小儿胆脂瘤型中耳炎的鼓室成形术

目的:探讨小儿胆脂瘤型中耳炎鼓室成形术最佳手术治疗策略。完壁式鼓室成形术和伴乳突根治的鼓室成形术作为治疗胆脂瘤型中耳炎的不同乳突处理方法,探讨其各自适应证及术后效果。方法:对1997年4月～2003年10月间入院手术的4～14岁的胆脂瘤型中耳炎患者42例(45耳)的完整资料进行     

胆脂瘤型和骨疡型中耳炎乳突根治并Ⅰ期鼓室成形术

目的 探讨胆脂瘤型和骨疡型中耳炎乳突根治并Ⅰ期鼓室成形术的术式选择、手术适应证及疗效.方法 回顾性分析78例（78耳）慢性化脓性中耳炎（胆脂瘤型58耳,骨疡型20耳）患者的手术方法及随访1～2年的效果,根据病变范围与程度不同,选择不同术式的乳突根治并Ⅰ期鼓室成形术,保留外耳道后壁乳突切开（完壁式）鼓室成形术28例,切除外耳道后壁乳突切开（开放式）鼓室成形术40例,上鼓室鼓窦开放、上鼓室外侧壁重建鼓室成形术6例,开放式乳突根治外耳道后壁重建鼓室成形术4例.结果 术后2个月干耳率为94.87%（74/78）,语频听力提高≥15dB占73.07%（57/78）,完壁式乳突根治加鼓室成形术后胆脂瘤复发率为14.28%（4/28）,开放式乳突根治加鼓室成形术后鼓膜穿孔率为15.00%（6/40）.结论 根据颞骨CT、听力学检查及临床特征,选择适当手术径路及方式,既可根除病灶,又可行听功能重建,提高干耳率与听力,故乳突根治Ⅰ期行鼓室成形术是有效可行的,但要指出,行完壁式根治伴鼓室成形术要严格掌握适应证,病变要轻并局限在上鼓室,同时要彻底清理胆脂瘤上皮,避免复发.     

粘连型胆脂瘤中耳炎的临床特点

目的探讨粘连型胆脂瘤中耳炎的临床特点.方法以52耳粘连型胆脂瘤中耳炎为对象,其中男30耳,女22耳;左侧24耳,右侧28耳.年龄8～70岁,平均34.72±14.06岁.全部病例均行鼓室成形术治疗,其中开放式37耳(71.2%),完壁式10耳(19.2%),其他5耳(9.6%).9耳因合并感音性聋未做听骨链重建,行O型鼓室成形术.其余Ⅰ型1耳,改良Ⅲ型16耳,改良Ⅳ型26耳.结果粘连型胆脂瘤中耳炎占胆脂瘤中耳炎的34.67% .镫骨上部结构消失25耳(48.1%),明显高于上鼓室型胆脂瘤(P<0.05).总听力改善率为69.8%,其中开放式75.9% ,完壁式55.6% ,其他60.0% .术后穿孔3耳,鼓膜紧张部重新粘连4耳.结论粘连型胆脂瘤型中耳炎并不少见;咽鼓管功能障碍可能是发病的直接原因;开放式乳突充填鼓室成形术疗效优于完壁式,粘连型胆脂瘤中耳炎选择完壁式应慎重.     

硬质耳内镜在完壁式乳突根治-鼓室成形术中的应用

目的探讨在完壁式乳突根治-鼓室成形术中使用硬质耳内镜的意义。方法对采用硬质耳内窥镜技术结合显微镜行完壁式乳突根治-鼓室成形术的42例(42耳)患者的临床资料进行分析。结果术后随访1年,42例(42耳)后天继发性胆脂瘤中耳炎患者中仅4例胆脂瘤复发,胆脂瘤复发率为9.52%,一年后纯音测听示34耳语言频率听力提高10dB以上。结论硬质耳内镜技术的应用可以弥补传统完壁式乳突根治-鼓室成形术的视野缺陷,若与显微镜配合手术,可使胆脂瘤复发率降低,疗效确切。     

