RU2791511C1 - Method for operation for chronic tubotympanic purulent otitis media - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to otorhinolaryngology. Access to the middle ear is performed with mobilization of the external auditory canal. At the same time, a skin incision is made along the entire length of the behind-the-ear fold. The soft tissues of the behind-the-ear region are dissected in layers to the bone, exposing the site of the mastoid process. The skin of the posterior, upper and lower walls of the external auditory canal is separated anteriorly along the entire length until the tympanic ring is reached. Then, a vertical skin incision of the posterior wall of the external auditory canal is made in the middle of the bone section of the external auditory canal, 1.0 cm long. Traction of the auricle is performed together with the skin of the posterior wall of the external auditory canal anteriorly, fixing the free ends of the silicone strip with a clip on the surgical underwear used to drape the surgical wound. Using a power tool equipped with a diamond cutter, the cortical layer of the posterior bone wall of the external auditory canal is removed until the anterior meatotympanic angle is visualized, creating a remodeled plane of the posterior bone wall of the external auditory canal. Next, the meatotympanic flap is mobilized by dissecting the tympanic ring from 6 to 1 hour clockwise for the right ear, or from 6 to 11 hours counterclockwise for the left ear. Then, after performing tympanoplasty, the placement of the graft used for plastic replacement of the tympanic membrane defect is controlled. After that, the edges of the skin incision of the external auditory canal are compared. A silicone protector is placed over the incision area. Then the surgical access is closed.

EFFECT: method allows to improve visualization during revision of middle ear structures and control during tympanoplasty and placement of a plastic flap to close a tympanic membrane defect, increase the efficiency of treatment of patients with chronic otitis media.

5 cl, 4 dwg, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used when performing hearing-improving operations in patients suffering from chronic tubotympanal purulent otitis media.

The main place in middle ear surgery is given to the treatment of chronic tubotympanic otitis media, which leads to persistent hearing loss, periodic suppuration and creates a risk of developing purulent-septic, including intracranial complications.

Reconstruction of the anatomical structures of the middle ear, plastic of the tympanic membrane, prosthetics of the auditory ossicles are associated with a serious risk of developing both intraoperative complications - vestibulopathy, sensorineural hearing loss, peripheral paresis of the facial muscles, and postoperative complications - displacement of the prosthesis, reperforation of the tympanic membrane, blunting of the anterior meatotympanic angle, development tertiary cholesteatoma.

Surgical access to the middle ear, which makes it possible to improve visualization during revision of the middle ear structures, to exercise control during ossiculoplasty and the placement of a plastic flap to close the tympanic membrane defect, is an urgent task.

As a rule, behind-the-ear and transcanal approaches are chosen as surgical approaches. There are many variations of each of these two approaches, quite variable in terms of the speed of its execution, the degree of visualization of the structures of the middle ear, and the possibilities for performing the bone stage of the surgical intervention.

A known method for the treatment of chronic otitis media, including operative access to the middle ear with mobilization of the external auditory canal, while making an incision along the behind-the-ear fold, separation of soft tissues and skin of the posterior wall of the external auditory canal, a vertical incision of the skin of the external auditory canal, mobilization of the meatotympanic flap (see Brackmann D.E., Shelton C, Arriaga M.A. "Otologic Surgery", 3rd edition, 2010, pp. 21-28).

When implementing this method, an incision is made along the behind-the-ear fold, soft tissues and skin of the external auditory canal are separated.

A vertical incision is made in the external auditory canal at the border of the proximal third of the bone part of the external auditory canal, after which two additional incisions are made in the posterior wall from the already made vertical incision with the formation of a tongue-like flap, the base of which lies on the border with the membranous-cartilaginous region, after which the tongue-shaped flap wrapped inside the ear canal.

Next, the meatotympanic flap is mobilized and proceed to the main stages of tympanoplasty. The intervention is completed with tamponade of the external auditory canal and layer-by-layer suturing of the behind-the-ear wound.

The disadvantage of this method is additional trauma to the skin of the external auditory canal, which can lead to soft tissue atresia in the bone part of the external auditory canal.

