residues from them.

A hearing-improving stage of the operation was performed. They made plastic of the lateral wall with a chondroperichondral flap. A diprospan solution of 1 ml is injected into the tympanal mouth of the auditory tube. A partial titanium PORP prosthesis of 2.5 mm was installed on the head of the stapes. Khilov's symptom is positive. A 2.5 mm cartilage plate and autofascation were placed on the cap of a partial titanium prosthesis PORP 2.5 mm under the remnants of a non-tympanic membrane using the Underlay technique. The external auditory canal was plugged with Merocell hemostatic material.

The behind-the-ear wound was sutured in layers. An aseptic dressing is applied.

The removed materials were sent for histological examination. Complications in the postoperative period were not observed. The postoperative function of the facial nerve was preserved and corresponded to grade I (norm) according to the House-Brackmann classification.

Sutures were removed on the seventh day after surgery. The patient was discharged on the 14th day after surgery with tampons in the external auditory canal. Tampons from the external auditory meatus were removed one month after surgery.

Otomicroscopy AD: the external auditory meatus is wide, free. Fascial flap pink, consistent, no defects.

According to tonal audiometry, an improvement in the patient’s auditory function was noted: maintaining the hearing threshold during bone conduction, reducing the hearing threshold during air conduction by 30-20 dB, and reducing the bone-air interval to 30 dB. The patient was diagnosed with right-sided conductive hearing loss of I degree.

According to the results of histological examination, the picture corresponded to a cholesteatoma.

Control examination after 6 months. AD: the external auditory meatus is wide, clear. Non-tympanic flap gray, no defects.

After 1 year, a diffusion-weighted MRI of the middle ear was performed according to the results of the study: no data were found for the patient's relapse of cholesteatoma.

Thus, this method allowed for surgical debridement of the protimpanum cholesteatoma with obstruction of the tympanic orifice of the auditory tube to improve the patient’s hearing and at the same time reduce the risk of residual and / or recurrent middle ear cholesteatoma.

Claims (3)

1. The method of surgical debridement of the cholesteatoma of the protimpanum, including access by the behind-the-ear approach, opening the tympanum and debridement of the middle ear, removing the bony septum between the auditory tube and the half-channel of the muscle that stretches the tympanic membrane, as well as removing the specified muscle, performing ossiculo- and myringoplasty, characterized in that at the same time as surgical debridement of the middle ear cholesteatoma resect the cholesteatoma from the tympanic orifice of the auditory tube and create an additional ventilation path ttic, in this case, an atticotomy is first performed, the anvil, the head of the malleus, transverse crest and cog tooth of the anterior attic are removed, then the handle of the malleus, together with the meatotympanic flap, is laterally displaced, and after removal of the bony septum between the auditory tube and the half-channel of the muscle that stretches the tympanic membrane, expand the protima due to the complete removal of the muscular-tubal bone canal from below to the spoon-shaped process and from above to the supratubular pocket, protiniculum is removed to the carotid canal, and after muscle removal, atyagivayuschey eardrum smoothed bone canopy protimpanuma top lateral wall of the glenoid fossa to the drum rings resected from protimpanuma cholesteatoma, tympanic mouth of the auditory tube, plastic operate hondroperihondralnym lateral wall flap. 2. The method of surgical debridement of the cholesteatoma of the protimpanum according to claim 1, characterized in that before the plastic of the lateral wall, a control revision of the tympanic orifice of the auditory tube and pockets of the protimpanum is performed. 3. The method of surgical debridement of the cholesteatoma of the protimpanum according to claim 1, characterized in that after the plastic surgery of the lateral wall, a solution of diprospan is introduced into the tympanic mouth of the auditory tube.

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