RU2755080C1 - Method for surgical treatment of isolated anomaly of the development of the middle ear - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: behind-the-ear incision with transmeatal access is performed. A checkup of the tympanic cavity and an assessment of the condition of auditory ossicles and the partial atretic plate are carried out. The atretic plate and the lateral wall of the attic are removed. The mobilization of the auditory ossicle chain is carried out, a gap between auditory ossicles and the bone tympanic ring of at least 1.5 mm is formed. A meatotimpanal flap is placed into position with the closure of the tympanic membrane defect with an autofascial flap. Tamponade of the external auditory canal and suturing of the behind-the-ear wound are performed. After assessing the condition of auditory ossicles and the partial atretic plate, bone bridges that fix ossicles to the atretic plate are removed using an instrument: a curette or a hook. After that, a fibrous layer and the mucous membrane are separated from the medial surface of the partial atretic plate until the latter is removed. After removing the atretic plate, an elongated hammer handle is partially resected. The use of protectors that protect the auditory ossicles is carried out. After that, a hollow above the projection of the bone tympanic ring is formed using boron. Then, protectors are removed. A silastic fragment is placed on the bone tympanic ring opposite the end of the hammer handle.

EFFECT: method makes it possible to increase the efficiency of hearing-improving operations in patients with isolated anomaly of the development of the middle ear and the presence of the partial atretic plate, reduce the traumaticity of the operation and prevent the refixation of the auditory ossicles.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used when performing hearing-improving operations in patients suffering from an isolated developmental anomaly of the middle ear, which are accompanied by the presence of a partial atretic plate.

A special place in middle ear surgery is given to isolated developmental anomalies as a pathology leading to significant hearing loss.

At the same time, the high frequency of unsatisfactory functional results of surgical interventions is also important. The complexity of surgical treatment consists in the great variability of anomalies and the inability to achieve a stable positive anatomical and functional result in some types of anomalies.

There is also a risk of complications such as vestibulopathy, sensorineural hearing loss, paresis or paralysis of the facial muscles.

There is a method of surgical treatment of anomalies of the middle ear with a partial atretic plate, including a behind-the-ear incision, revision of the tympanic cavity, assessment of the condition of the auditory ossicles and the severity of the partial atretic plate, removal of the partial atretic plate, mobilization of the auditory ossicles, followed by placing the meatotympanic flap in place with the placement of the auto-facial flap, tamponade of the external auditory canal, suturing behind the ear (see H. Schuknecht ((Congenital aural atresia, Laryngoscope 99 (1989), St. Louis, Mo., USA, pp. 908-917)).

When implementing this method, a transmastoidal approach is performed with the formation of an antromastoidal cavity for opening the attic.

The disadvantage of this method is the need to form an antromastoidal cavity to approach the auditory ossicles from the attic, which leads to difficulties in mobilizing the ossicular chain and increases the volume of surgical intervention.

There is also a high risk of damage to the ossicular chain, conditions for cicatricial fixation of the ossicular apparatus and displacement of the fascial flap remain, which leads to unsatisfactory anatomical and functional results. The functional result in the implementation of this method often does not fit into the framework of socially adequate hearing.

There is also known a method of surgical treatment of anomalies of the middle ear with a partial atretic plate, including a behind-the-ear incision with transmeatal access, revision of the tympanic cavity, assessment of the condition of the auditory ossicles and a partial atretic plate, removal of the bony bridges fixing the auditory ossicles to the partial atretic plate, mobilization of the auditory ossicles, followed by placing the meato-tympanic flap in place with the placement of the autofascial flap, tamponade of the external auditory canal and suturing the ear wound. (see U. Fisch, P. Chang, T. Linder "Meatoplasty for lateral stenosis of the external auditory canal", Laryngoscope 112 (2002) , St. Louis, Mo., USA, pp. 1310-1314).

When performing this method, the bone bridges fixing the auditory ossicles to the partial atretic plate are removed using a bur.

The disadvantage of this method is the increased risk of developing sensorineural hearing loss, which is associated with the removal of bone bridges using a bur (vibration is transmitted to the stirrup and can damage the annular ligament and membranous labyrinth).

The closest in technical essence to the claimed solution is a method of surgical treatment for anomalies with a partial atretic plate, including a behind-the-ear incision with transmeatal access, separation of the meato-tympanic flap with tympanotomy, revision of the tympanic cavity, assessment of the condition of the auditory ossicles and partial atretic plate, removal, partial atretic plate mobilization of the ossicular chain and the formation of a gap between the auditory ossicles and the bony tympanic ring of at least 1.5 mm, followed by placing the meato-tympanic flap in place with the placement of an autofascial flap, tamponade of the external auditory canal and suturing of the ear wound (see Seidman, Michael DMD, FACS; FACS; Babu, Seilesh MD "A New Approach for Malleus / Incus Fixation: No Prosthesis Necessary", Otology & Neurotology: Middle Ear & Mastoid Disease 111 (2004), pp. 442-443).

When implementing this method, remove the bone bridges that fix the auditory ossicles to the partial atretic plate using a laser.

