RU2371155C1 - Method of eliminating neotympanic membrane lateralisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, particularly otolaryngology, and can be applied in tympanoplasty. Method involves parotid access, separation of soft tissues and skin of external acoustic meatus up to neotympanum membrane, neotympanum membrane slicing in two layers, external epidermal and internal mucous layers, separation and depression of internal layer till it contacts malleus, or, in the absence thereof, sound conducting link. Latch-shaped meatotympanic flap is formed on pedicle in the area of rear wall of external acoustic meatus, combining skin of rear, top and bottom walls of external acoustic meatus and external epidermal layer of neotympanum membrane. Flap is dislocated downwards, its forward sections are placed on the front wall bone of acoustic meatus up to tympanum ring, and remaining major part is used as tympanum membrane autotransplant and laid in bone tympanum ring.

EFFECT: eliminated lateralisation of neotympanic membrane, improved morphological and functional results of tympanoplasty.

1 ex, 3 cl, 2 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in performing tympanoplasty.

Tympanoplasty is a functional reconstructive surgical intervention on the ear, performed to create an air-bearing tympanic cavity, including reconstruction of the auditory ossicles (ossiculoplasty) and the tympanic membrane (myringoplasty).

Myringoplasty is a surgical operation performed to close a tympanic membrane defect formed as a result of trauma or a chronic purulent process in the middle ear, which can be an independent operation or the final stage of tympanoplasty.

As a rule, for myringoplasty, single-layer grafts are used, such as autofascation, vein, auto-cartilage, adipose tissue or, more rarely, two-layer grafts, where auto- and allo-cartilage, various synthetic materials are used as the inner supporting layer. The eardrum, restored as a result of myringoplasty, is called the neotympanic membrane.

In the process of engraftment, the eardrum graft can shift, thicken, and fester, which can ultimately lead to the development of adverse outcomes in myringoplasty, such as lateralization of the non-tympanic membrane and blunting of the anterior metatympanic angle.

Lateralization of the non-tympanic membrane is an unfavorable outcome of myringoplasty, consisting in the displacement of the non-tympanic membrane outward in relation to the natural (anatomical) position of the eardrum. The neotympanic membrane in this case, as a rule, is thickened, which is associated with one of the lateralization mechanisms, a long-term graft disease in the early postoperative period. Epidermisation of the graft from the outside and epithelization from the inside, occurring during this period, “fixes” the sharply thickened graft, later the graft fibroses with the formation of lateralization.

Blunting of the anterior meatotympanic angle is an unfavorable outcome of myringoplasty, consisting in the displacement of the non-tympanic membrane to the outside only in the area of the anterior wall of the external auditory canal, which is accompanied by an increase in the angle between the non-tympanic membrane and the front wall of the external auditory canal - its blunting.

The lateralization of the non-tympanic membrane and the blunting of the anterior meatotympanic angle significantly worsen the functional results of tympanoplasty, therefore, the development of an effective method for their elimination is an urgent task.

There is a known method for eliminating lateralization of a non-tympanic membrane, including performing a circular incision of the skin of the ear canal just above the non-tympanic membrane, separating the skin and non-tympanic furniture and lowering to the anatomical level of the tympanic ring (Toc M. “Guide to middle ear surgery”, volume 3, Tomsk, Siberian State Medical University , 2008, p. 57).

The disadvantages of this method are: a violation of the blood supply to the non-tympanic membrane and, as a result, a worsening of engraftment; the formation of a circular skin defect, which lengthens the healing time and increases the likelihood of repeated lateralization of the non-tympanic membrane due to the fibrous process.

There is also a method for eliminating lateralization of a non-tympanic membrane, according to which the height of the sound-conducting circuit is increased, trying to eliminate diastasis, namely, to level the distance between the lateralized non-tympanic membrane and the element of the sound-conducting chain in order to improve the patient’s hearing (Toc M. “Middle Ear Surgery Manual”, vol. 3, Tomsk, Siberian State Medical University, 2008, pp. 57-58).

This is possible due to the installation of a longer prosthesis, partial or complete, as well as due to the introduction, for example, of a cartilage graft between the neotympanic membrane and the element of the sound-conducting circuit. In this case, the non-tympanic membrane is left at the same level where it was formed.

Thus, this method solves only the functional component of the lateralization problem of the non-tympanic membrane, without affecting the anatomical component.

The method allows to solve the problem of violation of sound conduction, but has significant limitations and disadvantages:

- it is difficult to implement in the presence of significant lateralization of the non-tympanic membrane (more than 3-5 mm);

- deterioration in functional results due to an increase in the number of elements of the sound-conducting circuit when using an additional transplant - “spacers”, its displacement or resorption in the postoperative period;

- maintaining the excess thickness of the non-tympanic membrane and, as a consequence, the deterioration of its sound-conducting properties.

The closest in technical essence to the claimed solution is a method of eliminating lateralization of the non-tympanic membrane after tympanoplasty (Anikin MI "Method of eliminating lateralization of the tympanic membrane", Ros. Otorinolar., Appendix No. 2, 2008, p.203 -207).

