RU2592602C1 - Method for ventilation of tympanic cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in proximal part of silicone tube for ventilation of tympanic cavity opening is made closed by Teflon piston placed in tube. Tube is laid and fixed in prepared bed posterosuperior wall of external auditory canal. Distal end is open to external auditory canal. Proximal end is fixed present to long leg of anvil. Outstand from tube piston end to long leg of anvil is fixed by perichondrium.

EFFECT: method provides for improvement of hearing due to recovery of air tympanic cavity by batch feed air only at pressure decrease in cavity of middle ear, in particular, in patients with obstruction of auditory tube suffered tympanoplasty.

1 cl, 2 ex, 2 dwg

Description

The invention relates to medicine, in particular to otorhinolaryngology, and may find application in patients with such forms of diseases of the middle, ear as: chronic exudative otitis media; atelectasis of the tympanum; chronic otitis media with full or partial epidermization of the tympanic cavity; tympanofibrosis and various forms of the final stage of chronic purulent otitis media, occurring against the background of persistent pronounced dysfunction of the auditory tube.

Currently, methods are used to ensure ventilation of the tympanic cavity, based on the use of ventilation coils and drainage tubes made of various materials (titanium, teflon, silicone, and other biocompatible polymers), which are installed in the tympanic cavity either through the tympanic membrane or under the meat-tympanal flap . They allow you to both evacuate the pathological discharge from the tympanic cavity, and to administer drugs in the opposite direction, acting directly on the site of inflammation, in addition, they create a constant constant pressure (atmospheric) on both sides of the tympanic membrane.

However, the constant communication of the tympanic cavity with the external auditory canal leads to the fact that the pressure in the tympanic cavity becomes equal to atmospheric, which cannot but have a negative effect on the state of the mucous membrane of the tympanic cavity, which plays a role in the gas exchange processes between the blood capillaries in the mucosa itself and air in the cavities of the middle ear. The decrease in gas pressure in the middle ear triggers the reflex mechanisms of the opening of the auditory tube for the portioned intake of air into the tympanic cavity from the nasopharynx. With persistent dysfunction of the auditory tube, these mechanisms are violated, which leads to unsatisfactory results after tympanoplasty, especially in the treatment of such severe forms of chronic otitis media as: atelectasis, tympanofibrosis and epidermis of the tympanic cavity. Recent studies show that the same atmospheric pressure on both sides of the eardrum has a negative effect on the mucous membrane, causing the development of tympanofibrosis, tympanosclerosis, cholesteatoma, biofilm. Given the above, there was a need to create a valve mechanism for ventilating the tympanic cavity bypassing the auditory tube, according to a mechanism of action similar to it.

Closest to our proposed method is the "Method of drainage of the tympanic cavity with the placement of the drainage tube under the meatotympanic flap in the bone bed created in the lower wall of the external auditory meatus" (patent RU 2391918). The essence of the method is that after a tympanotomy with revision of the tympanic cavity, removal of exudate from it, or tympanoplasty, a drainage tube is inserted into the hypothympanum, placing it under the meatotympanic flap in the bone bed, specially created in the lower wall of the external auditory meatus.

The disadvantages of this method are:

1) the constant communication of the tympanal cavity with the external auditory meatus;

2) the lack of a mechanism for the portioned intake of air into the tympanic cavity, which entails the development of tympanosclerosis or tympanofibrosis with prolonged use of the tube.

To eliminate these shortcomings, we offer a method of ventilation of the tympanic cavity developed by us. The essence of the method lies in the fact that after tympanotomy with revision of the tympanic cavity and performing all sanitizing and reconstructive stages of the operation with persistent pronounced dysfunction of the auditory tube, a silicone tube is used that is placed and rigidly fixed in the posterior-upper wall of the external auditory canal under the fibrous ring in a previously created the bone bed, and the distal end of the tube opens into the external auditory meatus, and the proximal end of the tube lies to the long leg of the anvil and has preliminarily shaped window which can be closed and opened in response to a decrease in gas pressure in the tympanic cavity and in response to loud sounds using Teflon piston that is positioned with one end inside the tube, the other is attached to the long leg of the anvil using perichondrium in the form of coupling.

