RU2394503C1 - Surgical technique in tympanosclerose - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology. Substance of the method consists in removal of the foci fixing the base of stapes in the oval window niche. It is combined with transection of a tendon of the stapedius muscle nearby the stapedius head and removal of the tendon of the stapedius muscle together with the pyramidal process.

EFFECT: use of the given invention allows improving functional effect of tympanoplasty and eliminating stapedius remobilisation with the tympanosclerotic foci.

2 ex, 3 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in performing operations in patients suffering from persistent hearing loss as a result of tympanosclerosis.

Tympanosclerosis is a special form of sclerosis of the mucous membrane of the tympanic cavity, in which the formation of the so-called tiposclerotic plaques occurs - dense whitish focal thickening of the mucous membrane. According to the literature, most often foci of tympanosclerosis are found in the area of the vestibule window, near the facial nerve canal and in the upper part of the promontorium, as well as in the attic; less often, tympanosclerotic foci are detected in the area of the mouth of the auditory tube and in the niche of the cochlea window.

Hearing loss in such patients is usually conductive or mixed and is mainly due to fixation of the auditory ossicles by foci of tympanosclerosis.

Fixation of the stapes with tympanosclerotic foci occurs quite often. The treatment of tympanosclerosis is only surgical, and one of the most important stages of the operation is the careful removal of foci that limit the mobility of the preserved elements of the sound-conducting circuit.

The surgeon's manipulations aimed at mobilizing the stapes are often laborious and involve certain risks, but at the same time, it is far from always possible to achieve good mobility of the stapes. Moreover, even when satisfactory mobility of the stapes is achieved during surgery, immobilization of the stapes in the postoperative period is often observed, and the long-term result of the operation is regarded as unsatisfactory. This necessitates the search for a more effective and safe way to mobilize stapes in tympanosclerosis.

There is a known method of surgery for tympanosclerosis, in which stapes superstructures are removed without mobilization of the stapes base, perforation of the stapes base is performed (stapedotomy), and a piston-like prosthesis is installed (see D.I. Tarasov “Diseases of the middle ear”, Moscow, Medicine, 1988, p. 193).

The disadvantages of this method is that such an intervention is associated with exposure to the inner ear, and in some cases is accompanied by the development of sensorineural hearing loss, up to complete deafness. The likelihood of developing labyrinthine complications increases in the presence of perforation of the tympanic membrane, therefore this method of operation has a limitation - it is recommended to use it only with repeated intervention, when a neotympanic membrane is already formed, but pronounced conductive hearing loss is maintained.

There is also known a method of surgery for tympanosclerosis, in which the base of the stapes is removed and the vestibule window is closed with an autofascial (venous, fatty, perichondral) graft, on which an ossicular prosthesis is installed (see Atlas of Operative Otorhinolaryngology, edited by BC Pogosov, Moscow, Medicine, 1983, p. 1983 .161-164).

The disadvantage of this method is the high risk of sensorineural hearing loss, up to complete deafness. There are frequent cases of complications in the form of vestibular dysfunction, as well as perilymphorrhea. This method of operation also has a limitation - it is recommended to use it only with repeated intervention, when a non-tympanic membrane is already formed, which is associated with a high risk of infection of the labyrinth.

The closest in technical essence to the claimed solution is the method of surgery for tympanosclerosis, in which the foci fixing the stapes are removed with a needle, hook or scraper up to the annular ligament, and then the stapes are mobilized (see Atlas of Operative Otorhinolaryngology edited by BC Pogosov, Moscow, Medicine 1983, p. 126).

The disadvantage of this method is that in some cases, despite the almost complete removal of foci of tympanosclerosis in the niche of the vestibule window, the stirrup remains sedentary, and the functional results of the operation are usually unsatisfactory.

In other cases, despite satisfactory results in the early postoperative period, gradual hearing impairment is observed in the future, which may be associated with the preservation of conditions for re-fixation of the stapes.

We analyzed the prevalence of tympanosclerosis. The analysis showed that in tympanosclerotic lesions of the vestibule window niche with fixation of the stapes, involvement of the staped muscle in the tendon process is observed in about 22% of cases.

The technical result of the proposed solution is to eliminate the fixation by tympanosclerotic foci of both the base and the arch of the stapes, which increases its mobility and reduces the possibility of re-immobilization of the stapes with foci of tympanosclerosis.

