RU2808546C1 - Myringoplasty method of closed tympanoplasty - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: postauricular approach is performed and the transmeatal route is used: the soft tissues of the postauricular region are dissected layer by layer to the bone, exposing the mastoid area. The skin of the posterior, upper and lower walls of the external auditory canal is cut off anteriorly along the entire length until the tympanic ring is reached. Then, a square-shaped autocartilage flap with side dimensions of 1.0 cm is taken from the medial surface of the auricle in the surgical wound. Next, four square-shaped autocartilage plates 0.1 mm thick are made, then round plates with a diameter of 5.0 mm are cut out from them, after then place them in saline solution. Next, from the completed postauricular access, a round autofascial flap with a diameter of 10.0 mm is harvested from the temporal muscle. Then the fibrocartilaginous ligament of Gerlach is separated from the bone tympanic ring along the entire length corresponding to the posterior quadrants of the eardrum. After de-epithelialization of the calloused edge of the perforation of the tympanic membrane, the tympanic cavity is inspected, the stratified squamous keratinizing epithelium grown into the tympanic cavity is removed, cicatricial adhesions and adhesions are dissected, and irrigated with saline. Then five cubic fragments of a highly purified gelatin sponge with a side size of 3.0 mm are placed into the tympanic cavity, with three fragments placed in the sections of the tympanic cavity corresponding to the anterior quadrants of the eardrum, and two fragments in the sections of the tympanic cavity corresponding to the posterior quadrants of the eardrum. Next, the previously prepared four round plates of autocartilage with a diameter of 5.0 and a thickness of 0.1 mm are laid, creating a three-dimensional plane of the neotympanic membrane due to the formation of a hemispherical shape of the native tympanic membrane with the base at the bone tympanic ring with the apex in the handle of the malleus. The first plate of autocartilage is placed in the projection of the anterior-superior quadrant of the eardrum, the second plate is placed in the projection of the anterior-inferior quadrant, the third plate is placed in the projection of the posterior-inferior quadrant, and the fourth plate is placed in the projection of the posterior-superior quadrant of the eardrum. One edge of the first plate rests on the handle of the malleus, and its other edge is inserted under the bone tympanic ring by 0.5 mm. Next, each subsequent plate, namely the second and third, is placed so that one of its edges is placed on top of the previous plate, overlapping it by 0.5 mm, and its other edge is placed under the bone tympanic ring by 0.5 mm. The fourth plate is placed on top of the first and third plates and on top of the bone tympanic ring, overlapping them by 0.5 mm. Then, a previously prepared autofascial flap is placed on top of the formed autocartilaginous frame, on top of which the remains of the tympanic membrane are placed.

EFFECT: method makes it possible to increase the effectiveness of myringoplasty by ensuring the tightness of the neotympanic membrane, to restore the patient's tonal hearing and the perception of high frequencies responsible for speech intelligibility.

4 cl, 7 dwg, 1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology and can be used when performing sanitizing and hearing-improving operations in patients suffering from chronic purulent tubotympanic or epitympanoantral otitis media, with subtotal or total perforation of the tympanic membrane, in which ossiculoplasty is not required.

Myringoplasty belongs to the general group of surgical hearing-improving interventions - tympanoplasty and is the plastic closure of a defect in the eardrum.

Material that is used as a free flap for plastic surgery of the tympanic membrane: autofat, thinned skin, autocartilage, allochondrium, autofascia, autoperichondrium, and in addition to free flaps, synthetic materials can be used.

In clinical practice on the territory of the Russian Federation, with the exception of clinical studies and testing, the use of plastic materials is regulated by Order of the Ministry of Health and Social Development of the Russian Federation of April 24, 2006 N 314 “On approval of the standard of medical care for patients with purulent and unspecified otitis media.”

In accordance with this standard, an otosurgeon has the right to perform tympanoplasty using autocartilage, as a monoflap, or in combination with other materials.

As a rule, an autocartilaginous flap is formed from quadrangular cartilage, the auricle, and less often a rib.

When performing myringoplasty, it is important to create conditions for the formation of a neotympanic membrane, which has the same three-dimensional spatial configuration as the native tympanic membrane with full contact of the membrane with the bone tympanic ring and the handle of the malleus. This is especially true for total and subtotal perforations of the eardrum, since it is this factor that allows the bone-air interval to be reduced to zero.

