上鼓室胆脂瘤与听骨链重建术

目的 :探讨上鼓室胆脂瘤患者在凿开上鼓室 ,清除胆脂瘤组织后重建上鼓室壁并一期听骨链恢复传音功能的方法和效果。方法 :对上鼓室胆脂瘤 2 3例行上鼓室凿开术 ,清除胆脂瘤上皮组织 ;酌情剪除锤骨头 ,取出砧骨体 ,然后行镫骨头上加高或锤骨长柄、镫骨头连接术。观察术后鼓膜愈合及听力恢复情况。结果 :随访 2 3例 4～ 1 2年 ,2 0例鼓膜愈合良好 ,2例鼓膜后上方外移 ,1例鼓膜发生 2mm穿孔并且胆脂瘤复发。术后气骨导差值 <1 0dB 8例 ,<2 0dB 6例 ,<3 0dB 6例 ,3 0dB以上 3例。以镫骨头上加高听力恢复最好。结论 :上鼓室胆脂瘤患者应以清除胆脂瘤上皮为前提 ,清除病变后根据情况重建上鼓室壁和听骨链 ,有助于恢复听力     

全中耳重建术治疗开放性乳突术后反复性耳漏

目的:探讨全中耳重建术治疗陈旧性乳突术腔感染的疗效。方法:115例、118耳开放性乳突手术后出现耳漏,用自体乳突骨皮质和软骨片行全中耳重建,其中71例同期或分期行鼓室成形术,定期随访观察术后中外耳的形态、听力恢复情况和干耳率。结果:90．7％的患耳感染被控制、耳漏停止而获得干耳,55．1％的患耳听力改善,11．0％的患耳行再次手术治疗(11例因耳漏再发,2例要求改善听力)。结论:全中耳重建术治疗开放性乳突手术后出现的反复性耳漏具有良好的效果。     

乳突根治术后的外耳道后壁及传音机构重建术

目的：为使乳突根治术后耳向外耳道开放的乳突腔重新中耳化和一期行听力重建。方法：用同种异体肋软骨为外耳道后壁重建材料,乳突充填材料,听骨链重建材料,对７１例乳突根治术后耳（流脓５３耳,干耳１８耳）作了中耳重建术。     

鼓室成形术中听骨链重建的研究进展

鼓室成形术是现代耳科学的重要组成部分,听骨链重建作为鼓室成形术的一部分,其目的是恢复中耳的传导机制,提高听力。一般听骨链异常最多见的是锤骨与镫骨之间的连接中断,其原因可能是病变腐蚀或外伤等所致,也可以是术中清除中耳病变而人为将其中断的结果。听骨链是维持正常听力所必需的重要传音结构,它的残缺将导致传导性耳聋。慢性化脓性中耳炎患者多数存在不同程度的听力障碍,其原因除了鼓膜穿孔外．多伴有听小骨的破坏和缺失,因而听骨链重建鼓室成形术可有效恢复听力。     

Perichondrium/cartilage composite graft for repairing large tympanic membrane perforations and hearing improvement

Background  The main risk factors for postoperative failure in tympanoplasties are large perforations that are difficult to repair, annular perforations, and a tympanic membrane (TM) with extensive granular myringitis that require middle ear exploration and mastoidectomy. The aim of this study was to investigate a novel technique of perichondrium/cartilage composite graft for repairing the large TM perforation in the patient of otitis media.
Methods  Retrospective chart reviews were conducted for 102 patients with large tympanic membrane perforations, who had undergone tympanoplasty from August 2005 to August 2008. Tympanoplasty or tympanomastoidectomy using a perichondrium/cartilage composite graft was analyzed. The tragal or conchal perichondrium/cartilage was used to replace the tympanic membrane in patients.
Results  Patients aged from 13 to 67 years were followed up in average for 24 months (10–36 months). Seventy-four ears (72.61%) were used the tragal perichondrium/cartilage as graft material and 27 ears (27.39%) were used the conchal perichondrium/cartilage. Graft take was successful in all patients. Postoperative complications such as wound infection, hematoma, or sensorineural hearing loss were not identified. Nine patients (8.82%) had the partial ossicular replacement prosthesis, 14 patients (13.72%) using the autologous curved incus and 79 patients (77.45%) without prosthesis. Successful closure occurred in 92% of the ears. A total of 85.8% patients achieved a postoperative hearing improvement.
Conclusions  The graft underlay tympanoplasty using perichondrium/cartilage composite is effective for the majority of patients with large perforation. The hearing was improved even if the mastoidectomy was required in the patients with otitis media with extensive granulation.

