RU2610797C1 - Method of mastoid plasty in endaural surgical access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology. Interchondral incision between tragus and helix is made to bone part of outer acoustic duct. Incision is continued on posterior wall of outer acoustic duct with formation of meatotympanic skin flap, which includes skin of bone part of outer acoustic duct with tympanic membrane. Skin of outer acoustic duct with periosteum is displaced in lateral direction with exposure of bone of posterior and superior walls of acoustic duct and mastoid process. To carry out sanitising stage of operation antromastoidotomy with ablation of mastoid process wall is performed. Muscular-periosteal flap with dimensions 5.0×1.5 cm, consisting of mastoid process periosteum and edge section of temporal muscle on lower feeding pedicle, is cut out above site of mastoid process in temporo-parotid area. Fragments of autocartilage, autofascia are laid into mastoid cavity and covered with formed muscular-periosteal flap after its displacement. Meatotympanic skin flap is placed over muscular-periosteal flap.

EFFECT: method makes it possible to achieve obliteration of created antromastoid cavity in endaural access without additional extension of operation field zone due to cutting out muscular-periosteal flap from the edge of temporal muscle and parotid area periosteum, as well as its displacement on lower pedicle into created antromastoid cavity.

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Description

The invention relates to the field of medicine, namely to otorhinolaryngology.

There are many different surgical approaches for sanitizing interventions on the temporal bone in patients with chronic purulent otitis media (HCHO), and each of them has its own indications and features. One of them is the endaural approach. This approach is performed with a limited spread of cholesteatoma (apical, antral) and structural features of the temporal bone (presentation of the sigmoid sinus and low location of the bottom of the middle cranial fossa), which provides minimally invasive surgery in this area with the preservation of healthy tissues and a reduction in the postoperative period due to rapid healing of the wound. With this approach, a significant drawback is the lack of tissue for the plastic stage - reduction (obliteration) of the created operating cavity during a common destructive process.

Analogs of the present invention were methods of reducing (obliterating) mastoid cavities during "open" sanitizing operations performed by behind-the-ear and endaural accesses. One of them is the “Method of mastoidoplasty” using a muscle flap on the feeding leg, formed from the temporal muscle during the behind-the-ear approach [1 - prototype]. It should be noted that mastoidoplasty with the behind-the-ear approach has always been used to close the exposed bone tissue of the created cavity and accelerate its epithelization. Considering that a surgically created antromastoid cavity significantly worsens auditory function (due to changes in acoustic resonance) and the quality of life of patients with chronic hypertension (regular cleaning), the current trend in planned sanitizing surgery for chronic hypertension is not only tympanoplasty, but also mastoidoplasty (or obliteration). In recent years, combined “hard” materials have been used for this with their mandatory closure by the periosteal, muscle and fascial flap to reduce (obliterate) the created cavity in the mastoid process [2, 3]. In the endaural approach, due to insufficient plastic material, synthetic materials (osteoconductive bioglass - BioSital) are used to reduce (obliterate) the cavity, less often autobone (taken during the operation), which is covered with chondro-perichondral fragments from the patient’s tragus and skin flaps from the ear canal [ four]. With this approach, bone tissue can be obtained a little, and the use of cartilage, as well as muscle transplant, requires additional incisions.

The technical result of the proposed method is to achieve reduction (obliteration) of the created antromastoid cavity during the endaural approach without additional expansion of the area of the surgical field by taking the muscle-periosteal flap from the edge of the temporal muscle and periosteum of the behind the ear and moving it on the lower leg to the created anthromastoid cavity.

The technique of the operation is as follows.

Under endotracheal anesthesia and infiltration anesthesia, an inter-cartilage incision (according to Heermann) is performed between the tragus and curl to the bony part of the external auditory meatus. From this zone, the continuation of the incision is a circular incision (according to Rosen) along the posterior wall of the external auditory canal with the formation of a meatotympanic skin flap (skin of the bony section of the external auditory canal with a tympanic membrane). Next, a lateral displacement of the skin of the external auditory canal with the periosteum with exposure of the bones of the posterior and upper walls of the auditory canal and the mastoid process (Fig. 1 Scheme of interchondral (according to Heermann) and circular (according to Rosen) sections, skin displacement to expose the mastoid process (in the supine position) )). After installation of the retractor, which pushes away the soft tissues, the site of the mastoid process, the external auditory canal and the eardrum are in the surgical field. Initially, an audit of the tympanic cavity is performed after the displacement of the meatotympanal flap and opening of the tympanic cavity. Depending on the spread of cholesteatoma in the middle ear, a phased attico-adito-anthromastoidotomy is performed using cutters or chisels.

