RU2726043C1 - Method for surgical treatment of patients with ossification of cochlear - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, particularly to otorhinolaryngology. That is followed by antromastoidotomy, posterior tympanotomy, identification and removal of a round window shelf. Segment of ossification is drilled along a basal curl with a reference point on its lateral wall and a color difference between a gray-yellowish labyrinth capsule and a white section of ossification filling the lumen of the spiral canal. After removal of a round window shelf and visualization of the section, where before the process of ossification the membrane of the round window was located, replacement of the diamond cutter with diameter of 2.3 mm is performed on the cutter with diameter of 1.4 mm. And during the whole reaming process, the intraoperative control of the length of the formed canal is carried out. At that, reaming is carried out in stages and after each step the length of the channel is measured with a measuring device in the form of a flexible conductor with a scale applied on it. Presence or absence of a lumen of a cochlea spiral passage not subject to ossification is considered. At that, through each 2.0 mm of the formed channel, a larger-diameter diamond milling cutter is changed to a smaller diameter cutter to produce a helical shape of the channel. Total length of passed section is determined. If the channel length is less than 8.0 mm, a cochlea spiral passage enters the lumen, an active electrode of the cochlear implant is introduced. If the canal length is equal to 8.0 mm, and there is no ingress into the lumen of the spiral channel of the cochlea, the operative intervention is terminated.EFFECT: method provides a reduced risk of traumatization of the modiolus, carotid artery canal and directly the artery itself when performing cochlear implantation in patients suffering bilateral chronic sensorineural severe hearing loss and deafness with ossification of the descending section of the spiral channel of the cochlea due to the intraoperative control of the bored section of ossification.1 cl, 5 dwg, 2 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can find application in performing cochlear implantation in patients suffering from bilateral chronic sensorineural hearing loss of high degree and deafness with ossification of the descending part of the cochlear spiral channel.

Cochlear implantation (hereinafter referred to as CI) is currently the most effective method of restoring auditory function in individuals suffering from high-grade sensorineural hearing loss (hereinafter referred to as SNT) and deafness. The surgical stage of CI consists in installing the implant body and introducing its active electrode into the cochleostomy through the window of the cochlea.

CHT is a polyetiological disease, usually not leading to structural changes in the cochlear spiral channel. However, the outcome of a number of diseases (meningitis, temporal bone injury, cochlear form of otosclerosis, Kogan’s syndrome, sarcoidosis (Bennier – Beck – Schauman disease), etc.) can be SNT, which develops as a result of the formation of new unorganized bone tissue that replaces healthy or obliterating space inside the bone labyrinth.

It is believed that the imposition of a cochleostomy allows you to bypass the site of ossification and get into the lumen of the spiral channel of the cochlea immediately after it. However, the application of this technique is fraught with getting into the ossified site and significant difficulties in detecting the lumen of the spiral channel of the cochlea, as well as differentiation of the vestibular and tympanic stairs, associated with the loss of anatomical landmarks.

Getting into the ossification site may be associated with the risk of inconsistency of the preoperative results of computed tomography (hereinafter referred to as CT) with intraoperative findings. There are frequent cases when CT data indicate the absence of ossification of the cochlear spiral channel, and during surgery, its presence is detected, or a longer section of the pathological process is revealed intraoperatively. The length of the ossification site, reaching 8 ± 0.68 mm, is potentially dangerous for applying a cochleostomy, since this distance corresponds to the area of rotation of the basal curl, where it borders the internal carotid artery, and the thickness of the bone capsule of the labyrinth separating it from the artery can be 0 , 77 mm.

An important condition is not only circumvention of the ossification site, but also minimizing the risk of injury:

- a modiolus, in the thickness of which there is a spiral ganglion, and its damage makes it impossible to conduct further rehabilitation of the patient due to the death of the conductive apparatus;

- the channel of the internal carotid artery (hereinafter - CVCA) and directly the artery itself, which can be a source of bleeding and lead to the death of the patient;

- the internal auditory canal (hereinafter - the VSP), provoking liquorrhea and, as a result, in case of infection, the development of meningitis.