There is also known a method for the treatment of chronic otitis media, including operative access to the middle ear with mobilization of the external auditory canal, while making an incision along the behind-the-ear fold, separation of the soft tissues and skin of the posterior wall of the external auditory canal, a vertical incision of the skin of the external auditory canal, mobilization of the meatotympanic flap ( see Pensak M.L., Choo D.I. "Clinical Otology" 4th Edition, 2015, pp. 215-230).

When implementing this method, an incision is made along the behind-the-ear fold, soft tissues and skin of the external auditory canal are separated.

A vertical incision is made in the external auditory canal at the border of the proximal third of the bone part of the external auditory canal, after which two additional incisions are made in the posterior wall from the already made vertical incision with the formation of a tongue-shaped flap, the base of which lies on the border with the membranous-cartilaginous region. After that, the tongue-shaped flap is turned outward, dislocating it from the ear canal.

Next, the meatotympanic flap is mobilized and proceed to the main stages of tympanoplasty. The intervention is completed with tamponade of the external auditory canal and layer-by-layer suturing of the behind-the-ear wound.

The disadvantages of this method are:

- additional trauma to the skin of the external auditory canal that can lead to soft tissue atresia of the external auditory canal in its bony part;

- trauma to the flap itself, malnutrition of which can lead to necrosis of the skin of the ear canal, diastasis between the distal and proximal parts of the skin of the external auditory canal, to the formation of cholesteatoma of the external auditory canal.

The closest in technical essence to the claimed solution is a method of surgery for chronic tubotympanic purulent otitis media, including prompt access to the middle ear with mobilization of the external auditory canal, while making a skin incision throughout the behind-the-ear fold, dissecting the soft tissues of the behind-the-ear region in layers to the bone, exposing the platform of the mastoid process, the skin of the posterior, upper and lower walls of the external auditory canal is separated anteriorly throughout until reaching the tympanic ring (see Sanna M., Sunose H., Mancini F., Russo A. “Middle Ear and Mastoid Microsurgery”, 2nd edition, 2012, pp. 70-73).

The disadvantages of this method are:

- there is a high risk of developing diastasis between the fibrocartilaginous ring (Gerlach's ligament) and the bone tympanic ring, especially in cases where the bone overhang was removed above the anvil-stapes joint;

- when laying the skin of the external auditory canal in place, it is impossible to achieve its full contact along the incision line due to the twisting of the free distal edge and the reduction of the proximal edge formed along the incision line;

- the skin of the posterior wall of the ear canal obstructs the view of the anterior meatotympanic angle.

The technical result of the proposed solution is to increase the effectiveness of the treatment of patients with chronic otitis media through surgical access, which improves visualization during revision of the structures of the middle ear and control during tympanoplasty and laying a plastic flap to close the defect of the eardrum.

To achieve the specified technical result in the operation method for chronic tubotympanal purulent otitis media, including prompt access to the middle ear with mobilization of the external auditory canal, while making a skin incision along the entire length of the behind-the-ear fold, dissecting the soft tissues of the behind-the-ear region in layers to the bone, exposing the area of the mastoid process, the skin of the posterior, upper and lower walls of the external auditory canal is separated anteriorly throughout until reaching the tympanic ring, according to the invention, then a vertical incision is made in the skin of the posterior wall of the external auditory canal in the middle of the bone section of the external auditory canal 1.0 cm long, a loop is passed through auditory meatus and the incision made in the silicone strip, traction of the auricle is performed along with the skin of the posterior wall of the external auditory canal anteriorly, fixing the free ends of the silicone strip with a clip on the surgical underwear used to drape the surgical wound, with using a power tool equipped with a diamond cutter, the cortical layer of the posterior bone wall of the external auditory canal is removed until the anterior meatotympanic angle is visualized, creating a remodeled plane of the posterior bone wall of the external auditory canal, then the meatotympanic flap is mobilized, dissecting the tympanic ring from 6 to 1 hour clockwise for right ear, or from 6 to 11 hours counterclockwise for the left ear, then after tympanoplasty, the placement of the graft used for plastic replacement of the tympanic membrane defect is controlled, after which the edges of the skin incision of the external auditory canal are compared, a silicone protector is placed on the incision area, then the surgical access is closed.

