RU2753141C1 - Method for preventing formation of retraction pockets - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology. A behind-the-ear access is performed, the skin of the posterior-superior wall of the external auditory canal is separated anteriorly to the annulus fibrosus. Tympanotomies, revision of the structures of the tympanic cavity are performed. The condition of the auditory ossicles, such as the malleus, incus, stapes, is assessed. Removal of the posterior superior sections of the bone tympanic ring and the lateral wall of the attic, removal of the head of the malleus, the body of the incus are performed. Grinding of the half-channel of the muscle stretching the eardrum is performed. Ossiculoplasty is performed. A meatotympanic flap is placed in place, followed by tamponade of the external auditory canal and suturing of the ear wound. The attic is remodeled by expanding it, while removing, in addition to the lateral wall, also the anterior and upper walls. After removal of the incus, the transverse ridge and epitympanic tooth are also removed, expanding the airway epitympanic passage. Before ossiculoplasty, plates of sodium salt of carboxymethylcellulose are laid in the area of the remodeled attic, the removed transverse ridge and epitympanic tooth, and in the area of the cut off semi-canal of the muscle stretching the tympanic membrane. After that, plastic of the lateral wall of the remodeled attic is performed with an autobone plate, which is fixed to the posterior wall of the external auditory canal with glass ionomer cement.

EFFECT: invention allows reducing the risk of development of retraction pockets in the postoperative period in patients with congenital malformation of the middle ear, accompanied by hypoplasia of the attic, by expanding the existing and creating additional ventilation paths inside the middle ear.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used when performing hearing-improving operations in patients suffering from an isolated anomaly of the middle ear, accompanied by hypoplasia of the attic.

A special place in middle ear surgery is given to isolated developmental anomalies as a pathology leading to significant hearing loss. In these diseases, a high proportion of unsatisfactory results of surgical intervention is observed, due to the development of retraction pockets of the tympanic membrane in patients in the postoperative period, which dictates the need for further developments in this area of medicine.

A known method for the prevention of the formation of retraction pockets, including the transmeatal pathway, in which the endaural approach is performed, partial removal of the lateral wall of the attic, the installation of a ventilation tube in the attic (see Bremond G., Magnan J., Acquaviva F. "The problem of aeration of the ear during closed techniques)), Ann Otolaryngol Chir Cervicofac, Elsevier, 1980, Jan-Feb; 97 (1-2): p. 79-84).

When implementing this method, endaural access is performed, drilling in the wall of the external auditory canal above the head of the malleus with further installation of the transattic tube, without revision of the tympanic cavity.

The disadvantages of this method are:

- a high risk of damage to the ossicle chain, since drilling during the endoural approach, limited by the space of the external auditory canal, is partially carried out "blindly", without examining the structures of the tympanic cavity;

- when the cutter comes into contact with the head of the hammer, there is a high risk of injury to the auditory ossicles, dislocation of the stapes or vibration trauma to the inner ear with the development of sensorineural hearing loss;

- the narrow spaces of the airways of the middle ear are not eliminated, and the ventilation tube serves as an infection gate into the middle ear cavity.

There is also known a method of preventing the formation of retraction pockets in the postoperative period, including behind-the-ear access, transmeatal pathway, revision of the tympanic cavity, assessment of the condition of the auditory ossicles and mobilization of the auditory ossicles with ossiculoplasty and subsequent placement of cartilage plates in various retraction areas, tamponade of the external auditory meatus and suturing wounds (see Anand V. Kasbekar, Virjen Patel, Mihiri Rubasinghe, and Venkat Srinivasan, “The Surgical Management of Tympanic Membrane Retraction Pockets Using Cartilage Tympanoplasty)), Indian J Otolaryngol Head Neck Surg, Association of Otolaryngologists of India, 2014, Dec; 66 (4): p. 449 -454).

When implementing this method, the head of the malleus, the body of the incus, the epitympanic tooth are preserved, and the cushion of the muscle stretching the tympanic membrane is not ground. Plastic surgery of the lateral wall of the attic, as such, is not performed, which may further lead to retraction of the tympanic membrane.

The disadvantages of this method are:

- the presence of bottlenecks in the airways of the middle ear due to the preservation of the head of the malleus, the body of the incus, the epitympanic tooth, the muscle cushion stretching the tympanic membrane, as a result of which the cause of the formation of retraction pockets (lack of ventilation) is not eliminated;

- plasty of retraction pockets is carried out with soft material (thinned cartilage plastics), prone to excessive scarring, displacement or re-formation of retraction pockets with insufficient material rigidity;

- there is no prevention of excessive cicatricial process in the area of the formation of the airways of the middle ear, leading to blockage of these pathways.