In cases of an antromastoidotomy with removal of the mastoid wall (the “open” version of the operation), after the completion of the sanitizing stage of the operation and removal of the retractor above the site of the mastoid process, a muscular-periosteal flap 5.0 × 1.5 is scissored in the temporoparietal region by the scissors cm (periosteum of the mastoid process and the marginal portion of m. temporalis) on the lower feeding leg. The flap moves to the formed cavity after performing tympanoplasty elements under the meatotympanic skin flap (Fig. 2. Scheme of preparation and mastoidoplasty of the muscle-periosteal flap from the temporoparietal region through the endaural incision: A. - cutting of the muscular-periosteal flap: 1 - Heermann incision 2 - muscle-periosteal flap; b. - moving the flap on the lower leg to the created antromastoid cavity (arrows - direction of displacement)). The operation is completed by laying on the eardrum and skin of the bony section of the external auditory canal of rubber or silicone strips and tamponade of the external auditory canal with antibiotic sponges. The interchondral section is sutured in layers.

The described surgical method for reducing (obliterating) the antromastoid cavity during the endaural approach can be performed with different distribution of the destructive cholesteatomic process, in the conditions of close proximity of the important anatomical structures - the sigmoid sinus and middle cranial fossa (complicating the operation by the behind-the-ear approach), which expands the possibilities of the endaural approach with sanitizing operations. This reduces the healing and rehabilitation time after surgery, improves the quality of hearing and life of the patient due to a decrease in the volume of the operating cavity.

Within 2 years, the method was applied in 5 patients with HGSO.

As an illustration of the use of the described method of mastoidoplasty with an endaural surgical approach, we present an observation.

Patient D., 43 years old, diagnosis: Chronic right-sided purulent otitis media (epimesotympanitis), cholesteatoma.

Upon admission, she complained of hearing loss in the right ear, a feeling of moisture in the right ear, mucopurulent discharge from the ear.

From the anamnesis, it is known that HGSO suffers from childhood. In adulthood, there was no progressive hearing loss. In the last two years, constant humidity in the right ear and mucopurulent discharge from this ear have been noted. Conducted computed tomography (CT) scan of the temporal bones showed: signs of right-sided chronic middle purulent otitis media with cholesteatoma of the attic-antrum region with a low location of the bottom of the middle cranial fossa. After the examination, she was hospitalized as planned in the department of the institute for surgical treatment.

ENT status: nose, pharynx, nasopharynx, larynx - no visible changes. On examination: behind the ear, auricles unchanged. Palpation of the tragus and mastoid processes is painless. With otomicroscopy, the external auditory meatus of the right ear is wide, free. The eardrum in the back of the stretched part with a marginal defect. The lateral wall of the attic-aditus is destroyed, with epidermization of this area and thick mucous discharge. The auditory tube passes through Valsalva, the left ear - without visible changes.

According to tonal threshold audiometry (TPA) data, conductive hearing loss in the right ear with a bone-air interval (CVI) in the range of spoken frequencies of 30 dB was detected before surgery.

A patient under endotracheal anesthesia with an endaural approach performed an operation on the right ear - endaural atticoantromastoidotomy with removal of the posterior wall of the external auditory canal, tympanoplasty type 3 and mastoidoplasty with a muscular-periosteal flap, autocartilage and autofascation "half-open".