     

纳米生物陶瓷在听小骨重建及乳突修复中的应用

目的 探讨以纳米羟基磷灰石（HA）为材料的生物陶瓷听骨假体替代中耳听骨缺损的生物相容性、手术应用及临床效果。方法 健康、白色豚鼠12只（24耳），双侧听泡置入HA块，1-4个月后每月3只断头取双侧听泡（6个），行植人物表面接触缘大体形态学及扫描电镜检查。临床应用HA行中耳手术47例，包括听骨链重建、外耳道后壁重建、乳突填充。结果 12只豚鼠23只听泡光镜及扫描电镜检查，植人物界面形态良好，结构完整，边界清晰。临床鼓室成形术病例术后愈合良好，听力较术前提高16dBHL；耳道后壁重建1例外耳道后壁感染，乳突填充病例术后外耳道宽敞，上皮愈合良好，愈合时间明显缩短。结论 HA作为听骨替代物及重建材料，以其优良的理化生物相容性在听骨链重建术、乳突填充外耳道后壁重建中均为合适的应用选择，所设计的HA听骨假体在材料选择及外形尺寸方面均适合于临床应用。     

多层螺旋CT三维成像对慢性中耳乳突炎的诊断价值研究

目的探讨多层螺旋CT（muhislicespiralCT,MSCT）三维重建对慢性中耳乳突炎患者中耳、乳突精细结构破坏的诊断价值。方法应用128层螺旋CT扫描机,对68例慢性中耳乳突炎患者行颞骨薄层扫描及透明化容积重建fvolumereconstruction,VR）、多平面重组（multipleplanereconstruction,MPR）,正常对照耳观察听骨链的形态结构;病变耳观察中耳乳突结构的改变及骨质破坏情况并与手术结果进行比较。结果正常组VR、MPR对锤骨、砧骨及锤砧关节均能清晰显示,MPR对镫骨及镫砧关节能部分显示。病变组76耳中耳乳突破坏MSCT诊断与手术病理结果基本一致。结论MSCT三维重建可清晰显示中耳的精细结构,对中耳乳突炎骨质破坏诊断准确,对镫骨、镫砧关节及其骨质破坏显示欠佳。     

Medpor耳支架全耳再造术的临床应用

目的：探讨应用Medpor人工耳支架全耳再造的手术方式、临床疗效及支架外露的处理方法。方法：2011 年1月至2015年12月在中南大学湘雅医院整形美容科应用Medpor人工耳支架全耳再造术治疗17例先天性小耳畸形患者 (包括2例双侧小耳畸形,共19只患耳)。采用颞浅筋膜瓣一次性全耳再造2例、皮囊下支架植入法一次性全耳再造2例 和分期法全耳再造13例。结果：17例患者随访1~3年,其中14例(共16只患耳)全耳再造患者获得理想外形。3例发生支 架外露,其中1例经扩创、外露支架表层削除及局部皮瓣转移得到修复,未明显影响外形;2例多次修复支架仍外露 遂最终摘除支架。1例患者全耳再造术后因诱发右侧肩周炎加重,患者强烈要求而摘除支架。结论：Medpor耳支架具 有组装较容易、组织相容性好、血管易长入、操作简便、手术省时、创伤较小、再造耳外形理想等优点;可作为不 愿切取自体肋软骨或肋软骨严重钙化的小耳畸形患者的替代选择,但支架外露的发生率较高及有手术失败的风险, 应严格掌握适应证,防止皮肤坏死、支架外露,远期疗效有待进一步观察。     

