RU2464937C1 - Method of ablation of paraganglioma of lateral scull base of otiatric shape - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to otorhinolaryngology. Essence of method consists in realisation of behind-the-ear access, separation of soft tissues and skin of external auditory canal, creation of trepanation cavity and ablation of tumour, if possible, with preservation of system of auditory ossicles. Dipantomy for right ear is performed from 5 o'clock to 12 o'clock, and for left ear from 12 o'clock to 7 o'clock. Smaller trepanation cavity, limited by tumour spread is formed. If tumour is spread to attic, attico-auditomy is performed, in case if tumour is spread into retrotympanium, opening of tympanic sinus is performed, in case of spread into hypotympanium, hypotympanotomy is performed, in case of spread into mastoid antrum, antrotomy is performed. After that, main feeding vessel is coagulated. In case if system of auditory ossicles is disturbed, ossiculoplasty is performed.

EFFECT: application of claimed invention makes it possible to carry out total ablation of tumour and preserve or restore mechanism of middle ear sound conducting, that is, perform tympanoplasty, simultaneously.

2 cl, 7 dwg, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can find application in the surgical treatment of a patient with an otiatric form of paraganglioma of the lateral base of the skull.

Paraganglioma of the lateral base of the skull (or glomus tumor of the ear) is an extremely vascular neoplasm of the paraganglion tissue of the sympathetic ganglia associated with the tympanic nerve or the mastoid branch of the vagus nerve.

In the literature, it has many synonyms - a hemodectoma, glomangioma, glomusangioma, glomic tumor, prescription and several others. The otiatric form includes paragangliomas of the lateral base of the skull of types A and B according to the classification of Fisch and Mattox, that is, those cases in which the tumor is limited by the borders of the drum-mastoid complex of the temporal bone.

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).

The generally accepted method for the treatment of paragangliomas of the lateral base of the skull of the otiatric form is surgical, which consists in their total removal.

Since the discovery of these tumors, surgical intervention has been a radical operation followed by removal of the tumor. In order to reduce intraoperative blood loss in the last decade, superselective embolization of the branches directly feeding the tumor is performed at the preoperative stage.

There is a method of removing paragangliomas of the lateral base of the skull of the otiatric form (see Vayshenker PG "Surgical treatment of glomus tumors of the middle ear and jugular fossa." Herald of Otorhinolaryngology, 1976, No. 3, pp. 72-76).

When using this method, an incision is made up to 7 cm long along the line of attachment of the auricle, which provides a wide approach to the tumor. In some patients, the incision is continued along the front edge of the sternocleidomastoid muscle. After detachment of the skin of the upper, back and partially lower walls of the external auditory canal, the lower and upper flaps are cut out for subsequent skin grafting.

This allows you to expand the surgical field, which at the same time is preparation for the completion of the intervention, since during enucleation of the tumor, as a rule, profuse bleeding occurs that interferes with the formation of skin flaps.

To expose the tumor, the cortical layer of the mastoid process, as well as the posterior and upper walls of the bony auditory canal, are removed. For a broader approach to the lower parts of the tympanic cavity, the posterior wall of the auditory canal is thinned 1-2 mm below the level of the horizontal semicircular canal, and the lower wall of the bony auditory canal is partially removed.

The second stage of the operation is begun by detecting a part of the tumor in the medial sections of the mastoid process of red or pink color with a smooth or slightly uneven surface that bleed when touched. To reduce bleeding, very carefully remove the bone around the tumor. The second stage of the operation ends when the tumor remains connected to the bone with a small base, passing without a visible border into the surrounding tissue. Depending on the size, the tumor is captured with ear forceps or a sharp spoon and removed. To stop the bleeding, the bone wound is tightly tamped with turundas with iodoform or Vasilieva paste.

The disadvantage of this method is the creation of a large trepan cavity and a high risk of bleeding and damage to the anatomical structures of the temporal bone (dura mater, sigmoid sinus, semicircular tubules).

In addition, sanguination after removal of the tumor indicates its incomplete resection, and the issue of hearing reconstruction is not resolved.

There is also a method of removing a paraganglioma of the lateral base of the skull of an otiatric form by performing posterior tympanotomy (see Forest JA III, Jackson CG, McGrew BM Long-Term Control of Surgically Treated Glomus Tympanicum Tumors // Otol Neurotol. - 2001. - Vol.22, Iss .2. - P.232-6).

When using this method, a standard arcuate incision is made along the behind the fold, the cortical layer of the mastoid is widely removed, its cellular structure is almost totally drilled with exposure of the sigmoid sinus, dura mater, synodural angle, lateral and posterior semicircular tubules.