It should also be noted that the introduction of the active electrode of the cochlear implant (hereinafter - AECI) through the cochleostomy into the middle or apical curls does not allow the use of a standard electrode and, as a result, the portion of the cochlea responsible for high frequencies falls out of the stimulation process, which reduces the success of subsequent rehabilitation.

The high probability of trauma to the structures of the inner ear and adjacent anatomical formations, the inability to use a standard electrode when applying a cochleostomy in the middle or apical curl, the absence of methods and tools for intraoperative measurement of the length of the ossification site to exclude complications necessitates further development in this field of medicine.

There is a method of surgical treatment of patients with cochlear ossification, including an anthromastoidotomy, removal of the posterior wall of the external auditory canal, eardrum, anvil, malleus, obstruction of the auditory tube, removal of the lateral wall of the cochlear canal of the cochlea with orientation to the difference in bone color, namely, pathological, again the bone is whiter than the labyrinth capsule, which has a yellowish tint throughout the canal and the placement of AECI into the canal (see Gantz BJ, McCabe BF, Tyler RS "Use of multichannel cochlearimplants in obstructed and obliterated cochleas", Otolaryngolology - Head and Neck Surgery, 1988, Vol. 98, p. 72-81).

The disadvantages of this method are: the formation of a large trepan cavity; the possibility of damage to the carotid artery, modiolus, mastoid and labyrinth sections of the facial nerve (which requires its intraoperative monitoring); the possibility of developing liquorrhea, postoperative extrusion of AECI and postoperative problems with stimulation of the auditory and facial nerve, such as pain, discomfort and fasciculation of the facial muscles of the face on the side of the operation; the risk of surgical trauma (vibrotrauma) with the subsequent development of vestibular disorders.

There is also known a method for the surgical treatment of patients with cochlear ossification, including an anthromastoidotomy, posterior tympanotomy, drilling tunnels in an ossified cochlea and the introduction of AECI (see Wang L., Zhang D. “Surgical methods and postoperative results of cochlear implantation in 79 cases of ossified cochlear ", Acta Otolaryngologica, 2014, Vol. 134, No. 12, p. 1219-1224).

The disadvantages of this method are the lack of intraoperative control over the length of the drilling site and the direction of the formed channel, and, as a result, the high risk of trauma to the modiolus, the possible development of cerebrospinal fluid, the risk of trauma to the CVAC and the artery itself.

The closest in technical essence to the claimed solution is a method of surgical treatment of patients with cochlear ossification, including an anthromastoidotomy, posterior tympanotomy, identification and removal of the canopy of the cochlear window, reaming and / or sawing of the ossification site along the basal curl with a reference to its lateral wall and the difference in color between the labyrinth capsule and the ossification site filling the lumen of the spiral channel (see Kuzovkov V.E. et al. “Method for the surgical treatment of patients with cochlear ossification”, Tavrichesky Biomedical Bulletin, Simferopol, 2017, v. 20, No. 3 -3, p. 117-123).

The disadvantage of this method is the lack of intraoperative control over the length of the drilled ossification site, since a length exceeding 8 mm is potentially dangerous for damage to the CVCA and the artery itself, and as a result, the development of bleeding and death of the patient.

The technical result of the proposed solution is to reduce the risk of trauma to the modiolus, the canal of the internal carotid artery and the artery itself when performing cochlear implantation in patients suffering from high-grade bilateral bilateral sensorineural hearing loss and deafness with ossification of the descending part of the cochlear spiral channel by performing intraoperative monitoring of the drilled ossification site.

To achieve the specified technical result in a method of surgical treatment of patients with cochlear ossification, including an anthromastoidotomy, posterior tympanotomy, identification and removal of the cochlear canopy, drilling the ossification site along the basal curl with a reference to its lateral wall and the color difference between the grayish-yellow labyrinth after removing the canopy of the cochlear window and visualizing the portion where the cochlear membrane was located before the start of the ossification process, the diamond mill is 2.3 mm in diameter and the mill is 1.4 mm in diameter, and during the entire drilling process, intra-operational control of the length of the formed channel is carried out, and the drilling is carried out in stages and after each stage the channel length is measured with a meter in the form of a flexible conductor with a scale applied to it, taking into account the presence or absence of the spiral channel of the cochlea, which is not subject to ossification, moreover, every 2.0 mm of the formed channel, the diamond mill of a larger diameter is changed to a mill of a smaller diameter to obtain a helical channel shape and the total length of the section passed is determined, and if the channel length is less than 8.0 mm getting into the lumen of the cochlear spiral channel of the cochlear implant, the active electrode is inserted into the cochlear implant, and if the channel length is 8.0 mm, and there is no getting into the cochlear spiral channel lumen, surgery is stopped.

