RU2469657C1 - Ossiculoplasty technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: technique consists in conductive stricture repair and fixation. The fixation is enabled by means of platelet enriched autoblood plasma bunch taken immediately before the operation.

EFFECT: use of the given invention enables avoiding intra- and postoperative conductive chain dislocation; the early postoperative fixation of the repaired ossicular chain ensures a better postoperative functional effect.

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Description

The present invention relates to medicine, namely to otorhinolaryngology, and can be used to fix the auditory ossicles or prostheses installed instead of them in the surgical treatment of middle ear pathology.

Despite significant successes in the surgical treatment of patients with pathology of sound-conducting structures, from 10 to 25% of patients in the long term report unsatisfactory functional results. The latter are often associated with a displacement of the sound-conducting structures of the middle ear after their reconstruction.

The reason for this displacement is, on the one hand, the presence of several elements movably interconnected, replacing missing auditory ossicles or their damaged parts. On the other hand, it is the difficulty of holding (fixing) in the right position the elements of sound conduction in the first days after reconstruction. An equally important reason for the displacement of the reconstructed elements is the postoperative deterioration of the function of the auditory tube due to tissue edema, as well as increased "load" on it, associated with the need to release the tympanic cavity from blood residues and wound discharge.

The above processes can lead to an unsatisfactory functional result requiring repeated surgical intervention.

There is a method of surgical treatment of patients with pathology of the auditory ossicle chain, during which bioglue is used to strengthen the elements of the sound-conducting system of the middle ear [Mirko Tos. Guidelines for Middle Ear Surgery, 2004, Volume 1, p.243].

The disadvantage of this method is the high cost of the material, the risk of contracting HIV and hepatitis increases. After using bio-glue, it is possible to develop an inflammatory process associated with the reaction of the body to its constituent components.

There is a method of ossiculoplasty, during the implementation of which various prostheses with fixing mechanisms are installed (a prosthesis replacing the Sheehy anvil, fixed with a wire to the handle of the malleus) [Mirko Tos. Guidelines for Middle Ear Surgery, 2004, Volume 1, p.376].

The disadvantage of this method is the difficulty of installing the prosthesis and the risk of rejection, as well as the absence in most cases of auditory ossicles, to which such a prosthesis can be fixed.

Use a fixing wire together with ionomercement [Mirko Tos. Guidelines for middle ear surgery, 2004, vol. 1, p. 318].

The disadvantage is the difficulty of fixing and the risk of rejection of the material used.

The closest analogue is the method of fixation of auditory ossicles using a Gel foam sponge. When performing reconstruction of the auditory ossicle chain after the completion of the sanitizing stage of the operation and preparation of the bed for placement of a nonimplantal graft, the reconstructed sound-conducting structures are fixed using a Gel foam sponge, which is placed around the auditory ossicle chain, filling the tympanic cavity. [Mirko Tos. Guidelines for Middle Ear Surgery, 2004, Volume 1, pp. 380-381].

The disadvantage of this method is the poor resorption of the material with the formation of scars and adhesions. Sponge Gel foam can cause adhesive processes in the tympanic cavity, which also disrupts the mobility of sound-conducting structures. The possible risk of developing an allergic reaction to the material used should be taken into account.

Tasks:

- improving the functional results of ossiculoplasty.

The essence of the method is the fixation of the sound-conducting circuit by a clot of platelet-rich plasma (OTP) from autologous blood taken from a patient immediately before surgery.

The technical result of the proposed method is laying around a sound-conducting chain of platelet-rich plasma. The tight-elastic consistency of the clot prevents the displacement of the sound-conducting chain during surgery and in the postoperative period. The elements included in the clot of OTP are exposed in the postoperative period of biodegradation (dissolve), like the blood itself. Thanks to the fixation of the restored chain of auditory ossicles in the early postoperative period, the functional result of the surgical intervention is improved.

The method was tested on 120 patients suffering from chronic otitis media with impaired sound conduction. There were 62 men and 58 women aged 18 to 60. All patients underwent a debridement operation of the closed type (separate atticoantrotomy) with one or another type of tympanoplasty. The operations were carried out by one surgeon to exclude the influence of surgical technique features on the outcome of the intervention. The main group consisted of 55 people who used OTP as a material for fixing the sound-conducting circuit. In the control group of 65 people, operations were performed without using plasma.