Next, a bone is drilled in the projection of the facial sinus of the retrotimpanum, thus performing posterior tympanotomy. This approach makes it possible to access the ossicular system, eardrum, labyrinth, internal carotid artery and facial nerve. The bone drum ring remains intact with the preservation of a thin bone bridge in the projection of the conductor into the cave. The trepan cavity is subsequently performed with a muscle or fat flap.

The disadvantages of this method is that this access is applicable only for small tumor sizes. Through the posterior tympanotomy, it is impossible to provide a sufficient overview of the anterior sections of the tympanic cavity (in particular, the auditory tube), an adequate revision of the sinuses of the retrotimpanum and the niches of the windows.

It is unreasonable to create the described large trepan cavity in the absence of a tumor in it, in addition, the probability of damage to the meninges or sigmoid sinus increases, and when performing tympanotomy, the risk of damage to the facial nerve.

Also, it is not possible to perform an audit of the course of the tympanic nerve in order to prevent relapse. Reconstruction of the sound conduction mechanism is difficult, which requires additional endaural tympanotomy.

The closest in technical essence to the claimed solution is a method of removing a paraganglioma of the lateral base of the skull of the otiatric form (see A. Lantsov, A. A. Methodovsky, P. P. Kryukov “Surgical treatment of middle ear glomus tumors.” Bulletin of Otorhinolaryngology, 2001 , No. 3, p. 12-13).

When using this method, a behind-the-ear approach is carried out, after it is completed, the skin of the upper, back and partially lower walls of the external auditory meatus is cut out the lower and upper rags for subsequent skin grafting, as this allows to expand the surgical field.

When a tumor is detected, bone is removed around the neoplasm to reduce bleeding, including removing the posterior wall along the fallopian canal to the bottom of the tympanic cavity as much as possible.

In this case, a single cavity is created between the auditory meatus and the mastoid process (that is, a radical operation is performed), in which the glomus tumor is well contoured, occupying only the front section of the newly formed cavity.

When the tumor remains connected to the bone with a small base, it is taken up with ear forceps or a sharp spoon and removed. To stop the bleeding, the wound is tightly tamped with turunds with iodoform. If necessary, blood or blood substitutes are transfused. In the postoperative period, antibiotics and sedatives are prescribed. Turunda is removed on the 6-8th day after surgery.

The disadvantages of this method are: the creation of a volumetric cavity with a large number of "beaks" and "patterns", a high spur of the facial nerve, due to developing bleeding, which leads to the onset of an operated ear disease (suppuration, epidermal defects, etc.); lack of control over blood loss, which makes it impossible to reconstruct the system of auditory ossicles.

In addition, working with a sharp spoon is dangerous in terms of damage to the sinus of the jugular bulb of the oval window and facial nerve.

The technical result of the proposed solution is to simultaneously perform the removal of the tumor and the preservation or restoration of the mechanism of sound conduction, that is, tympanoplasty.

To achieve the specified technical result in a method for removing a paraganglioma of the lateral base of the skull of an otiatric form, including behind-the-ear access, separation of soft tissues and skin of the external auditory meatus, creation of a trepanation cavity and removal of the tumor, according to the proposal, the tumor is removed, preserving the auditory ossicle system, if possible, tympanotomy for the right ear from 5 hours to 12 hours, for the left ear from 12 hours to 7 hours, form a small trepanation cavity, which is limited thyroid tumor, moreover, when a tumor spreads to the attic, an attic-aditotomy is performed, when a tympanic sinus is distributed into the retrotympanum, a hypothypanotomy is performed when it spreads to the hypothympanum, an anthrotomy is performed when the mastoid is spread into the cave, and then the main feeding vessel is coagulated if of bones is broken, ossiculoplasty is performed.

Also, according to the proposal, when performing attico-aditotomy, or opening the tympanic sinus, or performing a hypotympanotomy, the bones are drilled within 1-5 mm or more.

The method is illustrated by drawings, where figure 1 schematically shows the stage of the operation after performing tympanotomy; figure 2 schematically shows the stage of the operation of revision of the tympanic cavity, in which the tumor substrate is well visualized and corresponds to type A according to the classification of Fisch &Mattox; figure 3 schematically shows the stage of the operation of revision of the tympanic cavity, in which the tumor substrate is not completely visualized and corresponds to type B according to the classification of Fisch &Mattox; figure 4 schematically shows the stage of the operation, in which an attic-aditotomy is performed, the posterior and lower portions of the bone drum ring are partially removed, while the boundaries of the tumor substrate are completely visualized in the surgical field; figure 5 schematically shows the stage of the operation, in which the anvil and the head of the malleus are removed, while the tumor substrate becomes available for manipulation; figure 6 schematically shows the stage of the operation, in which the tumor substrate is removed, the growth source located in the projection of the course of the tympanic nerve is coagulated, the additional tumor growth sites accessible for coagulation are well visualized; Fig. 7 schematically shows the stage of the operation, in which the tumor substrate and additional foci of the tumor are already coagulated, a rigid endoscope revises the sines and niches of the windows, after which the tympanic cavity is ready to reconstruct the sound conduction system.