The implementation of intraoperative control over the length of the drilled ossification site by repeated, stepwise measurement of the newly formed channel allows the surgical intervention to be stopped under two conditions: when the channel length is 8.0 mm (size was established during numerous experiments), as well as in the absence of clearance of the cochlea spiral channel, not subject to ossification. Thus, this eliminates the possibility of damage to the CVAC and directly to the artery itself, and, consequently, the risk of bleeding and death of the patient.

After removing the canopy of the cochlea window niche using a diamond cutter with a diameter of 2.3 mm and visualizing the area where the membrane of the cochlear window was located before the start of the ossification process, the diamond cutter 2.3 mm is replaced by a diamond mill with a diameter of 1.4 mm. And the reaming site of the ossification of the basal curl of the cochlea is carried out with an orientation on the difference in color between the site of ossification, which is white, and the labyrinth capsule, which has a gray-yellow color.

When a re-formed channel is repeatedly measured in the process of drilling with a meter, which is inserted into it, and the length of the channel is determined by the scale applied to the meter.

Establishing the exact size of the channel length is necessary for the phased change of a diamond mill with a larger diameter to a mill with a smaller diameter, namely, a diameter of 1.0 mm, 0.8 mm, 0.6 mm every 2 mm, and also to determine the total length of the passed section.

The diameter of the cutters is changed due to the fact that normally the channel of the cochlea has a helical course around the modiolus, where the spiral ganglion is located. If, during the drilling of the ossification section of the basal curl of the cochlea, the cutters are not to be changed from a larger diameter to a smaller diameter, but only a diamond cutter of a larger diameter is used, a channel is formed that has a straight path rather than a helical one. As a result, the risk of trauma to the modiolus and, as a consequence, the spiral ganglion increases, which can lead to unsatisfactory results of subsequent auditory-speech rehabilitation.

Moreover, if you immediately take a cut of a smaller diameter, this will significantly increase the risk of trauma to the modiolus during channel formation.

When the length of the ossification site is less than 8 mm, the cochlea enters the basal curl, after which AECI is introduced. If the length of the newly formed channel is 8 mm, the surgery is stopped, since this distance corresponds to the rotation of the basal curl of the cochlea, namely, the place of transition of its descending part to the ascending one, as a result of which visual control over the formation of the channel is not possible.

Also, this area is dangerously close to the CVAC and, accordingly, to the artery itself. As a result of perforation through the bone wall with a small diameter diamond cutter, trauma to the internal carotid artery and the development of bleeding and death of the patient are possible.

From the foregoing, it follows that the introduced distinguishing features affect the specified technical result, are with him in a causal relationship.

The method is illustrated by drawings, where in FIG. 1 shows an antromastoid cavity and posterior tympanotomy; in FIG. 2 shows the region of the ossified membrane of the cochlea after removal of the canopy of the cochlea; in FIG. 3 shows a change in the shape of a white spot to an oval; in FIG. 4 is a schematic diagram of a ossification site; in FIG. Figure 5 shows the measurement of drilled ossification sites.

The following positions are used in the drawing: 1 - an antromastoid cavity; 2 - back tympanotomy; 3 - a canopy of a window of a snail; 4 - diamond mill; 5 - the process of ossification; 6 - a window of a snail; 7 - labyrinth capsule; 8 - channel of the internal carotid artery; 9 - meter.

The method is as follows.

Surgical intervention is performed under endotracheal anesthesia.

An S-shaped incision is made in the behind-the-ear region. Form and exfoliate skin and muscle-periosteal flaps. Prepare a bed for the implant body and a groove for laying the electrode. Boron form an antromastoid cavity 1, through the posterior tympanotomy 2 open the tympanic cavity.

