RU2553945C1 - Method of restoring posterior wall of external acoustic duct - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: external wall of the attic is ablated. The posterior wall of the external acoustic duct is ablated with the exposure of mastoid cells. Revision of the middle ear cavities, chains of the acoustic ossicles is carried out. Bone shelves and pathologically changed tissues are ablated with smoothing the trepanation cavity wall. Autogenic bone flour is obtained from the mastoid cortical bone. The bone flour is covered with biological glue "BioGlue" from two sides with 1 mm thick layers. A 3-5 mm thick plate, corresponding in shape and dimensions to the bone defect of the posterior wall is formed and fixed on the cavity walls in the area of projection of the posterior wall of the external acoustic duct. Ossiculoplasty, myringoplasty are carried out. Plasty of the external wall of the attic is carried out by the autocartilage and perichondrium. The thinned autofascia of the temporal muscle or perichondrium is put above the transplant plate. A meatotympanic flap is laid above the autofascia/ perichondrium at a natural level. Tamponade of the external acoustic duct is carried out.EFFECT: method ensures the effective treatment of chronic purulent otitis of the middle ear, complete restoration of the middle and external ear architectonics, makes it possible to avoid trauma of the auricle cartilage, displacement of the transplant in the post-operative period, post-operative complications due to the application of the autotissue as the transplant, formation of a specified plate of the transplant and application of biological glue BioGlue.3 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and is intended for surgical restoration of the posterior wall of the external auditory meatus.

Timely implementation of radical surgery for carious-granulation and cholesteatomic forms of chronic purulent otitis media prevents the occurrence of intracranial complications. [12]. Persistent otorrhea, marked hearing loss, vestibular disorders are common phenomena after undergoing classical radical surgery that adversely affect the patient’s psychoemotional state. [2; 3].

The impossibility of wearing a hearing aid, a limitation in the choice of a profession, negative aesthetic results after meatoconchoplasty, increased economic costs due to the repeated treatment of chronic purulent otitis media lead to social maladaptation of the individual. The above factors determine the role of chronic suppurative otitis media as a socially significant disease.

In order to improve hearing and eliminate the disadvantages of classical radical surgery, sparing surgeries were developed with preservation of the intact structures of the middle ear during the reconstruction phase. There are open and closed versions of such operations and many of their modifications. They have both certain advantages and disadvantages. The closed version involves the preservation or restoration of the posterior wall of the external auditory meatus with the formation of an air-bearing tympanic cavity and a transformation system. [four; 5].

The prior art various methods of sanitizing reconstructive operations, in particular:

1) The method of primary reconstruction of the posterior-upper wall of the external auditory meatus during hearing-enhancing operations. RU No. 2268660 C2, 2006

2) The method of reconstruction of the lateral wall of the attic and the posterior wall of the external auditory canal. RU No. 2371105 C1, 2009

3) A method for restoring the posterior wall of the external auditory meatus during general cavity surgery on the middle ear. RU No. 2480161 C2, 2012

4) The method of mastoidoplasty. RU No. 2074688, 1992.

5) A method for forming a non-tympanic cavity after a general cavity operation. SU No. 1793910 A3, 2000

6) A method for reconstructing a hearing-improving operation. SU No. 1802706 A3, 1993

7) A method for the surgical treatment of chronic destructive otitis media. RU No. 2284158 C1, 1996

8) A method for the treatment of purulent diseases of the middle ear. SU No. 1456098 A1, 1989

9) The method of mastoidoplasty. RU No. 2074688, 1997

10) A method of performing a closed version of sanitizing operations on the middle ear in patients with chronic purulent epithympanitis with cholesteatoma. RU No. 2428155 C1, 2010

11) The method of mastoidoplasty in patients with chronic purulent otitis media. UA No. 62692 A, 2003

12) A method for reconstructing a trepan cavity after radical mastodectomy. UA No. 11862, 2003

13) A method for reconstructing the lateral wall of an attic in the treatment of chronic suppurative otitis media. UA No. 62396, 2003

