RU2438638C2 - Intraoperative diagnostic technique for patency of natural fistulae of tympanic diaphragm in patients with chronic otitis media with apical retraction pockets of eardrum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely otorhinolaryngology, and can be used for intraoperative diagnostics of the patency of natural fistulae of a tympanic diaphragm and aditus in the patients with chronic otitis media with apical retraction pockets of an eardrum. A method involves tympanotomy, husking of an epidermal apical retraction pocket and the introduction of a liquid in retrotympanic portions of an middle ear. A staining liquid is introduced through an attic needle into an anterior fistula of the tympanic diaphragm. And if the liquid level decreases, the incomplete block is diagnoses, if the liquid remains unchanged, the complete block is diagnosed. To be sure that the natural fistulae of the tympanic diaphragm function well, this procedure is carried out once again and follow the surgical elimination of the tympanic isthmus block. A defect of the retraction pocket is grafted with an autocartilage plate. The tympanic isthmus is drained.

EFFECT: use of the given invention allows providing better diagnostic results and decreasing a number of postoperative recurrences.

2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology.

Inflammatory pathology of the middle ear is an important problem of modern otorhinolaryngology. A special place in it is occupied by chronic otitis media, conservative treatment of which gives only a short-term effect, temporarily stopping the inflammatory process in the tympanic cavity (1, 2).

The term chronic otitis media (CHD) with a retraction pocket or atelectatic otitis media means inflammation, which is accompanied by a decrease in the volume of the middle ear due to the displacement of the eardrum inward towards the promontorium and / or epitympanum with the formation of retraction pockets up to the complete epidermization of the tympanic cavity. This disease develops against the background of negative pressure that is created in one or another section of the middle ear against the background of dysfunction of the auditory tube and / or natural anastomoses of the tympanic diaphragm and aditus (6). Thus, the root cause of atelectatic otitis media is dysfunction of the auditory tube, and subsequently the attached block of the tympanic isthmus and aditus. However, it should be borne in mind that the term otitis media itself implies the presence of an inflammatory process in the cavities of the middle ear, which in this disease, at least in the initial stages, is aseptic in the face of negative pressure.

Surgical treatment of patients with chronic obstructive pulmonary disease with retraction pockets should be aimed not only at eliminating the latter, but mainly at eliminating the causes leading to their occurrence, i.e. a block located in the narrow places of the middle ear (auditory tube, tympanic isthmus, aditus). To a greater or lesser extent, understanding of this installation is performed for dysfunctions of the auditory tube and is almost completely absent with aditus block (7). We, in our daily practice, are not supporters of expectant tactics in the treatment of atelectatic otitis media, because we consider any retraction pocket as a pre-cholesteatoma, in the presence of which its involution and self-healing never occurs. From this provision it follows that any retraction pocket is subject to surgical treatment. It consists of tympanotomy, revision of the tympanic cavity, especially the tympanic orifice of the auditory tube and the tympanic isthmus, in the presence of a mechanical block of which (scars, immature fibrous tissue, granulation), the latter must be removed, then the epidermal pocket is hushed, we strengthen the atrophic sections of the tympanic membrane with autotissues ( we give preference to auto-cartilage of the auricle or tragus, sometimes combining it with autofascia of the temporal muscle; in rare cases, we use autobone of the ear canal - especially but if there is a defect attic lateral wall), the operation finishing method developed by us natural anastomoses tympanic drainage aperture and a drainage tube aditusa silicone, meatotimpanalny installed under the flap, which is then fit into place.

Diagnosis and surgical treatment of chronic cholelithiasis with retraction pockets of the tympanic membrane is still an urgent problem of otorhinolaryngology.

There are various intraoperative methods for diagnosing aditus block and anastomoses of the tympanic diaphragm. For example, the saline solution was injected into the retrotimpanal sections of the middle ear using an attic needle, then fluid was quickly aspirated from the tympanic cavity using an electric suction pump, and then it was observed whether the tympanic cavity was filled again with physiological saline or not (3). However, this technique allows us to judge the elimination of the posterior fistula block of the tympanic diaphragm and aditus and, to a lesser extent, the anterior fistula, in connection with which we developed an intraoperative diagnostic technique that allows us to judge its patency (3, 4).