The following positions were used in the drawings: 1 - tumor substrate, 2 - additional tumor foci, 3 - anvil, 4 - malleus, 5 - facial sinus, 6 - oval window, 7 - round window, 8 - primary tumor growth zone, 9 - rigid endoscope with a viewing angle of 30 degrees, 10 - stirrup.

The method is as follows.

As a preoperative preparation, an angiography of the external carotid artery basin is performed from the lesion side for 24-72 hours, followed by superselective embolization with microparticles (100-1000 nm) of polyvinyl alcohol of the branches directly feeding the tumor.

General (intubation anesthesia, neuroleptanalgesia) 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, behind the ear region and the external auditory canal is performed.

Then perform an arcuate incision of the skin and soft tissues to the bone in the behind-the-ear area with a length of about 5 cm and separation of the soft tissues. In the upper corner of the wound, a fragment of autofascia of the temporal muscle with a diameter of 2-2.5 cm is isolated.

Next, perform the separation of the skin of the posterior wall of the external auditory meatus, tympanotomy (figure 1).

For the right ear, a tympanotomy is performed from 5 to 12 hours. For the left ear, a tympanotomy is performed from 12 to 7 hours. These stages make it possible to achieve a wide overview of the surgical field and, at its completion, to visualize the tumor 1 completely (type A1 - figure 2) or partially (types A2 and B - figure 3).

Then, a revision of the tympanic cavity is performed, and the volume of the tumor spread, for example, into the auditory tube, retrotimpanum, hypothympanum, attic (for types A2 and B) is estimated, and for type A1, possible additional foci of tumor development 2, which may be along the drum, are excluded a nerve.

For type A1, surgery is continued with the destruction of the tumor substrate by galvanocauter, an ultrasonic scalpel, or a CO2 laser.

For types A2 and B, tympanotomy provides adequate visualization only in a limited number of cases (type A2 - propagation only into the auditory tube), therefore, to remove the tumor from the attic and enter the cave, atticoaditotomy is performed (Fig. 4) and the anvil 3 and the head of the malleus 4 are removed (figure 5); the bone drum ring above the hypothympanum is removed from the hypothympanum with a mill; remove the bone drum ring from the sinuses of the retrotimpanum with a milling cutter from the back, open the facial sinus 5 and, if necessary, thin the posterior bone wall to the level of the descending part of the facial nerve, which provides expanded access to the sinuses and the oval 6 and round 7 labyrinth windows.

Then the tumor is squeezed with cotton balls and, if possible, removed with a single block of forceps-cups, and also, using the methods described above, its destruction is performed. The key point at this stage is the detection of the main bone vessel feeding the tumor, which coincides with the zone of primary tumor growth 8 on the medial wall of the tympanic cavity, closer to the hypothympanum (in the projection of the course of the tympanic nerve), and its coagulation, which allows achieving hemostasis. After that, the entire stroke of the tympanic nerve along the entire possible length is coagulated by a galvanocauter, which allows to destroy possible additional foci of the development of a glomus tumor (Fig. 6).

Particular attention is paid to tumor fragments in the niche of the round window, the facial and tympanic sinuses, in the cells of the hypothympanum, the revision of these departments is performed by a rigid endoscope 9 with a viewing angle of 30 degrees or a micromirror (Fig. 7).

During surgery, depending on the size of the eardrum defect and the need for ossiculoplasty, several types of autografts are taken. The source of fascia autograft is the fascia of the temporal muscle, and the graft after drying is an oval plate with approximate volumes of 0.1-0.5 × 7-10 × 9-12 mm. Cartilage autograft is a plate with dimensions of 0.5 × 2.5 × 3.5 mm with rounded edges, its source is cartilage of tragus (tragus) or shell cavity (cavum conchae). An auto-fat graft is taken from the subcutaneous layer of the ear section.

If the chain of auditory ossicles after the performed manipulations remains intact, the eardrum is put in place, and when possible perforations appear, myringoplasty is performed with autogyros or autofasion. Along the periphery, the autofascial graft is covered with previously displaced skin of the external auditory meatus for better nutrition and additional fixation of the two-layer graft.