The closest in technical essence to the claimed solution is a method for preventing the formation of retraction pockets, including behind-the-ear access, separating the skin of the posterior-superior wall of the external auditory canal anteriorly to the annulus fibrosus, performing tympanotomy, revising the structures of the tympanic cavity, assessing the state of the auditory ossicles, such as the malleus, incus, stapes, removal of the posterior-upper sections of the bony tympanic ring and lateral wall of the attic, removal of the malleus head, incus body, grinding the fold of the muscle stretching the tympanic membrane, performing ossiculoplasty, placing the meatotympanic flap in place followed by tamponade of the external auditory canal and ear canal (see Marchioni D., Mattioli F., Alicandri-Ciufelli M., Presutti L. “Endoscopic approach to tensor fold in patients with attic cholesteatoma)), Acta Otolaryngol, Elsevier, 2009, Sep; 129 (9): p. 946 - 954).

When implementing this method, the air-conducting paths of the tympanic cavity are restored, the transverse ridge and epitympanic tooth are not grinded. The plastic of the lateral wall of the attic is performed with autocartilage.

The disadvantages of this method in the aspect of patients with a hypoplastic attic are:

- lack of remodeling (expansion of the walls of the attic with boron) of the narrowed attic, which leads to insufficient ventilation of the posterior-upper floor of the middle ear, followed by the formation of a retraction pocket in the postoperative period;

- the use of cartilage as a material for plastics of the lateral wall of the attic contributes to the appearance of a cicatricial process and cannot give it the necessary rigidity, which can lead to retraction and migration of the plate;

- the impossibility of fixing the cartilaginous plate as the lateral wall of the attic leaves the risk of its displacement and blockage of the airways of the middle ear;

- there is no prevention of excessive cicatricial process in the area of the formation of the airways of the middle ear, leading to blockage of these pathways.

The technical result of the proposed solution is to reduce the risks of developing retraction pockets in the postoperative period in patients with congenital malformation of the middle ear, accompanied by hypoplasia of the attic, by expanding the existing and creating additional ventilation paths inside the middle ear.

To achieve the specified technical result in a method for preventing the formation of retraction pockets, including behind-the-ear access, separating the skin of the posterior-superior wall of the external auditory canal anteriorly to the annulus fibrosus, performing a tympanotomy, revising the structures of the tympanic cavity, assessing the state of the auditory ossicles, such as the malleus, incus, stapes , removal of the posterior-upper sections of the bony tympanic ring and the lateral wall of the attic, removal of the head of the malleus, the body of the incus, grinding the semi-canal of the muscle stretching the tympanic membrane, performing ossiculoplasty, placing the meatotympanic flap in place followed by tamponade of the external auditory canal and suturing the ear wound , remodel the attic by expanding it, while removing, in addition to the lateral wall, also the anterior and upper walls, and after removing the incus, the transverse ridge and epitympanic tooth are also removed, expanding the airway epitympanic passage, and ne before ossiculoplasty, plates of sodium salt of carboxymethylcellulose are laid in the area of the remodeled attic, the removed transverse ridge and epitympanic tooth, and in the area of the semicanal of the muscle stretching the tympanic membrane, after which the plastic of the lateral wall of the remodeled attic is performed with an autobone plate of the wall, which is fixed to the auditory wall by the auditory wall cement.

Removal of the incus and the head of the malleus, which are fixed by fibrous or bony adhesions to the walls of the attic, significantly increases the volume of the attic and eliminates the narrowing in it.

Removal of the transverse crest and epitympanic tooth expands the epitympanic passage, which is the main route of ventilation of the upper middle ear and attic.

Remodeling of the attic, carried out by removing the overhanging parts of the lateral, anterior and upper walls of it, as well as the transverse ridge and epitympanic tooth with burs, can significantly expand its lumen and improve ventilation of the posterior-upper floor of the middle ear.

Laying plates of sodium salt of carboxymethylcellulose, which reduces the scarring process, in the area of the remodeled attic, the removed transverse ridge and epitympanic tooth, as well as in the area of the reduced semi-canal of the muscle stretching the tympanic membrane, prevents the development of coarse scars leading to a decrease in ventilation of the tympanic cavity and maintain the patency of the formed airways.

Plasty of the lateral wall of the attic with an autobone plate allows you to create a rigid lateral wall, more resistant to retraction and collapse of the airways.

Additional fixation of the autobone plate with glass ionomer cement prevents the plate from displacement in the postoperative period and prevents the formation of a retraction pocket in the upper sections.

