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.     

中耳胆脂瘤和慢性化脓性中耳炎手术临床分析

目的　探讨中耳胆脂瘤和慢性化脓性中耳炎术式选择及临床效果。方法　对110例中耳乳突病变,包括中耳胆脂瘤和慢性化脓性中耳炎,根据范围显微镜下实施完壁式或开放式乳突根治,部分同时鼓室成形术,随访术后干耳状况、并发症、复发情况以及术后听力改善程度等。结果　110例患者中66例中耳胆脂瘤、44例慢性化脓性中耳炎,出现颅内外并发症者7例。手术方式：51例（46.36%）行完壁式乳突根治术,46例（41.81%）同时行鼓室成形术,59例（53.64%）行开放式乳突根治术。完壁式乳突根治术后听 力提高＞25 dB 37例（33.64%）,＞15 dB 14例（12.72%）;开放式乳突根治术后听力提高＞15 dB 5例（4.55%）,听力减退4例（3.64%）,比较手术前后言语频率区平均听阈,差异有统计学意义（P＜0.05）。术后随访1年发现开放式和完壁式两组胆脂瘤复发共4例。结论　中耳胆脂瘤与慢性化脓性中耳炎通过选择恰当手术方式可获得较好的临床疗效。     

慢性化脓性中耳炎患者术前颞骨CT检查对术式选择的意义

目的 探讨慢性化脓性中耳炎患者术前颞骨CT检查在术式选择中的作用.方法 101例慢性化脓性中耳炎患者术前行颞骨HRCT检查,结合听力学及耳内镜检查情况选择不同手术方式,并将术中所见(包括乳突、鼓窦、上鼓室以及听骨链及鼓室粘膜状态)与术前颞骨CT扫描结果比较.结果 101例患者中,39例术前CT显示乳突鼓窦未见密度增高影,均行鼓室成形术,其中术前CT显示听骨病变1例,而术中发现听骨链病变8例,二者符合率为12.5%(1/8);62例术前CT显示鼓窦、乳突腔有低密度影充填,但乳窦气房存在,无骨质吸收及破坏,鼓窦入口无扩大45例,行鼓室成形术,其中4例显示听骨链有病变,28例显示鼓室粘膜增厚,均行鼓室成形术,而术中发现听骨病变15例,鼓室黏膜病变19例,两种病变的术前CT与术中所见的符合率分别为26.67%(4/15)和67.86%(19/28);其余17例术前CT显示鼓室、鼓窦入口、乳突有低密度影充填,且乳窦气房骨质吸收和破坏,鼓室人口扩大,均行乳突根治+鼓室成形术,术前CT与术中所见一致,均可见听骨链及乳突、鼓窦病变.所有患者术后三个月的干耳率为93.07%(94/101),言语频率平均气导听力提高15～18 dB.结论 慢性化脓性中耳炎患者术前颞骨CT检查对听骨链、鼓室粘膜病变的评估的准确性有限,部分患者需要行颞骨高分辨率CT三维重建检查,不能仅凭CT决定术式,应结合听力学检查决定手术方式.     

慢性化脓性中耳炎及中耳胆脂瘤术前颞骨CT及耳内镜评估的意义

目的 探讨颞骨CT及耳内镜对慢性化脓性中耳炎静止期及中耳胆脂瘤术前评估的重要性。方法 回顾性分析慢性化脓性中耳炎静止期及中耳胆脂瘤患者42耳病历资料,从CT、耳内镜及术中发现进行分析。结果 ①根据CT结合术中所见,慢性化脓性中耳炎静止期CT分型分为单纯型、硬化灶型、肉芽型、硬化灶肉芽型。胆脂瘤型CT主要表现为听骨链消失或锤砧关节消失,乳突大部分呈硬化型,少部分为板障型,上鼓室鼓窦扩大,上鼓室、中鼓室甚至后鼓室乳突腔为软组织影占据,部分病例外半规管骨质破坏、面神经管水平段骨质破坏,部分病例外耳道后壁骨质破坏;单纯型CT示中耳鼓室乳突呈不完全气化型;硬化灶型CT示中耳鼓室乳突呈硬化型,病变局限于中鼓室,锤骨柄及镫骨周围有“类似骨质影”包裹;肉芽型、硬化灶肉芽型CT相似,示病变累及鼓室及乳突,听骨链基本完整,面神经管水平段骨质完整,但硬化灶型与肉芽型区别之处在于前者鼓室内听骨链周围有“类骨质”样散在高密度影。②耳内镜所见慢性化脓性中耳炎静止期鼓膜紧张部穿孔,鼓膜可有钙化斑;中耳胆脂瘤型则有上鼓室内陷或穿孔、后上象限穿孔、大穿孔、外耳道顶壁或后上壁下塌。结论 慢性化脓性中耳炎静止期及中耳胆脂瘤的术前CT及耳内镜评估,对病变性质、范围、程度及指导手术起重要作用。     

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.     