When removing the auditory ossicles, ossiculoplasty is performed with a partial ossicular prosthesis by installing the prosthesis on the head of the stapes 10 (partial ossicular replacement prosthesis - PORP) or with a full (total ossicular replacement prosthesis - TORP) prosthesis with the border of the prosthesis bonded by an auto-cartilage plate from the tympanic membrane or neotymal membrane myringoplasty.

The operation is completed by fixation of the two-layer graft by tamponade of the external auditory meatus, for example, a hemostatic sponge or silk thread. The behind-the-ear wound is sutured in layers, and drainage is established if necessary.

The method is illustrated by the following examples.

Example 1. Patient B., born in 1945 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 of the Ministry of Health and Social Development of the Russian Federation” with a diagnosis of paraganglioma of the lateral base of the skull on the right, type A2 according to Fisch, right-sided conductive hearing loss of 2 degrees.

Upon admission, the patient complained of hearing loss and a feeling of throbbing in her right ear. From the anamnesis it is known that in the patient these complaints appeared within the last 4 months.

An objective 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. A red-burgundy pulsating mass prolapses behind the eardrum, mainly in the lower quadrants. 2 m whispering, 4 m colloquial speech. Rinne test - negative, Jelle - positive. AS - the external auditory meatus is free. The eardrum is gray shiny with pronounced contours and identification points. Whispering speech of 5 m, colloquial speech of 6 m. Samples of Rinne and Jelle are positive. Lateritization in the Weber sample to the right.

The results of tonal threshold audiometry testified to right-sided conductive hearing loss with sound conduction thresholds in the speech frequency zone on the right of 45 dB in the presence of a bone-air interval of 20 dB.

The patient was performed superselective embolization of the branches of the ascending pharyngeal and occipital arteries directly feeding the tumor.

Then the operation was performed to remove the paraganglioma of the lateral base of the skull.

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 with a length of about 5 cm and the separation of soft tissues. In the upper corner of the wound, a fragment of autofascia of the temporal muscle with a diameter of 2 cm was isolated. Next, the skin of the posterior wall of the external auditory meatus was separated. A tympanotomy was performed from 5 to 12 hours. The meatotympanal flap is thrown forward. The bone canopy over the anvil-stirrup joint was removed by the cutting mill.

Drum cavity revision performed. A burgundy soft-tissue formation was revealed that almost completely fills the tympanic cavity with a base on the cape of the medial wall, which extends into the hypothympanum, protimpanum, and auditory tube into the niche of the round window. Additional tumor foci were also detected on the medial wall of the tympanic cavity anterior to the oval window.

The cutting drum removed the bone drum ring above the hypothympanum, removed the bone drum ring from the back to the level of the descending part of the facial nerve, and opened the facial sinus.

The main substrate of the tumor is squeezed with cotton balls and then destroyed by an ultrasonic scalpel. The base of the tumor is coagulated by a unipolar galvanocauter. Additional foci destroyed by galvanocauter. The chain of auditory ossicles is saved. The symptom of transmitting the pressure of the perilymph from the oval window to the round is positive. The meatotympanal flap was put in place and reinforced by autofascation according to the under-lay technique. A tamponade of the external auditory canal was performed. The behind-the-ear wound is sutured in layers. An aseptic dressing is applied.

The postoperative period was uneventful. When discharged on the 13th day after surgery: AD - the external auditory meatus is wide, free, there are no discharge. The eardrum is gray, slightly pasty, defects or retractions (retraction pockets) are not detected.

Control examination 1 year after surgery:

AD - the external auditory meatus is free, there is no discharge. The eardrum is gray shiny, with pronounced contours and identification points. Whispering speech of 5 m, colloquial speech of 6 m. Samples of Rinne and Jelle are positive. Lateralization in the Weber sample is not determined.

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 25 dB and the presence of a bone-air interval of 10 dB.

Example 2. Patient S., born in 1969 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 of the Ministry of Health and Social Development of the Russian Federation” with a diagnosis of paraganglioma of the lateral base of the skull on the right, type B1 according to Fisch, right-sided conductive hearing loss of 2 degrees.

Upon admission, the patient complained of hearing loss and a feeling of throbbing in her right ear. From the anamnesis it is known that in the patient these complaints appeared within the last 24 months.