When using a graft of a single rigid structure, such as solid cartilage, it is impossible to form a dome-shaped neotympanic membrane intimately connected to the entire surface of the malleus handle.

The use of only a soft graft, such as fascia or perichondrium, does not ensure complete contact of the neotympanic membrane and the handle of the malleus in the early postoperative period due to fluctuations in intratympanic pressure, which leads to partial or complete lateralization of the neotympanic membrane.

There is a known method of treating patients with perforated otitis media, which includes separating the epidermal layer of the eardrum, closing the perforation with a graft placed externally on the previously exposed fibrous layer (see patent RU No. 2330638, IPC A61F 11/00, 2008).

When carrying out this method, under local anesthesia, the skin of the external auditory canal is separated through the transmeatal route according to Rosen to the fibrous ring of the tympanic membrane, then the entire outer epidermal layer of the tympanic membrane.

Using a pre-dried graft cut from the autofascia of the temporalis muscle, the perforation of the tympanic membrane is closed, placing the graft on its exposed fibrous layer.

The previously separated epidermal layer of the eardrum is returned to its place. The operation is completed by placing rubber strips on the eardrum and tamponade of the ear canal with gelatin sponge balls containing an antibiotic.

The disadvantages of this method are:

- high probability of retraction of the autofascial flap into the tympanic cavity with total and subtotal perforations of the tympanic membrane;

- legal restrictions on the use of this method - the use of autofascia as a monoflap is possible only within the framework of a clinical trial;

- a high risk of developing tertiary cholesteatoma and unsatisfactory audiological results due to the lack of a revision stage of the tympanic cavity in order to assess the condition of the mucous membrane of the tympanic cavity and the chain of auditory ossicles.

There is also a known method for closing a perforation of the eardrum, which includes surgery under local or general anesthesia, placement of a graft followed by tamponade of the ear canal (see patent RU No. 2556620, IPC A61F 11/00, A61B 17/00, A61L 27/00, 2015).

When implementing this method, plates from Alloplant “allogeneic cartilage” are prepared in advance. For convenience, an operating microscope and a razor blade are used, under sterile operating room conditions, cutting the cartilage into fragments up to 0.2-0.3 mm thick with a diameter of 0.8-0.9 cm, after which they are placed in a bottle with a fixing liquid.

The operation is performed under local or general anesthesia, the incision is made endourally according to Heerman, and a meatotympanic flap with deepithelialized edges of the tympanic membrane is separated. Use the standard “onlay” technique.

At the final stage of the operation, a single allocartilage graft plate is placed on the edges of the defect of the eardrum, and the allocartilage plate should be 1.0-1.5 mm larger than the size of the perforation, with the obligatory covering of its edges with the skin of the ear canal.

The skin is smoothed over the graft using instruments. In this case, a small section of the bone of the auditory canal is left open, which subsequently epithelializes on its own.

Next, tamponade of the ear canal is carried out with gauze turundas for 7-10 days.

The disadvantages of this method are:

- high probability of diastasis between the allochondral graft and the handle of the malleus, which has a detrimental effect on the functional result;

- the neotympanic membrane loses the three-dimensional plane of the native tympanic membrane due to the use of a single graft, which increases the air-bone interval, leading to worse audiological results;

- the absence of a revision stage of the tympanic cavity creates a high risk of unsatisfactory anatomical and functional results of the operation.

The closest in technical essence to the claimed solution is the method of myringoplasty, including separation of the remnants of the tympanic membrane from the lateral process and the handle of the malleus, de-epithelialization of the calloused edge of the perforation of the tympanic membrane, closure of the defect, tamponade of the external auditory canal, application of a bandage (see patent RU No. 2485917, IPC A61F 2/18, A61F 11/00, 2013).

When implementing this method, the ear canal and eardrum are cleaned, de-epithelialized, the perforation area is measured, a perichondrial-cartilaginous autograft is formed, and the defect is subsequently closed.

In this case, an autograft is formed in the shape of a truncated cone with an angle at the wide base of 40-50 degrees and with a base size exceeding by 1.0 mm the size of the perforation of the tympanic membrane, and the graft is installed in the perforation with a wide base in the direction of the tympanic cavity, and the perichondrium is placed on the deepithelialized surfaces.

