RU2277400C1 - Surgical method for closing fistula horizontal semicircular duct in circumscribed labyrinthitis cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves cutting out feeding pedicle flap. Mucous membrane is removed from external surface of the horizontal semicircular duct along fistula boundary 1-3 mm far from it. Preserved allocartilage plate is placed over fistula and surrounding surface and proper tissue of the patient is laid above it. The cut pedicle flap is laid on top.

EFFECT: enhanced effectiveness in forming dense wall on defect surface.

Description

The invention relates to medicine, namely to otorhinolaryngology, and can find application in the treatment of fistulas of the horizontal semicircular canal with limited labyrinthitis.

The main cause of limited labyrinthitis is chronic suppurative otitis media. In chronic otitis media, a constant opening remains in the eardrum, the auditory ossicles are destroyed, hearing is reduced, and suppuration is repeated from time to time. Chronic otitis media is especially dangerous if the so-called caries (cholesteatoma) are formed in the ear, which gradually destroys the bone, as a result of which the purulent process passes to the inner ear and internal otitis media - labyrinthitis. In this case, the bone capsule of the labyrinth, mainly of the horizontal semicircular canal, is destroyed with the formation of a fistula (fistula), reaching the inner wall of the capsule of the labyrinth - endosta.

One of the main signs of the disease is periodic labyrinth attacks, caused by the penetration of toxins into the labyrinth through the formed fistula. Attacks are expressed by dizziness, accompanied by nausea or vomiting, imbalance and the appearance of spontaneous nystagmus - a kind of eye movement. Characteristic is also the presence of a fistula (fistulous) symptom. Due to the presence of a fistula in the horizontal semicircular canal when air thickens in the external auditory canal of the affected ear, nystagmus appears, accompanied by dizziness.

A known method of eliminating the fistula of the horizontal semicircular canal (see Woolstein H.L. “Hearing-improving operations”, M .: Medicine, 1972, p.303-307), in which the first stage with the behind-the-ear approach, a typical general cavity radical operation is performed to eliminate the infectious process in the middle ear, while granulation tissue, cholesteatomic masses to the bony edges of the fistula are removed from the middle ear. In the presence of cholesteatoma in the fistula, it is partially removed, retaining the matrix. In the presence of granulation tissue, it is also partially removed without affecting the fistula itself. In conclusion, the postoperative cavity is lined with a graft of fascia and thinned skin, and the auditory canal is covered with a graft of whole skin, and the fistula of the semicircular canal is left free. The second stage after the healing of the cavity is an operation in which the granulation tissue or matrix of cholesteatomas left after the first operation is removed. Then, the purified fistula is covered either with a graft from whole skin, or simultaneously with a fragment of autofascia of the temporal muscle and a graft from whole skin, the edges of which are inserted side to side with grafts introduced to heal the cavity during the first operation.

The disadvantages of this method are:

- two surgical interventions (operations) that must be performed to eliminate the fistula of the horizontal semicircular canal;

- soft tissues (skin, fascia) used for plastic fistula do not always lead to its fusion, and even the overgrown fistula has a relatively soft wall, as a result of which dizziness and symptoms of maze dysfunction can persist.

There is also known a method of surgical closure of the fistula of the vestibule of the labyrinth (see patent RU No. 2140244, A 61 F 11/00, 1999) by intramuscular opening of the tympanic cavity and removal of the alloplastic prosthesis, in which the mucous membrane and scars are separated from the walls of the vestibule niche, and they cover the fistula and lay on top of a new graft.

In this operation, an auto-cartilage is used, from which a prosthesis is placed on top of the graft. The size of the prosthesis is significantly smaller than the size of the fistula, which is necessary for the implementation of oscillatory movements and, accordingly, sound transmission. Oscillatory movements are performed by the mucous membrane with scars of the walls of the vestibule niche, the membrane of which, in fact, is closed the fistula of the vestibule of the labyrinth. The small auto-cartilage prosthesis here does not serve to close the fistula, since it must be movable and is the transmission link between the middle ear ossicles (anvil malleus) and the membrane that covers the fistula.