新疆地区66例中耳胆脂瘤手术治疗的临床分析

目的探讨新疆地区中耳胆脂瘤手术临床效果和相关的经验教训。方法对66例中耳胆脂瘤患者实施完壁式乳突根治或同时鼓室成形术和开放式乳突根治术并进行随访,观察其干耳恢复状况、并发症、复发情况以及术后听力改善程度。结果维吾尔族患者居多,近50%,19例行完壁式乳突根治术,47例行开放式乳突根治术;2例完壁式乳突根治患者术后半年复发(3.03%),第二次行开放式手术;其余均获得干耳;完壁式乳突根治术后言语频率平均听阈提高>25d B 16耳(24.24%),>15d B 7耳(10.61%),开放式手术听力提高>15d B 2耳(3.03%),术前和术后言语频率平均听阈差异分析有统计学意义(p<0.001)。结论完壁式鼓室成形术,如果适应证掌握得当,技术条件许可,可以有效保留原中耳乳突解剖结构和改善听力,应予优先选择,病变范围广泛无法施行鼓室成形术者应选择开放性手术。     

完壁式乳突根治鼓室成形术治疗胆脂瘤中耳炎

目的:探讨完壁式乳突根治鼓室成形术治疗胆脂瘤中耳炎的临床效果和相关的经验教训.方法:对57例胆脂瘤中耳炎患者实施完壁式乳突根治鼓室成形术.结果:随访1～8年,平均3.7年.术后5例感染流脓,其中3例经及时处理得到控制并愈合,2例二次手术处理后愈合;3例术后因胆脂瘤复发行开放式乳突手术获干耳;鼓膜完整但有内陷者29例,其中2级内陷者13例;术后8个月及1年人工听骨脱出各1例.术后言语频率气导听阈降低>10 dB HL为72.2%(39/54),气骨导差<20 dB HL为53.7%(29/54),气骨导差缩小25 dB HL以上占42.6%(23/54).结论:施行完壁式乳突根治鼓室成形术,如果适应证掌握得当,技术条件许可,患者能按时随访.可以有效保留原中耳乳突解剖结构和改善听力,提高患者生活质量,应予优先选择该术式.     

儿童胆脂瘤中耳炎术式的选择和应用

目的：探讨儿童胆脂瘤中耳炎手术的术式选择和治疗结果。方法：对25例儿童胆脂瘤中耳炎患者的临床表现、术式、预后进行回顾性分析。18例行改良乳突根治伴鼓室成形术（开放式手术）,1例行耳道完壁式乳突切开伴鼓室成形术（关闭式手术）,6例行乳突根治术。结果：24例患者为一期干耳,所有患者均无胆脂瘤复发。术后气导平均听力改善7例,无改变7例,下降11例。结论：儿童胆脂瘤的病变较成人广泛,侵袭性强。手术应力求彻底清除病灶,在此基础上争取保留或改善听力。因根据患者的病变范围决定手术方式,通常多采用开放式技术。术后听力改变与术式无关,主要取决于病变的范围和程度。     

保留乳突的改良完壁式鼓室成形术的临床疗效观察

目的 探讨局限于上鼓室区病变的慢性化脓性中耳炎、中耳胆脂瘤行上鼓室径路保留乳突的改良完壁式鼓室成形术的长期临床疗效.方法 诊断慢性化脓性中耳炎、中耳胆脂瘤47例(47耳)患者,结合患者专科检查,依据手术方式不同分A、B两组,A组行上鼓室径路保留乳突的改良完壁式鼓室成形术,B组行完壁式乳突切开+鼓室成形术.术后随访5～7...     