The disadvantages of this method are:

- the use of solid cartilage leads to the formation of an opaque neotympanic membrane, which makes it difficult to visualize and assess the objective status in the postoperative period, preventing timely suspicion and detection of the development of tertiary and residual cholesteatoma in the postoperative period;

- the use of cartilage as a single block does not ensure contact between the neotympanic membrane and the handle of the malleus, which is associated with a high risk of developing lateralization of the neotympanic membrane, which leads to an increase in the air-bone interval;

- there is no revision of the tympanic cavity, which does not provide sanitation of chronic purulent otitis media as a source of chronic infection.

The technical result of the proposed solution is to increase the effectiveness of myringoplasty by ensuring the tightness of the neotympanic membrane while simultaneously restoring in the patient both tonal hearing and the perception of high frequencies responsible for speech intelligibility.

To achieve the specified technical result in the method of myringoplasty with closed-type tympanoplasty, including separation of the remnants of the tympanic membrane from the lateral process and the handle of the malleus, de-epithelialization of the calloused edge of the perforation of the tympanic membrane, closure of the defect, tamponade of the external auditory canal, application of a bandage, according to the invention, before separating the remnants of the tympanic membrane membranes perform postauricular access and use the transmeatal route: cut the soft tissues of the postauricular region layer by layer to the bone, exposing the mastoid area, separate the skin of the posterior, upper and lower walls of the external auditory canal anteriorly along the entire length until reaching the bone tympanic ring, then from the medial surface of the auricle in the surgical wound, a square-shaped autocartilage flap with side dimensions of 1.0 cm is taken, then four square-shaped autocartilage plates 0.1 mm thick are made, then round plates with a diameter of 5.0 mm are cut out of them, after which they are placed in a physiological solution , then from the completed postauricular access from the temporal muscle, a round-shaped autofascial flap with a diameter of 10.0 mm is taken, after which the fibrocartilaginous ligament of Gerlach is separated from the bone tympanic ring along the entire length corresponding to the posterior quadrants of the tympanic membrane, and after de-epithelialization of the calloused edge of the perforation of the tympanic membrane membranes, inspect the tympanic cavity, remove the stratified squamous keratinizing epithelium that has grown into the tympanic cavity, dissect cicatricial adhesions and adhesions, irrigate with saline solution, after which five cubic fragments of a highly purified gelatin sponge with a side size of 3.0 mm are placed into the tympanic cavity, three fragment is placed in the sections of the tympanic cavity corresponding to the anterior quadrants of the eardrum, and two fragments are placed in the sections of the tympanic cavity corresponding to the posterior quadrants of the eardrum, then the previously prepared four round plates of autocartilage with a diameter of 5.0 and a thickness of 0.1 mm are placed, creating this is a three-dimensional plane of the neotympanic membrane due to the formation of a hemispherical shape of the native tympanic membrane with the base at the bone tympanic ring with the apex in the handle of the malleus, for this the first plate of autocartilage is placed in the projection of the anterior-superior quadrant of the tympanic membrane, the second plate - in the projection of the anterior-inferior quadrant, the third plate - in the projection of the postero-inferior quadrant, and the fourth plate - in the projection of the postero-superior quadrant of the tympanic membrane, while one edge of the first plate rests on the handle of the malleus, and its other edge is inserted under the bone tympanic ring by 0.5 mm, then each subsequent plate, namely the second and third, is placed so that one of its edges is placed on top of the previous plate, overlapping it by 0.5 mm, and its other edge is inserted under the bone tympanic ring by 0.5 mm, and the fourth plate placed on top of the first and third plates and on top of the bone tympanic ring, overlapping them by 0.5 mm, then a previously prepared autofascial flap is placed on top of the formed autocartilaginous frame, on top of which the remains of the tympanic membrane are placed.

The inventive technical solution allows for the treatment of patients with chronic otitis media by reliable fixation of a combined autocartilaginous-autofascial flap corresponding to the three-dimensional plane of the native eardrum.

The dome (or hemispherical) shape of the native eardrum with its base at the bone tympanic ring and its apex in the handle of the malleus provides amplification, according to the physical properties of acoustics, of high-frequency sound waves that have a sharp directionality. The perception of sound at high frequencies ensures speech intelligibility.

With the loss of the native configuration of the neotympanic membrane, the perception of high frequencies is reduced, which worsens the audiological result and the subjective sensation of speech perception.

Also, the dome shape of the eardrum, attached to the hammer, provides the principle of a chain lever, increasing, at least twice, the sound pressure on the hammer.

