RU2316269C2 - Method for surgical treatment of chronic purulent otitis media - Google Patents

Abstract

FIELD: medicine, otolaryngology.

SUBSTANCE: the present innovation is based upon simultaneous implementation of sanitizing and functional stages. While forming mastoid cavity it is necessary to keep a bridge, perform the plasty of posterior wall of meatus acusticus along with forming two fragments out of meatus acusticus skin - the upper and the lower, which should be sutures to parotid periosteum. On revising a tympanic cavity and removing pathological elements it is necessary to fulfill tympanoplasty at applying a skin flap being cut from posterior-upper wall of meatus acusticus. Then the plasty in question should be supplemented with developing a flap out of parotid skin, its length being necessary to cover the aditus, this cut flap should be put onto the bottom of mastoid cavity and fixed towards the lower skin flap. Application of the present innovation enables to avoid pus entering into auditory media of tympanic cavity in case of relapses and create additional conditions for sound delivering towards the labyrinth.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to the surgical treatment of chronic suppurative otitis media.

From the practice of otorhinolaryngology, many methods of surgical treatment of chronic purulent otitis media are known. The most common of them: radical surgery on the middle ear (Preobrazhensky Yu.B. Essays on the history of radical ear surgery (over a 100-year development) // West Otorhinolar. - 1992. - No. 4. - P.39-42.) , operations performed by the “open method” - conservatively radical, modified radical, radical with tympanoplasty, etc. (Borisenko O.N. Clinical and experimental substantiation of surgical treatment methods for patients with chronic purulent otitis media: Abstract. Dis ... d- RA Medical Sciences. - Kiev, 2001), and performed by the "closed method" - intact canal mastidectomy (Atlas of operative otorhinolaryngology. / Ed. by prof. V.S. Pogosov. - M .: Medicine, 1983, 416 p.), separate atticoantrotomy with tympanoplasty, etc. (Gusakov A.D. Reconstruction of a sound-conducting apparatus with closed variants of functional reconstructive operations in patients with chronic purulent otitis media: Abstract of thesis ... of a doctor of medical sciences. - Zaporozhye, 1985. - 42 p.).

The basis for the development of radical operations was the simple trepanation of the mastoid process (Kessel, 1885), which was then supplemented by the removal of the posterior wall of the auditory meatus and the wall of the attic, as a result of which the tympanic and mastoid cavities are combined into one. The main goal of the radical operation is to eliminate the focus of infection in the middle ear in order to prevent the development of intracranial complications. In this regard, it has not lost its relevance today.

With the "open" methods of surgical treatment of chronic otitis media, the intact areas of the sound-conducting system, sometimes the "bridge" or the high "spur," are preserved as much as possible. Tympanoplasty is more often performed in the second stage.

The disadvantages of radical and "open" operations include:

- the presence of an open mastoid cavity, which requires regular systematic care;

- often observed "trepanation cavity disease", associated mainly with incomplete epidermization, accompanied by otorrhea and relapse of cholesteatoma;

- repeated functional surgical interventions;

- the occurrence of difficulties in the formation of a sound-conducting system.

In "closed" operations, the posterior wall of the ear canal is preserved, and the mastoid cavity is either obliterated or drained through the aditus into the tympanic cavity. One of the options for tympanoplasty is performed by the first or second stage.

When the mastoid process of pneumatic type is rehabilitated, the small, separate cells located in the scales of the temporal bone, the apex of the mastoid process, and zygomatic bone remain uncovered and the latent putrefactive process in them gives relapses. Pus flowing into the tympanic cavity contributes to the destruction of preserved auditory ossicles or to rotting of recreated sound conduction elements after tympanoplasty.

The disadvantages of “closed” sanitation operations on the ear include:

- impossible visual control of the mastoid cavity;

- the impossibility of sanitation of all cells of the mastoid process, especially with the pneumatic type of structure;

- high relapse rate of cholesteatoma;

- often the developing block of aditus leads to the separation of the mastoid and tympanic cavity, contributing to the destruction and otogenic complications.