外耳道胆脂瘤并发化脓性腮腺炎1例并文献复习

目的 探讨外耳道胆脂瘤并发化脓性腮腺炎病因及诊治经验,并进行外耳道胆脂瘤诊疗相关文献复习。 方法 回顾性分析1例外耳道胆脂瘤并发化脓性腮腺炎病例资料,主要症状为左耳听力下降伴流脓,左侧面部红肿疼痛。颞骨CT及耳部核磁示:左侧外耳道内胆脂瘤形成,累及乳突、鼓室、鼓窦、腮腺及咽旁间隙。临床诊断:外耳道胆脂瘤(左,Holt Ⅲ期)、化脓性腮腺炎(左)。手术方式为左耳外耳道胆脂瘤切除术、开放式乳突根治术、鼓室成形术、人工听骨植入术、耳甲腔成形术、腮腺脓肿清除术及腮腺瘘修补术。 结果 术中彻底清除外耳道及中耳内胆脂瘤及腮腺脓肿,并修复腮腺瘘。术后随访患者恢复良好,无胆脂瘤复发残留及腮腺炎复发相关症状出现。 结论 外耳道胆脂瘤具有骨质破坏的潜能。而HoltⅢ期外耳道胆脂瘤并发化脓性腮腺炎病例罕见,明确病因并依据病变侵袭范围选择个体化的治疗方案尤为关键。     

胆脂瘤型中耳炎16例

胆脂瘤型中耳炎16例中男13例,女3例,均为单侧胆脂瘤型中耳炎,左耳10例,右耳6例,25～40岁.术中发现听骨完全消失9耳,部分听骨残存7耳,多为锤、砧骨破坏消失,面神经水平段暴露6耳.术前纯音测听语言区平均听阈骨、气导差为30～40dB.乳突X线片示12例X线片有0.2～0.3cm的类圆透亮区,周边硬化致密,不同程度地累及鼓室、鼓窦入口和鼓窦.4例透亮影周边部分硬化,有轻度不规则的侵蚀性骨破坏.16耳均行乳突手术治疗,手术采取耳内进路,经外耳道开放上鼓室,与外耳道连通,要点是削低外耳道后壁并彻底清除上鼓室、鼓窦、乳突病变,形成大的外耳道口,这对术腔通气极为重要,术腔采用游离皮瓣覆盖以加快干耳.术中见上鼓室、鼓窦、乳突腔内有完整包膜的胆脂瘤或豆腐渣样胆脂瘤上皮.胆脂瘤仅位于上鼓室5耳,其余11耳鼓窦、鼓窦入口及乳突腔内均有大量胆脂瘤.术后听力提高13耳,占80%;听力改进15～25dB 4耳,占25%;10～20dB 9耳,占56%;听力无明显改进3耳,占19%.无面瘫和外淋巴漏等并发症发生.13耳术后均得1干耳,3耳继发流脓.     

慢性化脓性中耳炎鼓膜紧张部大穿孔手术方法的选择

目的探讨慢性化脓性中耳炎鼓膜紧张部大穿孔手术方式选择的依据,明确乳突CT正常的患者进行乳突探查的必要性。方法病例材料来源于北京大学人民医院耳鼻咽喉科2014年至2015年收治的慢性化脓性中耳炎患者102例,所有患者均为鼓膜紧张部大穿孔,术前完善检查,102例患者中乳突CT异常的患者为85例(83.33%),乳突CT正常并且干耳2月以上患者17例(16.67%)。所有患者均全麻下进行乳突开放术及鼓室成形术。结果 102例患者术后随访鼓膜愈合均良好,乳突CT正常的患者在术中探查乳突、鼓窦、鼓室、听骨链、咽鼓管口区域,发现所有患者均存在一个及以上区域的病变,多处病变影响乳突鼓窦引流。结论乳突CT正常不能成为慢性化脓性中耳炎单纯鼓膜修补的标准,除外伤性鼓膜穿孔外均应进行乳突探查。     