乳突腔充填术在开放式鼓室成形术中的应用

目的 :探讨乳突腔充填术在开放式鼓室成形术中对恢复生理性外耳道功能的作用。方法 :对行开放式鼓室成形术的 85例 85耳胆脂瘤型中耳炎 ,以乳突皮质骨、同种异体软骨和 U形肌骨膜瓣同期行乳突腔充填。听骨链重建情况 :因骨导域值增高或行阶段性手术未作听骨链重建 10耳 ,鼓室成形术改良 型 40耳 ,改良 型35耳。结果 :总听觉改善率 76 % ,其中改良 型为 80 % ,改良 型为 71.4%。术后干耳率为 97.6 % ,平均干耳时间(19.86± 5 .31) d。术后随访半年以上 ,具有圆滑外耳道以及良好自净作用的占 89.4%。未见胆脂瘤复发病例。结论 :对没有条件行完壁式鼓室成形术的胆脂瘤型中耳炎 ,行乳突充填可以有效地克服开放式鼓室成形术破坏生理外耳道结构的不足 ,保存外耳道皮肤的自净作用 ,提高患者术后的生活质量。     

开放式与完壁式鼓室成形伴听骨链重建术后效果对比分析

目的比较开放式与完壁式鼓室成形伴听骨链重建治疗中耳胆脂瘤的疗效,探讨中耳胆脂瘤手术方式的选择。方法 90耳中耳胆脂瘤分别行开放式鼓室成形伴听骨链重建术与完壁式鼓室成形术伴听骨链重建术。术后均随诊24个月,以术后干耳率、纯音平均听阈、平均气骨导差和听骨链重建成功率为指标进行评价,比较两组的疗效。结果开放式鼓室成形术后干耳率100%,未出现胆脂瘤复发;听力重建成功率62.8%。完壁式鼓室成形术后干耳率81.8%,胆脂瘤复发4耳(10.50%);听力重建成功率68.4%。结论开放式鼓室成形伴听骨链重建术是治疗中耳胆脂瘤安全有效的术式,术后干耳率高,并发症少,复发率低,听力重建效果良好。     

Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children

Objective/Hypothesis: Cases of cholesteatoma in pediatric patients were reviewed to determine which factors influence the outcome of surgical treatment. Cholesteatoma is considered a more aggressive disease in children than in adults. The outcomes of intact canal wall (ICW) mastoidectomy and canal wall down (CWD) mastoidectomy were assessed, as comparisons of different surgical technique. Study Design: A retrospective analysis of all cases of pediatric cholesteatoma treated at a single institution by the senior author (P.R.L.) over a period of 11 years was conducted. Methods: Patient information was collected from an otology database, patient records, and audiology files. Results: Sixty-six patients, aged 10 months to 18 years, were treated and followed for an average of 37.7 months (range 12.2 months to 12. 5 y). ICW mastoidectomy with tympanoplasty was the primary surgical treatment in 41 patients. Nineteen percent had residual disease at a planned second stage surgery and 22% developed recurrent cholesteatoma for a total recidivism rate of 41%. A SRT of less than 30 dB HL was achieved in 75% of these patients. Seventeen patients underwent CWD mastoidectomy with tympanoplasty initially. Two patients (12%) had residual cholesteatoma found at a planned second state procedure, and no recurrent cholesteatoma was encountered. Seventy-two percent maintained a SRT of less than 30 dB HL. Conclusions: These results support the continued use of ICW mastoidectomy with tympanoplasty for pediatric cholesteatoma. If planned second stage surgery is necessary, the long-term results of an ear with useful hearing and few problems with chronic medical care are gratifying. For reasons of anatomy or in an only hearing ear, CWD mastoidectomy with tympanoplasty provides a safe ear and good hearing results. Mastoid cavity care must be maintained indefinitely in many cases.     

Modified intact canal wall mastoidectomy — long term results in hearing and healing

Introduction  The classic intact canal wall (ICW) mastoidectomy with tympanoplasty (combined approach tympanoplasty) [1, 2] has anatomic constraints for clearance of disease from the anterior attic and sinus tympani leading to high recidivism. Farrior [3, 4] described the modification of this technique and senior author (AM) has been using it with further modifications since 1973. Materials and methods  We report our long-term experience in hearing and healing in 126 cases with special reference to the age (pediatric versus adults), ossicle status (presence or absence of stapes suprastructure) and type of cholesteatoma (Attic versus posterior-superior versus secondary acquired cholesteatoma). Results  All the patients had unsafe CSOM and underwent Modified ICW mastoidectomy with primary ossiculoplasty except five where the procedure was staged. Conclusion  Modified ICW technique is a one-stage procedure with the lowest recidivism rate when compared to various other ICW techniques. There is no significant difference in relation to age of the patient or type of cholesteatoma if the operative cases are selected judicially.     