The technical result of the proposed method is the possibility of portionwise passing air into the tympanic cavity bypassing the auditory tube, and the valve mechanism we offer allows air to enter the tympanic cavity only at a negative pressure in it and in response to loud noises and remains impassable for air (the window in the tube is closed by a piston ) at the same pressure on both sides of the tympanic membrane, which is physiological and allows you to use this mechanism of ventilation of the tympanic cavity for d itelnogo time until the cause Eustachian tube dysfunction is fixed.

The method is as follows.

Intraoperatively after treatment of the surgical field with an alcoholic skin antiseptic under local anesthesia, an Ramen intrarameal incision is made, then the skin of the external auditory canal with the fibrous ring is separated. After tympanotomy, an audit of all departments of the tympanic cavity is performed, all sanitizing and reconstructive stages of the operation are performed. A bone bed is formed in the canopy area above the stirrup on the back wall of the external auditory meatus, into which a 5 mm long silicone tube with an external diameter of 3 mm and an internal lumen of 2 mm is placed, which is tightly fixed to prevent its displacement. The proximal end of the tube is located in the tympanic cavity anterior to the long leg of the anvil, and the distal end is in the lumen of the external auditory meatus. A 3 mm long, 2 mm thick Teflon piston is installed in the proximal end of the tube, that is, it fits snugly against the inner walls of the tube, its end protruding from the tube is fixed to the long anvil leg with a perichondria in the form of a sleeve. From the proximal end of the silicone tube towards the periphery at a distance of 2 mm, a window with a size of 1 × 1 mm is cut. The Teflon piston is attached to the long leg so that its working end enters the silicone tube 3 mm towards the periphery of the tube, thereby closing the window completely cut out in the tube. With a decrease in pressure in the tympanic cavity, the eardrum is retracted, thereby plunging the stirrup into the vestibule window. The Teflon piston, along with the long leg of the anvil, is also immersed, thereby opening the cut-out window of the tube. Air from the external auditory meatus rushes into the tympanum. The pressure in the tympanic cavity is equalized with atmospheric pressure, the tympanic membrane is in its original position, the stirrup and long leg of the anvil are shifted to its original position, the valve closes.

In FIG. Figures 1 and 2 show the operation phases of the valve mechanism for ventilation of the tympanic membrane.

In FIG. 1 shows the valve opening state. The arrows indicate the direction of movement of the stapes and the long leg of the anvil at negative pressure in the tympanic cavity.

1 - stirrup - immersed in the vestibule.

2 - a long process of the anvil, shifted towards the window of the vestibule.

3 - coupling from perichondria, which fastens the Teflon piston to the anvil, excluding its displacement.

4 - a teflon piston of cylindrical shape with a radius of 2 mm.

5 - window in the handset (open).

6 - silicone tube with a clearance radius of 2 mm.

7 - formed bone bed in a canopy over the stirrup for fixing the tube.

8 - the lumen of the external auditory meatus.

In FIG. 2 shows the state of valve closing.

The arrows show the movement of the stapes and the long leg of the anvil to its original position when pressure is equalized on both sides of the non-tympanic membrane.

1 - stirrup - in the starting position.

2 - a long process of the anvil - in the initial position.

3 - coupling from perichondria, which fastens the Teflon piston to the anvil, excluding its displacement.

4 - a teflon piston of cylindrical shape with a radius of 2 mm.

5 - window in the tube (closed by a piston).

6 - silicone tube with a clearance radius of 2 mm.

7 - formed bone bed in a canopy over the stirrup for fixing the tube.

8 - the lumen of the external auditory meatus.

The method is illustrated by the following examples.

Patient L., 30 years old, was admitted to the Department of Otorhinolaryngology, Federal State Budgetary Healthcare Institution Clinical Hospital №86 05/19/2014 with a diagnosis of Chronic left-side adhesive otitis media. Condition after tympanoplasty of the left ear in 2011 and 2013.

On admission, she complained of decreased hearing in the left ear, constant stuffiness in the left ear, periodic cracking in the ear when swallowing.