To achieve the specified technical result in the method of operation for tympanosclerosis, including the removal of foci that fix the base of the stapes in the niche of the vestibule window, according to the invention, the tendon muscle tendon is also intersected near the head of the stapes and the tendon tendon is removed together with the pyramidal process.

The method is illustrated by drawings, where Fig. 1 is a view of a tympanic cavity, where 1 is a stirrup, 2 are foci of tympanosclerosis, 3 is a tendon of the stirrup muscle, 4 is a pyramidal process; figure 2 presents a view of the tympanic cavity after removal of foci of tympanosclerosis and intersection of the tendon of the stirrup muscle, where 3 is the tendon of the stirrup muscle (crossed); figure 3 presents a view of the tympanic cavity after removal of part of the tendon of the stirrup muscle along with the pyramidal process.

The method is as follows.

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

The section, as a rule, is behind the ear, less often - endaural. The operation steps required in this particular case are performed, which include separation of soft tissues and skin, preparation of a bed for placement of a tympanic membrane transplant, revision of the tympanic cavity, and removal of pathological tissues. If stiffness 1 stiffness caused by foci of tympanosclerosis 2 is detected, carefully remove all, if possible, foci 2 to the annular ligament of stapes 1 and check stapes mobility 1. If stapes 1 is not sufficiently motivated, microsurgical scissors (laser, needle) cross tendon of stapedius muscle 3 near the head stapes 1. This, as a rule, achieves the required mobility of stapes 1. The tendon of the stirrup muscle 3 is removed together with the pyramidal process 4.

Then, if required, an ossicular prosthesis is installed. The operation is completed by laying a meatotympanal flap or, in the presence of a tympanic membrane defect, by performing myringoplasty.

The method is illustrated by the following examples.

Example 1

Patient V., born in 1974, was admitted to the clinic of the ear pathophysiology department of the Federal State Institution “St. Petersburg Research Institute of Ear, Throat, Nose and Speech” with a diagnosis of left-sided chronic purulent otitis media (mesotympanitis). Remission.

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 - about 12 years ago. In childhood, he underwent bilateral tonsillectomy.

On examination: The mucous membrane of the nose is pink, wet. Nasal septum - slightly curved to the right. The nasal passages are free. The nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink, dry. 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. The eardrum is gray, the contours are clear. 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. Defect of the tympanic membrane in the posterior quadrants, non-marginal, through which foci of tympanosclerosis are determined in the tympanic cavity. Whispering speech - up to 0.5 m, colloquial speech - 3-4 m. The symptom of Lewis-Federichi is negative, the lateralization in the Weber test is on the left side.

The results of tonal threshold audiometry: left-side conductive hearing loss with sound conduction thresholds in the area of speech frequencies of 40-50 dB in the presence of a bone-air interval of 35-40 dB.

The patient was performed tympanoplasty on the left ear.

Operation description. In conditions of endotracheal anesthesia, an arcuate incision was made in the skin and soft tissues to the bone in the behind-the-ear region with a length of about 5 cm along the transitional fold. Separation of soft tissue anterior to the external auditory meatus has been performed. A fragment of autofascia of the temporal muscle with a diameter of 2 cm was highlighted in the upper corner of the wound. Next, the skin was separated from the posterior wall of the external auditory meatus and a “bed” for graft placement was prepared.

When revising the tympanic cavity, it was found that the auditory ossicle chain was preserved, but motionless due to fixation of the stapes by foci of tympanosclerosis. Foci of tympanosclerosis were also found in the region of the canal of the facial nerve and at the promontorium. It was also found that the tendon of the stirrup muscle is rigid due to involvement in the tympanosclerotic process.

All, if possible, tympanosclerotic plaques that fix the base of the stapes are removed. When checking the mobility of the stapes, it was found that, despite the almost complete absence of foci of tympanosclerosis in the area of the vestibule window, the chain of auditory ossicles remains inactive. Microsurgical scissors crossed the tendon of the stirrup muscle near the head of the stapes. The chain of auditory ossicles immediately became mobile. In order to prevent re-fixation of the stapes in the area of his head, the pyramidal process was removed along with the remains of the tendon of the stirrup muscle, for which a microsurgical spoon was used.

Fascial autograft was placed on a previously prepared bed. At the periphery, the graft was covered with previously displaced skin of the external auditory meatus to ensure good nutrition and additional fixation of the graft.