Surgical treatment of pediatric cholesteatomas

OBJECTIVE:: Management of pediatric cholesteatomas remains controversial. We reviewed our 16-year experience in the surgical treatment of cholesteatomas in children and describe a treatment paradigm. STUDY DESIGN:: The authors conducted a retrospective review. METHODS:: A total of 106 mastoidectomies (86 for an acquired cholesteatoma and 20 for a congenital cholesteatoma) were performed in children 16 years old and younger from 1988 to 2003. Follow up ranged from 2 years to 12 years with a mean follow-up period of 6 years. Hearing outcomes, cholesteatoma recidivism, and dry mastoid cavity were the main outcomes measured. RESULTS:: Seven (7%) patients had revision surgery for cholesteatoma recidivism. Rates of cholesteatoma recurrence for canal all up (CWU) and canal wall down (CWD) mastoidectomy groups were similar (8% vs. 6%). The percentage of patient with good serviceable hearing (pure-tone average 相似文献   

Cholesteatoma in children: techniques and results

A retrospective analysis of the medical records of all cases of cholesteatoma in children treated between 1981 and 1996 was performed. The charts of 59 children with cholesteatoma were reviewed. A total of 62 ears received surgery over 15 years. The median follow-up period was 5 years. There were 132 operations. An intact canal wall (ICW) procedure was performed in 29% of the ears in the first stage, a canal wall down (CWD) procedure in 37%, a transmeatal atticotomy (TA) in 21%, a tympanoplasty (T) in 6.5% and a myringoplasty (M) in 6.5% of the ears. The ICW procedure had a higher rate of residual/recurrent cholesteatoma than did CWD (P=0.8), TA (P=0.4), T (P=0.5), and M (P=0.05). The CWD procedure had a lower rate than TA (P=0.7), but a higher rate than T (P=0.6) and M (P=0.09). Lastly, TA had a higher rate than T (P=0.7) and M (P=0.1). Auditory results were similar for type II and type III reconstructions (P=0.5). An air-bone gap of less than 20 dB was achieved in 51% of the ears, and 80% had a gap of less than 40 dB. We found a clear difference, although not statistically significant, in the personal rate of recurrent cholesteatoma. It was 26% for surgeons who had performed more than 350 otological surgeries and fell to 15% for the most-experienced surgeon (1715 operations). It rose to 34% for the less experienced surgeons (P=0.8). We recommend that surgery for children with cholesteatoma be reserved for experienced surgeons.     

Revision surgery for chronic otitis media: recurrent-residual disease and hearing

The aim of this study was to determine the effect of surgical approach, intact canal wall (ICW) or canal wall down (CWD), upon the success of revision surgery for chronic otitis media (COM). A retrospective analysis of 367 patients (including 65 children aged <15 years) who underwent revision tympanoplasty because of persistent disease was performed. Single-staged tympanoplasty was performed, preserving the canal wall when present. Hearing was reconstructed with allograft incus. Follow-up ranged from one to 15 years. Hearing was determined by pre- and post-operative air-bone gaps. Post-operative re-perforation, aural discharge and/or cholesteatoma rates were similar for CWD and ICW. Cholesteatoma could present following the revision, even though it was not apparent at surgery. Following tympanoplasty, the final hearing was not significantly affected by the surgical approach or presence of cholesteatoma. Improvement in hearing was adversely affected by cholesteatoma or an absent stapes suprastructure. Revision ICW and CWD operations were both successful in controlling signs of COM. Cholesteatoma is a peripheral risk in COM and may become apparent after revision surgery.     