From the anamnesis it is known: the patient considers herself a patient since 2008, when she had purulent otitis media on her left ear, against a background of chronic nasal congestion, about which she was hospitalized in the ENT department of Bryansk, where conservative therapy was carried out. The inflammatory process in the middle ear subsided, but the patient continued to complain of decreased hearing and congestion in the left ear. Upon examination at the State Clinical Hospital No. 86, the patient was diagnosed with Chronic left-sided otitis media with epidermalization of the tympanic cavity. Chronic rhinitis The first stage was performed submucosal vasotomy of the lower nasal concha, nasal breathing was restored. The next step is tympanoplasty of the left ear with the installation of a drainage tube. Discharged with improvement; hearing in the left ear improved. During the wearing of the drainage tube there were no complaints. After 4 months, the drainage tube independently shifted into the external auditory meatus, after which the patient again began to note the above complaints. In November 2013, a tympanotomy with tympanoscopy was performed at the Federal State Budget Health Institution City Clinical Hospital No. 86, after which the patient noted an improvement in hearing. In May 2014, after a runny nose, complaints about hearing loss in the left ear and a feeling of fluid transfusion in the left ear reappeared. Hospitalized at the Federal State Budget Health Institution City Clinical Hospital No. 86.

Upon admission: satisfactory condition. By internal organs and systems without features. When examining the ENT organs: nose, oropharynx, larynx - without visible changes. EARS: AD - the external auditory meatus during otoscopy is wide, the skin is not changed. B / p - gray, shiny, identification marks are clearly expressed. Patency of the auditory tube according to Toynbee and Valsalva is not broken. Hearing: ШР = 6 m; PP> 6 m. AS - the external auditory meatus with otoscopy is wide, the skin is not changed. The non-tympanic membrane in the posterior regions is represented by the plates of auto-cartilage; in the anterior regions, the scar membrane, translucent gray. In the tympanic cavity, a liquid with air bubbles is visible through the membrane. Dysfunction of the auditory tube on the left III degree. Hearing: ShR = 3 m; RR> 6 m. When examined with tuning forks, data for left-sided conductive hearing loss. On the audiogram, conductive hearing loss of the first degree with a bone-air interval of up to 25 dB. The patient underwent surgical treatment: 05/21/14 - tympanotomy on the left with revision of the tympanic cavity and installation of a tube with a valve mechanism. Under local anesthesia, intrameal access via Rosen performed a separation of the meat flap. The fibrous ring is weakly expressed. In the tympanic cavity, exudate was evacuated, scars were dissected, a chain of auditory ossicles was mobilized. Transfer to snail window saved. The mucous membrane in all departments is preserved. A silicone film is laid on the cape. On the posterior-upper wall in a canopy over the stirrup in the formed bone bed, a modified silicone tube 5 mm long is fixed with a 1 × 1 mm window cut into it at a distance of 2 mm from the edge, into the proximal lumen of which there is a 3 mm Teflon piston fixed by perichondria in in the form of a coupling to the long leg of the anvil, so that the cut window of the tube is closed. A warm sterile solution of hydrocortisone suspension was introduced into the tympanic cavity. The meat-tympanal flap is put in place, rubber strips are laid on top. Ear canal tamponade with cotton balls with antibiotic. The postoperative period without complications. Tampons from the ear removed on the 3rd day. Otomicroscopy performed: Modified tube in place, functional. After filling the lumen of the tube through the needle with a sterile Dexamethasone solution (the solution does not pass into the tympanic cavity), with the Toynbee test, it is seen how the solution in the lumen of the tube begins to shift into the tympanum cavity; a similar displacement, but less pronounced, occurs with a loud sound over the patient's ear (for example, tapping metal instruments against each other). The patient was discharged from the hospital on the 12th day with improved hearing in the left ear. When viewed after 3 and 6 months: AS - neotympanic membrane gray, modified tube in place. In the Toynbee test, the Dexamethasone solution, which fills the tube lumen, is shifted towards the tympanal cavity. Hearing an audiogram is normal. Further observation.

Patient Yu., 27 years old, was admitted to the otorhinolaryngology department of the Federal State Budgetary Healthcare Institution Clinical Hospital No. 86 on 02/03/2014 with a diagnosis of Chronic bilateral otitis media, on the right, with epidermalization of the tympanic cavity. Condition after tympanoplasty on the left ear in September 2013. Bilateral mixed hearing loss III degree.

On admission, she complained of reduced hearing in both ears, more in her right ear.