14) A method for restoring the posterior wall of the external auditory meatus during general cavity surgery on the middle ear. RU No. 2480161 C2, 2011

The closest solution is developed by Mukhamedov I.T. "A method of reconstructing the lateral wall of the attic and the posterior wall of the external auditory canal" RU No. 2371105 C1, 2009, which consists in the fact that the lateral wall of the attic and the posterior wall of the external auditory canal is restored with a single auto-cartilage graft from the cartilage of the auricle, the lateral wall is formed by graft flexion, with difficulty in flexion, cartilage incisions are made on the convex side of the graft and the cartilage graft is installed in a posterior wall defect formed in front of the bone defect Ki of the external auditory canal of the groove.

The disadvantages of this method include the following:

1) When taking ear cartilage, the operation time increases; the auricle is additionally injured, which can lead in the early postoperative period to the formation of otogematoma and chondroperichondritis of the auricle.

2) To take a single graft, large cartilage is required, which, on the one hand, can lead to deficiency of autotissue, if the trepanation cavity is large, on the other hand, it can deform the auricle.

3) The amount of cartilage may be sufficient, but not suitable for the formation of a graft (calcifications in the cartilage with metabolic disorders).

4) Technical complexity - the lateral wall of the attic is formed by bending a single graft. During extrusion in the area of the lateral wall of the attic, the graft may be displaced in the region of the posterior wall of the external auditory meatus.

To eliminate these shortcomings, we propose a method of reconstruction of the posterior wall of the external auditory canal that was developed by us when performing a closed version of surgical debridement of the ear, including the formation of a three-layer graft to close the defect of the posterior wall of the external auditory canal in the form of a plate 3-5 mm thick, consisting of three layers - internal - from autocostal flour and two external, which are layers of biological glue, which is installed in a pre-prepared receiving bed.

The method allows to avoid trauma to the auricle cartilage, transplant displacement in the postoperative period while maintaining all the advantages of using autotissue to form the posterior wall of the external auditory canal in case of chronic suppurative otitis media, which will lead to improved morphofunctional results of the operation in the long-term postoperative period.

The method is as follows:

Under endotracheal anesthesia or local anesthesia with a 2% solution of lidocaine with a volume of about 10.0 ml (access behind the ear, the path is intrameal or transcortical), the 1st - sanitizing - stage of the operation is performed, at the beginning of which the cortical bone of the mastoid bone is removed with boron, and areas where there is no ingrown epidermis, autogenous bone meal is collected using a bone trap (granules up to 0.5 mm). Then, the outer wall of the attic, the posterior wall of the external auditory canal is removed, the mastoid cells are fully opened, the cavities of the middle ear, the auditory ossicles are revised, bone canopies and pathologically altered tissues are removed, and the walls of the trepan cavity are smoothed as much as possible. When smoothing the spur, which is the lower boundary of the bone defect of the posterior wall of the external auditory canal, in one embodiment of the method, a bed is prepared for a graft of the posterior wall of the external auditory canal, for example, by forming a recess.

Then, the 2nd - reconstructive stage of the operation is performed: The size and shape of the bone defect of the posterior wall of the external auditory meatus are preliminarily determined. To do this, a template is made from sterile white glove paper - a plate is cut in size larger than the size of the defect and installed in the projection of the defect. On the free edge of the blood impregnation determine the size and shape of the defect.

In accordance with the obtained template, a transplant is made. The transplant is formed using the “sandwich” technique: autogenous bone meal is placed on a glass slide, leveled, forming a layer 1-3 mm thick. Further, the autologous layer on both sides is covered with BioGlue biological adhesive layers using the applicator attached to it, the layer thickness is 1 mm. Thus, a three-layer graft is obtained to close the defect of the posterior wall of the external auditory meatus in the form of a plate 3-5 mm thick, which is installed in a pre-prepared receiving bed.

In the second embodiment of the method, the fixation of the graft can also be achieved without forming a recess in the region of the lower border of the bone defect. In this case, the plate is fixed on the walls of the cavity in the area of the projection of the posterior wall of the external auditory meatus using the spot application of bioglue.