The disadvantage of this method is that it is applicable only for closing the fistula of the vestibule of the labyrinth (its oval window) in the treatment of otosclerosis in case of complications arising from surgery. In this case, the problem of conducting sound is mainly solved. When closing the fistula of the horizontal semicircular canal of the labyrinth, the task of transmitting sound is not posed, therefore, any sound-conducting prostheses are not needed. Means are needed for reliable elimination of a defect in a hard bone wall.

The closest in technical essence to the claimed solution is a method of closing the fistula of the horizontal semicircular canal by mastoidoplasty with limited labyrinthitis (see Melanyin V.D., Vasilyeva V.P. "Mastoidoplasty with limited labyrinthitis", M .: Medicine, "Bulletin of Otorhinolaryngology" No. 4, 1980, p. 26).

In this method, a flap on the lower feeding leg is cut from the skin of the external auditory canal. Having retreated 1 mm from the posterior edge of the fistula of the horizontal (lateral) semicircular canal in the direction from the top of the spur to the back of the cave roof, place the auto-cartilage plate (nasal septum) and isolate the antrum from the mastoid, into which fragments of the same cartilage or bone of the patient are placed. On the front surface of the plate of the cartilage that separates the antrum from the mastoid cavity, a flap is laid, cut from the skin of the external auditory meatus, under which a periosteum flap is placed from the behind-the-ear area. Then the ear canal and the antrum are tamped, the ear wound is sutured with the placement of the drainage tube.

The disadvantage of this method is that the fistula itself is closed not by cartilage, but by soft tissues. Cartilage and bone tissue are used for partial plugging of bulky cavities near the fistula, which can cause infection of the labyrinth. And since the fistula itself (and not the volume cavities near it) is closed by soft tissues, the formation of a dense wall at the site of the defect is not ensured. In addition, the skin flap covering the fistula is often lysed, which leads to non-closure of the defect.

It should also be noted that this method is quite complicated, includes a large number of surgical operations and is not limited to the fistula itself, the method involves the use of a large volume of both foreign and own tissues, which against the background of chronic inflammation increases the possibility of complications from the labyrinth due to suppuration and lysis of these tissues.

The technical result of the proposal is to create a simple, highly reliable, precision way to close the fistula of the horizontal semicircular labyrinth channel by forming a dense wall at the defect site to eliminate limited labyrinthitis and its symptoms, as well as to prevent complications.

To achieve the specified technical result in the method of surgical closure of the fistula of the horizontal semicircular canal with limited labyrinth, in which a flap is cut out on the feeding leg, and cartilage is also used, covering it with a cut flap and placing the patient’s own tissue under this flap, according to the invention, before laying the flap with the external the surface of the horizontal semicircular canal along the edge of the fistula, departing from it by 1-3 mm, remove the mucous membrane, and close the cartilage, and completely the fistula, and swirling its surface remote from the mucosa, the cartilage plate is used as canned allohryascha.

The presence of distinctive features, namely the removal of the mucous membrane from the outer surface of the horizontal semicircular canal along the edge of the fistula, departing from it by 1-3 mm, closing the cartilage completely of the fistula and its surrounding surface with the mucous membrane removed, the use of cartilage in the form of a plate of canned allo cartilage, indicate on the conformity of the claimed technical solution to the patentability criterion of "novelty."

The method is as follows.

The patient is standing on his back, the head is turned upside down by the operated ear. Local anesthesia or general anesthesia under endotracheal anesthesia. Antiseptic treatment of the skin of the auricle, parotid region, and external auditory canal is performed. With the behind-the-ear approach, a typical skin incision is made along the transitional fold at the attachment site of the auricle. A skin flap on the feeding leg is cut from the skin of the ear canal. Separate soft tissue to the bone. With the use of a drill, a typical general cavity radical operation is performed, while, if possible, they preserve the structures of the middle ear (auditory ossicles or their remains, remnants of the eardrum). Pathologically altered tissues (granulations, cholesteatomic masses, carious-altered bone tissues) are removed. The wound is cleaned of purulent discharge by washing it with an antiseptic solution (dioxidine, furatsillin). Under the microscope, they find a defect in the bone wall of the lateral semicircular canal - the fistula. Above the fistula, the cholesteatoma or granulation tissue is removed to the level of the bone edge of the fistula, without penetrating into the semicircular canal.