耳内镜下外耳道“锁孔”技术处理累及乳突的中耳胆脂瘤的初步实践

目的本文旨在探索耳内镜手术中的“锁孔”技术在中耳胆脂瘤手术中的临床应用价值。方法2017年1月至2018年12月间收治的65名单侧中耳胆脂瘤患者,27例患者术前的颞骨CT提示低密度影及骨质破坏局限于上鼓室,鼓窦和乳突区域未见异常;38例患者术前的颞骨CT显示上鼓室内形成的低密度影像,存在骨质破坏,而鼓窦及乳突内也存在类似的低密度影像,难以确定病变是否累及乳突腔。术中耳内镜下经耳道“锁孔”技术早期探查上鼓室、鼓窦和后方的乳突腔内的空间,确定胆脂瘤范围,修正手术方案、优化手术策略。结果术前通过颞骨薄层CT显示的胆脂瘤仅局限于上鼓室的27例患者中,其中17例患者的影像学病变范围与“锁孔”技术探查结果吻合;另外10例病变累及鼓窦及乳突。术前38例患者的影像学显示上鼓室胆脂瘤可能累及鼓窦和乳突,术中通过“锁孔”技术验证,29例为上鼓室胆脂瘤侵及乳突;9例为堵塞形成的黏膜增厚及肉芽组织等非胆脂瘤病变。患者术后随访时间均超过了2年,随访方式为耳内镜及颞骨CT,8例患者的鼓窦及乳突区存在可疑软组织影,进行了便捷的内镜下“锁孔”的探查,鼓窦及乳突区未见胆脂瘤复发,软组织影为增厚黏膜及肉芽。结论在耳内镜下经外耳道径路,可结合持续灌流模式,在耳道后上壁快速开放直径4-6mm的骨窗,通过“锁孔”可以早期明确和判断中耳胆脂瘤累及乳突、鼓窦、上鼓室的病变范围,有利于修正手术方式,减少不必要的骨质磨除,更利于微创的实现和便于手术中耳道重建。     

中耳乳突外科中的自体骨粉乳突填充与外耳道成形

目的探讨慢性化脓性中耳乳突炎乳突填充外耳道成形手术的处理方法及手术理念.方法总结分析1998年1月～2004年1月间经2年以上随访的548例（耳）乳突根治及乳突鼓室成形术同时以自体乳突皮质骨粉行乳突填充、重建外耳道后壁耳道成形的病例,基本术式包括切除外耳道后壁的乳突鼓室成形术、保留骨桥的乳突鼓室成形术、乳突根治术.结果乳突填充外耳道成形术后外耳道形态良好,愈合时间显著缩短,术后复发率低,效果良好,符合外耳道生理及形态学要求.结论对于乳突开放或乳突根治的病例,在彻底清除病灶的基础上同时行乳突腔填充外耳道成形术,恢复外耳道解剖形态,应作为乳突手术的重要步骤之一;同时填充封闭上鼓室、鼓窦,以防回缩袋形成,减少胆脂瘤复发的潜在危险,乳突皮质骨粉为理想填充材料.     

完整骨性外耳道鼓室成形术治疗胆脂瘤型中耳炎疗效观察

目的 探讨完整骨性外耳道鼓室成形术对骨性外耳道缺损重建及对听力、干耳、术后大术腔引起耳部不适症状的影响。方法 2006～2010年收治胆脂瘤型中耳炎72例,按手术方式分为两组：对照组为开放式,采用乳突根治术或改良乳突根治术;观察组为完整骨性外耳道鼓室成形术,术中在彻底切除病变组织的同时保留或重建骨性外耳道。结果 与传统乳突根治术或改良乳突根治术相比,完整骨性外耳道鼓室成形术在听力提高、干耳及消除不适症状方面有更好疗效。结论 胆脂瘤型中耳炎术中保留或重建骨性耳道对术后提高听力、尽早干耳及消除“根治腔病”疗效显著。     

Long-term follow-up evaluation of mastoidectomy in children with non-cholesteatomatous chronic suppurative otitis media