Next, the canopy of the window of the cochlea 3 is identified and removed with a diamond mill 4, then the place where the membrane of the window of the cochlea 6 was located before the start of the ossification process 5 is removed.

The channel is drilled along the basal curl, with a reference to its labyrinth capsule 7 and the color difference between the labyrinth capsule 7 and the site of the ossification process 5, filling the lumen of the spiral channel.

With adequate irrigation of this area, the labyrinth capsule 7 will have a gray-yellow hue, while the pathological bone of the ossification 5 site will be whitish. Moreover, in the process of sawing the spiral channel, a white round spot corresponding to the window of the cochlea 6 will gradually change its shape to an oval.

This is a consequence of the fact that the trajectory of the tympanic staircase is not perpendicular to the plane of the membrane of the cochlea window 6 (symptom of the reed core).

It has been experimentally established that the length of the portion of the ossification process 5 available for drilling is 8.0 mm in accordance with the average distance from the membrane of the window of the cochlea 6 to the place of rotation of the descending part of the basal curl of the cochlea into the ascending one, and the thickness of the labyrinth capsule 7 in the rotation area, delimiting the basal curl of the cochlea from the canal of the internal carotid artery 8 is equal to 1.23 ± 0.46 mm The thickness of the bone plate delimiting the basal curl of the cochlea and the VSP is 0.5 ± 0.14 mm.

As the ossification section 5 is being drilled, the length of the distance traveled is measured by a meter 9, which is inserted into the drilled channel, and the length of the formed channel is fixed by the applied marks. The meter 9 of the drilled ossification section 5 is made of medical silicone. It is a conductor similar to the standard AECI in size and shape. Its working length to the stopper is 18.0 mm. A graduated scale equal to 1.0 cm is applied to it. The distance between the marks corresponds to 0.5 mm. The diameter of the tip is 0.5 mm.

When the length of the newly formed channel equal to 8.0 mm, surgery is terminated due to the fact that subsequent visual monitoring of the formation of the channel is impossible, and there is also a potential risk (with further reaming) of trauma to the internal carotid artery, the development of bleeding and death of the patient.

When the length of the ossification section 5 is less than 8.0 mm, the spiral channel of the cochlea enters the lumen. Next, the implant body is fastened in the prepared bed, then, through the posterior tympanotomy 2 and the newly formed channel, the active cochlear implant electrode is inserted into the cochlear spiral channel. Perform telemetry of the implant. The wound is sutured in layers. An aseptic pressure bandage is applied. For the prevention of bacterial infections, antibiotic therapy is prescribed for 7 days. On the day after surgery, CT of the temporal bones is performed to verify the introduction of AECI into the cochlear spiral channel.

The method is illustrated by the following examples.

Example 1

Patient S., born 2014 He was admitted to the clinic of the Department of Diagnostics and Rehabilitation of Hearing Impairment of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech with a diagnosis of bilateral chronic sensorineural hearing loss, IV degree.

From the anamnesis it is known that the patient suffered bacterial meningitis a year before admission. Within three months after suffering meningitis, a gradual bilateral decrease in hearing loss to deafness was observed.

On examination: The mucous membrane of the nose is pink, wet. The septum of the nose is slightly curved. The nasal passages are free. The nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink, moist. The palatine tonsils are pink, behind the arches, the gaps are clear, there are no raids on the tonsils. The mucous membrane of the larynx is pink, moist. The vocal folds are white, their movement in full. The glottis is wide, symmetrical.

AD - the external auditory meatus is free. The eardrum is gray, the contours are clear, there are no defects. AS - the external auditory meatus is free. The eardrum is gray, the contours are clear, there are no defects.

During the examination: tonal threshold audiometry - bilateral sensorineural hearing loss of the fourth degree; impedanometry - tympanogram type A from two sides; otoacoustic emission was not detected on both sides; KSVP - KSVP thresholds are not registered at a maximum signal level of 100 dB; CT of the temporal bones, performed immediately before surgery (the day before): CT signs of bilateral partial ossification of the basal curl of the cochlea AS 2.0 mm long, AD 5.0 mm, the cells of the mastoid processes are pneumatic, the tympanic cavities are free, the auditory ossicles are well visualized, without pathology, internal auditory canals symmetrical.

