RU2581759C1 - Method for repair of bone defect of posterior wall of external auditory canal - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in the patients with chronic purulent othelcosis, cholesteatoma sanation soup transmeatal and transcortical access. Lateral attic wall are removed, expanded aditus and removal of posterior wall of the external auditory canal. In the distal preserved bone "bridge" of the rear wall thickness not less than 3 mm. Graft of plate "Osteomatrix" in the form of a bone defect. At the end of the graft is formed recess. Graft is set so that to recess captured bone "bridge". Over a graft is laid autofibrinous membrane is covered with perichondrium or fascia temporal muscle. Meatotympanic flap is placed back.

EFFECT: method provides more effective surgical treatment, prevents the development of "disease operated ear" due to fixation of the implant, its plastic properties, osteogenesis stimulation.

1 cl, 2 ex, 1 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and is intended for the simultaneous restoration of the natural architectonics of the external auditory canal (NSP) after performing the “open” version of the sanitizing operation on the ear.

There are various methods of sanitizing reconstructive plastic surgery on the ear, 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. and Agaronova Z.B. "A method of restoring the posterior wall of the external auditory canal during general cavity surgery on the middle ear" (patent RU No. 2480161 C2, 2012), which consists in removing the outer wall of the attic, the posterior wall of the external auditory canal, maximally opening the mastoid cells, revise the cavities of the middle ear, the chain of the auditory ossicles, remove pathologically altered tissues. For reconstruction of the posterior wall of the external auditory meatus, a “punctum” plate is used, on the upper and lower sides of which the grooves are cut with a scalpel. The plate is set so that the grooves capture preformed bone ridges on the remains of the upper and lower walls of the external auditory meatus, completely covering the defect.

This method has the following disadvantages:

- at the sanitizing stage, the anatomical ratios of the middle and outer ear are violated, the cells of the mastoid process are maximally opened, which unreasonably increases the volume of the trepan cavity. With maximum opening of the cells of the mastoid process, the mucous membrane is removed, which negatively affects reconstructive intervention and can lead to fibrosis;

- at the reconstructive stage, the installed “Perfoosta” plate in the distal section does not contact the bone wall (lack of formation of a bed for implantation) due to its absence (the back wall of the external auditory meatus is completely removed). This can adversely affect the processes of graft engraftment and, in the long term, lead to its resorption in the distal section, and retraction of the wall into the retro-tympanic space.

To address these shortcomings, we propose a method for plastic surgery of a bone defect in the posterior wall of the external auditory canal, including debridement of the middle ear cavity, the formation of an implantation bed for plastic surgery of the posterior wall of the external auditory canal with the formation of a bone “bridge” in the distal section, and subsequent plastic surgery of the posterior wall by our autocomposite graft .

The technical result of the claimed method is the achievement of a pronounced persistent positive effect due to the combined use of techniques aimed at maximizing the preservation of the posterior bone wall of the external auditory meatus, the most complete rehabilitation of the affected cells of the mastoid process using the most gentle methods.

The formation of a bone “bridge” at the level of the outer surface of the mastoid process makes it possible to adequately review the cavities of the middle ear and to completely rehabilitate the cells of the mastoid process, the thickness of the “bridge” of 3 mm is optimal for supporting the function for the formed graft. Moreover, the combination of the formation of a “bridge” with the use of a “gentle” transcortical access for the rehabilitation of the affected mastoid cells allows preserving the topographic and anatomical ratios of the middle and outer ear and ensures the maximum effect of the rehabilitation, and at the same time prevents postoperative complications in the form of a relapse of inflammatory processes and retraction of the reconstructed posterior wall of the NSP into the retro-tympanic departments.

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, the 1st - sanitizing - stage of the operation is performed. The section behind the ear, the surgical approach is transmeatal.