The tiled principle of laying ultrathin autocartilaginous plates makes it possible to form a three-dimensional plane of the neotympanic membrane corresponding to the native configuration of the tympanic membrane.

The tiled principle of laying ultrathin autocartilaginous plates eliminates the formation of diastasis between the graft and the bone tympanic ring.

The use of ultrathin autocartilaginous plates makes it possible to achieve transparency of the neotympanic membrane in the long-term postoperative period, which ensures timely detection of residual or tertiary cholesteatoma.

The autocartilaginous frame prevents the retraction of the autofascial flap into the tympanic cavity, including with total perforations in the early postoperative period.

The autocartilaginous frame prevents the formation of retraction pockets in the long-term postoperative period.

The combination of autocartilage with autofascia ensures rapid epithelization of the neotympanic membrane.

The use of a limited amount of gelatin sponge prevents the formation of scars in the tympanic cavity, prevents the flap from retracting into the tympanic cavity, and ensures rapid cleansing of the tympanic cavity from hemorrhagic clots.

From the above it follows that the introduced distinctive features influence the specified technical result and are in a cause-and-effect relationship with it.

The method is illustrated in the drawings, where:

- in fig. Figure 1 shows the stage of making a transmeatal path to the tympanic cavity and forming a meatotympanic flap;

- in fig. Figure 2 shows the stage of laying the first autocartilaginous plate;

- in fig. Figure 3 shows the stage of laying the second autocartilaginous plate;

- in fig. Figure 4 shows the stage of laying the third autocartilaginous plate;

- in fig. Figure 5 shows the stage of laying the fourth autocartilaginous plate;

- in fig. Figure 6 shows the stage of laying the autofascial flap;

- in fig. Figure 7 shows the stage of laying the remains of the eardrum.

The following positions are used in the drawings: 1 - bone tympanic ring; 2 - autofascial flap; 3 - remnants of the eardrum; 4 - hammer handle; 5 - calloused edge of the perforation of the eardrum; 6 - first autocartilaginous plate; 7 - second autocartilaginous plate; 8 - third autocartilaginous plate; 9 - fourth autocartilaginous plate.

The method is carried out as follows.

Stage 1

Surgery is performed under combined endotracheal anesthesia. The patient's position on the table is typical - lying on his back with his head turned towards the opposite ear. A facial nerve monitoring system is installed on the facial muscles.

A postauricular approach is performed and the transmeatal route is used: the soft tissues of the postauricular region are dissected layer by layer to the bone, exposing the mastoid area. Using a microraspator, the skin of the posterior, upper and lower walls of the external auditory canal is separated anteriorly along its entire length until reaching the bone tympanic ring 1.

Stage 2

From the medial surface of the auricle, in the surgical wound, an autocartilaginous flap of a flat plane, square in shape, with side dimensions of 1.0 cm is taken.

Next, use the Kurz Precise cartilage cutter (8000 155, registration number of the medical device, FS No. 2006/1297).

In this case, four plates of autocartilage with a thickness of 0.1 mm and a square shape are made. Then, using an ear funnel with an internal diameter of 5.0 mm, fragments are cut out from square-shaped autocartilage plates with the following characteristics: four round autocartilage plates with a diameter of 5.0 mm and a thickness of 0.1 mm.

These ultrathin plates are placed in a Petri dish filled with saline solution.

Next, from the completed postauricular access from the temporal muscle, an autofascial flap 2 of a round shape, with a diameter of 10.0 mm, is harvested.

Stage 3

Using a round Plester knife, the fibrocartilaginous ligament of Gerlach is separated from the bone tympanic ring 1 along the entire length corresponding to the posterior quadrants of the eardrum.

Then, using a microneedle and microscissors, the remains of the tympanic membrane 3 are separated from the lateral process and the handle of the malleus 4.

After that, the calloused edge 5 of the eardrum perforation is de-epithelialized with a microneedle and cup-shaped forceps. The tympanic cavity is inspected, the stratified squamous keratinizing epithelium grown into the tympanic cavity is removed, and cicatricial adhesions and adhesions are dissected. Next, the tympanic cavity is irrigated with saline solution.

Stage 4

Five cube-shaped fragments of highly purified gelatin sponge with a side size of 3.0 mm are placed into the tympanic cavity.

Three fragments of gelatin sponge are placed in sections of the tympanic cavity corresponding to the anterior quadrants of the eardrum, two fragments are placed in sections of the tympanic cavity corresponding to the posterior quadrants of the eardrum.

