RU2475195C1 - Method of treating chronic othelcosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology and surgical otorhinolaryngology, and can find application in treating chronic othelcosis. Substance of the method consists in approaching and sanitating a tympanic cavity, an antrum and a cell system of mastoid bone. The antrum is approached with a surgical bur through a posterior bone wall of an external auditory canal. A window 0.4x0.4 cm is formed therefor. The antrum and the cell system of mastoid bone are inspected. Pathological substrate if any is removed. Thereafter, a defect of the posterior bone wall of the external auditory canal is closed by a fragment of a cortical layer of a mastoid plate shaped and sized by the defect.

EFFECT: use of the given invention enables objective assessment of the mastoid cavity states, preserving the anatomical ratios within an external and middle ear, and recovering the auditory function avoiding extensive hearing-destructive operations.

2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and is used to diagnose the condition of the mastoid part of the temporal bone.

There is a method of closed management of the mastoid cavity after anthromastoidotomy in children, including the installation of two tubes in the postoperative mastoid cavity, while the tube for irrigation is perforated along the length, and the tube for removing the contents of the cavity is fixed in the lower corner of the skin wound, washing the cavity by introducing solutions through the tube for irrigation, characterized in that the tube for irrigation is installed in the entrance to the cave and fixed at the upper corner of the skin wound, then set the tube for removal, which erforirovana in length, and at its inner end groove is formed, in which the first stack pipe and is carried out simultaneously evacuating the cavity through the tube contents to derive (RF Patent №2272580).

There is a method of surgical intervention in the middle ear for chronic otitis media and cholesteatoma - "Canal wall down (CWD)" with removal of the posterior bone wall of the ear canal with simultaneous closure of the defect with a flexible plate of a composite material, such as hydroxyapatite and polymer, in combination with a connective tissue flap ( Zanetti D, Nassif N, Antonelli AR Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: a pilot study. // Otol Neurotol. 2001, 22 (6): 745-53).

There is a method of treating chronic otitis media according to the Stack method, which uses a soft tissue incision along the behind-the-ear fold. After the incision of the soft integument and separation of the periosteum, the elevator separates the upper and posterior walls of the ear canal. To improve access to the deep sections of the auditory meatus on the gauze tape, the skin part of the meatus is pulled, which facilitates the further stages of the operation. Using a hook-bent probe, a study of the drum space is carried out, after which they begin to demolish its lateral wall. The surgical field is thoroughly cleaned of blood, a narrow grooved bit is installed on the edge of the outer wall of the drum space, which carefully cuts off the bone chips. Under constant control of the hook-shaped bent probe, the outer wall of the drum space is gradually removed. Having opened the drum space, the affected bones and granulations are removed with a hooked probe and a small spoon, which expands the approach to the cave of the mastoid process. Having identified the place of entry into the cave, gradually open its outer wall. Opening the cave entrance makes visible a horizontal semicircular canal, which greatly facilitates orientation. The opening of the cave of the mastoid process is carried out by the demolition of the posterior wall of the auditory meatus and the outer wall of the mastoid process. After removal of the pathological contents, bone alignment, skin plastic and suturing of the behind the wound with preliminary introduction through the external auditory canal into the wound cavity of the tampon is performed (Elantsev B.V. Operative otorhinolaryngology. Alma-Ata, 1959, p. 483).

The disadvantage of this method is its complexity and violation of the anatomical relationships in the outer and middle ear.

The method we have chosen as a prototype.

The problem solved by the invention is to develop a method for the surgical treatment of chronic otitis media and at the same time adequate revision of the antrum and mastoid cell system in order to detect the presence of a pathological substrate.

The technical result is an objective assessment of the state of the cavities of the mastoid process, an accurate diagnosis and surgical intervention with the preservation of the anatomical relationships in the outer and middle ear and auditory function, without resorting to extensive hearing-destructive operations.

The essence of the invention lies in the fact that the endaural access after separation of the meatotympanic flap anteriorly revises the tympanic cavity, including the attic region; for revision of the antrum and the cellular system of the mastoid of the temporal bone with a surgical bur in the posterior bone wall of the external auditory meatus, a “window” of 0.4 × 0.4 cm is formed through which an examination is performed using otomicroscopy and angular rigid endoscopes. If a pathological substrate (exudate, limited cholesteatoma) is detected, it is removed and, in the absence of the need to expand the surgical field, the defect of the posterior bone wall of the external auditory meatus is closed with a fragment of the cortical bone of the mastoid site modeled in shape and size.

The method is as follows: access to the antrum is carried out with a surgical bur through the posterior bone wall of the external auditory meatus, forming a “window” of 0.4 × 0.4 cm in size, the antrum and the cellular system of the mastoid process of the temporal bone are examined, the pathological substrate is removed, and the defect the posterior bone wall of the external auditory meatus is covered with a fragment of the cortical bone of the mastoid site modeled in shape and size.

Clinical example 1

Patient D., 11 years old, was admitted to the ENT department of the Scientific Center for Children's Health of the Russian Academy of Medical Sciences with a diagnosis of Right-sided chronic epitympanoanthral otitis media. When otomicroscopy was determined epitympanal perforation of the right tympanic membrane, there was no detachment at the time of inspection. According to computed tomography of the temporal bones: there is a destruction of the lateral wall of the attic, a slight expansion of the entrance to the antrum; the tympanic cavity, including attic, antrum and part of the cells of the mastoid process, are filled with a pathological substrate of soft tissue and liquid density. With tonal threshold audiometry: right-sided conductive hearing loss of I degree. 07/08/2011 performed right-sided endaural separate atticoadditusoantrotomy. Right-sided tympanoplasty type I.

