开放式鼓室成形术治疗胆脂瘤型中耳炎疗效观察

目的探讨开放式鼓室成形术治疗胆脂瘤型中耳炎的临床效果和影响预后的因素.方法对胆脂瘤型中耳炎116例行开放式鼓室成形术,并对手术方法进行分析.结果经1-5年随访,颞肌筋膜完全成活109例,6例再穿孔,1例复发流脓,患者均有短且大的外耳道,术腔上皮化、干耳.术后9个月听力提高10dB56例、15-20dB34例,25-30dB6例,20例无变化.结论施行开放式鼓室成形术,只要彻底清除乳突、中耳病变,恢复中耳通气功能,可以消除炎症,防止胆脂瘤复发和提高听力.     

Cholesteatoma in children: results in open versus closed techniques.

Cholesteatoma in children presents characteristics that differentiate it from the adult condition. Surgery has been performed in 55 ears. The main reason for referral was otorrhoea (83 per cent), either alone (29 per cent) or with hearing loss (54 per cent). Apart from three cases with an intact eardrum, a perforation was always present mostly posterior-superior (50 per cent). Open techniques were performed in 27.3 per cent of the ears and the closed technique in 72.7 per cent. Only in 18 per cent of cases was the ossicular chain normal and mobile. The attic was occupied by cholesteatoma in 79 per cent. Recurrence took place in 37 per cent and 13 per cent of the closed and open techniques respectively. Open techniques tend to be employed in the presence of extensive disease, whereas the closed technique is reserved for those with a more localized problem.     

Cholesteatoma surgery

The results of surgery in 266 cholesteatomatous ears were analyzed. In most cases the canal down technique was used. The mean follow-up period was 6.0 years. The incidence of postoperative cholesteatoma was 6%, which is significantly lower than the incidence of residual and/or recurrent cholesteatoma following intact canal wall tympanoplasty reported by several other authors. The canal down technique seems to be superior to the canal up technique in the management of large cholesteatomas.     

Cholesteatoma surgery in children

We recently reviewed the records of 1024 operations for aural cholesteatoma, of which 181 were in children. Our surgical management was the same as for adults. Complications of the disease (labyrinthine fistula, facial paralysis, total sensorineural impairment, and meningeal complications) were less common in patients under 16 years of age. This appears to be related to duration of disease rather than to age. The disease in children tends to be more difficult to eradicate. Staging the operation is required more frequently and there is a higher incidence of residual disease at planned second-stage operations. Postoperative serous otitis media, though infrequent, was more common in those patients 16 years of age and older than in children. Persistence of this middle ear fluid, requiring a ventilation tube, was more common in younger children. The functional results of reconstructive middle ear surgery were the same in adults and children.     

Cholesteatoma surgery: canal wall down procedures

We prefer the intact canal wall technique for tympanoplasty with mastoidectomy, but use a canal wall down procedure in up to 25% of cases. Creating a round cavity with a large meatus is imperative if one is to obtain a trouble-free ear. The five types of canal wall down procedures are defined, as are our indications for using them. Results in 19 only hearing ears and 19 labyrinthine fistula cases are presented, along with 64 tympanoplasty cases.     

Cholesteatoma surgery today*

Four present-day surgical techniques are reviewed to assess their respective merits in surgery for cholesteatoma. The oldest method with an open cavity in ears with mastoid extension of cholesteatoma if combined with partial obliteration is still suitable for less experienced surgeons. Transcanal atticotympanotomy is suitable for limited epitympanic and tympanic cholesteatomas as long as it provides a direct view of the operative field. In similar ears, canal wall up surgery is employed if, additionally, mastoidectomy is needed because of chronic inflammation. Canal wall down surgery with full cavity obliteration with a musculoperiosteal flap, bone chips and bone pate should be the method of choice for all cholesteatomas extending beyond the facial nerve canal. The canal skin is kept as an intact tube and provides quick healing. Open cavities should be revised using similar obliteration techniques but, because of the lack of an intact canal skin tube, making use of a large modified Körner skin flap.     

Cholesteatoma,epidermization: choice between closed and obliteration technique*

The surgical techniques used in almost 500 cholesteatomatous ears are described in detail. Intact canal wall and obliteration procedures are discussed. The anatomical and functional results are reported and the indications for each technique are analysed.     

Cholesteatoma surgery: the influence of the canal wall

Although there is an increasing awareness of the risks of complications following intact canal wall tympanoplasty (ICWT) for cholesteatoma, long-term evidence to support a preference for alternative techniques in which the canal wall having been removed, the resultant cavity is obliterated, is comparatively scarce. In order to clarify this uncertainty, long-term results with both operations have been analyzed to determine incidence rates for postoperative complications and functional results. Recurrent cholesteatoma (retraction pocket) has occurred in 14% of ICWT ears and 1% of ears with mastoid obliteration and tympanic reconstruction. The incidence of clinically detected residual disease with both operations has been extremely low so far, in spite of greater than 20% incidence of epithelial pearls at the second stage of separate planned two-stage procedures with each technique. It is concluded that reduction to the greatest degree possible of cholesteatomatous complications from tympanoplasty necessitates removal of the canal wall.     