Around the fistula, the mucous membrane is removed 1-3 mm from its edges. On the wall defect of the horizontal semicircular canal (fistula) and the wound surface created around it with the mucous membrane removed, lay a sterile allograft plate from canned costal cartilage (allochondral cartilage). On top of the allochondria, partially covering the surrounding surface, a flap from the fascia of the temporal muscle of the patient is laid. In those rare cases when a thin layer of granulations is preserved on the fistula, a small thin fragment of the fascia of the patient’s temporal muscle is additionally placed (under the allochondral fistula) before laying the cartilage allograft. Then, a skin flap on the feeding leg is placed on the fistula area and the surrounding cavity walls. The cavity is plugged with gauze turunda, impregnated with a synthomycin emulsion or provazelinoy turunda with a broad-spectrum antibiotic (for example, with cefazolin). A sore wound is sutured, a cotton-gauze aseptic dressing is applied. In the postoperative period, conventional therapy is carried out: antibacterial - for 7 days (for example, cefazolin 1.0 × 2-3 times a day intramuscularly), dehydration (for example, lasix), sometimes detoxification, supplemented, according to indications, with another treatment - depending on the general status of the patient. Turunda from the postoperative cavity and ear canal is removed on the 5-6th day, sutures from the ear region - on the 6-7th day. Local treatment is carried out according to the generally accepted technique for radical operations on the ear: careful cleaning of the cavity, insufflation or instillation of antibacterial drugs, physiotherapeutic procedures (KUV, UHF and others).

It should be noted that in the absence of an exacerbation of the purulent process in the ear or the presence of only cholesteatoma, this method can be performed both behind the ear and endaurally (through the ear canal), which is less traumatic for the external ear and the surrounding soft tissues and does not require a skin incision in behind the ear area.

The claimed method provides reliable closure of the fistula of the horizontal semicircular canal with the restoration of its dense wall. The method is precise and gentle, since the defect (fistula) is closed directly, in which plastic of the mastoid cavity is not required. When implementing the method, a minimal amount of plastic material is used, which significantly reduces the possibility of suppuration and lysis used in the plastic surgery of own and foreign tissues, which prevents complications from the maze. Thanks to this method, limited labyrinthitis and its symptoms are eliminated in almost all cases.

From the above it follows that the technical result of the invention is achieved by a new set of essential features, therefore, the claimed method meets the patentability criterion of "inventive step".

The method of closing the fistula of the horizontal semicircular canal with limited labyrinthitis is illustrated by the following example.

Patient X., born in 1952, medical history No. 1801, was admitted to the clinic of St. Petersburg Research Institute of ENT SPECIALIST on August 28, 2003 with complaints of periodic dizziness, gait instability, suppuration and a sharp decrease in hearing in the left ear. From the anamnesis, it is known that a patient from the age of five suffers from chronic left-sided purulent otitis media with periodic exacerbation, in 1997 she underwent a radical operation on her left ear in Krasnodar, after which suppuration from the ear and periodic dizziness did not stop. The patient was repeatedly treated in hospitals at the place of residence with a short-term effect.

Diagnosis at admission: chronic left-sided purulent otitis media, cholesteatoma, limited labyrinthitis. Otoscopy of the left ear: total defect of the tympanic membrane, postoperative cavity with scar membranes, high “spur”, severe mucosal edema, purulent discharge, cholesteatomic masses, pressure nystagmus positive (dizziness and characteristic nystagmus appear when the air thickens in the ear canal). Hearing: cp - 0 m, pp - at the sink; tonal audiometry data - a pronounced mixed hearing loss in the left ear. Otoscopy of the right ear: without pathological changes, cp - 6 m, pp> 6 m; tonal audiometry data - without pathologies. Vestibulometric studies (computed electrooculography) indicate an active course of limited labyrinthitis in the left ear.