In the course of the spread of the cholesteatoma matrix, the outer wall of the attic is removed, the aditus expands, the posterior wall of the external auditory canal is removed. The matrix of cholesteatomas is allocated in one block and removed. In this case, a bone “bridge” is formed - a bone section of the posterior wall of the external auditory meatus, thinned both from the side of the mastoid process and the external auditory meatus, which goes from the bottom of the auditory meatus to the tegmen at the height of the mastoid process. Its thickness is not less than 3 mm, the width depends on the degree of preservation of the bone of the posterior wall of the NSP, taking into account the spread of the pathological process and is determined individually. To rehabilitate the affected cells of the mastoid process, “gentle” transcortical access is used - the cortical bone is removed with a cutter, thinning the saved “bridge” in the distal section as much as possible, without violating its architectonics. As a result, a “bed” is formed for implantation of an autocomposite graft (the Osteomatrix plate in composition with autofibrin), which is illustrated in FIG. 1, where:

1. The drum section of the operating cavity;

2. Bone "bridge" preserved during removal of the posterior wall of the external auditory meatus;

3. Defect of the posterior wall of the external auditory meatus (there is an instrument in the lumen of the defect);

4. The mastoid section of the operating cavity.

Next, an audit is made of the cavities of the middle ear, the auditory ossicles chain, pathologically altered tissues are removed.

Then the 2nd - reconstructive stage of the operation is carried out, where an autocomposite graft is prepared: the Osteomatrix bone implant is removed from the sterile blister pack and immersed for 5 minutes in a 0.9% NaCl solution (100.0 ml) with the addition of a broad-spectrum antibiotic (ceftriaxone - 1 g). Such manipulation allows you to simulate the implant, to give it a certain shape. Next, according to the size of the bone defect of the posterior wall of the NSP, the Osteomatrix plate (3-5 mm thick) is cut out and a longitudinal recess is formed on its side on the side that will face the “bridge”. The graft is placed in the area of the bone defect so that the created recess in the distal edge of the Osteomatrix plate captures the bone “bridge” that was preserved when the posterior wall of the external auditory meatus was removed. Due to the hydrophilicity of the biomaterial during implantation, the edges of the plate are saturated with wound, the adaptation process in the implantation zone improves - the graft is fixed on the walls of the bone defect (upper, lower and distal).

An autofibrin membrane is laid on top of the Osteomatrix plate, which is prepared as follows: to obtain an autofibrin membrane, the method of single centrifugation of the patient’s whole venous blood using an EBA 20 apparatus from Hettich (Germany) is used. After taking 8 ml of blood into vacuum tubes "Vacuette" (with coagulation activator and dividing olefin gel), centrifugation is performed at a speed of 2800 rpm for 12 minutes. As a result of the separation of whole blood, a fibrin clot is formed, consisting of fibrin, white blood cells and platelets. Get several fibrin clots, which are combined into one membrane and placed on top of the plate "Osteomatrix". The fibrin membrane is quite dense and easily fits on top of the Osteomatrix plate.

The autocomposite graft thus formed, in turn, is covered by perichondrium or autofascia of the temporal muscle. The meatotympanal flap is placed on top of the reconstructed wall; spongostan tampons with an antibiotic are placed in the external auditory canal. The defect of the cortical bone of the mastoid process is closed by the Osteomatrix plate, on top of which muscular-periosteal flaps cut out in the behind-the-ear region are placed.

The method is illustrated by the following examples.

Example No. 1. Patient K., 59 years old, was admitted to the Department of Ear Diseases of the Federal State Budgetary Institution of the NCC of Otorhinolaryngology of the FMBA of the Russian Federation 12.11.14 g, with a diagnosis of Chronic bilateral suppurative otitis media. From the anamnesis: sick with chronic left-sided purulent otitis media for more than ten years, when frequent exacerbations were noted, especially when water got into the ears and during hypothermia. Periodically took courses of conservative treatment in the hospital and outpatient - with a temporary effect. Last exacerbation in the left ear - 2 months 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. Palpation of the behind the ear area is painless. There is a perforation of the unstretched part of the tympanic membrane through which sulfur cholesteatomic masses are visualized, after removal of which bone destruction was detected in the lateral wall of the attic and the proximal external auditory meatus.