From the above it follows that the introduced distinctive features affect the specified technical result, are in a causal relationship with it.

The method is illustrated by drawings, where:

- in Fig. 1 shows the normal tympanic cavity;

- in Fig. 2 shows the tympanic cavity with a remodeled attic due to the removal of its lateral, anterior and upper walls and an anvil-hammer conglomerate fixed in the attic;

- in Fig. 3 shows the stage of removal of the incus and the head of the malleus;

- in Fig. 4 shows the stage of removal of the transverse ridge and epitympanic tooth, the airway epitympanic passage is expanded;

- in Fig. 5 shows the stage of laying the plates of sodium salt of carboxymethylcellulose in the area of the expanded attic, the removed epitympanic tooth and in the area of the worn out cushion of the muscle stretching the tympanic membrane;

- in Fig. 6 shows the stage of formation of the lateral wall of the attic with an autobone plate.

In the drawing, the following positions are used: 1 - tympanic cavity; 2 - hammer; 3 - anvil; 4 - stirrup; 5 - bone tympanic ring; 6 - lateral wall of the attic before the intervention; 7 - area of the anterior attic; 8 - remodeled attic; 9 - hammer head 2; 10 - transverse ridge; 11 - epitympanic tooth; 12 - epitympanic course; 13 - half-channel of the muscle pulling the eardrum; 14 - plate of sodium salt of carboxymethylcellulose; 15 - autologous bone plate.

The method is carried out as follows.

Surgical intervention is performed under endotracheal anesthesia. To exclude damage to the branches of the facial nerve in cases of abnormal location of the facial nerve canal, intraoperative monitoring of the facial nerve is used. Orientation is carried out according to the data of computed tomography of the temporal bone, virtual CT endoscopy and the system of surgical navigation control.

A behind-the-ear access is performed, the skin of the posterior-superior wall of the external auditory canal is separated anteriorly to the annulus fibrosus. Tympanotomy and revision of the structures of the tympanic cavity 1, assessment of the condition of the auditory ossicles: malleus 2, incus 3 and stapes 4 are performed.

The posterior-upper sections of the bone tympanic ring 5 and the lateral wall of the attic 6 are removed with a bur with a burr for a detailed view and access to the auditory ossicles (malleus 2, incus 3 and stapes 4).

With a bur, the hypoplastic attic is expanded by removing the bone in zone 7 of the anterior attic, obtaining a remodeled (wide) attic 8.

Removal of the anvil 3 and the head 9 of the hammer 2 fixed in the remodeled attic 8 is performed to expand the space in it.

The transverse ridge 10 and the epitympanic tooth 11 are removed, expanding the airway epitympanic passage 12.

Bone protrusions are also grinded with boron in the area of the semicanal of the muscle 13, which stretches the tympanic membrane, further expanding the airway in the area of the epitympanic passage 12.

Then, the plates of sodium salt of carboxymethylcellulose 14 are laid in the area of the remodeled attic 8, the removed transverse ridge 10, the epitympanic tooth 11, in the area of the semicanal of the muscle 13 stretching the tympanic membrane to prevent excessive scarring, which reduces the efficiency of the operation.

Plasty of the lateral wall of the remodeled attic 8 is performed with an autobone plate 15, which is fixed to the posterior wall of the external auditory canal with glass ionomer cement to prevent retraction in this area of the tympanic membrane and prevent the development of retraction pockets.

The axes of the cooler are repaired with a titanium prosthesis.

Blood from the tympanic cavity is aspirated in order to avoid the development of the adhesive process in the future. At the end of the operation, the meatotympanic flap is placed in place.

The behind-the-ear incision is sutured in layers. Produce tamponade of the ear canal with a sponge or thread tamponade.

The method is illustrated by the following example.

Patient K., born in 2007, was admitted to the adult surgical department of the St. Petersburg Research Institute of Ear, Throat, Nose and Speech with a diagnosis of congenital isolated developmental anomaly of the middle ear on the left, left-sided conductive hearing loss III degree.

Upon admission, the patient noted a non-progressive hearing loss in the left ear, noted from early childhood.

On examination: the nasal mucosa is pink, moist. The septum of the nose in the midline. The nasal passages are free. The vault of 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, there are no raids, the gaps are clean. The mucous membrane of the larynx is pink, moist. The vocal folds are white, their movement is full. The glottis is wide and symmetrical.

AS - the external auditory canal is wide, free. The tympanic membrane is gray, the contours are clear. He does not hear whispering speech, he perceives spoken speech from 1.5 m. Weber's test - lateralization to the left. Rinne's test is negative. Jelly test is negative.