In this regard, the development of a method for intraoperative diagnosis of the block of natural anastomoses of the tympanic diaphragm in patients with chronic obstructive pulmonary disease with retraction tympanic pockets is an important step in determining the effectiveness of surgical treatment and reducing the frequency of relapses.

There are various diagnostic methods.

1. "A method for diagnosing a block of natural anastomoses of the tympanic diaphragm and aditus with contrast computed tomography in patients with chronic purulent otitis media (meso- and epithympanitis)", patent for the invention No. 23744993 from 10.12.09.

2. “Aditus block and its clinical significance in chronic suppurative otitis media” (4).

3. “The effectiveness of separate atticoantrotomy with tympanoplasty in chronic suppurative otitis media” (3).

Closest to the proposed method for intraoperative diagnostics of the patency of natural anastomoses of the tympanic diaphragm is the method of intraoperative injection of physiological saline into the retrotypanal middle ear via natural anastomoses with a syringe and attic needle, followed by rapid aspiration of this fluid from the ear canal and the mesohypothymanum if the suction pump returns to Mesohypothympanum (from the retrotympic divisions), then the block is absent; if not, then there is a block of anastomoses and aditus (4). We take it as a prototype.

The disadvantages of this method are:

1) the inability to judge the presence of a block of the anterior fistula, which the attic reports, therefore, a retraction pocket with a mesohypothympanum, because physiological saline is injected with an attic needle into the aditus region practically “blindly” and enters the retrotympanal parts of the middle ear;

2) lack of information about the severity of the block of natural anastomoses, if any.

To eliminate these shortcomings, a developed method of intraoperative diagnostics of the patency of natural anastomoses of the tympanic diaphragm in patients with chronic otitis media with retraction attic eardrum pockets is proposed.

The purpose of the invention is to increase the efficiency of intraoperative diagnostics and reduce the number of relapses in the formation of retraction eardrum pockets in the postoperative period in patients with chronic otitis media with retraction attic eardrum pockets.

This goal is achieved: to eliminate these shortcomings, a method for intraoperative diagnosis of a block of natural anastomoses of the tympanic diaphragm has been developed. This method differs from the prototype in that it allows you to establish not only the fact of the presence or absence of a block of natural anastomoses of the tympanic diaphragm, but also its severity.

Description of the invention

Under local anesthesia, Sol / Lidocaini 2% - 6.0, under the control of an operating microscope, an endaural incision of the skin of the auditory meatus along Rosen is performed. The skin of the ear canal is separated by a rasper, preferably together with the periosteum to the fibrous ring: tympanotomy is performed. The separated area of the skin of the ear canal, together with part of the eardrum and the fibrous ring, leans forward; removed with a chisel and curettes, a bone canopy over the stirrup along the long leg of the anvil - for better visualization of the tympanic isthmus and to establish the presence or absence of its block. Through this or an additional incision, depending on the location of the attic retraction pocket of the tympanic membrane, it is husked. The resulting attical defect is filled with liquid (preferably with a dye - methylene blue), which either enters the tympanum (mesogypotympanum) in the absence of a block, or remains unchanged - in the presence of a block of the tympanic isthmus. To assess the severity of a complete or incomplete block, using an electric suction device, an attic needle is placed in the region of the anterior fistula of the tympanic diaphragm. If the fluid level decreases, the block is incomplete; if it is, then, respectively, complete. We repeat the same procedure after surgical removal of the tympanic isthmus block to ensure that the natural fistula of the tympanic diaphragm functions well. The operation is completed by plastic surgery of the retraction pocket defect with an auto-cartilage plate and drainage of the tipanal isthmus or a silicone tube that is inserted into the ear canal under the meatotympanic flap - with a full block, or by laying silicone films with its partial block. We lay the meat-tympanal flap in place, fix it with rubber strips; the ear canal is swabbed with cotton balls with an antibiotic.