An endaural access is performed to revise the tympanic cavity, including the attic region, to reveal a thick exudate, a polyposely changed mucous membrane, adhesions, there are no data on the presence of cholesteatoma. Given the presence of a pathological substrate on CT of the temporal bones in the antrum and cells of the mastoid process, in order to revise this area, they access the antrum through the posterior bone wall of the external auditory meatus. For this, a “window” measuring 0.4 × 0.4 cm is formed with a surgical bur. When revising the antrum and the mastoid cell system using angular optics, the presence of exudate and edematous mucous membrane was detected, and no cholesteatoma was found. The pathological substrate is removed, the cavity is washed with a direct mucolytic solution. The defect of the posterior bone wall of the external auditory meatus is closed with a fragment of the cortical bone of the mastoid site modeled in shape and size; stratified cartilage fragments of the tragus with perichondrium fill the defect with the lateral wall of the attic, the posterior and lower parts of the tympanic membrane and the external auditory canal. Tamponade of the right external auditory meatus for 21 days. No complications. When tampons are removed from the external auditory canal, the formed lateral wall of the attic and the meatotympanic flap are consistent, the posterior wall of the external auditory canal is pink and vascularized. With repeated tonal threshold audiometry after 2 months, an increase in the thresholds of sound perception by 5-15 dB in the field of speech frequencies is noted.

Thus, the revision of the antrum and mastoid process through the “window” in the posterior wall of the external auditory meatus with the subsequent closure of the defect by the bone fragment made it possible to avoid the formation of a radical ear cavity and maintain the ratio of the main anatomical structures of the external and middle ear, and to improve hearing in the operated ear.

Clinical example 2

Patient L., 13 years old, was in the ENT department of the Scientific Center for Children's Health RAMP with a diagnosis of Left-sided chronic epitympanantral otitis media. From the anamnesis it is known that for 3 years there is periodic suppuration from the left ear, hearing loss on the left. During otomicroscopy, the epitympanal perforation of the left tympanic membrane, proceeding from the perforation of the polyp, and the scarce purulent discharge were determined. According to computed tomography of the temporal bones, the destruction of the lateral wall of the attic, the expansion of the entrance to the antrum, are noted on the left; in the atticoantral region, a pathological substrate of soft tissue density is determined, the cellular system of the mastoid process is pneumatized. According to tonal threshold audiometry, left-sided conductive hearing loss of I degree. 01/24/2009 Left-sided separate atticoantrotomy with removal of limited cholesteatoma, tympanoplasty type I with plastic of the lateral wall of the attic was performed. After cutting the external auditory meatus along Heerman with additional endaural sections, the meatotympanal flap was separated anteriorly and downward, and the carious lateral wall of the attic was removed. After removal of the polyposis of the mucous membrane in the region of the posterior attic, a limited encapsulated cholesteatoma is determined, which extends into the region of the addus. For revision of the antrum and the cellular system of the mastoid process through the posterior bone wall of the external auditory canal, a “window” with a diameter of 4-5 mm is formed by the surgical bur. When examining the antrum and adjacent cells of the mastoid process using otomicroscopy and angular rigid endoscopes, the antrum of the encapsulated cholesteatoma was revealed at the entrance to the antrum; the antrum and cells of the mastoid process are free, the mucous membrane covering the mastoid part of the temporal bone is pale pink. After mobilization of the cholesteatomic sac in the posterior attic, the limited atico-antral cholesteatoma in the form of an “hourglass” of 7 × 4 mm in size was removed from the side of the antrum. The chain of auditory ossicles is preserved, functioning. The “window” in the posterior-upper wall is closed by a fragment of the cortical bone layer, previously taken from the site of the mastoid process of the corresponding shape and size. The lateral wall of the attic was plasticized with a chondroperichondral flap; the meatotympanal flap was fixed in its initial position. Tamponade of the left external auditory meatus. No complications. After removal of the tampons after 3 weeks, the meatotympanic flap and walls of the external auditory meatus are well-to-do. The patient is observed for 2 years - there is no data for a relapse of cholesteatoma, tympanoplasty is consistent. An increase in sound conduction thresholds by 5-15 dB over the entire frequency range is noted.

Thus, the application of the method of access to the antrum and mastoid process by forming a “window” in the posterior wall of the external auditory meatus made it possible to radically remove the limited cholesteatoma of the atticoantral region, objectively assess the condition of the mastoid cavities, preserve the anatomical relationships in the outer and middle ear and auditory function, not resorting to extensive destructive surgery.

The method allows to objectively assess the condition of the cavities of the mastoid process, to preserve the anatomical relationships in the outer and middle ear and auditory function, without resorting to extensive hearing-destructive operations.

Claims (1)

A method of treating chronic otitis media, including access to the tympanic cavity, antrum and the cellular system of the mastoid process of the temporal bone and their rehabilitation, characterized in that the access to the antrum is performed by surgical boron through the posterior bone wall of the external auditory meatus, while forming a “window” of size 0 , 4 × 0.4 cm, the antrum and the cellular system of the mastoid process of the temporal bone are examined, the pathological substrate is removed, and the defect of the posterior bone wall of the external auditory canal is closed with the simulated shape and size fragment cortical bone mastoid site.