This method includes the following steps. By means of behind-the-ear access, soft tissues and skin of the external auditory meatus are separated to the neotympanic membrane. Next, the non-tympanic membrane is layered on the outer epidermal layer and the inner mucosal fibrous layer. Then, the inner mucous-fibrous layer is separated along the perimeter downward and reduced to the level of the tympanic ring in such a way as to achieve contact with the hammer (an element of the sound-conducting circuit), and the outer epidermal layer is dissected crosswise and placed on the boneless walls of the external auditory canal.

The disadvantage of this method is that the outer surface of the formed non-tympanic membrane is a wound surface and is completely devoid of epidermal cover. This creates the conditions for repeated lateral displacement of the non-tympanic membrane with scars formed between the wound surfaces of the membrane and the walls of the ear canal outside of it.

The technical result of the invention is to improve the morphological and functional results of tympanoplasty.

To achieve the specified technical result in a method for eliminating lateralization of a non-tympanic membrane, including ear access, separation of soft tissues and skin of the external auditory meatus to a non-tympanic membrane, delamination of the non-tympanic membrane into two layers, the external epidermal and internal mucous membranes, separation and lowering of the inner layer to contact with the hammer , and in its absence, with the element of the sound-conducting circuit, according to the proposal, a tongue-shaped meatotympanic flap is formed on the supply leg in the area of the front wall of the external auditory canal, including the skin of the posterior, upper, lower walls of the external auditory canal and the outer epidermal layer of the non-tympanic membrane, which are displaced downward, while its front sections are laid on the bone of the front wall of the auditory canal to the level of the tympanic ring, and the remaining large part is used as an autograft of the tympanic membrane, laying on a bone drum ring.

Also, according to the proposal, when the non-tympanic membrane is stratified into two layers, an excess of fibrous tissue between the layers is simultaneously excised, mainly in the region of the anterior meatotympanic angle. The skin defect of the external auditory meatus arising from the reduction of the meatotympanic flap is eliminated by laying a free skin autograft taken from the behind-the-ear incision.

The method is illustrated by drawings, where figure 1 is a schematic side view of the ear canal and tympanic cavity before surgery; figure 2 schematically shows a side view of the ear canal and tympanic cavity after surgery.

The method is as follows.

General anesthesia (intubation anesthesia) or local anesthesia is used.

The position of the patient during surgery - lying on his back, head turned to the side with the operated ear up. First, antiseptic treatment of the skin of the auricle and the external auditory canal is performed.

A skin incision is performed in the behind-the-ear region along the transitional fold, soft tissues are separated in the region of the mastoid process to the posterior wall 1 of the external auditory meatus, and further, the skin 2 is separated from the external auditory meatus in the direction of the tympanic cavity 3 to the non-tympanic membrane without any additional incisions. Separation is started from the back wall, gradually expanding the separation zone to the upper and lower walls, and only the skin of the front wall 4 is left unseparated from the bone at the level of the non-otimal membrane.

The non-tympanic membrane is stratified into the outer epidermal layer 5 and the inner mucous layer 6, while excising an excess of fibrous tissue 7 between them and in the region of the anterior metatympanic angle. The thickened non-tympanic membrane delaminates quite easily, so the outer side covered with the epidermis is not damaged.

Then the inner mucous layer 6 is separated along the perimeter downward and reduced to the level of the drum ring 8 so as to achieve contact with the hammer 9, and in its absence with the element of the sound-conducting circuit.

Next, visually evaluate the distance between the actual and natural (anatomical) level of the non-tympanic membrane, that is, determine the distance by which it is necessary to lower the non-tympanic membrane. This is necessary in order to further form an adequate meatotympanal flap 10.

The formation of the meatotympanal flap 10 begins with a transverse section of the previously separated skin 2 of the posterior wall 1 of the external auditory meatus. The level of the incision is determined by the surgeon depending on the distance by which the membrane must be lowered so that the edge of the meatotympanic flap 10 after displacement has sufficient support on the bone walls of the external auditory meatus.

Further, cuts along the upper and lower walls towards the non-tympanic membrane complete the formation of the meatotympanic flap 10, while the flap 10 remains connected only with the skin of the anterior wall 4 of the ear canal.

The meatotympanal flap 10 is displaced downward, while its front sections are placed on the bone of the anterior wall 4 of the ear canal to the level of the tympanic ring 8 (the natural anatomical level of the eardrum), and the rest is used as an autograft of the eardrum, laying on the bone drum ring 8.

The skin defect 2 of the external auditory meatus, which inevitably occurs when the flap 10 is brought down, is eliminated by laying a free skin autograft 11 taken from the behind-the-ear incision.

Next, tamponade of the external auditory meatus is carried out, for example, with a silk thread soaked in iodine-oil solution, and suturing on the behind the wound.

The method is illustrated by the following example.

Patient I., born in 1970, medical history No. 1374, was admitted to the clinic of the pathophysiology ear department of the Federal State Institution “St. Petersburg Research Institute of Ear, Throat, Nose and Speech” with a diagnosis of Left-side adhesive otitis media. Condition after tympanoplasty on the left ear. Lateralization of the non-tympanic membrane.