Also according to the invention, the skin incision along the entire length of the behind-the-ear fold is made from top to bottom, 5.0-6.0 cm long, the silicone strip is made 30.0 cm long, 0.5 cm wide, the diameter of the diamond cutter head is 4.0 mm , and the silicone protector uses a round shape 1.0 cm in diameter.

A skin incision along the behind the ear fold allows you to get the maximum level of visualization in the area of the external auditory canal and mastoid process.

Removal of the cortical layer of the posterior bone wall of the external auditory canal makes it possible to increase the viewing angle in the coronal plane, in particular, to provide visualization of the anterior meatotympanic angle.

A vertical skin incision of the external auditory canal in the middle of the bony part of the external auditory canal allows mobilization and traction of the distal external auditory canal and auricle anteriorly, separately from the meatothymanal flap.

The use of a silicone strip passed through a vertical incision makes it possible to minimize trauma to the skin of the external auditory canal without making additional incisions in the external auditory canal.

The achieved mobility of the meatotympanic flap, separated from the distal part of the skin of the external auditory canal, allows you to effectively control the process of ossiculoplasty, placement of a graft for tympanic membrane defect plasty, and tamponade of the proximal external auditory canal.

Sufficient width of the meatotympanic flap due to its part, which is the proximal skin of the external auditory canal, avoids diastasis between the meatotympanic flap and the bone tympanic ring.

Thus, the claimed method provides quick access to the middle ear, improves the quality of visualization during the main stages of reconstructive intervention on the ear - tympanoplasty.

From the foregoing, 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 middle ear, external auditory canal and auricle in a horizontal plane;

- in Fig. 2 shows the formed skin incision along the behind-the-ear fold with sequentially dissected soft tissues of the behind-the-ear region up to the mastoid platform and the formed vertical skin incision of the posterior wall of the auditory canal, made in the center of the bone section of the external auditory canal;

- in Fig. 3 shows the volume of visualization of the tympanic membrane and structures of the middle ear, achieved as a result of traction of the auricle together with the auditory canal anteriorly, removal of the cortical bone of the posterior wall of the external auditory canal, and mobilization of the meatothymapal flap;

- in Fig. 4 shows the final stage of surgical access - matching the edges of the incision of the external auditory canal and suturing the behind the ear incision.

The following positions are used in the drawings: 1 - auricle; 2 - behind the ear fold; 3 - skin of the posterior wall of the external auditory canal; 4 - incision along the behind-the-ear fold; 5 - drum ring; 6 - the middle of the bone section of the external auditory canal; 7 - silicone strip; 8 - cortical layer of the bone posterior wall of the external auditory canal; 9 - anterior meatotympanic angle; 10 - remodeled plane of the posterior bone wall of the external auditory canal; 11 - meatotympanic flap; 12 - achieved visualization volume; 13 - auditory ossicles; 14 - tympanic mouth of the auditory tube; 15 - transplant; 16 - silicone protector; 17 - p-shaped seam.

The method is carried out as follows.

Surgical access is carried out under conditions of combined endotracheal anesthesia. The position of the patient on the table is typical - lying on his back with his head turned towards the opposite ear.

The soft tissues of the behind-the-ear region and the posterior surface of the auricle 1 are infiltrated with saline in a volume of 20.0 ml, sticking the needle into the behind-the-ear fold 2.

Next, the skin of the posterior wall of the external auditory canal 3 is infiltrated with saline in a volume of 5.0 ml. Next, with a belly scalpel, an incision 4 of the skin is made along the entire length of the behind-the-ear fold 2 in the direction from top to bottom, 5.0-6.0 cm long.

Using a monopolar electrosurgical instrument with a needle-type electrode, the soft tissues of the behind-the-ear region are dissected in layers to the bone, exposing the site of the mastoid process.

The bone raspator produces traction of the soft tissue array of the posterior edge of the incision 4, including the skin, subcutaneous tissues and periosteum posteriorly. The bone raspator produces traction of the skin, soft tissues and periosteum of the anterior edge of the incision anteriorly.

The skin of the posterior, upper and lower walls of the external auditory canal is separated with a microraspator anteriorly along the entire length until reaching the tympanic ring 5.

With a pointed scalpel, a vertical incision is made in the skin of the posterior wall of the external auditory canal in the middle of the bone section 6 of the external auditory canal, 1.0 cm long. A silicone strip 7, 30.0 cm long and 0.5 cm wide, is passed through the auditory canal and the incision.