The method is as follows. Immediately before the operation, the patient is taken blood from the cubital vein and placed in a tube containing a clot activator specially designed for receiving OTP. Blood in a test tube is centrifuged until an OTP is obtained. After separation, three fractions are formed in the tube. Top - platelet-poor plasma, then - platelet-rich plasma along with leukocytes in the form of an activated clot and erythrocyte mass.

The platelet-rich plasma clot is removed from the tube with sterile forceps and placed in a Petri dish, where the pieces of OTP are separated with a scalpel. After the completion of the sanitation phase of the operation, a bed is prepared for the placement of a nonimplantal graft. In patients with chronic purulent otitis media, in violation of the integrity or absence of the auditory ossicle chain, prostheses such as TORP or PORP are made of biological tissues (cartilage, bone) or synthetic materials (titanium, teflon). After that, to obtain reliable fixation of the prosthesis in the desired position, pieces of OTP are tightly packed around it. From above, the eardrum graft is placed (usually the fascia of the temporal muscle).

The functional results of the operation were evaluated after 1, 3, and 12 months. Functional results were evaluated using tonal threshold audiometry. The average value of the bone-air interval in the area of speech frequencies was determined.

The indicators of audiometric studies were as follows. In the main group, where OTP was placed into the tympanic cavity as the fixing material of the reconstructed sound-conducting system, the value of the bone-air interval after 1 month was 35 ± 3 dB, after three months - 15 ± 4 dB, and after 12 months - 10 ± 3 db Cases of violation of the sound conduction function have not been established.

In the control group, 56 of 61 patients, one month after the operation, the bone-air interval corresponded to 25 ± 3 dB, after three months - 15 ± 4 dB - after 12 months - 10 ± 3 dB. In the remaining 5 patients of the control group who underwent a sanitizing operation, the bone-air interval at all observation periods was 30 ± 3 dB.

The latter indicates a shift in the sound-conducting structures in these patients.

Example 1: Patient X., 34, was admitted to the hospital GUZ KB No. 3 with a diagnosis of right-sided chronic purulent otitis media. Whispering speech on the right ear - 0.7 m, on the left ear - 6.0 m. When conducting otomicroscopy, perforation was revealed that captures the central section of the eardrum. On the audiogram, indicators of the study of the right ear: a bone-air gap of 35 dB in the area of speech frequencies. Immediately before the operation, the patient was taken blood from the cubital vein and placed in a tube containing a clot activator specially designed for receiving OTP. In vitro blood was centrifuged until an OTP was obtained. The platelet-rich plasma clot was removed from the tube using sterile forceps and placed in a Petri dish, where the pieces of OTP were separated with a scalpel.

Surgical treatment was performed - a separate atticoantrotomy with tympanoplasty of type 2 on the right middle ear. The mallet is carious modified, removed. A defect in the long process of the anvil was revealed. Anvil removed. A recess was made in her body for the head of the stapes. The anvil is laid on the head of the stapes and reinforced with pieces of platelet-rich plasma.

A month later, when performing an audiometric study, the HF interval is 35 dB, whisper speech (SH) is 0.5 m.

Three months later, on the HF audiogram, the gap is 15 dB, and ShR is 4 m.

Twelve months later, on the KB audiogram, the interval was 10 dB, whispering speech was 4.5 m.

This example confirms the possibility of using platelet-rich plasma as a fixing material when performing ossiculoplasty.

Thus, the use of OTP as a material that fixes the sound-conducting system in the early postoperative period, when performing ossiculoplasty, facilitates the fixation of prosthetic chain elements, reduces the risk of displacement of auditory ossicles in the postoperative period until physiological fixation is formed. All this allows us to improve the functional result of the treatment and reduce the percentage of relapses associated with the instability of the restored sound-conducting system.

Claims (1)

The method of ossiculoplasty, including restoration of sound-conducting structures and their fixation, characterized in that the fixation is carried out by a clot of platelet-rich plasma from autologous blood taken from a patient immediately before surgery.