The prototype of the proposed method for the treatment of chronic suppurative otitis media can be considered the operation described by H. Woolstein (H. Woolstein. Hearing-improving operations. M .: Medicine, 1972, - P. 226-234), which consists in the formation of a mastoid cavity through the behind-the-ear incision, mastoid plastic cavity periosteal aponeurotic flap to reduce its volume and use for tympanoplasty free transplant. The disadvantages of the prototype include:

- insufficient rehabilitation of the mastoid process, especially with the pneumatic type of its structure;

- the need to reduce the mastoid cavity;

- poor review of the postoperative cavity, which will complicate the care and control of it;

- frequent pathological scarring, which eliminates the functional stage of the operation;

- rejection of a neomeatal flap due to insufficient nutrition.

The aim of the invention is the prevention of relapse after surgical treatment of chronic suppurative otitis media with the pneumatic type of the mastoid process and improving hearing.

The goal of the invention is achieved by the fact that during the formation of the mastoid cavity, a “bridge” is maintained, then, after the completion of the sanitizing stage of the operation, the plastic of the posterior wall of the ear canal is supplemented by the formation of a flap on the feeding leg from the skin of the ear region, the length required to cover the aditus, then after revisions of the tympanic cavity and removal of pathological elements perform tympanoplasty using a skin flap on a feeding leg cut from the ear canal.

The essence of the invention is illustrated by the drawings of figures 1, 2, 3, where:

1. Aditus

2. The Bridge

3. Postoperative mastoid cavity

4. Upper flap cut from the skin of the ear canal

5. A skin flap on the feeding leg, formed from the skin of the ear canal, used for tympanoplasty

6. Lower flap cut from the ear canal

7. Flap cut from the skin of the ear region

The proposed method is performed as follows: under intubation anesthesia, an incision is made in the skin and soft tissues in the behind-the-ear area at the place of attachment of the auricle. Soft tissues are separated, the site of the mastoid is exposed. A mastoid process is performed. "Bridge" (2) do not shoot down, to maintain the fibrous ring (figure 1). T-shaped plastic of the ear canal is performed, with the formation of two skin flaps - the upper (4) and lower (6), which are sutured with catgut to the periosteum of the ear region. Next, under an operating microscope, after revision of the tympanic cavity and removal of pathological elements, one of the tympanoplasty options is performed (Fig. 2). A skin flap on the leg (5) is taken from the posterior-upper wall of the auditory meatus and a tympanic membrane defect is covered by it. To increase the epidermis front of the mastoid postoperative cavity (3), a skin flap is cut out from the behind the ear region on the feeding leg (7) about 1 cm wide, with a base at the lower corner of the wound so long that they can cover the aditus. The cut flap (7) is laid on the bottom of the mastoid cavity (3) to the aditus (1) and is fixed to the lower skin flap (6), formed during plastic surgery of the ear canal. Nodal sutures are applied layerwise to the behind-the-ear wound (Fig. 3). To prevent the formation of a fistula, a notch is made on the flap cut from the skin of the ear region. Thus, a mastoid cavity is formed, isolated from the tympanic cavity, but opening in the ear canal. Sound performance is improved by removing pathological elements from the tympanic cavity and performing tympanoplasty.

Thus, with such an operation, even with exacerbations of inflammation in the mastoid process, pus will be released directly into the auditory meatus, bypassing the tympanic cavity. The consequence of this is the preservation of the sound-conducting system.

The proposed method was introduced into the work of the ENT department of the Alexander Mariinsky Regional Clinical Hospital in Astrakhan and was used in the treatment and rehabilitation of 17 patients with chronic purulent otitis media. The following are examples of testing.

