RU2367398C1 - Tympanoplasty type 1 technique in sub- and total tympanic membrane defects with two-pedicle positioned skin flap - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and can be used in surgical treatment of chronic otitis media. Substance of the technique implies the inspection and sanitation of tympanic cavity, and formation of a two-pedicle meatotympanic flap which is used to close a tympanic perforation. Herewith, two parallel, circular skin incision of acoustic meatus from roof to bottom. One incision is made closer to fibrous ring, while another one is made at the required distance from the first depending on the perforation dimensions. Then the skin flap is separated as a two-pedicle strip: one within the roof of acoustic meatus, another - within the bottom. The rest of acoustic meatus skin and epidermis are cut off from the rest of tympanic membrane within both pedicles. Then the skin flap is positioned on tympanic membrane to close the perforation completely.

EFFECT: application of the present invention allows improving tympanoplasty effect and reducing number of recurrences due to maintained sufficient blood supply and fixation of the flap.

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Description

The invention relates to medicine, namely to otorhinolaryngology.

Tympanoplasty is an operation aimed at improving hearing, during which an audit of the tympanic cavity, the chain of auditory ossicles is performed, if necessary, rehabilitation and / or ossiculoplasty, the final stage of which is myringoplasty (restoration of the integrity of the eardrum).

Like any other operation, tympanoplasty, when performed, has a sequence. A surgical approach or access can be transmeatal, ateric, and endoural to provide the greatest view of the entire surgical field. After the formation of wide access to the elements of the tympanic cavity or other parts of the middle ear, they proceed to the next stage of tympanoplasty - removal of all pathologically changed tissues (OKPatyakina, 1981; V.T. Palchun, 2002; A.A. Mironov, 2002; BC Korvyakov, 2007).

The next stage of tympanoplasty is ossiculoplasty - restoration of the mobile chain of auditory ossicles (N.G. Sidorina et al., 2000; V.D. Melanin, 2000).

The final stage of tympanoplasty is myringoplasty. A non-tympanic membrane should be tried to form at a natural level.

Various materials have been proposed for myringoplasty: allogeneic tissues - dura mater, amnion, sclera, cadaveric eardrum, canned periosteum of the flat bones of the skull; M.P. Nikolayev (1998) tested a new method of myringoplasty using tachocomb. However, it is generally accepted that the best material for myringoplasty is autotissue: autofascia, auto-cartilage, etc. For the purpose of myringoplasty, previously used free skin grafts that were transplanted to the remains of the tympanic membrane (Tirsch plastic surgery). Currently, this technique is practically not used, because skin grafts are necrotic. Widespread use was found in skin flaps cut out from the ear canal, which receive nutrition through one “leg”, this method can be used for plastic surgery of small perforations, because to close the subtotal and total defects of the eardrum, large skin flaps are required, the blood supply of which through one “feeding” leg is insufficient, which is the reason for the failure and relapse of perforation.

Given the above nuances of tympanoplasty, in order to eliminate them, various modifications of tympanoplasty aimed at eliminating the inflammatory process and restoring the tympanic membrane are proposed, in particular:

1) the method of tympanoplasty. SU 1487903 A1, 1989;

2) myringoplasty with a double fascial flap. RU 2157161 C1, 1999;

3) the method of plastics perforation of the tympanic membrane, RU 2256415 C1, 2004;

4) a method of forming a non-tympanic membrane in tympanoplasty. RU 2289377 C1, 2006;

5) the method of tympanoplasty I - type with subtotal and total defects of the tympanic membrane. Lyulko V.K., Marchenko V.M. Atlas of ear surgery. Kiev, Health, 1989, p.128-129.

Closest to our proposed method of tympanoplasty is the method developed by Lyulko V.K., Marchenko V.M. Atlas of ear surgery. Kiev, Zdorovye, 1989. P.128-129, including the formation of wide access to the elements of the tympanic cavity, removal of pathologically changed tissues and directly myringoplasty using a flap from the skin of the external auditory meatus on one feeding leg, which allows to increase the efficiency of tympanoplasty due to more reliable fixation graft on the bed. We take this method as a prototype.