腭裂与中耳功能障碍的相关性

目的:探讨腭裂手术对患者中耳功能的影响,为早期改善患者中耳功能提供依据。方法:对112例(224耳)腭裂患者进行年龄分组,采用声导抗、纯音测听或听性脑干反应检查。65例腭裂伴分泌性中耳炎患者在作腭裂修复术的同时,行鼓室置管术,术前术后作听力学检测,术前对鼓室分泌物作细菌培养。结果:腭裂患者常伴有不同程度的中耳功能障碍,腭裂修复术能明显改善患者中耳功能(P<0.05)。鼓室分泌物G+、G-细菌培养阳性率为22.86%、23.53%,且多为低毒性条件致病菌。结论:腭裂患者常有中耳功能障碍,应重视其早期预防与治疗,早期修复腭裂有助于咽鼓管功能恢复。     

螺旋CT仿真内镜和后处理在中耳病变中的应用

目的：探讨CT仿真内镜和后处理技术应用于中耳听骨链病变的价值及局限性。方法：95例、108耳采用不同方式扫描与重建。结果：95例、108耳中双耳发病26例，95例中102耳患有中耳乳突炎。其中听骨链畸形15例，胆脂瘤69例，骨疡型中耳乳突炎21例，外耳道癌侵犯中耳3例。结论：CT仿真内镜和其它后处理方法能清楚显示听骨链和锤、砧骨的大小、形态及相互之间的关系，也能较好地显示听骨链及锤、砧骨的解剖结构畸形、变异，对诊断中耳胆脂瘤及中耳乳突炎等疾病有重要价值，为检查耳部病变及手术前准备影像学资料提供了新的方法。     

一次手术完成的全耳廓再造5例报告

目的：探讨改进耳廓再造的手术方法。方法：在发区内做切口，沿毛囊根部水平向前掀起足够大小的薄型皮瓣，同时剪除毛囊，不要影响皮瓣血液循环。取自体肋软骨雕刻，突出耳轮、耳甲，保持耳颅角３０度左右的耳支架。用薄型皮瓣覆盖耳支架，耳后组织瓣覆盖支架后面的裸露部分，创面植皮。结果：一次性全耳廓再造，手术次数由６次减少到１次，再造耳接近正常耳的厚度，皮肤色泽一致，效果满意。结论：一次手术完成的全耳廓再造术具有手术次数少，效果理想，外形逼真的特点     

Rib Cartilage Assessment Relative to the Healthy Ear in Young Children with Microtia Guiding Operative Timing

Background:

The optimal age at which to initiate for auricular reconstruction is controversial. Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction. We developed a method to guide the timing of auricular reconstruction in children with microtia ranging in age from 5 to 10 years.

Methods:

Rib cartilage and the healthy ear were assessed using low-dose multi-slice computed tomography. The lengths of the eighth rib cartilage and the helix of the healthy ear (from the helical crus to the joint of the helix and the earlobe) were measured. Surgery was performed when the two lengths were approximately equal.

Results:

The preoperative eighth rib measurements significantly correlated with the intraoperative measurements (P < 0.05). From 5 to 10 years of age, eighth rib growth was not linear. In 76 (62.8%) of 121 patients, the eighth rib length was approximately equal to the helix length in the healthy ear; satisfactory outcomes were achieved in these patients. In 18 (14.9%) patients, the eighth rib was slightly shorter than the helix, helix fabrication was accomplished by adjusting the length of the helical crus of stent, and satisfactory outcomes were also achieved. Acceptable outcomes were achieved in 17 (14.0%) patients in whom helix fabrication was accomplished by cartilage splicing. In 9 (7.4%) patients with insufficient rib cartilage length, the operation was delayed. In one (0.8%) patient with insufficient rib cartilage length, which left no cartilage for helix splicing, the result was unsatisfactory.

Conclusions:

Eighth rib cartilage growth is variable. Rib cartilage assessment relative to the healthy ear can guide auricular reconstruction and personalize treatment in young patients with microtia.     