OBJECTIVE: In spite of declining prevalence chronic suppurative otitis media without cholesteatoma (CSOM) still poses a significant health problem. Randomized clinical trials comparing medical and surgical intervention are not available. Hence, the treatment of CSOM is almost exclusively based on empirical experience. The purpose of the present study was to evaluate the long-term effects of mastoidectomy combined with myringotomy and exploration of the middle ear in children with CSOM. METHODS: 47 children with CSOM underwent surgery including mastoidectomy. Ear status was investigated peri-operatively and at a long-term follow-up (5-21 years post-operatively). MAIN OUTCOME MEASURES: Final success rate, FS (dry ears for several years) and the optimal final success rate, OFS (dry ears for several years without re-operations and without retractions/perforations) were estimated. RESULTS: No serious surgical complications occurred. Post-operatively re-mastoidectomy was performed in 13% and re-myringoplasty/tympanoplasty in 21%. At the long-term follow-up the FS rate was 94% and the OFS rate was 61%. CONCLUSIONS: Surgery alone did not entirely cure CSOM which may justify randomized studies comparing conservative treatment and myringoplasty with/without mastoidectomy. Finally, mastoidectomy in these patients must be considered as a last resort when intense conservative treatment fails.     

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.     

330例乳突再手术相关因素分析

目的对慢性化脓性中耳炎和中耳胆脂瘤乳突再手术的相关因素进行分析。方法回顾性分析330例(338耳)乳突再手术的临床资料。记录再手术前患者的影像学检查、是否合并慢性鼻-鼻窦炎、术中所见、病菌培养结果、术后病理结果及听力变化情况等。结果乳突轮廓化不全256耳;外耳道口狭窄247耳;面神经嵴高169耳;乙状窦前移105耳;中颅窝脑板低垂97耳;面神经走行异常8耳;咽鼓管鼓室口病变118耳;慢性鼻-鼻窦炎91耳;术后未定期换药18耳;二期听力重建8耳;术后面瘫3耳。病菌培养结果:真菌感染82耳,细菌感染74耳,真菌合并细菌感染12耳;术后病理:慢性炎症183耳,胆脂瘤140耳,肿瘤6耳。再手术行听力重建的125例患者术后平均气导听阈及平均气骨导差均较术前显著下降(P<0.001)。结论乳突再手术常见原因有术后不干耳、二期听力重建、术后面瘫,预防术后不干耳可以有效降低再次手术发生率。     

老年外耳道胆脂瘤(附34例报告)

目的探讨老年外耳道胆脂瘤临床特征。方法回顾性分析34例老年外耳道胆脂瘤临床表现及诊治方法。结果本组外耳道胆脂瘤自发性者27例,外耳道狭窄所致者7例。以慢性耳钝痛及耳漏为主要表现,均有不同程度骨性外耳道侵蚀扩大,其中5例侵犯中耳乳突,面神经垂直段骨管破坏2例。行外耳道胆脂瘤清除术及外耳道成形术、改良乳突根治术治愈,随访1~5年无复发。结论老年外耳道胆脂瘤具有破坏性,多为自发性,须与外耳道恶性肿瘤、坏死性外耳道炎等相鉴别,治疗原则为彻底清除胆脂瘤。     

Acquired middle ear cholesteatoma in children with cleft palate: Experience from 18 surgical cases

Objectives

To review an institutional experience with the surgical management of middle ear cholesteatoma in children with cleft palate.

Materials and methods

We analyzed retrospectively 18 children diagnosed with cleft palate who underwent surgery for acquired middle ear cholesteatoma between 2000 and 2007. The following data were recorded: age, sex, history of ventilation tube insertion, status of the contralateral ear, cholesteatoma location and extension, and surgical technique involved. Cholesteatoma recidivism, stable mastoid cavity and hearing levels were the main outcomes measured.

Results

Follow-up ranged from 5 to 12 years (mean 8 years). Twelve children underwent planned staged canal wall up mastoidectomy: a residual cholesteatoma was found and removed during the second-look procedure in 2 ears (16.6%); two children (16.6%) showed a recurrent cholesteatoma and required conversion to canal wall down mastoidectomy. A modified Bondy technique was chosen in two children with an epitympanic cholesteatoma with an intact tympano-ossicular system, while in the remaining four subjects a canal wall down mastoidectomy was performed because of an irreparable erosion of the postero-superior canal wall: no cases of recurrent cholesteatoma were observed in these 6 children; revision mastoidectomy was needed in one patient for cavity granulation. A postoperative air-bone gap result of 0–20 dB was achieved in 11 children (61.1%); in 5 cases (27.7%) postoperative air-bone gap was between 21 and 30 dB, while in 2 (11.1%) was >30 dB. Bone conduction thresholds remained unaffected in all cases.