The disadvantages of this method are: 1) for subtotal and especially total defects of the tympanic membrane, a large graft is required, in this case, one feeding “leg” cannot always provide blood supply (“nutrition”) to the flap from the skin of the external auditory canal, which may cause it necrosis and lead to tympanoplasty failure;

2) the flap proposed by us on two feeding legs can only move forward and backward to a limited extent, across the conditional line of the connecting leg, the flap on one feeding leg, laid on the remains of the eardrum, can freely move up - down, forward - backward, inwards - outward, in this connection, the likelihood of a flap displacement and recurrence of perforation increases.

To eliminate these shortcomings, we propose a method of tympanoplasty of the 1st type developed by us for sub- and total defects of the tympanic membrane with a displaced skin flap on two feeding “legs”.

The purpose of the invention: to increase the effectiveness of tympanoplasty by improving blood supply to the skin flap and preventing its displacement.

This goal is achieved through the formation of a skin flap on two feeding legs, which fits on the remains of the epidermal eardrum, completely closing the perforation. The skin flap is not necrotic, because has two feeding "legs", does not shift and does not sink, because feeding "legs" fix the flap in the right position.

Our proposed method can be used in the surgical treatment of patients with chronic otitis media.

Description of the invention. Under local anesthesia with a 2% solution of 6.0 ml of lidocaine, through the external auditory canal, under the control of an operating microscope, the edges of the perforation of the tympanic membrane are refreshed, then two parallel circular incisions of the skin of the auditory canal are made from the upper wall to the lower, one closer to the fibrous ring, the other stepping back to the required distance from the first, depending on the size of the perforation, after which the skin flap is separated in the form of a “strap” on two feeding “legs”: one in the region of the upper wall of the auditory passage ode, the other - the bottom; in the area of both legs, the remains of the skin of the ear canal and the epidermis are excised from the remnants of the eardrum, because an offset skin flap will be placed in their place. After that, revision and rehabilitation of the cavities of the middle ear are performed, if necessary, the transformation system of the middle ear is restored, then myringoplasty is transferred to the skin flap on two feeding “legs”, placed on a tympanic membrane and the perforation is completely closed, the presence of two feeding legs ensures blood supply to the flap, preventing its necrosis and excludes the likelihood of its displacement all the more so the retreat. Rubber strips are placed on the non-tympanic membrane, tamponade of the external auditory canal with cotton swabs with antibiotics.

An example of a specific implementation No. 1

Patient M., 45 years old, was admitted to the ENT department of the FSI NCC of Otorhinolaryngology of the Russian Health Ministry on 02.10.06 with a diagnosis of chronic right-sided otitis media (mesotympanitis), without exacerbation, medical history No. 3934. From the anamnesis, he suffers from chronic right-sided otitis media from childhood, was treated periodically, on an outpatient basis without a pronounced, short-term effect. Objectively: AD - the behind-the-ear area is not changed, the external auditory meatus is free, wide, there is subtotal perforation of the tympanic membrane, the fibrous ring is preserved, the visible part of the mucous membrane of the tympanum is pale pink, there is no discharge, the auditory tube is passable during the Valsalva test. Hearing in the right ear: sp. - 1.0 m, river 3.0 m.

The patient in the department was examined and prepared for surgical treatment. 04.10.06 under m / a tympanoplasty of the right ear of type I was performed according to the technique we proposed. At the end of the operation, the patient noted an improvement in hearing. The postoperative period was uneventful, antibacterial and antihistamine therapy and a daily toilet of the right ear were carried out under the control of an operating microscope and a set of exercises for the auditory tube. On the 14th day after the operation, the patient was discharged home in satisfactory condition, the hearing improved: sp. 3.0 m, p.p. more than 5.0 m, non-tympanic membrane of pink color, no perforation, auditory tube is passable during the Valsalva test.