耳显微外科听力重建术67例临床观察

目的报告耳显微外科听力重建术６７例（７２耳）,主要对适应症、手术相关问题、移植物选择等方面进行临床研究,此手术目的旨在既根治病灶又恢复中耳传音机构以改善听力。方法选择耳内或耳后切口,鼓窦进路,行各型鼓室成形术、耳道成形术,手术均在耳显微镜下进行。结果本组６７例中,耳畸形１１例（１３耳）,静止性中耳炎５６例（５９耳）,术后语言频率较术前平均提高１０分贝以上５９耳,占８１．９％,移植物一期成活６３耳,成活率为８３．９％。结论耳显微外科听力重建术在耳鼻喉科领域占有重要地位,耳显微外科术者必须具备颞骨解剖训练基础及耳显微镜下操作技巧,这是手术成功的关键     

耳内镜下手术治疗单纯先天性中耳畸形疗效分析

目的：探讨单用耳内镜手术治疗单纯先天性中耳畸形的疗效。方法：回顾性分析2017年1月至2021年6月在温州医科大学附属第一医院收治的27例单纯先天性中耳畸形患者的临床资料,对术前高分辨率计算机断层扫描结果、术中所见、手术方式及术前后听力学资料进行分析。结果：27例患者均为单耳发病,24例患者为传导性聋,3例混合性聋且以传导性为主。Teunissen-Cremers分型I型5例,II型6例,III型15例,IV型1例。术中分别使用PORP 8例、TORP 7例和Piston 11例行听骨链重建术。1例IV型患者系前庭窗闭锁,听骨及面神经严重畸形,行加长的7.0 mm Piston锤骨前庭桥接术。27例患者术前平均气导为（62.1±8.3）dB HL,术后6个月平均气导为（30.6±7.4）dB HL（t=19.47,P＜0.001）。15例（55.6%）气导听力提高超过30 dB HL。术前平均气骨导差为（43.1±9.3）dB HL,术后6个月为（13.4±5.2）dB HL（t=16.75,P＜0.001）。结论：单纯先天性中耳畸形主要表现为听骨链畸形,单用耳内镜诊治先天性中耳畸形具有视野清晰、操作准确、无需外耳道或耳后切口、创伤小、并发症少、术后听力恢复好的优点。     

耳垂型小耳畸形的肋软骨全耳郭再造

目的利用自体肋软骨全耳郭再造矫正耳垂型小耳畸形。方法20012~005年50例耳垂型小耳畸形患者(54耳),应用自体肋软骨二期全耳再造法进行耳郭再造,手术Ⅰ期为耳解剖结构三维轮廓再造,包括自体肋软骨耳支架成形、乳突区皮瓣转位和Ⅰ期耳垂转位;Ⅱ期为颅耳角再造。结果本组50例中47例手术效果满意;2例外耳轮软骨尖端弹开外露,行外露软骨再固定,局部皮肤转瓣缝合后痊愈;1例于Ⅱ期术后3个月出现颅耳角回缩。随访3月~4年,再造耳郭具有个性化的三维立体轮廓,拥有良好的颅耳角。结论应用自体肋软骨进行二期全耳再造,是矫正耳垂型小耳畸形较为理想的手术方法。     

上鼓室封闭和外侧壁重建技术在鼓室成形术中的应用

目的 观察上鼓室封闭和外侧壁重建技术在防止鼓室成形术后胆脂瘤复发或听骨链运动受限中的效果。方法 （1）上鼓室成形技术;对病灶清除后听骨链完好者,重建上鼓室外侧壁,采用2种材料;（1）“骨水泥”板（用凝血酶纤维蛋白元粘合剂与自体乳突皮质骨粉黏合而成）：（2）耳廓软骨。（2）上鼓室封闭技术;用骨粉和凝血酶纤维蛋白元黏合剂将上鼓室完全封闭。结果 150例术后观察3-5年,无继发性上鼓室严重内陷和继发性胆脂瘤,术后鼓膜再穿孔8例（5.33%)。97.5%上鼓室成形听力改善;80.8%上鼓室封闭 听骨链重建术听力改善,另21例未重建听骨链。结论 上鼓室封闭和上鼓室成型可以防止胆脂瘤复发。上鼓室外侧壁重建还可保证听骨链的正常活动空间。     