The patient underwent cochlear implantation on his right ear.

In conditions of endotracheal anesthesia and local infiltration anesthesia, an S-shaped incision was made in the right behind the ear region. Formed and exfoliated skin and muscle-periosteal flaps. A bed was prepared for the implant body and the groove for laying the electrode. An antromastoidotomy was performed with burs; a tympanic cavity was opened through the posterior tympanotomy. The canopy of the cochlea was identified and removed by a diamond mill with a diameter of 2.3 mm.

Then, the ossification site was drilled along the basal curl, with a reference to the color difference between the labyrinth capsule having a gray-yellow color and the ossification site (filling the lumen of the spiral channel) with white color.

The drilling of the ossification site began with a diamond mill with a diameter of 1.4 mm. For a phased change of cutters, from a larger diameter to a smaller one, which is made every 2.0 mm, a newly formed tunnel was measured by introducing a meter into it, and the channel depth was determined from the marks applied to it. Measurement was performed 5 times.

After reaching the level of 5.0 mm, there was no basal curl entering the lumen, which contradicted the CT data, which indicated the length of the ossification site equal to 5.0 mm.

This fact confirmed the possibility of inconsistency of CT data and preoperative findings, which may lead to the impossibility of introducing AECI with an ossification length of more than 8.0 mm. Given the presence of the remaining 3.0 mm before turning the basal curl, the reaming of the ossification site was continued. At a distance of 7.0 mm from the window of the cochlea, a spiral channel of the cochlea fell into the lumen.

The phased measurement of the length of the drilled ossification section made it possible to change diamond cutters from a larger diameter to a smaller one every 2.0 mm and to visually monitor the color difference between the labyrinth capsule and the ossification site.

As a result of this, a tunnel was formed not of a straight line, but of a helical shape, the modiolus, in which the spiral ganglion is located, was not injured.

Next, the implant body was fixed in the prepared bed and the active electrode of the cochlear implant was inserted through the posterior tympanotomy into the cochlear canal. Implant telemetry performed. Then a layer-by-layer suturing of the wound was made with absorbable material, an aseptic pressure dressing was applied.

For the prevention of bacterial infections, antibacterial therapy was carried out for 7 days. The day after surgery, a CT of the temporal bones was performed, according to which AECI was completely inserted into the cochlear canal. The postoperative period was uneventful. One month after the operation, the processor is connected.

The results of subsequent auditory-speech rehabilitation are satisfactory, not statistically different from the results obtained in the group of patients with progressive course of SNT, and better than the results of speech perception in patients after a traumatic brain injury (fracture of the temporal bones).

Example 2

Patient K., born 2016 was admitted to the clinic of the Department of Diagnostics and Rehabilitation of Hearing Disorders of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech with a diagnosis of bilateral chronic sensorineural hearing loss of the fourth degree.

From the anamnesis it is known that the patient suffered bacterial meningitis 6 months before admission. After discharge, complete deafness was recorded on both ears.

On examination: The mucous membrane of the nose is pink, wet. The septum of the nose is slightly curved. The nasal passages are free. The nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink, moist. The palatine tonsils are pink, I degree, in the gaps of the pathological discharge there are no raids on the tonsils. The mucous membrane of the larynx is pink, moist. The vocal folds are white, their movement in full. The glottis is wide, symmetrical.

AD - the external auditory meatus is free. The eardrum is gray, the contours are clear, there are no defects. AS - the external auditory meatus is free. The eardrum is gray, the contours are clear, there are no defects.

During the examination: tonal threshold audiometry - bilateral sensorineural hearing loss, IV degree, deafness; impedanometry - tympanogram type A from two sides; otoacoustic emission was not detected on both sides; KSVP - KSVP thresholds are not registered at a maximum signal level of 100 dB; CT of the temporal bones performed immediately before surgery (the day before) - CT signs of bilateral partial ossification of the basal curl of the cochlea AD 4.0 mm in length, AS 6.0 mm, the cells of the mastoid processes are pneumatic, the tympanic cavities are free, the auditory ossicles are well visualized, without pathology The internal auditory canals are symmetrical.