Next, the previously prepared four ultrathin plates of autocartilage are sequentially laid, creating a three-dimensional plane of the neotympanic membrane due to the formation of a hemispherical shape of the native tympanic membrane with the base at the bone tympanic ring with the apex in the handle of the malleus.

The first plate 6 of autocartilage is placed in the projection of the anterior superior quadrant of the tympanic membrane so that one edge of the first plate 6 rests on the handle of the hammer 4, and the other edge of the first plate 6 is inserted under the bone tympanic ring 1 by 0.5 mm.

The second plate 7 of autocartilage is placed in the projection of the anterior-inferior quadrant of the tympanic membrane so that one edge of the second plate 7 is on top of the first plate 6, overlapping it by 0.5 mm, and the other edge of the second plate 7 is placed under the bone tympanic ring 1 on 0.5 mm.

The third plate 8 of autocartilage is placed in the projection of the posteroinferior quadrant of the tympanic membrane so that one edge of the third plate 8 is on top of the second plate 7, overlapping it by 0.5 mm, and the other edge of the third plate 8 is placed under the bone tympanic ring 1 on 0.5 mm.

The fourth plate 9 of autocartilage is placed in the projection of the postero-superior quadrant of the tympanic membrane so that one edge of the fourth plate 9 is on top of the first plate 6, overlapping it by 0.5 mm, the other edge of the fourth plate 9 is on top of the third plate 8, overlapping it by 0.5 mm. In this case, the edge of the fourth plate 9 is located on top of the bone tympanic ring 1, overlapping it by 0.5 mm, that is, the fourth plate 9 is located on top of the plates 6 and 8, as well as on top of the bone tympanic ring 1.

The tiled principle of laying ultra-thin autocartilaginous plates makes it possible to form an autocartilaginous frame of a hemispherical shape with the base at the bone tympanic ring and the apex in the handle of the malleus.

Next, a pre-prepared autofascial flap 2 is placed on top of the formed autocartilaginous frame.

Thus, a combined autocartilaginous-autofascial flap is obtained that corresponds to the three-dimensional plane of the native tympanic membrane.

After that, the remains of the tympanic membrane 3 are placed on top of the autofascial flap 2, while the combined autocartilaginous-autofascial flap is securely fixed.

Stage 5

The external auditory canal is loosely packed using 30 cubic pieces of highly purified gelatin sponge with a side size of 3.0 mm. The access is closed by placing four U-shaped sutures on the postauricular incision. Apply a bandage.

The method is illustrated by the following example.

Patient E., born in 1995 was admitted to the clinic for surgical treatment for adults of the Federal State Budgetary Institution "St. Petersburg Research Institute of ENT" of the Ministry of Health of the Russian Federation with a diagnosis of right-sided chronic tubotympanic purulent otitis media, conductive hearing loss of 1 degree on the right.

Upon admission, the patient noted decreased hearing in the right ear, periodic suppuration from the right ear, no more than one episode within six months. These complaints have bothered the patient since childhood.

On examination: the nasal mucosa is pink and moist. Nasal septum in the midline. The nasal passages are free. The nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink and moist. The palatine tonsils are pink, behind the arches, there are no plaques, the lacunae are clean. The mucous membrane of the larynx is pink and moist. The vocal folds are white and their movement is full. The glottis is wide and symmetrical.

AD - the external auditory canal is wide and free. Eardrum with a total defect. Whispered speech 2.0 m, spoken speech -6.0 m. Weber test - lateralization to the right. Rinne's test is negative. The Jelly test is negative.

AS - the external auditory canal is wide and free. The eardrum is gray, the contours are clear. Whispered speech is 6 m, spoken speech is more than 6 m. The Rinne test is positive. The Jelly test is positive.

Results of tonal threshold audiometry: Right-sided conductive hearing loss 1 with sound conduction thresholds in the speech frequency zone of 35-40 dB in the presence of a bone-air interval of 20 dB.

On a computed tomogram of the temporal bones: on the right, the external auditory canal is free, the mastoid cave is airy, the cellular system of the mastoid process is sclerotic, the tympanic cavity is airy, the chain of auditory ossicles is well visualized and intact.

Stage 1

The surgery was performed under combined endotracheal anesthesia.

The patient's position on the table is typical - lying on her back with her head turned to the left. A facial nerve monitoring system was installed on the facial muscles.