An objective 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. Behind the eardrum, a red-burgundy pulsating mass is protruding, protruding into the lumen of the external auditory canal. 2 m whispering, 4 m colloquial speech. Rinne test - negative, Jelle - positive. AS - the external auditory meatus is free. The eardrum is gray shiny with pronounced contours and identification points. Whispering speech of 6 m, colloquial speech of 6 m. Samples of Rinne and Jelle - positive. Lateralization in the Weber sample to the right.

The results of tonal threshold audiometry testified to right-sided conductive hearing loss with sound conduction thresholds in the area of speech frequencies on the right of 45-50 dB in the presence of a bone-air interval of 30 dB.

The patient was performed superselective embolization of the branches of the right maxillary and temporal arteries directly feeding the tumor.

Then the operation was performed to remove the paraganglioma of the lateral base of the skull.

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 with a length of about 5 cm and the separation of soft tissues. In the upper corner of the wound, a fragment of autofascia of the temporal muscle with a diameter of 2 cm was highlighted. Next, skin separation of the skin of the posterior wall of the external auditory meatus was performed. A tympanotomy was performed from 5 to 12 hours.

During revision of the tympanic cavity, the tumor fills the entire tympanic cavity, spreads to the attic, envelops the chain of auditory ossicles, spreading under the hammer, anvil and stapes, into the area of the cochlear window, hypothympanum, and auditory tube.

The Stacke osseous stage was completed - an atticoaditotomy was performed, the bone drum ring above the hypothympanum was removed by cutting, the posterior bone wall was thinned to the level of the descending part of the facial nerve, which provided adequate access to the sines and windows of the labyrinth.

The tumor is squeezed with cotton balls and removed with a single block of forceps-cups together with an anvil and a hammer. The main bone vessel feeding the tumor was found on the medial wall of the tympanum, its coagulation was performed, which made it possible to achieve hemostasis. After that, the entire course of the tympanic nerve along the entire possible length is coagulated by a galvanocauter.

A rigid endoscope with a viewing angle of 30 degrees revised the niches of the round window, facial and tympanic sinuses.

Ossiculoplasty was performed with a partial (partial ossicular replacement prosthesis - PORP) titanium prosthesis with a demarcation of the prosthesis head by an auto-cartilage plate from a neotympanic membrane formed from a fascia flap of the temporal muscle with a size of 1 × 1 cm.

An external auditory meatus tamponade was made with silk thread and gauze turunda, sutures were made on soft tissues and skin, an aseptic dressing.

The postoperative period was uneventful. When discharged on the 13th day after surgery: AD - the external auditory meatus is wide, free, there are no discharge. The eardrum is gray, slightly pasty, defects or retractions (retraction pockets) are not detected.

Control examination 1 year after surgery:

AD - the external auditory meatus is free, there is no discharge. The eardrum is gray, shiny, with pronounced contours and identification points. Whispering speech of 5 m, colloquial speech of 6 m. Samples of Rinne and Jelle are positive. Lateralization in the Weber sample is not determined.

The results of the control tonal threshold audiometry indicate a decrease in the threshold of sound conduction on the right ear in the area of speech frequencies to 30-35 dB and the presence of a bone-air interval of 30 dB.

The method was tested in the department of pathophysiology of the ear of the Federal State Institution "St. Petersburg Research Institute of ENT of the Ministry of Health and Social Development." Conducted 6 operations using the proposed method. Patients achieved excellent and good functional and excellent morphological results. With a follow-up period of 6 to 18 months, no relapses and procedures of the tumor were detected.

The inventive method provides total removal of the tumor and preventing the development of procedures and the identification of additional foci of the tumor; performing simultaneously with the removal of the tumor, preservation or restoration of the mechanism of sound conduction of the middle ear.

Claims (2)

1. A method of removing a paraganglioma of the lateral base of the skull of an otiatric form, including behind-the-ear access, separation of soft tissues and skin of the external auditory canal, creating a trepan cavity and removing the tumor, characterized in that the tumor is removed, preserving, if possible, maintaining the system of auditory ossicles, while performing tympanotomy for the right ear from 5 h to 12 h, for the left ear from 12 h to 7 h, a small trepan cavity is formed, limited by the spread of the tumor, and when the tumor spreads to the attic, a Tyco-aditotomiyu propagating in retrotimpanum produce autopsy tympanic sinus during propagation in gipotimpanum produce gipotimpanotomiyu propagating in the mastoid cave operate antrotomiyu and then coagulated main supply receptacle, and if the system is broken ossicles produce ossikuloplastiku. 2. A method for removing a paraganglioma of the lateral base of the skull of an otiatric shape according to claim 1, characterized in that when performing attico-aditotomy, or opening the tympanic sinus, or performing a hypotympanotomy, bones are drilled within 1-5 mm or more.

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