The patient underwent cochlear implantation on his left ear.

Under conditions of endotracheal anesthesia and local infiltration anesthesia, an S-shaped incision was made in the left behind the ear region. Formed and exfoliated skin and muscle-periosteal flaps. A bed was prepared for the implant body and the groove for laying the electrode. An antromastoidotomy was performed with burs, a tympanic cavity was opened through the posterior tympanotomy, the canopy of the cochlea was identified, and its removal was performed with a diamond cutter with a diameter of 2.3 mm.

Then, the ossification site was drilled along the basal curl, with a reference to the color difference between the labyrinth capsule having a gray-yellow color and the ossification site (filling the lumen of the spiral channel) with white color. The drilling of the ossification site began with a diamond mill with a diameter of 1.4 mm.

In the process of drilling, the milling cutters were gradually replaced from a larger diameter to a smaller diameter. Each 2.0 mm was replaced, and a newly formed channel was measured by introducing a meter into it, and the channel depth was determined from the marks applied to it.

That is, after 2.0 mm from the area where the membrane of the cochlea window was located before the ossification, the diamond cutter was changed by 1.0 mm, after another 2.0 mm by 0.8 mm. After passing the next 2.0 mm, the length of the total covered area, according to measurements, was 6.0 mm, but at the same time, the spiral channel of the cochlea did not enter the lumen, which did not correspond to CT data indicating an ossification length of 6.0 mm

The diamond cutter was changed to a diameter of 0.6 mm and the drilling of the ossification section continued. In subsequent measurements, the total channel length was 8.0 mm. After that, the reaming was stopped, since this distance corresponds to the place of transition of the descending part of the cochlea's basal curl to the ascending one, and, consequently, subsequent visual control of the formation of the canal will be impossible, and with continued reaming, there is a risk of perforation in the CVAC and damage to the artery itself with the development of bleeding and death of the patient.

This method with phased measurement of the length of the drilled section made it possible to gradually change the diameter of the cutters, to control the color difference between the labyrinth capsule and the ossification section, to form a helical channel, thereby eliminating the risk of injury to modiolus, spiral ganglion cells and VSP.

Next, layer-wise suturing of the wound with absorbable material was carried out. An aseptic pressure dressing is applied.

For the prevention of bacterial infections, antibacterial therapy was carried out for 7 days, aseptic dressing change.

Thus, the application of the proposed method allows visual control and the formation of a helical channel, thereby eliminating trauma to the modiolus, minimizes the risk of damage to the CVAC and the artery and the VSP, while ensuring the complete introduction of a standard cochlear implant electrode into the cochlear spiral channel, thereby achieving satisfactory results of subsequent auditory-speech rehabilitation.

Claims (1)

A method for the surgical treatment of patients with cochlear ossification, including an anthromastoidotomy, posterior tympanotomy, identification and removal of a canopy of the cochlear window, reaming of the ossification site along the basal curl with a reference to its lateral wall and the color difference between the grayish-yellowish labyrinth capsule and the white area filling the lumen of the spiral channel, characterized in that after removing the canopy of the cochlea window and visualizing the area where the cochlear membrane was located before the ossification process began, the diamond cutter with a diameter of 2.3 mm was changed to a mill with a diameter of 1.4 mm and during the entire drilling process they carry out intraoperative control over the length of the formed channel, moreover, they are drilled in stages and after each stage the length of the channel is measured with a meter in the form of a flexible conductor with a scale applied to it, taking into account the presence or absence of clearance of the spiral channel of the cochlea that is not subject to ossif ikations, moreover, every 2.0 mm of the formed channel, the diamond cutter of a larger diameter is changed to a cutter of a smaller diameter to obtain a helical shape of the channel and the total length of the section passed is determined, and if the spiral cochlea of the cochlea enters the lumen with a channel length of less than 8.0 mm, the active electrode of the cochlear implant is introduced, and if the channel length is 8.0 mm, and there is no contact with the cochlear spiral channel, surgery is stopped.

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