The soft tissues of the postauricular area and the posterior surface of the auricle were infiltrated with physiological solution in a volume of 20.0 ml.

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

A postauricular approach was performed and the transmeatal route was used.

Using an abdominal scalpel, a skin incision was made along the entire length of the postauricular fold from top to bottom, 5.0 cm long.

Using a monopolar electrosurgical instrument with a needle-type electrode, the soft tissues of the postauricular region were cut layer by layer down to the bone, exposing the mastoid area.

A bone rasp was used to traction the soft tissue mass of the posterior edge of the incision, which included the skin, subcutaneous tissue and periosteum posteriorly. Anterior traction of the skin, soft tissues and periosteum of the anterior edge of the incision was performed using a bone rasp.

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

Stage 2

From the medial surface of the auricle, in the surgical wound, an autocartilaginous flap of a flat plane, square shape, with side dimensions of 1.0 cm was taken.

Next, four plates of autocartilage with a thickness of 0.1 mm were prepared using a cartilage cutter.

Then, using an ear funnel with an internal diameter of 5.0 mm, round fragments were cut out from square-shaped autocartilage plates with the following characteristics: four autocartilage plates with a diameter of 5.0 mm and a thickness of 0.1 mm.

These plates were placed in a Petri dish filled with saline solution.

Next, from the postauricular approach, a round autofascial flap with a diameter of 10.0 mm was harvested from the temporal muscle.

Stage 3

Using a round Plester knife, the fibrocartilaginous ligament of Gerlach was separated from the bone tympanic ring along the entire length corresponding to the posterior quadrants of the eardrum.

Then, using a microneedle and microscissors, the remains of the tympanic membrane were separated from the lateral process and the handle of the malleus.

After that, the calloused edges of the perforation of the eardrum were de-epithelialized using a microneedle and cup forceps. They inspected the tympanic cavity, dissected cicatricial adhesions and adhesions. The mobility and integrity of the auditory ossicular chain was checked.

Next, the tympanic cavity was washed with saline solution.

Stage 4

Five cube-shaped fragments of a highly purified gelatin sponge (Spongostan, registration certificate FSZ 2011-08964) with a side size of 3.0 mm were placed into the tympanic cavity.

Three fragments were placed in sections of the tympanic cavity corresponding to the anterior quadrants of the eardrum, two fragments were placed in sections of the tympanic cavity corresponding to the posterior quadrants of the eardrum.

Next, we sequentially laid the previously prepared four plates of autocartilage.

The first plate of autocartilage was placed in the projection of the anterosuperior quadrant of the tympanic membrane so that one edge of the plate rested on the handle of the malleus, and the other edge was placed under the bone tympanic ring by 0.5 mm.

The second plate of autocartilage was placed in the projection of the anterior-inferior quadrant of the tympanic membrane so that one edge of the second plate was on top of the first plate 6, overlapping it by 0.5 mm, and the other edge of the second plate was placed under the bone tympanic ring by 0.5 mm .

The third plate of autocartilage was placed in the projection of the posteroinferior quadrant of the tympanic membrane so that one edge of the third plate was on top of the second plate, overlapping it by 0.5 mm, and the other edge of the third plate was placed under the bone tympanic ring by 0.5 mm.

The fourth plate was placed in the projection of the postero-superior quadrant of the tympanic membrane so that one edge of the fourth plate was on top of the first plate, overlapping it by 0.5 mm, the other edge of the fourth plate was on top of the third plate, overlapping it by 0.5 mm.

In this case, the edge of the fourth plate is located on top of the bone tympanic ring, overlapping it by 0.5 mm, that is, the fourth plate is located on top of the first and third plates, as well as on top of the bone tympanic ring.

Next, a previously prepared autofascial flap was placed on top of the formed autocartilaginous frame. Then the remains of the tympanic membrane were placed on top of the autofascial flap.

Stage 5

The external auditory canal was loosely tamponed using 30 cube-shaped fragments of highly purified gelatin sponge (Spongostan, registration certificate FSZ 2011-08964) with a side size of three millimeters.

The access was closed by placing four U-shaped sutures on the postauricular incision. They applied a bandage.

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 were removed on day 21.

During the control examination on the 21st day after surgery: AD - the external auditory canal is wide and free, the neotympanic membrane is wealthy, pale pink, well vascularized, without granulation tissue.