AD - the external auditory meatus is wide, free. The tympanic membrane is gray, the contours are clear. Whispering speech 6 m, colloquial speech more than 6 m. Rinne's test is positive. Jelly test is positive.

The results of tone threshold audiometry: left-sided conductive hearing loss grade III with sound conduction thresholds in the speech frequency zone 60 - 65 dB in the presence of a bone-air gap of 50 dB.

On a computed tomogram of the temporal bones on the left, the external auditory canal is free, the cells of the mastoid process are pneumatized, the tympanic cavity is free, the incus and malleus are represented by a single conglomerate fixed to the medial and lateral walls of the attic.

The patient underwent reconstructive surgery on the left ear.

Under the conditions of endotracheal anesthesia, an arcuate incision of the skin and soft tissues to the bone was made in the behind-the-ear region about 4.0 cm long, 1.0 cm away from the transitional fold, the tissues were separated anteriorly.

The skin of the ear canal is separated up to the annulus fibrosus. Tympanotomy was performed. During the audit of the tympanic cavity, it was found that the incus and malleus were represented by a single immobile conglomerate.

The lateral wall of the attic was removed, the posterior-upper sections of the bone tympanic ring were removed.

The attic was remodeled by expanding it in the area of the anterior attic. Disconnected the incus-stapes junction. The head of the malleus was resected, the incus-malleus conglomerate was removed.

The transverse ridge and epitympanic tooth were removed, the fold of the muscle stretching the tympanic membrane was ground off.

The epitympanic course is widened.

The plates of sodium salt of carboxymethylcellulose were laid in the area of the remodeled attic, the removed transverse ridge, the epitympanic tooth, and in the area of the grinded muscle cushion stretching the tympanic membrane.

Ossiculoplasty was performed with a partial titanium prosthesis. Performed aspiration of blood from the tympanic cavity. The plastic of the lateral wall of the attic was performed with an autobone plate, which was fixed with glass-ionomer cement.

The meatotimanal flap is in place. Tamponade of the external auditory canal was performed with a sponge. The behind-the-ear wound was sutured in layers. Aseptic bandage applied

For the prevention of bacterial infections, antibiotic therapy was carried out for 7 days. The postoperative period was uneventful. The stitches were removed on the 7th day. Tampons from the external auditory canal were removed on the 7th day.

At the control examination on the 14th day after the operation: AS - the external auditory canal is wide, free, the tympanic membrane without defects, slightly hyperemic, edematous. There is no retraction of the tympanic membrane.

At the control examination 12 months after the operation: AS - the external auditory canal is wide, free, the tympanic membrane without defects, gray, the contours are preserved. There is no retraction of the tympanic membrane.

According to the results of control tone threshold audiometry: AS - sound conduction thresholds in the speech frequency zone 33 - 37 dB in the presence of bone-air gap up to 15 dB.

It is clear from the example that the claimed method allows to achieve stable anatomical and functional results - the patient did not have a retraction pocket 12 months after the operation, since optimal conditions were created for ventilation of the middle ear and to prevent cicatricial adhesions in the tympanic cavity.

The inventive method allows to improve ventilation of the antrum and mastoid process due to the expanded epitympanic airspace, prevents excessive cicatricial process in the newly formed airways of the middle ear and displacement, deformation and retraction of the newly formed lateral wall of the attic.

Claims (1)

A method for preventing the formation of retraction pockets, including behind-the-ear access, separating the skin of the posterior-superior wall of the external auditory canal anteriorly to the annulus fibrosus, performing tympanotomy, revising the structures of the tympanic cavity, assessing the condition of the auditory ossicles, such as the malleus, incus, stapes, removing the posterior-superior sections of the bone tympanic ring and the lateral wall of the attic, removal of the malleus head, incus body, grinding the semi-canal of the muscle stretching the tympanic membrane, performing ossiculoplasty, placing the meatotympanic flap in place followed by tamponade of the external auditory canal and suturing the ear wound, characterized by the fact that it remodels expansion, while removing, in addition to the lateral wall, also the anterior and upper walls, and after removing the incus, the transverse ridge and epitympanic tooth are also removed, expanding the airway epitympanic passage, and before ossiculoplasty, the plates are laid ric salt of carboxymethylcellulose in the area of the remodeled attic, the removed transverse ridge and epitympanic tooth and in the area of the semicanal of the muscle stretching the tympanic membrane, after which the plastic of the lateral wall of the remodeled attic is performed with an autobone plate, which is fixed to the posterior wall of the external auditory canal with glass ionomer cement.

Images