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 - ciprolet - 4 drops 2 times a day - 10 days.

The following dressings were performed on 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 swollen, no defects.

Results of control tonal threshold audiometry: AS - sound conduction thresholds in the area of speech frequencies of 10-15 dB in the presence of a bone-air interval of up to 10 dB.

During the follow-up examination 1 year 7 months after the operation: AS - the external auditory meatus is free, there are no discharge. The non-tympanic membrane is gray, there are no defects, the contours of the handle of the malleus are determined.

Results of the control tonal threshold audiometry: AS - sound conduction thresholds in the area of speech frequencies of 15-20 dB in the presence of a bone-air interval of 10-15 dB.

Example 2

Patient V., born in 1963, 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-sided chronic purulent otitis media (mesotympanitis). Remission.

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, rare exacerbations, the last exacerbation - about 2 years ago.

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, moist. Tonsils - behind the arms, gaps - free. The laryngeal mucosa is pink, moist. The vocal folds are white, their movement is in full.

AD - the external auditory meatus is free. The eardrum is gray, the contours are clear. 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. Eardrum defect - subtotal. Whispering speech is near the auricle, colloquial speech is up to 2 m. The symptom of Lewis-Federici is negative, the lateralization in the Weber test is on the left side.

The results of tonal threshold audiometry: left-side conductive hearing loss with sound conduction thresholds in the area of speech frequencies of 50-60 dB in the presence of a bone-air interval of 45-55 dB.

The patient was performed tympanoplasty on the left ear.

Operation description. In conditions of endotracheal anesthesia, an arcuate incision was made in the skin and soft tissues to the bone in the behind-the-ear region with a length of about 5 cm along the transitional fold. Separation of soft tissue anterior to the external auditory meatus has been performed. In the upper corner of the wound, a fragment of autofascia of the temporal muscle 2.5–3 cm in diameter was highlighted. Next, the skin was separated from the posterior wall of the external auditory meatus and a “bed” for graft placement was prepared. During the audit of the tympanic cavity, it was found that the auditory ossicle chain was preserved, but motionless due to total fixation by the foci of tympanosclerosis.

Anvil-stirrup articulation was performed. The anvil was removed and the head of the malleus was resected. The tympanosclerotic plaques fixing the stapes base were removed.

When checking the mobility of the stapes, it was found that, despite the absence of foci of tympanosclerosis in the area of the vestibule window, the stirrup remains inactive. Microsurgical scissors crossed the tendon of the stirrup muscle near the head of the stapes. The stirrup immediately became mobile. In order to prevent re-fixation of the stapes in the area of his head, the pyramidal process was removed along with the remains of the tendon of the stirrup muscle, for which a microsurgical spoon was used.

Fascial autograft placement was performed using the underlay technique on a previously prepared bed. Ossiculoplasty is performed by installing a titanium prosthesis on the stapes head. Differentiation of the proximal part of the prosthesis from the fascial autograft was performed by an ultra-thin auto-cartilaginous plate.

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 canal was removed on the 11th day, on the day of discharge. It is recommended to instill drops in the ear - ciprolet - 4 drops 2 times a day - 10 days.

The following dressings were performed on the 14th, 18th and 25th days after the operation.

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, swollen, no defects.

Results of control tonal threshold audiometry: AS - sound conduction thresholds in the area of speech frequencies of 10-15 dB in the presence of a bone-air interval of up to 10 dB.

During the follow-up examination 1 year 2 months after the operation: AS - the external auditory meatus is free, there is no discharge. The non-tympanic membrane is gray, there are no defects, the contours of the proximal part of the prosthesis are determined.

Results of control tonal threshold audiometry: AS - sound conduction thresholds in the area of speech frequencies of 10-15 dB in the presence of a bone-air interval of 10 dB.

The inventive method allows to improve the functional results of tympanoplasty in patients with tympanosclerosis and significantly reduce the incidence of such an unfavorable outcome of the operation in tympanosclerosis, as a stirrup fixation.

Claims (1)

The method of operation for tympanosclerosis, including the removal of foci that fix the base of the stapes in the niche of the vestibule window, characterized in that they additionally intersect the tendon of the stirrup muscle near the head of the stapes and remove the tendon of the stapes together with the pyramidal process.

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