Audiometry from 02/21/14: left-side mixed hearing loss III art. with a secondary sensorineural component at high frequencies, on the right, mixed hearing loss, II art. KVI on the left 15 dB.

CT of the temporal bones from 02/01/14 g: CT signs of bilateral chronic otitis media, with caries of the lateral wall of the tympanic cavity and auditory ossicles, on the left is a soft-tissue substrate. The auditory tube is passable along Valsalva.

Hearing (AS): S.Sh. +; Sh.R a.s., P.P. 2 m W is not lateralized, R-.

The patient was examined in the department and prepared for surgical treatment. 11/13/14 under the ETH performed Tympanoplasty on the left ear with simultaneous sanitizing intervention, with the restoration of the posterior wall of the external auditory canal according to the proposed method with an autocomposite graft using microsurgical 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 canal on the 21st day after surgery, after which the patient was discharged home in satisfactory condition. During the control audiometry, a month after the operation, the hearing improved: a reduction in the “bone-air” interval by 15 dB, Sh.R. 1 m, P.P. 3.5 m. Non-tympanic membrane of pink color, epidermized, no perforations. Plastic surgery of the posterior wall of the external auditory canal is consistent, with palpation with a button probe, it is hard, the skin of the posterior wall is epidermized, flat edema in some places, the auditory tube is passable during the Valsalva test.

Example No. 2. Patient K., 30 years old, was admitted to the Department of Ear Diseases of the FSBI NCC of Otorhinolaryngology of the FMBA of the Russian Federation on 04.06.13, with a diagnosis of chronic right-sided purulent otitis media. From the anamnesis: Sick for many years. Recently, hearing has worsened, periodically treated as outpatients.

Upon admission to the hospital: complaints of hearing loss in the right ear, occasional meager discharge from the right ear. Objectively: AD - Auricle, the ear region is not changed, palpation and percussion are painless. In the unstretched part of the tympanic membrane, perforation - cholesteatomic masses are visualized. Hearing (AD): S.Sh.-; Sh.R. 1 m, P.P. 4 m, R-.

The patient was examined in the department and prepared for surgical treatment. 12/10/14, under m / a the operation was performed: Tympanoplasty on the right ear, with simultaneous sanitizing intervention, with the restoration of the transformation system and the posterior wall of the external auditory meatus, using the proposed technique. The postoperative period was uneventful, antibacterial and antihistamine therapy was carried out, a set of exercises for the auditory tube. On the 15th day after surgery, the patient was discharged home in satisfactory condition. Spongostan tampons are completely removed from the external auditory meatus on an outpatient basis on the 21st day after surgery. With control audiometry, the hearing improved: a reduction in the “bone-air” interval by an average of 25 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.

The method allows to increase the effectiveness of surgical treatment of patients with chronic purulent otitis media, prevents the development of "operated ear disease", improves functional results.

Claims (1)

A method for plasty of a bone defect in the posterior wall of the external auditory canal in patients with chronic purulent otitis media, which consists in the fact that, during the spread of the matrix, cholesteatomas remove the lateral wall of the attic, expand the aditus, remove the posterior wall of the external auditory canal, and audit the cavities of the middle ear and the auditory circuit bones, remove pathologically altered tissues, characterized in that when removing the bone posterior wall of the external auditory canal in its distal section, the bone "bridge - a bone section of the posterior wall of the external auditory canal with a thickness of at least 3 mm, then a graft is formed from the Osteomatrix plate according to the shape of the defect of the posterior wall of the external auditory canal, and a recess is formed at the end of this plate on the side facing the bone bridge, while the graft is placed in the area of the bone defect in such a way that the created recess in the distal edge of the plate captures the saved bone "bridge", then autofibrin is placed on top of the Osteomatrix plate the ovarian membrane, they cover it with perichondrium or autofascia of the temporal muscle, the meatotympanic flap is placed over the reconstructed wall, and spongostan tampons with antibiotic are placed in the external auditory canal.

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