Figure 1 shows a diagram of the formation of the graft and bed for him, where:

A is a three-layer graft consisting of:

B - a layer of autogenous bone meal,

C1 and C2 - layers of biological adhesive "BioGlue" 1 mm thick;

D - bed for a transplant of the posterior wall of the external auditory meatus;

E - lower border of the bone defect of the posterior wall of the external auditory meatus

Figure 2 shows the possibility of fixation of the graft without forming a bed for a transplant of the posterior wall of the external auditory canal, where F are the fixation points of the graft on the walls of the cavity in the projection area of the posterior wall of the external auditory canal using bioglue.

Then, ossiculoplasty, myringoplasty, plastic of the outer wall of the attic, auto-cartilage and perichondrium are performed. A perichondrium or a thinned fascia of the temporal muscle is laid on top of the transplant plate. Then the meatotympanal flap is placed on top of the autofascia at a natural level.

Spongostan swabs with antibiotic are installed in the external auditory meatus.

The method improves the surgical treatment of chronic suppurative otitis media by restoring the architectonics of the middle and outer ear after surgical debridement with removal of the posterior wall of the external auditory meatus. The application of this approach at the reconstructive stage of the surgical treatment of chronic purulent otitis media can prevent the development of "operated ear disease" and improve the functional result.

An example of a specific implementation No. 1

Patient S., 23 years old, was admitted to the ENT department of the FSI NCC of Otorhinolaryngology of the FMBA of the Russian Federation on 02.04.13, with a diagnosis of Chronic left-sided purulent otitis media. Radical operation on the left ear from 2006. From the anamnesis: he has been suffering from chronic left-sided purulent otitis media since childhood, when frequent exacerbations were noted, especially when water got into the ears and during hypothermia. In 2006, a radical operation was performed on the left ear. Suppuration periodically resumed, was repeatedly treated conservatively with a temporary effect. Last exacerbation in the left ear - 1 month ago.

Upon admission to the hospital complaints of hearing loss in the left ear, periodic purulent discharge from the left ear. Objective research data: AS - the auricle is not changed, a postoperative scar is visualized in the behind-the-ear region, with palpation, a retraction in the area of the mastoid process, which is painless, is determined.

The postoperative cavity is clearly contoured, the spur is medium. The mastoid section is partially epidermized, sometimes covered with a thickened mucous membrane, crust. The remains of the tympanic membrane in the anterior sections are soldered to the promontorial wall. The area of the niche of the vestibule and cochlea window is covered with a thickened mucous membrane, scanty purulent discharge. The auditory ossicles are not visualized. The auditory tube is passable along Valsalva.

Hearing (AS): S.Sh. -; Sh.R.a.s., P.P. 3 m. W to the left, R -.

The patient was examined in the department and prepared for surgical treatment. 04/03/13 g under m / a Sol. Lidocaini 2% - 10.0 performed a sanitizing operation on the left ear, with reconstruction of the posterior wall of the external auditory canal according to our proposed technique. The postoperative period was uneventful, antibacterial and antihistamine therapy was carried out, a set of exercises for the auditory tube. Spongostan tampons are completely removed from the external auditory meatus on the 23rd day after surgery. On the 28th day after the operation, the patient was discharged home in satisfactory condition. With control audiometry, the hearing improved: a reduction in the “bone-air” interval by an average of 15 dB. The non-tympanic membrane is pink in color, epidermized, the plastic of the posterior wall of the external auditory meatus is consistent, the skin of the posterior wall is slightly swollen, there are no perforations, and the auditory tube is passable during the Valsalve test.

An example of a specific implementation No. 2

Patient S., 34 years old, was admitted to the ENT department of the FSI NCC of Otorhinolaryngology of the FMBA of the Russian Federation on January 15, 13, with a diagnosis of left-sided epithympanitis. From the anamnesis: Periodic suppuration from the left ear and hearing loss in the left ear are noted for 10 years. Treated conservatively with a temporary effect. Last exacerbation 3 months ago.