Case Study 1

Patient Gelman V.V., 53 years old (medical history No. 878 of 2008), was admitted to the ENT department of KB No. 86 with DZ: “Left-side adhesive otitis media”, suffering from ear diseases for about 2 years. AS p.p. 5.0, sh.r. 3.0 m., In the unstretched part of the tympanic membrane there is a retraction pocket, the bottom of which is boundless (passage to the attic?). A tympanotomy was performed with the removal of the aditus block and natural anastomoses of the tympanic diaphragm with drainage of the tympanum. In the course of the operation, the patency of the anterior fistula of the tympanic diaphragm was diagnosed, an incomplete block was found that was removed, the retraction pocket was pulled out and the tympanic membrane defect was made. The postoperative period without features. Antibiotic therapy, daily toilet of the ear cavity, electrical stimulation of the muscles of the pharyngeal mouth of the left auditory tube. Discharged 14 days after surgery. At the time of discharge, the non-tympanic membrane in place is well-to-do, the auditory tube is passable. Rumor p.p. 5.0 m., Highway 4.0 m.

At re-examination: Tympanoplasty is consistent, non-tympanic membrane is gray, no perforation. The hearing is stable.

Case Study 2

Patient Vagapova OV, 39 years old (medical history No. 4547 from 2009), was admitted to the ENT department of the KB No. 86 with DZ: “Chronic bilateral otitis media”. From the anamnesis: from childhood sick with chronic otitis media. Objectively: AD: there is no discharge in the ear canal, Mt is gray, soldered to the medial wall of the tympanic cavity, in the posterior sections there is an attical retraction pocket. In the department under the m / a, an audit of the right tympanic cavity was performed with the block of natural anastomosis of the diaphragm and aditus removed (scar tissue was excised), the anterior anastomosis of the tympanic diaphragm and aditus, which were subsequently removed, was intraoperatively diagnosed, the retraction pocket was completely isolated. The postoperative period without features. Received antibacterial, hemostatic and anti-inflammatory therapy. Daily ear toilet. The postoperative cavity of the correct form, is epidermized, there is no discharge. The auditory tube is passable. Discharged 15 days after surgery. At re-examination: tympanoplasty is wealthy, hearing is stable.

Bibliography

1. Patyakina O.K. Microsurgery for chronic otitis media / O.K. Patyakina, V.P. Bykova // X-region, scientific-practical. conf. otolaryngologists: Abstract. doc. - Orenburg, 1995 .-- S.41-42.

2. Tarasov D.I. Diseases of the middle ear / D.I. Tarasov, O.K. Fedorova, V.P. Bykova. - M .: Medicine, 1988 .-- 288 p.

3. Savin B.C. The effectiveness of separate atticoantrotomy with tympanoplasty in chronic suppurative otitis media: Dis. ... Ph.D. - M., 1981. - 147 p.

4. Khrabrikov A.N. Aditus block and its clinical significance in chronic suppurative otitis media (clinical and morphological study): Dis. doctor of medical sciences - M., 1984. - 202 p.

5. Ars B. [Pockets of tympanic membrane retraction] / B.Ars, M. // Acta. Otorrinolaringol. Esp. - 1996. - V.6, No. 47. - P. 417-424.

6. Ars B. Tympanic membrane. Retraction pocket / B.Ars // Acta Otorhinolaryngol. Belg. - 1995. - V.2, No. 49. - P.163-171.

7. Ars V.M. Tympanic membrane retraction pockets. Etiology, pathogeny, treatment / Ars V.M. // Acta. Otorhinolaryngol. Belg. - 1991. - V.3, No. 45. - P.265-277.

Claims (1)

A method for intraoperative diagnosis of the patency of the natural anastomoses of the tympanic diaphragm in patients with chronic otitis media with attical retraction pockets of the tympanic membrane by tympanotomy with husking of the epidermal attic retraction pocket of the tympanic membrane and the introduction of fluid into the region of the retrotypanal middle ear, characterized by the use of through which dye fluid is introduced into the anterior anastomosis of the timp of the diaphragm, moreover, if the fluid level decreases, an incomplete block is diagnosed, if the fluid persists, the block is diagnosed as complete, and to make sure that the natural fistula of the tympanic diaphragm function well, the same procedure is repeated after surgical removal of the tympanic isthmus block and plastic surgery of the retraction defect is performed pocket plate auto-cartilage and drainage of the tympanic isthmus.