Pediatric cholesteatoma: a retrospective review

OBJECTIVES: The optimal treatment for pediatric cholesteatoma is controversial. Management decisions including intact canal wall versus open cavity techniques, second look procedures and staging ossicular reconstruction continue to be debated. In an attempt to clarify this issue we conducted an 11-year retrospective analysis of our experience with cholesteatoma presenting in our pediatric population. STUDY DESIGN: Retrospective review of children undergoing surgical intervention for cholesteatoma at a tertiary care pediatric hospital between 1 July 1992 and 1 July 2003 by the senior author. METHODS: Comparison of recurrence rates in intact canal wall (ICW) versus canal wall down (CWD) procedures; with analysis of second-look procedures, ossicular chain reconstruction (OCR) and hearing results in the management of pediatric cholesteatoma. RESULTS: Two hundred and sixty-two children with 278 cases of cholesteatoma underwent surgical resection. Of these children, 221 were managed via an ICW approach while the remaining 57 underwent a CWD procedure. The overall recurrence rate in this series was 16%, with 17% in the ICW group and 12% in the CWD group. OCR was performed in 97% of the ICW cases at time of second-look procedure, with 75% undergoing reconstruction with partial ossicular reconstruction prosthesis. The average air-bone gap improvement in these patients was 10.8 dB, with an average hearing improvement of total ossicular reconstruction of 5.8 dB. The average hearing improvement in the CWD group, all managed with cartilage interposition grafts, was 3.7 dB. CONCLUSIONS: Management of pediatric cholesteatoma requires a highly individualized approach that takes into account anatomic, clinical and social factors to determine the most successful surgical treatment paradigm.     

canal wall reconstruction mastoidectomy

Objective To investigate the advantages of canal wall reconstruction(CWR) mastoidectomy, a single-stage technique for cholesteatoma removal and posterior external canal wall reconstruction, over the open and closed procedures in terms of cholesteatoma recurrence. Methods: Between June 2002 and December 2005, 38 patients (40 ears) with cholesteatoma were admited to Sun Yat-Sen Memorial Hospital and received surgical treatments. Of these patients, 25 were male with ages ranging between 11 and 60 years(mean = 31.6 years) and 13 were female with ages ranging between 20 and 65 years (mean = 38.8 years). Canal wall reconstruction(CWR)mastoidectomy was performed in 31 ears and canal wall down(CWD) mastoidectomy in 9 ears. Concha cartilage was used for ear canal wall reconstruction in 22 of the 31 CWR procedures and cortical mastoid bone was used in the remaining 9 cases. Results At 0.5 to 4 years follow up, all but one patients remained free of signs of cholesteatoma recurrence, i.e., no retraction pocket or cholesteatoma matrix. One patient, a smoker, needed revision surgery due to cholesteatoma recurrence 1.5 year after the initial operation. The recurrence rate was therefore 3.2% (1/31). Cholesteatoma recurrence was monitored using postoperative CT scans whenever possible. In the case that needed a revision procedure, a retraction pocket was identified by otoendoscopy in the pars flacida area that eventually evolved into a cholesteatoma. A pocket extending to the epitympanum filled with cholesteatoma matrix was confirmed during the revision operation, A decision to perform a modified mastoidectomy was made as the patient refused to quit smoking. The mean air-bone gap in pure tone threshold was 45 dB before surgery and 25 dB after(p < 0.05). There was no difference between using concha cartilage and cortical mastoid bone for the reconstruction regarding air-bone gap improvement, CT findings and otoendoscopic results. Conclusion CWR mastoidectomy can be used for most patients with acquired middle ear cholesteatoma, including children. The CWR technique provides improved exposure of the middle ear, especially the anterior epitympanum, without creating a mastoid bowl and reduces the incidence of residual and recurrent disease, including cholesteatoma and otorrhea.     