An example of a specific implementation No. 2. Patient B., 38 years old, was admitted to the ENT department of the Federal State Clinical Center for Otorhinolaryngology of the Federal Health Service on 06/18/07 with a diagnosis of chronic right-sided post-traumatic otitis media, exacerbation, medical history No. 2763. From the anamnesis in 2005, a post-traumatic rupture of the right tympanic membrane, further suppuration of the right ear every 3-4 months, in December 2006, tympanoplasty of the right ear was performed, without effect. Upon admission to the hospital complaints of decreased hearing in the right ear. Objective research data: AD external auditory meatus wide, free, subtotal, central, eardrum defect present. With audiometry: Right-sided conductive hearing loss of I degree. The patient in the department was examined and prepared for surgical treatment. 06/20/07 under m / a tympanoplasty of the right ear of type I was performed according to the technique we proposed. The postoperative period was uneventful, antibacterial and antihistamine therapy and a daily toilet of the right ear were carried out under the control of an operating microscope and a set of exercises for the auditory tube. On the 17th day after the operation, the patient was discharged home in satisfactory condition, with control audiometry the hearing was within normal limits. The non-tympanic membrane is pink, there is no perforation, the auditory tube is passable during the Valsalva test.

Bibliography.

1. Patyakina O.K. Tympanoplasty in chronic suppurative otitis media / O.K. Patyakina // Actual issues of otorhinolaryngology: Abstract. doc. / IV scientific - prakt. Conf. Otorhinolaryngologists. - M. - 1981. - S. 72-75.

2. Nikolaev M.P. Mastoidoplasty with hydroxapatite and collapol in patients with chronic purulent otitis media / M.P. Nikolayev, P.M. Nikolayev, I.P. Vasilenko // Actual problems of phoniatrics and clinical deafness. - M., 1998 .-- S. 129 - 131.

3. Sidorina N.G. The use of allotissue in reconstructive surgery after general cavity ear surgery / N.G. Sidorina, B.C. Korvyakov // Materials of the scientific-practical conference "Problems of implantology in otorhinolaryngology". - M., 2000. - P.46-48.

4. Melanin V.D. Free transplantation of bone and cartilage tissue in otorhinolaryngology / V.D. Melanin // Materials of the scientific-practical conference "Problems of implantology in otorhinolaryngology". - M., 2000. - P.24-26.

5. Mironov A.A. Problems of diagnosis and treatment of chronic suppurative otitis media / A.A. Mironov // Materials of the Russian Scientific and Practical Conference "Modern problems of diseases of the upper respiratory tract and ear." - M., 2002. - P.97-100.

6. Palchun V.T. Preparation of a patient with chronic purulent mesotympanitis for ear surgery / V.T. Palchun, L.A. Luchikhin, A.A. Mironov // Materials of the Russian Scientific and Practical Conference "Modern problems of diseases of the upper respiratory tract and ear." - M., 2002. - P.107-108.

7. Korvyakov B.C. Modern aspects of surgical treatment of patients with inflammatory diseases of the middle ear: Dis. ... doctor. Honey. Science. - Moscow. 2007 .-- 200 p.

Claims (1)

The method of tympanoplasty of type I for sub- and total defects of the tympanic membrane with a displaced skin flap on two feeding legs by forming wide access to the elements of the tympanic cavity, removing pathologically changed tissues and directly myringoplasty using a flap from the skin of the external auditory canal, characterized in that make two parallel, circular cuts of the skin of the auditory meatus from the upper wall to the lower, one closer to the fibrous ring, the other, retreating to the required distance from the first, depending on the size of the perforation, after which the skin flap is separated in the form of a strap on two feeding legs: one in the region of the upper wall of the ear canal, the other - lower; in the area of both legs, the remains of the skin of the ear canal and epidermis are excised from the remnants of the eardrum, then the skin flap is moved, it is placed on the eardrum and the perforation is completely closed.