Upon admission, the patient complained of hearing loss in his left ear. From the anamnesis it is known that the patient suffers from chronic otitis media since childhood, the last exacerbation of about 5 years ago. In 2007, he underwent surgery - tympanoplasty on the left ear.

On examination: The mucous membrane of the nose is pink, wet. The septum of the nose is along the middle plane. The nasal passages are free. The nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink, dry. Tonsils - behind the arms, gaps - free. The laryngeal mucosa is pink, moist. The vocal folds are white, their movement is in full. The glottis is wide.

AD - the external auditory meatus is free. Eardrum gray, atrophic, contours preserved. Whispering speech of 6 m, colloquial speech of more than 6 m. Symptoms of Lewis-Federichi and Gelle are positive. AS - the external auditory meatus is free, there is no discharge. The neotympanic membrane is pinkish, there are no defects, visually - it is clearly shifted outward (lateralization). Whisper speech - up to 0.5 m, colloquial speech - up to 5 mm. The symptom of Lewis-Federichi is negative, the lateralization in the Weber sample is on the left side.

The results of tonal threshold audiometry testified to left-sided conductive hearing loss with sound conduction thresholds in the area of speech frequencies on the left of 45-50 dB in the presence of a bone-air interval of 40-45 dB.

The patient underwent a reoperation on the left ear in order to eliminate lateralization of the non-tympanic membrane.

Description of the operation: In conditions of endotracheal anesthesia, an arcuate incision was made in the skin and soft tissues to the bone in the behind-the-ear area about 5 cm long along the old scar. Separation of the soft tissues anteriorly to the external auditory meatus was performed, and further, the skin of the posterior wall of the external auditory meatus was separated to the neotympanic membrane. The non-tympanic membrane was delaminated into the outer epidermal and inner mucous layers. Excess fibrous tissue, mainly in the region of the anterior meatotympanic angle, is excised by the consequence of micro scissors. Separated the inner mucous layer along the perimeter down and down to the level of the drum ring, laid on the handle of the malleus.

A transverse incision was made of the previously separated skin of the posterior wall of the external auditory meatus about 1.5 cm above the non-tympanic membrane. Further, cuts along the upper and lower walls in the direction of the non-tympanic membrane formed a meatotympanic flap on the front feeding leg.

The meatotympanal flap is displaced downward, its front sections are laid on the bone of the front wall of the auditory meatus to the level of the tympanic ring, the anterior meatotympanic angle is indicated; the rest of the meatotympanal flap is laid on the bone tympanic ring, forming a new eardrum, tightly pressed to the handle of the malleus.

The skin defect of the posterior external auditory meatus was eliminated due to the free skin autograft taken from the behind-the-ear section.

The tamponade of the external auditory meatus was made with silk thread, sutures were put on the ear wound; aseptic dressing.

The postoperative period was uneventful. Sutures were removed on the 7th day. The tampon from the external auditory meatus was removed on the 10th day, on the day of discharge. It is recommended to instill drops in the ear - cypromed - 4 cap. 2 times a day - 10 days.

The following dressings were performed 12, 16 and 22 days after surgery.

At the control examination on the 30th day after the operation: AS - the external auditory meatus is free, there is no discharge. The neotympanic membrane is pink, somewhat edematous, has a conical shape; defects or retractions (retraction pockets) were not detected. There is no lateralization of the non-tympanic membrane.

The results of the control tonal threshold audiometry indicate a decrease in the threshold of sound conduction on the left ear in the area of speech frequencies to 10-15 dB and the presence of a bone-air interval of 5-10 dB.

The inventive method allows to avoid such adverse outcomes of myringoplasty as lateralization of the neotympanic membrane and blunting of the anterior meatotympanic angle.

Claims (3)

1. A way to eliminate lateralization of the non-tympanic membrane, including ear access, separation of soft tissues and skin of the external auditory meatus to the non-tympanic membrane, stratification of the non-tympanic membrane into two layers, the external epidermal and internal mucous membrane, separation and lowering of the inner layer to contact with the hammer, and when it absence, with an element of the sound-conducting circuit, characterized in that a tongue-shaped meatotympanic flap is formed on the supply leg in the region of the anterior wall of the external auditory an ode, which includes the skin of the posterior, upper, lower walls of the external auditory meatus and the outer epidermal layer of the non-tympanic membrane, which is displaced downward, while its front sections are laid on the bone of the front wall of the auditory meatus to the level of the tympanic ring, and the rest is used as an autotransplant of the tympanic membrane laying on a bone drum ring. 2. The method according to claim 1, characterized in that when the non-tympanic membrane is stratified into two layers, an excess of fibrous tissue between the layers is simultaneously excised, mainly in the region of the anterior meatotympanic angle. 3. The method according to claim 1, characterized in that the skin defect of the external auditory meatus arising from the lowering of the meatotympanic flap is eliminated by laying a free skin autograft taken from the region of the behind-the-ear incision.

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