乳突尖部分切除加自体骨粉鼓室上壁重建在鼓室成形术中的应用

目的探讨面神经监护仪下乳突尖部分切除加自体骨粉鼓室上壁重建在鼓室成形术中的应用价值。方法 42例慢性化脓性中耳炎均行开放式鼓室成形术,其中22例行自体骨听力重建(自体骨组),20例行钛听骨重建(钛听骨组)。观察术后2组患者干耳率、干耳时间、外耳道形态、听力及并发症发生情况。结果 2组患者耳后切口均Ⅰ期愈合,术后无眩晕、面瘫、耳鸣等并发症发生;患者术后乳突腔上皮化好,无结痂,无鼓膜内陷粘连。自体听骨组和钛听骨组干耳率分别为95.5%(21/22)和95.0%(19/20),2组患者干耳率比较差异无统计学意义(P>0.05)。2组患者干耳时间比较差异无统计学意义(P>0.05);术前2组患者气导值和气骨导差值比较差异均无统计学意义(P>0.05);术后2组患者气导值和气骨导差值均显著低于术前(P<0.05);术后钛听骨组患者气导值、气骨导差值均显著低于自体听骨组(P<0.05)。结论面神经监测仪能有效识别暴露及薄骨管面神经,有利于预防术中面神经的损伤;乳突切除加自体骨粉鼓室上壁重建可获得良好的干耳效果,并可减少术后术腔结痂;钛听骨为良好的听骨链重建材料,在听力改善方面优于自体骨。     

Recent Advances in the Treatment of Deafness

By the utilization of reconstructive procedures (tympanoplasty), middle ear and mastoid infections can be eliminated with the acquisition of a clean, dry ear in about nine out of 10 cases, and hearing can be improved in about half of the patients so treated. Incapacitating attacks of Ménière's disease can be successfully treated in selected cases by labyrinthectomy, ultrasound destruction of the vestibular system, or streptomycin treatment. With the advent of the transistor, improved power packs and miniaturization, hearing aids have become more acceptable to patients with sensorineural hearing losses. The most successful procedure for the management of otosclerosis is the stapedectomy operation.     

Modification of closed tympanoplasty in middle ear cholesteatoma

Background Classic mastoidectomy and modified mastoidectomy are traditional surgical procedures for middle ear cholesteatoma with goals of eradicating diseases, creating dry ears and preventing severe complications. However, the drawback of these procedures is the lack of hearing improvement. Therefore, our study aimed to investigate the effects and safety of a modification of closed tympanoplasty for middle ear cholesteatoma. Methods Eighty-three patients were recruited in this study based on the following two criteria： each patient had middle ear cholesteatoma in one ear; the affected ears had a functional eustachian tube and had neither intracranial nor extracranial complications. All the patients received a modification of closed tympanoplasty which included ossicular reconstruction with total ossicular replacement prosthesis （TORP） or partial ossicular replacement prosthesis （PORP） and membrane repair with conchal cartilage-perichondral complex. Results All the 83 cases had dry ears with membranes healed within 4-6 postoperative weeks. After 6 postoperative months, there were 3 cases with re-perforation at the tympanic membrane center and after 1.5 postoperative years, there were 5 cases with cholesteatoma recurrence （6.02%）. Function tests after one postoperative year exhibited an improvement of pure tone audiometry （PTA） in 27 cases that was more than 30 dB, in 33 cases between 20-29 dB, 14 cases with improvement between 10-19 dB, and in 9 cases there was no improvement. Conclusions The modified closed tympanoplasty procedure for middle ear cholesteatoma in the present study has all the advantages of both close-cavity and open-cavity procedures. It has low recurrence rate and good hearing improvement.     

改良完壁式乳突切除术及鼓室成形术治疗慢性中耳乳突炎的疗效分析

目的:探讨改良完壁式乳突切除术及鼓室成形术治疗慢性中耳乳突炎的疗效。方法:对72例慢性中耳乳突炎患者行改良完壁式乳突切除术及鼓室成形术的治疗过程进行分析及总结。结果:术后观察患者6个月,胆脂瘤型、骨疡型、混合型术后气导、骨导平均听阈均显著大于术前;骨疡型术后听力改善比例最高,改善率为84.0%,其次为胆脂瘤型,改善率为71.0%,混合型最差,改善率为62.5%。3个月内全部干耳。结论:改良完壁式乳突切除术及鼓室成形术治疗慢性中耳乳突炎既能彻底清除病灶,又能尽可能地保留与中耳传声功能相关的组织结构,可早日干耳,提高听力。