Butterfly cartilage graft inlay tympanoplasty for large perforations

OBJECTIVE: Butterfly graft inlay tympanoplasty is a well-established technique for the repair of small perforations. However, the efficacy of the technique for medium and large tympanic membrane perforations remains unknown. STUDY DESIGN: Retrospective case series. METHODS: Postauricular tympanoplasty and tympanomastoidectomy using a large butterfly cartilage inlay graft (>4 mm diameter to total drum replacement) were analyzed in 90 pediatric patients (99 ears). RESULTS: Patient ages ranged from 2 to 20 years; mean follow-up duration was 27.6 months. Successful closure occurred in 92% of the ears. No graft lateralized nor displaced into the middle ear. No retraction pocket occurred during the follow-up period. In 62 cases, intact canal wall or canal wall window tympanomastoidectomy was performed; Fifty-one (82.2%) of the patients having mastoidectomy procedures had chronic otitis media with cholesteatoma. The mean preoperative to postoperative four-tone air-bone gap improved from 23 to 21 dB; the number of patients with 0 to 10 dB hearing results increased from 16 ears preoperatively to 32 ears postoperatively. Postoperative suboptimal results included eight patients with postoperative perforations in the residual tympanic membrane adjacent to an intact cartilage graft; two of these patients were the only individuals who exhibited otorrhea. CONCLUSIONS: Cartilage butterfly graft inlay tympanoplasty is effective in the vast majority of patients with moderate to large perforations. The closure rate exceeded 90% with no graft displacement, postoperative adverse events were respectably low, and hearing results improved or remained stable despite the need for concurrent mastoidectomy in the majority of patients.     

筋膜外植法鼓室成形术的手术体会

目的 探讨筋膜外植法在鼓室成形术中的应用及价值.方法 回顾分析筋膜外植法鼓室成形术63耳,随访观察患者的外耳道宽敞度、鼓膜形态及听力恢复情况.结果 本组病例包括中耳胆脂瘤25耳,慢性化脓性中耳炎38耳.手术方式分别为筋膜外植法鼓室成形术、筋膜外植法鼓窜成形术+完肇式乳突根治术和筋膜外植法鼓室成形术+开放式乳突根治术三种类型,中耳胆脂瘤和慢性化脓性中耳炎患者实施三种手术的数最分别为4、17、4耳和19、18、1耳.术后切口全部Ⅰ期愈合.随访0.5～3.5年,外耳道宽敞,鼓膜形态良好,听力提高或维持术前水平,未有听力下降者.按时随访者未发现有明显并发症.结论 筋膜外植法鼓室成形术具有操作流程规范、术野暴露充分、病变清除彻底等优点,在慢性中耳炎的外科治疗中具有积极意义.     

Surgical strategy for cholesteatoma in children

OBJECTIVE: We reviewed our experience with childhood cholesteatoma in children under 15 years old. Based on cumulative postoperative data, we propose a modified canal-wall-up technique in conjunction with a planned, staged operation. METHODS: From 1982 to 1997, 56 children with cholesteatoma (58 ears, total) underwent surgery in our department. In the early period (1982-1990), canal wall-down mastoidectomy was performed in 52% (21 of 40 ears), and canal wall-up mastoidectomy in 48% (the remaining 19 ears). In the late period (1991-1997), 18 ears with cholesteatoma underwent surgery. The canal-wall up mastoidectomy was performed in 89% (16 ears), and canal-wall-down mastoidectomy in the remaining 11% (two ears). RESULTS: In the early period (1982-1990), cholesteatoma recurred more frequently in the canal-wall-up mastoidectomy group than in the canal-wall down mastoidectomy group (53 vs. 14%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, and perforation of the eardrum, occurred more frequently in the canal-wall-down mastoidectomy group than in the canal-wall-up mastoidectomy group. In the late period (1991-1997), in the canal-wall-up mastoidectomy group, ten ears underwent one-stage surgery. Planned staged tympanoplasty was completed in six ears. After one-stage surgery, four of ten ears experienced residual cholesteatoma. Two of the recurrent ears had undergone planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) images, 12 of 15 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. CONCLUSION: Our strategy for pediatric cholesteatoma in the future is to use canal-wall-up mastoidectomy when possible. If aeration in the attic and antrum is observed by preoperative CT-scan image and no erosion in the malleus and incus exists, the one-stage surgery will be chosen. If no aeration is observed by CT-scan and/or erosion exists in the surgical findings, planned staged tympanoplasty will be necessary. This strategy allows a high incidence of aeration of the attic and antrum, and prevents the formation of the attic retraction pocket while enabling the early detection of residual cholesteatoma by means of CT.