The disadvantage of this method is that the conditions remain for the refixation of the ossicular chain and for the displacement of the fascial flap, which also leads to an unsatisfactory functional result.

Also, it is impossible to remove a thick partial atretic plate with a laser; there is a risk of damaging the adjacent fibrous layer and mucous membrane.

The technical result of the proposed solution is to increase the efficiency of hearing-improving operations in patients with an isolated anomaly in the development of the middle ear and the presence of a partial atretic plate by reducing the trauma of the operation and preventing refixation of the auditory ossicles.

To achieve the specified technical result in the method of surgical treatment of an isolated anomaly in the development of the middle ear, including performing a behind-the-ear incision with transmeatal access, revising the tympanic cavity and assessing the condition of the auditory ossicles and a partial atretic plate, then removing the atretic plate and the lateral wall of the attic, mobilizing the auditory ossicle chain , the formation of a gap between the auditory ossicles and the bony tympanic ring of at least 1.5 mm, placing the meato-tympanic flap in place with the closure of the tympanic membrane defect with an autofascial flap, tamponade of the external auditory canal and suturing the ear wound, according to the invention, after assessing the condition of the auditory ossicles and partial atretic the plates remove the bone bridges that fix the bones to the atretic plate using a tool: a curette or a hook, after which the fibrous layer and mucous membrane are separated from the medial top the elongated handle of the malleus is partially resected, protectors are applied to protect the auditory ossicles, after which a burrow is formed over the projection of the bone tympanic ring, then the protectors are removed, and a fragment of the silastic is placed on the bone tympanic ring opposite the end of the hammer handle.

Removing the bone bridges that fix the bones to the atretic plate using a cold instrument (curette, hook), before using a bur, avoids the transmission of vibrations from the drill to the inner ear and helps prevent sensorineural hearing loss.

Careful separation of the fibrous layer from the inner surface of the partial atretic plate until it is completely removed allows preserving its blood supply as a feeding part for the autofascial flap, which has a positive effect on the survival of this flap.

Partial resection of the lengthened malleus handle with a nibbler allows to form a gap of at least 1.5 mm between the end of the malleus handle and the bone tympanic ring, preventing re-fixation of the malleus.

Protecting the ossicles with protectors, which are then removed, prevents accidental injury to the tympanic cavity and ossicles caused by bur.

Milling on the bone tympanic ring of the hollow, where the meato-tympanic and autofascial flaps will be placed, prevents their displacement (lateralization) in the postoperative period due to an increase in the contact area of the flaps with the bone and contributes to the formation of guides for their fixation during engraftment.

Laying on the bone tympanic ring of a fragment of medical silicone (silastic) opposite the end of the hammer handle additionally avoids unnecessary fixation of the hammer in a narrow place in the tympanic cavity.

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 tympanic cavity at the beginning of its revision after separation of the tympanic membrane;

- in Fig. 2 shows the tympanic cavity with the removed atretic plate and the lateral wall of the attic, the separated fibrous layer and the mucous membrane from under the atretic plate, partially resected by the handle of the hammer;

- in Fig. 3 shows the tympanic cavity with a removed atretic plate and a lateral wall of the attic, a protector installed to protect the auditory ossicles and a milled hollow in the area of the bony tympanic ring;

- in Fig. 4 shows the tympanic cavity in its final form before the placement of the meatotympanic and autofascial flaps with the removed atretic plate and the lateral wall of the attic, milled with a hollow in the area of the bony tympanic ring, and laid silastic material between the bony tympanic ring and the partially resected handle of the malleus.

In the drawing, the following positions are used: 1 - the back wall of the external auditory canal; 2 - bone tympanic ring; 3 - partial atretic plate; 4 - tympanic cavity; 5 - hammer; 6 - anvil; 7 - stirrup; 8 - bone bridges; 9 - fibrous layer and mucous membrane; 10 - lateral wall of the attic; 11 - protector; 12 - hollow above the projection of the bone tympanic ring; 13 - silastic.

The method is carried out as follows.

Surgical intervention takes place 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 computed tomography of the temporal bone.

A behind-the-ear incision is made with a transmeatal access. The skin of the posterior wall of the external auditory canal 1 is separated anteriorly to the bony tympanic ring 2. Then the tympanic membrane is separated to a partial atretic plate 3.

Spend tympanotomy, revision of the tympanic cavity 4. Assess the size of the partial atretic plate 3, its connection with the auditory ossicles: hammer 5, incus 6 and stirrup 7.

In the presence of bone bridges 8 connecting the auditory ossicles, namely: malleus 5, incus 6, stirrup 7, with a partial atretic plate 3, they are removed with a curette or crochet to avoid

transmission through them of vibrations of the drill from the atretic plate to the inner ear.

The fibrous layer and mucous membrane 9 are carefully separated from the inner surface of the partial atretic plate 3 to preserve the feeding layer of the tympanic cavity 4.

The atretic plate 3 is removed with a bur to the level of the bone tympanic ring 2.