T-cartilage tympanoplasty for an open oval window

A T shaped cartilage, placed into the open oval window, functions as a stapes. The transvers part of the T prevents a too deep insertion into the vestibule. If necessary small stripes of connective tissue seal the vestibule.     

Cholesteatoma surgery of the middle ear: Reflections on recurrences

Summary The frequency of recurrences (40%–60%) found during follow-up of closed technique for cholesteatoma surgery suggests that this technique should be systematically carried out in two stages. The greater frequency of recurrence in children indicates the necessity for revision surgery when the closed technique has been used. Where for some reason this cannot be undertaken, the open technique should be chosen at the outset. In case of revision, the safety offered by the closed technique is comparable with that obtained by the open technique and the rate of recurrence would be less than 5%.MD, S.H.O., ENT department     

Tympano-cartilago-stapediopexy: a method to improve hearing in open technique tympanoplasty

Canal wall-down technique tympanoplasty was indicated in about 41 per cent of our cases with chronic suppurative otitis media. In this series done during the last four years, of 576 tympanoplasties, 240 cases needed type III tympanoplasty. In 145 cases, myringostapediopexy was carried out using temporalis fascia grafting over the head of the stapes. Tympano-cartilago-stapediopexy was performed in the other 95 cases by using tragal cartilage and perichondrium over the stapes. A comparison between the results of both methods of grafting is discussed. Improvement in hearing was achieved after tympano-cartilago-stapediopexy. This method proved to be suitable for those cases which need open technique tympanoplasty.     

乳突鼓室成形手术的分期问题

目的探讨分期乳突鼓室成形术在以提高听力为目的的功能性耳显微外科中的作用.方法本文总结了海军总医院1993-2003年3月2700例各类中耳手术中分期鼓室成形术102例,随访1～5年,手术主要类型为保留外耳道后壁的乳突切开鼓室成形术、切除外耳道后壁的乳突切开鼓室成形术,保留骨桥的乳突切开鼓室成形术,文中对分期手术的理念、适应症选择、手术方式选择及移植筋膜感染、不愈合等问题进行了分析.结果 102例分期手术中,85例(83.3%)愈合良好,其中7例一期术后干耳,但二期手术中发现后鼓室及鼓窦处胆脂瘤珠及肉芽组织;17例存在不同程度的问题,出现率16%,包括一期术后出现移7植物穿孔或延迟愈合,在后鼓室、鼓窦、面神经隐窝等处发现胆脂瘤肉芽组织,但鼓室粘膜有不同程度的修复.102例分期手术术后1年气导听力(O.5K、1k、2k平均听力)较术前提高15 dBHL.结论在彻底清除病灶基础上,合理而有计划的行分期手术修复鼓室粘膜,恢复中耳含气空腔,为听骨链重建创造条件,以提高听力,不失为较佳的选择.     

A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: The closed vs. The open technique

Cholesteatoma has long been a formidable adversary to the otologic surgeon. The surgical treatment has been basically by two methods, open and closed. It was felt that a study should be undertaken to compare the results obtained over a long period of time, utilizing these two methods. A need for this study existed as the same number of new cases of cholestentoma was presenting each year. In reviewing the literature, it is found that new advancements have not yet been made in the prevention of the disease and the medical and surgical management has remained essentially the same. The ideal goal of successful surgery, namely an ear without disease, with normal hearing, and an intact drum and posterior canal wall, has been difficult to achieve in a high percentage of cases. To achieve this goal, two main surgical methods have evolved: the classical “open method,” and the more recent “closed method.” In the open method cases, the hearing results were often poor and the cavity presented a management problem. In the closed method there has been a fairly high occurrence of residual, and/or recurrent cholesteatoma which necessitated a second procedure. These two methods were compared by reviewing a large number of histologically proved cholesteatoma cases 10 years after surgery, to determine the incidence of recurrence of cholesteatoma and the residual hearing function. The results of this study show conclusively that the hearing was better using the closed method, but the recurrence rate was considerably higher. This paper presents a practical method of approach to the management of all presenting cases of cholesteatoma.     

Concurrent nasal surgery and tympanoplasty in adults

We conducted a retrospective chart review to determine if performing simultaneous nasal surgery and tympanoplasty jeopardizes tympanic membrane graft survival and the surgical outcome. Our study population consisted of 14 consecutively presenting adults with nasal septal deviation and otologic pathology who had undergone simultaneous nasal and otologic procedures at an academic tertiary care medical center. Surgical procedures included septoplasty and bilateral inferior turbinate submucous reduction with concurrent primary or revision tympanoplasty with or without mastoidectomy and ossicular chain reconstruction. Follow-up ranged from 1.8 to 29.8 months (mean: 12.8 ± 10.8). The primary outcomes measures were tympanic membrane graft survival and surgical success; the latter was defined as an absence of middle ear effusion and a lack of need for pressure-equalization tube placement in patients with intact grafts. We found that 13 of the 14 tympanic membrane grafts (92.9%) survived at the most recent follow-up and that 11 patients (78.6%) achieved an aerated middle ear without the need for a pressure-equalization tube. These rates compare favorably with those quoted in the literature for tympanoplasty performed without concomitant nasal surgery. We conclude that septoplasty can be safely and effectively performed at the same time as tympanoplasty with or without mastoidectomy with no increase in the risk of surgical failure.