Traction of the auricle is performed together with the skin of the posterior wall of the external auditory canal anteriorly, fixing the free ends of the silicone strip 7 with a clip on the surgical underwear used to drape the surgical wound.

Using a power tool equipped with a diamond cutter 4.0 mm in head diameter, the cortical layer of the posterior bone wall of the external auditory canal 8 is removed until the anterior meatotympanic angle 9 is visualized, creating a remodeled plane of the posterior bone wall of the external auditory canal 10.

Next, the meatotympanic flap 11 is mobilized by dissecting the tympanic ring from 6 to 1 hour clockwise for the right ear, or from 6 to 11 hours counterclockwise for the left ear.

At this stage, the implementation of surgical access is fixed - a full-fledged visualization volume 12 of the entire plane of the tympanic membrane, auditory ossicles 13, tympanic mouth of the auditory tube 14.

Then tympanoplasty is performed.

After completing the necessary steps of tympanoplasty, the placement of the graft 15 used for plastic replacement of the tympanic membrane defect is controlled.

Next, the edges of the incision 4 of the skin of the external auditory canal are compared. A silicone protector 16 of a round shape 1.0 cm in diameter is placed on the incision zone. The surgical access is closed by applying 4 p-shaped sutures 17 to the incision 4 along the behind-the-ear crease.

The method is illustrated by the following example.

Patient A., born in 1985 was admitted to the otorhinolaryngological department of the St. Petersburg Research Institute of ENT, Ministry of Health of the Russian Federation with a diagnosis of right-sided chronic tubotympanal purulent otitis media, conductive hearing loss of the 2nd degree on the right.

Upon admission, the patient noted hearing loss in the right ear, periodic suppuration from the right ear, not more than one episode within six months. These complaints disturb the patient from childhood.

On examination: the nasal mucosa is pink, moist. 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 lacunae are clear. The mucous membrane of the larynx is pink, moist. The vocal folds are white, their movement is in full. The glottis is wide and symmetrical.

AD - external auditory canal is wide, free. A tympanic membrane with a subtotal defect that has a callused edge throughout. Whispered speech 1.0 m, colloquial speech - 4.0 m. Weber's test - lateralization to the right. Rinne's test is negative. Jelly test is negative.

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

The results of tone threshold audiometry: Right-sided conductive hearing loss 2 with sound conduction thresholds in the speech frequency zone of 45 - 50 dB in the presence of an air-bone interval of 30 dB.

On a CT scan of the temporal bones: on the right, the external auditory meatus is free, the cells of the mastoid process are sclerotic, the mastoid cavern is pneumatized, the tympanic cavity is free, a defect in the long process of the incus is determined.

Surgery was performed under conditions of combined endotracheal anesthesia.

The soft tissues of the behind-the-ear region and the posterior surface of the auricle were infiltrated with saline in a volume of 20.0 ml.

Then, the skin of the posterior wall of the external auditory canal was infiltrated with saline in a volume of 5.0 ml.

Then, with a belly scalpel, a skin incision was made along the entire length of the behind-the-ear fold in the direction from top to bottom, 5.0 cm long.

Using a monopolar electrosurgical instrument with a “needle” electrode, the soft tissues of the behind-the-ear region were dissected in layers to the bone, exposing the area of the mastoid process.

The bone raspator produced traction of the soft tissue array of the posterior edge of the incision, which included the skin, subcutaneous tissues and periosteum posteriorly. The bone raspator performed traction of the skin, soft tissues and periosteum of the anterior edge of the incision anteriorly.

The skin of the posterior, upper and lower walls of the external auditory canal was separated with a microraspator anteriorly throughout the entire length until reaching the tympanic ring.

With a pointed scalpel, a vertical incision was made in the skin of the posterior wall of the external auditory canal in the middle of the bone section of the external auditory canal, 1.0 cm long. A silicone strip 30.0 cm long and 0.5 cm wide was passed through the ear canal and the incision with a loop.

The traction of the auricle together with the skin of the posterior wall of the external auditory canal was performed anteriorly, fixing the free ends of the silicone strip with a clip on the surgical underwear used to drape the surgical wound.

