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 surgery: open vs closed tympanoplasty

The purpose of this report is to compare closed tympanoplasty (canal wall up) and open tympanoplasty (canal wall down) performed in ears with extensive cholesteatoma operated on and followed up during the past 11 years. The study has demonstrated that there are no significant differences between open and closed tympanoplasties in terms of both postoperative subjective problems and auditory results. The only definite difference relates to recurring cholesteatoma: canal wall-up operations are complicated by recurrence of cholesteatoma in a not insignificant number of ears and require a planned two-stage procedure in all the cases. By contrast, the postoperative clinical course of open tympanoplasties has been only rarely affected by cholesteatomatous complications. It is concluded that reduction of cholesteatoma recurrence to the greatest degree possible necessitates removal of the canal wall. Open tympanoplasty is an effective alternative for closed tympanoplasty in all cases in which there is a contraindication to preserving the canal wall and in all patients whose medical or social conditions prevent scheduling an operation in more stages.     

Functional results of tympanoplasty using autologous cartilage

During 6 years we performed 352 tympanoplasty surgeries and used cartilage plates in 175 cases (49.7%). Total or subtotal defects of the tympanum were found in 83 patients. The tragus or floor of the auricle cartilage was used for surgery. Good morphological results were seen in 93.1% cases by the end of the 1st month and in 92% cases by the end of the 2nd month of observation; good functional results were recorded in 75.4% and 69.1% cases, respectively. Socially adequate hearing improvement was observed in 63.4% patients. In summary, the de novo built system of air conduction becomes functionally operational 9 to 12 months after surgery and remains stable thereafter.     

Anatomical and functional reconstruction of old radical mastoidectomy cavities by obliteration tympanoplasty

One hundred and seventeen patients who had previous radical mastoidectomies, atticotomies or Bondy operations were operated on between 1973 and 1984. An open technique with obliteration and traction meatoplasty was used in one stage in 19 ears (normal mucosa in mesotympanum) and in 2 stages in 98 ears (poor mesotympanum which needed to be dissected and covered with silastic sheeting). The second stage was performed 12 to 18 months later. Closure of the tympanic membrane was achieved in 93% of ears at the first stage. In 6 ears out of 81 second stages, residual cholesteatoma was found in the mesotympanum. No residual cholesteatoma was subsequently observed behind the flap but only 4 ears were checked behind the flap at the second stage. An air-bone gap within 20 dB was achieved in 85% of ears if the stapes was intact and surgery was performed in one stage, and in 55% of ears of the stapes was intact and surgery performed in 2 stages. If the crura were missing, an air-bone gap within 20 dB was achieved in 57% of ears in 2 stages.     

The use of Silastic in tympanoplasty surgery*

Silastic has a relatively high incidence of late complications when used as a middle ear liner in unstaged tympanoplasty procedures. This does not seem to be the case in staged procedures where it is removed at the second operation or in cases where small pieces are used to prevent refixation of the malleus or stapes. At the present time, the use of gelfilm seems to be the most acceptable alternative.     

Vertigo in suction of open mastoid cavities ("radical surgery cavities")

BACKGROUND: Vertigo during suction-cleaning of open mastoid cavities is caused by cold stimulation of the vestibular organ. In clinical and model-experimental measurements we tried to estimate the physical background and the dimension of this temperature drop. METHODS: Using different techniques like thermo-probes, thermovision, or additional model experiments temperature changes during suction were measured in 5 volunteers with open mastoid cavities. These registrations were carried out with special regard to the moisture of the cavity-walls. RESULTS: Distinct temperature changes during suction were observed. In moist cavities superficial temperature decrease was much higher than in dry ones. Using additional model experiments, temperature conduction towards e.g. the horizontal semicircular canal could be simulated. DISCUSSION AND CONCLUSIONS: Among other mechanisms like replacement of sucked-off air by colder air, or taking away warm air close to the cavity walls, effects of evaporative cold seem to be very significant. This could be demonstrated by moistening cavity walls in patients as well as in model experiments. The conclusion to keep the cavity walls as dry as possible is already a clinical demand. In this paper, the physical background and the dimensions of thermal effects during suction-cleaning could be elucidated.     

Functional septal surgery: computer simulated surgery

Septal surgery is one of the most commonly performed nasal surgeries. It aims at restoring nasal patency and symmetrical air passages. However classical surgery may narrow the originally wider side necessitating additional surgery at the level of the turbinates. This study was performed to demonstrate that properly targeted and tailored surgery with limited interference at the level of specific areas may not only be enough but it may also more efficacious than more extensive surgery. The coronal CT scans of 16 patients with septal deviation were transferred to a computer and the cross-sectional areas (CSA) of both passages calculated before and after various simulations of septal surgery. In 8/16 cases the more limited surgery resulted in a wider total CSA and also more symmetrical right and left passages. This is more physiological both in terms of function and subjective feeling by the patients. We suggest that for all patients planned to undergo septal surgery a pre-operative coronal CT should be studied and the surgery planned to achieve the most optimal result rather than remove indiscriminately all deviated elements.     

The flexible endaural tympanoplasty: pathology-guided, pathogenesis-oriented surgery for the middle ear.

The flexible approach to tympanoplasty has been found to be adaptable to various forms of pathologic conditions found in the temporal bone, including inflammation and infection, congenital stenosis, benign and malignant tumors, and traumatic injuries. This approach finds its best indication among all pathologic conditions in the temporal bone, in the surgical treatment of otitis media, and its sequelae. A procedure conceived to treat this dynamic process must be adaptable to new circumstances and new findings and be ready to manage unexpected situations. The flexible tympanoplasty is a step-wise approach designed to explore the contents of the middle ear methodically and in the process disclose, confirm, and often treat disease.     

Open cavities in cholesteatoma surgery: checklist for proper surgery and perioperative care

Decisions in cholesteatoma surgery regarding open versus closed techniques are based on the extent of the cholesteatoma, the degree of pneumatization of the middle ear and mastoid and the integrity of the remaining mucosa following complete resection of all disease. Checklists regarding handling of the soft tissues, drilling of the temporal bone with complete exenteration of the tympanomastoid air cell tracts, lowering of the facial ridge, partial obliteration of the cavity and meatoplasty and postoperative care are presented. Adhering to these checklists should enable every otologic surgeon to perform a safe open cavity and to end up with a dry, mostly self-cleaning cavity.