The elongated hammer handle 5 is shortened with a bite, thereby forming a gap of at least 1.5 mm between the end of the hammer handle 5 and the bone tympanic ring 2. If the mobilization of the auditory ossicle chain is insufficient, then after removing the partial atretic plate 3, the lateral wall of the attic 10 is removed to release hammer 5 and incus 6.

Protect the auditory ossicles with a protector 11, after which a hollow 12 is formed over the projection of the bone tympanic ring 2 with a bur for more reliable fixation of the meato-tympanic and autofascial flaps in the future. After the end of the work with the boron, the protectors 11 are removed from the drum cavity 4.

On the bone tympanic ring 2, a fragment of silastic 13 (medical silicone) is placed opposite the end of the hammer handle 5. In the absence of an anvil 6 or superstructures of the stirrup 7, ossiculoplasty is performed.

Blood from the tympanic cavity 2 is aspirated in order to avoid the development of the adhesive process in the future.

At the end of the operation, the meato-tympanic flap is placed on the formed hollow 12 above the projection of the bone tympanic ring. The defect of the tympanic membrane, resulting from the removal of the partial atretic plate 3 and the lateral wall of the attic 10, is closed with an autofascial flap, which is also placed on the hollow 12 above the projection of the bony tympanic ring.

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., 47 years old, 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. Through the tympanic membrane, a partial atretic lamina is visualized, soldered to the elongated handle of the malleus. 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 test is positive. Jelly test is positive.

The results of tonal threshold audiometry: Left-sided conductive hearing loss of the III degree with sound conduction thresholds in the speech frequency zone of 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, partial atretic plastic is visualized, which merges with the elongated handle of the malleus.

The patient underwent reconstructive surgery on the left ear.

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

The soft tissues were separated anteriorly, the skin of the posterior and upper walls of the external auditory canal was separated.

An annulus fibrosus and a partial atretic plate were visualized. The skin and fibrous layer were separated from the atretic plate; the tympanic cavity and auditory ossicles were partially visualized, fixed to the atretic plate with thin bone cords and adhesions.

The curette removed the bony bridges and adhesions fixing the auditory ossicles to the atretic plate, the auditory ossicles were mobilized.

The fibrous-mucous layer was separated from the inner surface of the partial atretic plate, after which the plate itself was removed with a bur, the lateral wall of the attic was also partially removed to form a gap between the auditory ossicles and the bone tympanic ring of at least 1.5 mm.

On examination, it was revealed that the hammer handle is elongated and is in close proximity to the wall of the tympanic cavity.

The handle of the hammer was shortened with micro forceps to avoid refixation; for the same purpose, medical silicone (silastic) was placed on the bone drum ring opposite it.

A protector is laid on the auditory ossicles, after which a groove is formed along the perimeter of the bone tympanic ring with a bur.

The protectors are removed. The tympanic membrane and fibrous layer covering the atretic plate, as well as an autofascial flap covering the defects of the tympanic membrane, are placed on the formed hollow above the projection of the bony tympanic ring to prevent their displacement (lateralization).

Blood from the tympanic cavity is aspirated.

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.

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.

This indicates a good anatomical result of the operation and the absence of displacement of the meatotympanic flap and 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 an air-bone gap of about 15 dB.

Diagnosed with mixed hearing loss on the right of 1 degree. This indicates a satisfactory functional result, the absence of refixation of the auditory ossicles, the absence of significant vibration trauma at the time of the operation, which made it possible for the patient to receive socially adequate hearing as a result of treatment and preserve it.

The claimed method avoids:

- significant vibration trauma to the inner ear and injury to the auditory ossicles when working with a bur due to their separation from the partial atretic plate with an instrument (curette, hook);

- to prevent refixation of the auditory ossicles due to partial removal of the lateral wall of the attic, partial resection of the hammer handle and placing medical silicone (silastic) on the bone ring opposite the hammer handle,

- to prevent displacement (lateralization) of the tympanic membrane and autofascial flap, due to the formation of a hollow in the area of the bony ring and the laying of the tympanic membrane and autofascial flap in this hollow.

Claims (1)

A method of surgical treatment of an isolated developmental anomaly of the middle ear, including performing a behind-the-ear incision with transmeatal access, revision of the tympanic cavity and assessment of the condition of the auditory ossicles and partial atretic plate, then removal of the atretic plate and the lateral wall of the attic, mobilization of the ossicular chain, formation of a gap between the auditory ossicles and a bone tympanic ring of at least 1.5 mm, placing the meatotympanic flap in place with the closure of the tympanic membrane defect with an autofascial flap, tamponade of the external auditory canal and suturing of the ear wound, characterized in that after assessing the condition of the auditory ossicles and a partial atretic plate, remove the bony bridges fixing the bones to the atretic plate using a tool: a curette or a hook, after which the fibrous layer and mucous membrane are separated from the medial surface of the partial atretic plate until the p Later, and after removing the atretic plate, the elongated handle of the malleus is partially resected, protectors are used to protect the auditory ossicles, after which a hollow is formed with a bur over the projection of the bone tympanic ring, then the protectors are removed and the silastic fragment is placed on the bone tympanic ring opposite the end of the hammer handle.

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