It was found intraoperatively: the lateral wall of the attic and aditus is destroyed and covered by the epidermis creeping along the cystic lining, spreading into the antrum. In the tympanic cavity, destruction of the auditory ossicle chain was revealed. The stirrup is movable, its arch is displaced to the channel of the facial nerve (LN). In the facial sinus - scars. Anvil is absent. The head of the malleus is carious changed, shrouded in a dense epidermis and removed. The LN canal in the tympanic section is partially exposed due to destruction of the bone wall, and is covered by the epidermis to the tendon of the muscle that stretches the eardrum. The tendon itself and the suprabaric part are free of the epidermis.

Using the motor system, the lateral wall of the attic, aditus and antrum was removed to the apex of the mastoid process. The mastoid process of the pneumatic type of structure, the antrum is small with a large number of cells into which the epidermis of the cholesteatoma is immersed. At the apex of the mastoid process and in the perifacial cells, dense clustered granulations were revealed. Above the cavity formed in the mastoid process in the temporomandibular region, the muscular-periosteal flap on the feeding lower leg is separated and isolated. An auto-cartilaginous half-plate (taken from the patient’s ear cartilage through an additional 1 cm incision) is placed under the tympanic membrane defect in the stretched section, resting on the head of the stapes and under the hammer handle, which is covered by autofascation (prepared through endaural access). Fragments of auto-cartilage, autofascia, which are covered by an offset muscular-periosteal flap, on top of which the remains of the meatal skin flap are laid, are placed in the created antromastoid cavity. The created cavity, the non-tympanic membrane and the ear canal are lined with rubber protectors and are plugged with an antibiotic sponge. The interchondral section is sutured in layers.

According to TPA, at discharge on day 5, stability of bone conduction thresholds was noted. Tampons and protectors in the ear canal lasted up to 16 days.

During dynamic observation after 1, 3 and 6 months after surgery: the behind-the-ear area is not changed, it is painless. Otoscopic picture on the right: the external auditory meatus is wide without detachable. Mastoid and antral areas are absent. Attica area is open, epidermized. Non-tympanic membrane is wealthy, mobile when blowing. The auditory tube is passable. According to TPA, a reduction in CVI to 20 dB at low and colloquial sound frequencies was noted on the side of the operated ear.

Bibliography

1. RF patent No. 2355369, IPC A61F 11/00 (2006.01). The method of mastoidoplasty / Shpotin V.P., Proskurin A.I., applicant and patent holder Shpotin V.P. - No. 2007116778/14; declared 05/03/2007; publ. 05/20/2009, bull. No. 14 (PC.). - 9 p.

2. Dornhoffer J. Retrograde mastoidectomy with canal wall reconstruction: a single-stage technique for cholesteatoma removal / Ann Otol Rhinol Laryng. - 2000. - V. 109. - No. 11. - P. 1033-1039.

3. Gantz B., Wilkinson E., Hansen M. Canal wall reconstruction tympanomastoidectomy with mastoid obliteration / Laryngoscope - 2005. - V. 115. - P. 1734-1740.

4. Kosyakov S.Ya., Bee E.B. Modern approaches to the treatment of chronic suppurative otitis media with cholesteatoma / Bulletin of Otorhinolaryngology. 2014, No.6, p. 4-7.

Claims (4)

The method of mastoidoplasty with sanitizing interventions on the temporal bone in patients with chronic purulent otitis media using endaural access, including filling the cavity of the mastoid process after the sanitizing stage of the operation on the middle ear with its own tissues, characterized in that an inter-cartilaginous incision is made between the tragus and curl to the bony part of the external auditory canal, the incision is continued along the posterior wall of the external auditory canal with the formation of a meatotympanic skin flap including the skin of the bony part of the external auditory canal with the tympanic membrane, laterally displaced the skin of the external auditory canal with the periosteum of the bone exposing posterior and upper walls of the auditory meatus and mastoid process, to perform the sanitizing stage of the operation, an anthromastoidotomy is performed with removal of the mastoid wall; above the site of the mastoid process, a muscle-periosteal flap 5.0 × 1.5 cm in size is made in the temporomandibular region, consisting of the periosteum of the mastoid process and the marginal portion of the temporal muscle, On the lower feeding leg, fragments of auto-cartilage, autofascia are placed in the mastoid cavity and covered with a formed muscle-periosteal flap after its movement, and over the muscle-periosteal the flap has a meatotympanal skin flap.

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