The diagnosis is final: chronic left-sided purulent otitis media, complicated by cholesteatoma and limited labyrinthitis, condition after radical surgery on the left ear from 1997.

Patient X. 09/10/2003 performed a radical operation with plastic fistula labyrinth according to the claimed method. General anesthesia, endotracheal. An incision of the skin and soft tissues of the left behind the ear region along the transitional fold. Separation of soft tissues to the bone.

Found: a postoperative cavity with uneven edges, a high "spur" (the remainder of the posterior-upper wall of the auditory meatus), a pathologically altered mucous membrane, cicatricial membranes, cholesteatomic masses, purulent discharge, in the area of a horizontal semicircular fistula channel 2 × 3 mm in size.

A skin flap on the feeding leg was cut from the skin of the ear region. Removed pathologically altered tissues (mucous membrane, cholesteatoma from the tympanic segment and fistula, scar membranes). By means of a drill, the uneven edges of the cavity are smoothed out, carious-changed areas of bone tissue are removed, and the “spur” is smoothed out. The wound was cleaned of purulent discharge by washing with a solution of an antiseptic (furatsillin).

Around the fistula, the mucous membrane is removed 2 mm from its edges. On the wall defect of the horizontal semicircular canal (fistula) and the wound surface created around it, a plate of a preserved allograft (costal allochondral cartilage) is laid, on top is a flap from the fascia of the patient’s temporal muscle. A skin flap on the feeding leg is laid on the fistula area and the surrounding walls of the cavity. The cavity is plugged with a hemostatic sponge and turunda with a synthomycin emulsion. Sutures on the behind the wound, aseptic dressing.

The postoperative period was uneventful. The patient received antibiotic lincomycin 30% 1.0 × 3 times a day intramuscularly (i / m), 7 days, analgin 50% 2.0 i / m for pain, diphenhydramine 1% 1.0 i / m, 1 once a day, 7 days. On the 5th day, turunda was removed from the ear, on the 8th day - hemostatic sponge, sutures were removed. Local treatment was carried out: toilet cavity, insufflation of antibacterial drugs and polcartolone.

At the time of discharge (the 27th day after the operation), the patient does not complain about the operated ear, dizziness ceased to disturb, stability was restored when walking, the postoperative cavity was almost completely epithelized, there was no discharge, the pressure nystagmus was absent, the hearing function on the left ear remained unchanged (cp - 0 m, pp - at the sink). The data of the control vestibulometric study (computed electrooculography) a month after the operation (09.10.2003) indicate moderate residual effects of limited labyrinthitis. In a control study after 6 months, neither subjective nor objective data for limited labyrinthitis and its symptoms were detected.

The method was developed and tested in the department of pathophysiology of the ear at the St. Petersburg Research Institute of ear, throat, nose and speech in 6 patients. All operations were performed with good functional results in the near and distant postoperative periods.

From the foregoing, it follows that the proposed method provides a technical result, does not cause difficulties, involves the use of developed materials and standard equipment, which indicates the compliance of the claimed technical solution with the patentability criterion of "industrial applicability".

Claims (1)

The method of surgical closure of the fistula of the horizontal semicircular canal with a limited labyrinth, in which a flap is cut out on the feeding leg, and cartilage is also used, covering it with a cut flap and placing the patient’s own tissue under this flap, characterized in that before laying the flap from the outer surface of the horizontal semicircular canal along the edge of the fistula, departing from it by 1-3 mm, the mucous membrane is removed, and the fistula is completely closed with the cartilage and its surrounding surface with the removed mucous membrane Coy, while the cartilage is used in the form of a plate of canned allo-cartilage.