Using a power tool equipped with a diamond cutter 4.0 mm in diameter of the head, the cortical layer of the posterior bone wall of the external auditory canal was removed until the anterior meatotympanic angle was visualized, creating a remodeled plane of the posterior bone wall of the external auditory canal.

Next, the meatotympanic flap was mobilized by dissecting the tympanic ring from 6 to 1 hour clockwise.

At this stage, the implementation of surgical access was recorded - a full-fledged visualization of the entire plane of the tympanic membrane, auditory ossicles, and the tympanic mouth of the auditory tube.

The callused edges of the perforation, a cariously altered anvil, and a polyp that blocked the tympanic mouth of the auditory tube were removed.

Next, the patient was fitted with a partial ossicular prosthesis on the head of the preserved stapes, and myringoplasty was performed using the medial placement method using a combined chondrofascial flap.

Under direct visualization through the performed surgical approach, the following were performed: control of the comparison of the prosthesis and the stirrup head, plastic flap and refreshed edges of the tympanic membrane defect, placement of the meatotympanic flap, tamponade of the bone section of the external auditory canal.

A round silicone protector 1.0 cm in diameter was placed on the incision zone.

The access was completed by applying four p-shaped sutures. To prevent bacterial infections, antibiotic prophylaxis was carried out for 7 days. The postoperative period proceeded without complications. The sutures were removed on the 7th day. Tampons from the external auditory canal are removed on the 21st day.

At the control examination on the 21st day after the operation: AD - the external auditory canal is wide free, neotympanic membrane is consistent, well vascularized, whisper speech is 6 meters.

At the control examination 12 months after the operation: AD - the external auditory meatus is wide free, the tympanic membrane is without defects, gray, the contours are preserved, the anterior meatotympanic angle is without blunting.

According to the results of the control tone threshold audiometry: AD - sound conduction thresholds in the speech frequency zone of 25-30 dB in the presence of a bone-air interval of up to 5 dB.

The proposed method has the following advantages:

- allows to achieve excellent anatomical and functional results in the surgical treatment of patients with chronic tubotympanal purulent otitis media;

- eliminates the displacement of the prosthesis used for ossiculoplasty and autograft, designed to close the defect of the eardrum;

- prevents the development of dystrophic and cicatricial deformities of the skin of the external auditory canal.

Claims (5)

1. A method of surgery for chronic tubotympanic purulent otitis media, including surgical access to the middle ear with mobilization of the external auditory canal, while making a skin incision along the entire length of the behind-the-ear fold, dissecting the soft tissues of the behind-the-ear region in layers to the bone, exposing the site of the mastoid process, separating the skin posterior, upper and lower walls of the external auditory canal anteriorly throughout until reaching the tympanic ring, characterized in that then a vertical incision is made in the skin of the posterior wall of the external auditory canal in the middle of the bone section of the external auditory canal 1.0 cm long, a loop is passed through the auditory canal and made an incision in the silicone strip, the auricle is pulled together with the skin of the posterior wall of the external auditory canal anteriorly, fixing the free ends of the silicone strip with a clip on the surgical underwear used to drape the surgical wound, using a power tool equipped with a diamond with a cutter, the cortical layer of the posterior bone wall of the external auditory canal is removed until the anterior meatotympanic angle is visualized, creating a remodeled plane of the posterior bone wall of the external auditory canal, then the meatotympanic flap is mobilized by dissecting the tympanic ring from 6 to 1 hour clockwise for the right ear, or from 6 to 11 hours counterclockwise for the left ear, then after tympanoplasty, the placement of the graft used for plastic replacement of the tympanic membrane defect is controlled, after which the edges of the skin incision of the external auditory canal are compared, a silicone protector is placed on the incision area, then the surgical access is closed . 2. The method according to p. 1, characterized in that the skin incision throughout the behind-the-ear fold is made from top to bottom, 5.0-6.0 cm long. 3. The method according to claim 1, characterized in that the silicone strip is made 30.0 cm long and 0.5 cm wide. 4. The method according to claim 1, characterized in that the diameter of the head of the diamond cutter is 4.0 mm. 5. The method according to claim 1, characterized in that a round silicone protector 1.0 cm in diameter is used.

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