From the anamnesis it is known: in childhood, she suffered bilateral purulent otitis media, after which she periodically noted purulent discharge from both ears during exacerbations. It was observed on an outpatient basis at an ENT specialist at a doctor's clinic in the community. Exacerbations about 1-2 times per year. Hearing in both ears progressively worsened, despite ongoing conservative therapy. After examination in the clinic she is directed to surgical treatment. In September 2013, she was operated on her left ear - tympanoplasty was performed, after which the patient noted an improvement in hearing, suppuration from the left ear no longer resumed. Received again for planned surgical treatment on the right ear. Hospitalized at the Federal State Budget Health Institution City Clinical Hospital No. 86

Upon admission: satisfactory condition. By internal organs and systems without features. When examining the ENT organs: nose, oropharynx, larynx - without visible changes. EARS: AD - The auditory meatus for otoscopy is wide. There is no pathological discharge in the lumen of the auditory meatus. Eardrum - absent. There is no fibrous ring. Complete epidermization of the tympanic cavity. The auditory tube (tympanal orifice) is blocked by the epidermis, not passable. Hearing: ShR - abs; РР = 1.5 m. AS - The auditory meatus during otoscopy is wide. There is no pathological discharge in the lumen of the auditory meatus. Non-tympanic membrane - represented by auto-cartilage plates, gray. With the Toynbee and Valstalva test, the non-tympanic membrane is mobile. Hearing: SR = ad conchae; RR = 3 m. When examined with tuning forks, bilateral conductive hearing loss is determined, with Weber’s test, lateralization of sound into the right hearing impaired ear. The audiogram shows a picture of bilateral mixed hearing loss of the third degree with a bone-air interval of up to 40-45 dB on the right ear, up to 30-35 dB on the left ear. The patient underwent surgical treatment: 02/05/14 - tympanoplasty of the right ear with the installation of a tube with a valve mechanism. Under local anesthesia, intrameal access via Rosen performed a separation of the meat flap. The fibrous ring is absent. The epidermis was separated from the medial wall, an air cavity was formed. The mucous membrane is preserved only in the region of the tympanic orifice of the auditory tube, a new fibrous ring and a non-tympanic membrane from auto-cartilage are formed. Silicone films are placed on the cape and under the non-tympanic membrane. On the posterior-upper wall of the external auditory canal in the canopy in the formed bone bed, a modified 5 mm silicone tube with a 1 × 1 mm window cut into it is fixed, a 3 mm long Teflon piston is inserted into the proximal lumen, fixed by a perichondria in the form of a coupling to a long anvil leg so that the cut out window of the tube is closed. The drum cavity is washed with warm saline with a suspension of hydrocortisone. The meat-tympanal flap is put in place, rubber strips are laid on top. Ear canal tamponade with cotton balls with antibiotic. The postoperative period without complications. Tampons from the ear removed on the 4th day. Modified tube in place, functional. Otomicroscopy was performed: after filling the tube’s lumen through the needle with sterile physiological saline (the solution doesn’t pass into the tympanic cavity), with Toynbee’s test, you can see how the solution in the tube’s lumen begins to shift into the tympanic cavity; the reaction to loud sounds is similar. The patient was discharged from the hospital on the 14th day with improved hearing in her right ear. Hearing SR = 1.5 m; PP> 6 m. When examined after 4 and 6 months, otomicroscopy: AD - non-tympanic membrane gray, determined air cavity, modified tube in place. In the Toynbee test, the Dexamethasone solution, which fills the tube lumen, is shifted towards the tympanal cavity. According to the audiogram, the positive dynamics reduced the bone-air interval on the right operated ear and corresponds to the picture of right-sided mixed hearing loss of the II degree with a bone-air interval of up to 10-15 dB at low frequencies, the picture is the same on the left. Further observation.

The method was applied in 7 patients with chronic otitis media with severe persistent dysfunction of the auditory tube. As a result of the operations, an improvement was observed, which consisted in the restoration of the air drum cavity, due to epithelization of its regenerating mucous membrane from its residues, which was established during repeated operations, as well as some positive dynamics in the restoration of the function of the auditory tube.

Claims (1)

A method of ventilating the tympanic cavity in patients with chronic otitis media, accompanied by severe persistent dysfunction of the auditory tube, which consists in the fact that after performing all stages of the operation on the middle ear, a silicone tube is used that is placed and fixed in the posterior-upper wall of the external auditory canal under the fibrous ring in pre-created bone bed, and the distal end of the tube opens into the external auditory meatus, and the proximal end of the tube lies to the long leg of the anvil and and there is a preformed window, and a Teflon piston is placed inside the proximal end of the silicone tube, the outer end of which is attached to the long leg of the anvil using a perichondria in the form of a sleeve.

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