Conclusions

Our results indicate that most cleft palate children with cholesteatoma can be managed with a canal wall up mastoidectomy with low complication rates. In extensive disease with large erosion of the canal wall as well in presence of a retraction pocket in the contralateral ear, a canal wall down mastoidectomy should be considered. In epitympanic cholesteatomas with an intact tympano-ossicular system and mesotympanum free of disease, the modified Bondy procedure is an effective surgical option. As in the general pediatric population, improvement or preservation of hearing can be obtained in most patients.     

Chronic suppurative otitis media following paediatric cochlear implantation

The objective of this study was to report and discuss the management of chronic suppurative otitis media (CSOM) following cochlear implantation in children. The study was a retrospective review of 650 patients receiving an implant at two paediatric tertiary referral centres for cochlear implantation. Nine patients were identified who developed CSOM following cochlear implantation (incidence 1.38%). The mean time interval between implantation and symptom development was 3.66 years (range 2-8 years) and the mean time interval between implantation and CSOM surgery was 5.02 years (range 2.2-8 years). All patients presented with otorrhoea and/or abscess formation over the implant site. Two patients underwent a modified radical mastoidectomy and seven underwent a combined approach tympanoplasty, three of whom required posterior canal wall reconstruction with cortical bone and one with cartilage. In four cases it was possible to remove the cholesteatoma without removing the implant. All but two patients were fitted with a contralateral implant. In the explanted ears the cochlear implant electrode was cut at the cochleostomy site, which was then covered with muscle. Chronic suppurative otitis media following cochlear implantation may occur either as a result of a posterior canal wall defect related to surgery or possibly de novo. Attempts should be made to save the implant, but explantation with reimplantation of the contralateral ear may be the only option. In these cases the intracochlear part of the electrode array should be left in situ to facilitate possible future reimplantation. Surgical options for management of CSOM should be individualized and may include both canal-wall up and canal-wall down techniques. To reduce the incidence of CSOM following implantation the authors recommend: (1) prompt treatment and careful follow-up of patients with a history of otitis media with effusion, (2) avoidance of excessive thinning of the posterior canal wall during mastoidectomy and (3) reconstruction of any accidental trauma to the annulus or posterior canal wall during posterior tympanotomy.     

耳内镜下儿童中耳胆脂瘤的处理及疗效分析

目的 探讨耳内镜下经耳道径路切除儿童中耳胆脂瘤的手术适应证及临床疗效，为该类疾病的处理提供临床参考。方法 回顾性分析2017年9月-2020年10月上海交通大学医学院耳科学研究所耳内镜下经耳道径路处理的20例中耳胆脂瘤患儿临床资料，患者年龄3~14岁，平均年龄为（7±0.5）岁。根据术前影像学评估，病变范围均在中耳范围内，手术方案为耳内镜经耳道径路中耳切除胆脂瘤，对于听骨链破坏者同期行人工听骨链重建。分析患者术后的临床疗效。结果 结合病史、耳内镜检查、术前CT及术中发现，20例患者中18例（90%）为先天性胆脂瘤，其中Potsic II期3例，Potsic III期15例。；2例（10%）为后天继发性局限性中耳胆脂瘤，病变主要位于上鼓室。所有患者均顺利完成手术，术后3个月均干耳。19例（95%）患者无复发。患者均随访1年以上，平均随访（34±8）个月，1例（5%）III期先天性胆脂瘤复发，再次行耳内镜经耳道径路手术，随访26个月未见复发。术前患者平均气导听阈（37.3±9.3）dB，术后平均气导听阈（29.8±6.3）dB，术后听力明显改善（P<0.05）。结论 儿童中耳胆脂瘤以先天性胆脂瘤常见。对于术前评估为局限性的中耳胆脂瘤患儿（Potsic分期I-III期），耳内镜下经耳道径路手术可提供清晰广角视野，在少量骨质切除的情况下，能更加微创地处理胆脂瘤并进行听骨链重建，病变残留复发率少，手术效果佳，是值得提倡的治疗方案。