Upon admission to the hospital: complaints of suppuration from the left ear and hearing loss in the left ear. Objectively: AS - The external auditory meatus is wide, free. The eardrum in the stretched part is saved, gray. In the back of the unstretched part there is perforation with the ingrowth of the epidermis in the attic and aditus.

(AS) S.Sh. -; Sh.R. - a / s; P.P. - 2.5 m; W to the left; R -, -; F

The patient was examined in the department and prepared for surgical treatment. 01/16/13 g under m / a Sol. Lidocaini 2% - 10.0 performed a sanitizing operation on the left ear with reconstruction of the posterior wall of the external auditory meatus according to our methodology. At the end of the operation, the hearing improved, sp. up to 50 cm, p.p. 3.5 m.

The postoperative period was uneventful, antibacterial and antihistamine therapy was carried out, a set of exercises for the auditory tube, spongostan tampons were completely removed from the external auditory canal on the 20th day after the operation. On the 20th day after the operation, the patient was discharged home in satisfactory condition, with control audiometry, the hearing improved: reduction of the “bone-air” interval by an average of 20 dB. The non-tympanic membrane is pink, epidermized, the posterior wall of the external auditory meatus is preserved throughout, the skin of the posterior wall is somewhat pasty, there are no perforations, the auditory tube is passable during the Valsalva test.

Bibliography

1. Janashia N.T. The volume of surgical intervention for exacerbation of chronic purulent-carious otitis media: dis. ... cand. honey. sciences. - M., 2011 .-- 145 s.

2. Eremeeva K.V., Kulakova L.A., Lopatin A.S. Features of sanitizing reoperations in the middle ear. // Bulletin of otorhinolaryngology. - 2009. - No. 4. - S. 45-46.

3. Karapetyan R.V., Anikin M.I., Bokuchava T.A. The choice of tactics for surgical treatment of patients with chronic epiantral otitis media with cholesteatoma, depending on the prevalence of the pathological process. // Russian otorhinolaryngology. - 2013. - No. 2. - S. 39-45.

4. Two modifications of the “closed” version of tympanoplasty / Yu.A. Sushko, O.N. Borisenko, I.A. Srebnyak, G.S. Polishchuk: Abstracts of the IVth international symposium "Modern problems of physiology and pathology of hearing" (Suzdal, June 19-21, 2001). - M., 2001. - P.170.

5. Korvyakov B.C. Modern aspects of surgical treatment of patients with inflammatory diseases of the middle ear: Dis. Doct. honey. Sciences - Moscow. 2007 .-- 200 p.

Claims (3)

1. A method of restoring the posterior wall of the external auditory canal in case of chronic suppurative otitis media, including the removal of the outer wall of the attic, the posterior wall of the external auditory canal with the opening of the mastoid cells, revision of the cavities of the middle ear, auditory ossicles, removal of bone awnings and pathologically altered tissues with smoothing walls of the trepanation cavity, while during the operation, autologous bone meal is obtained from the cortical bone of the mastoid process, which is covered with biolo with BioGlue glue on both sides with 1 mm thick layers, forming a 3-5 mm thick plate corresponding in shape and size to the bone defect of the posterior wall, and fix it on the cavity walls in the area of the projection of the posterior wall of the external auditory canal, after which ossiculoplasty is performed , myringoplasty, plastic of the outer wall of the attic by auto-cartilage and perichondrium, on the graft plate, thinned autofasion of the temporal muscle or perichondrium is laid out, then the meatotympanal flap is placed on top of the autofasion / perichondrium eggs on a natural level, then produce tamponade of the external auditory canal. 2. The method according to p. 1, characterized in that before fixing the plate in the region of the lower border of the bone defect of the posterior wall of the external auditory meatus, a recess is formed, a bed is prepared for the graft of the posterior wall of the external auditory meatus. 3. The method according to p. 1, characterized in that the plate is fixed on the bone walls of the trepanation cavity in the area of the projection of the posterior wall of the external auditory meatus by the spot application of bioglue.

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