During a follow-up examination 12 months after surgery: AD - the external auditory canal is wide and free, the eardrum is without defects, gray, transparent, the contours are preserved, the anterior meatotympanic angle is without blunting.

According to the results of control tone threshold audiometry: AD - sound conduction thresholds in the speech frequency zone of 15 - 20 dB in the presence of a bone-air interval of up to 5 dB.

In the extended frequency range, sound conduction thresholds were 15-20 dB with an air-bone gap of up to 5 dB, indicating restoration of the operating condition of the chain lever mechanism of the neotympanic membrane and excellent audiological results in terms of high-frequency sound conduction and speech intelligibility. The inventive method has the following advantages:

- allows you to achieve lasting anatomical results when performing closed tympanoplasty in patients with chronic purulent otitis media;

- ensures high efficiency of postoperative control by maintaining the transparency of the newly formed eardrum;

- restores the native three-dimensional plane of the eardrum;

- ensures tight contact of the neotympanic membrane and the handle of the malleus;

- prevents retraction of the flap in the early postoperative stage;

- prevents the development of retraction pockets in the neotympanic membrane in the long-term postoperative period.

Claims (4)

1. A method of myringoplasty for closed-type tympanoplasty, including separation of the remnants of the tympanic membrane from the lateral process and the handle of the malleus, de-epithelialization of the calloused edge of the perforation of the tympanic membrane, closure of the defect, tamponade of the external auditory canal, application of a bandage, characterized in that before separating the remnants of the tympanic membrane, a post-auricular access and use the transmeatal route: dissect the soft tissues of the postauricular area layer by layer to the bone, exposing the mastoid area, separate the skin of the posterior, upper and lower walls of the external auditory canal anteriorly throughout until reaching the bone tympanic ring, then from the medial surface of the auricle in the surgical wound a square-shaped autocartilage flap with side dimensions of 1.0 cm is collected, then four square-shaped autocartilage plates 0.1 mm thick are made, then round plates with a diameter of 5.0 mm are cut out of them, after which they are placed in a physiological solution, then from After completing the postauricular approach from the temporal muscle, a round-shaped autofascial flap with a diameter of 10.0 mm is collected, after which the fibrocartilaginous ligament of Gerlach is separated from the bone tympanic ring along the entire length corresponding to the posterior quadrants of the tympanic membrane, and after de-epithelialization of the calloused edge of the perforation of the tympanic membrane, a revision is performed tympanic cavity, remove the stratified squamous keratinizing epithelium that has grown into the tympanic cavity, dissect cicatricial adhesions and adhesions, irrigate with saline solution, after which five cubic fragments of a highly purified gelatin sponge with a side size of 3.0 mm are placed in the tympanic cavity, and three fragments are placed into sections tympanic cavity, corresponding to the anterior quadrants of the tympanic membrane, and two fragments - into the sections of the tympanic cavity, corresponding to the posterior quadrants of the tympanic membrane, then the previously prepared four round plates of autocartilage with a diameter of 5.0 and a thickness of 0.1 mm are laid, creating a three-dimensional plane of the neotympanic membranes due to the formation of a hemispherical shape of the native tympanic membrane with the base at the bone tympanic ring with the apex in the handle of the malleus; for this, the first plate of autocartilage is placed in the projection of the anterior-superior quadrant of the tympanic membrane, the second plate - in the projection of the anterior-inferior quadrant, the third plate - in projection of the posterior-inferior quadrant, and the fourth plate - in the projection of the posterior-superior quadrant of the tympanic membrane, with one edge of the first plate resting on the handle of the hammer, and its other edge is inserted under the bone tympanic ring by 0.5 mm, then each subsequent plate, namely, the second and third, are placed so that one of its edges is placed on top of the previous plate, overlapping it by 0.5 mm, and its other edge is placed under the bone tympanic ring by 0.5 mm, and the fourth plate is placed on top of the first and third plates and on top of the bone tympanic ring, overlapping them by 0.5 mm, then a previously prepared autofascial flap is placed on top of the formed autocartilaginous frame, on top of which the remains of the tympanic membrane are placed. 2. The method according to claim 1, characterized in that a facial nerve monitoring system is installed on the facial muscles. 3. The method according to claim 1, characterized in that the external auditory canal is loosely tamponed using 30 cubic fragments of a highly purified gelatin sponge with a side size of 3.0 mm. 4. The method according to claim 1, characterized in that the access is closed by placing four U-shaped sutures on the postauricular incision.

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