Example 1. Patient G., born in 1961, (source No. 3858) was admitted to the ENT department on 12.03.2005 with complaints of severe pain in the right ear, suppuration from it, and an increase in body temperature. According to the patient since childhood, exacerbation 1-2 times a year. In 2003, a general cavity surgery was performed on the left middle ear. DS: Exacerbation of right purulent epitympanitis. Condition after surgical treatment on the left middle ear. When otoscopy: AD - in the auditory meatus moderate purulent discharge with a sharp putrid odor. The eardrum is scarred, hyperemic. In the posterior-upper quadrant, the defect is up to 3 mm in diameter. AS - in the cavities of the middle ear, the state after radical surgery. The middle ear cavity is clean, dry, the epidermis is complete. Hearing: ШР - AD 3.0 m, AS - 0.5 m. On the audiogram, the hearing loss in both ears is mixed, on the right there is a conductive break in speaking frequencies of 25-30 dB, on the left - 40-50 dB. When radiography of the temporal bones according to Schuller and Mayer against the background of the sclerotic structure of the right mastoid process revealed significant destructive changes in the cells of the mastoid process and antrum. Given the localization of destructive changes and the need to maintain a socially appropriate hearing, surgery was performed according to the scheme described above on 03.22.05. Perforation of the tympanic membrane, after revision of the tympanic cavity and removal of pathologically altered tissue, is covered by a skin flap on the leg from the posterior-upper wall of the ear canal. The postoperative period was uneventful. Tampons from the mastoid cavity were removed on the 4th day, sutures from the postoperative wound on the 7th. Discharged 1.04.05 for outpatient monitoring. It was observed in dynamics for 6 months. Complete epidermization of the mastoid cavity and its cleansing after three weeks, the eardrum defect is completely closed. Hearing improved in whispering by 1 meter, in the audiogram for conversational frequencies by 10-15 dB.

Example 2. Patient A., born in 1982, suffers from chronic purulent otitis media since childhood. Repeatedly undergone a course of conservative anti-inflammatory therapy with temporary clinical improvement. First hospitalized in the ENT department on 09/20/04. When otoscopy: AD - in the ear canal is a slight mucopurulent discharge with a putrefactive odor. The eardrum is scarred, hyperemic, in the anteroposterior quadrant a defect of up to 2 mm in diameter. AS - the ear canal is dry. The eardrum is slightly hyperemic in the anteroposterior quadrant with a defect of up to 3 mm in diameter. Hearing SR - AD = AS 4 m. On the audiogram, hearing loss in both ears is a type of disturbance in sound conduction, the conductive component at talking frequencies of 15-25 dB. On radiographs of the temporal bones according to Schuller and Mayer against the background of pneumatic mastoid processes, destructive cavities, more pronounced on the left, are determined. By the above method, sanitizing operations were performed on both middle ears. The first, given the exacerbation, is on the right middle ear - 09/28/04 (source No. 15532), the second - on the left middle ear - 7/04/05 (source No. 5261). In both operations, after revision of the tympanic cavity under an operating microscope with a magnification of × 12, tympanoplasty of the first type was performed using a flap on a leg from the skin of the posterior-upper wall of the ear canal. Dynamic observation for six months. The epidermization of the mastoid cavities was completed after three weeks, the defects of the tympanic membranes were closed. At the last examination (October 2005), the postoperative mastoid cavities are clean, the epidermis is complete, and there are no defects in the tympanic membranes. Hearing SR - AD = AS - 6.0 meters, on the audiogram, the bone-air interval at conversational frequencies disappeared. The patient passed a professional commission and was hired by the internal affairs bodies.

When performing the proposed surgical intervention, it is possible to achieve:

- radical rehabilitation of the mastoid process;

- the formation of a volumetric resonating cavity of the mastoid, widely open in the area of sound conduction, which improves hearing;

- a good review of the postoperative cavity during otoscopy, due to the maximum removal of the posterior-upper wall of the ear canal;

- complete and rapid epidermization of the postoperative cavity, which allows to reduce the rehabilitation time and reduce the frequency of relapses;

- uncoupling of the mastoid and tympanic cavities, which prevents the exudate from entering the tympanic cavity from the mastoid, where relapses most often appear, which significantly improves sound conduction;

- to provide a stable effect of the functional operation, since even with exacerbations the sound conduction elements are protected.

Claims (1)

A method for the surgical treatment of chronic purulent otitis media, consisting of the simultaneous execution of the sanitizing and functional stages, characterized in that when the mastoid cavity is formed, a bridge is maintained, plastic surgery of the posterior wall of the auditory canal with the formation of two flaps from the skin of the auditory canal - the upper and lower ones, which are hemmed periosteum of the ear region, after revision of the tympanic cavity and removal of pathological elements, tympanoplasty is performed using a skin flap on pita the leg, cut from the posterior-upper wall of the ear canal, then the plastic is supplemented with the formation of a flap on the feeding leg from the skin of the ear region, the length required to cover the aditus, the cut flap is laid on the bottom of the mastoid cavity and fixed to the lower skin flap.

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