保留外耳道后壁上鼓室切开软骨重建术治疗中耳胆脂瘤

目的探讨在保持外耳道后壁完整的情况下,切除上鼓室外侧壁并软骨封闭治疗中耳胆脂瘤的疗效。方法2009年11月～2012年7月对123例（123耳）中耳胆脂瘤患者行保留外耳道后壁的乳突切开、上鼓室盾板切除及面神经隐窝向上鼓室开放,清除病变后行上鼓室软骨封闭及乳突腔填塞术,术后随访6～38个月,观察胆脂瘤复发、上鼓室回缩袋形成情况及听力提高水平,分析其疗效。结果123例中,2例中耳腔胆脂瘤复发,6例术后耳后切口感染,3例鼓膜边缘穿孔延迟愈合,2例人工听骨脱出,4例术后耳道后壁肿胀或皮肤缺损,其余病例术后换药2～3次后鼓膜、外耳道形态恢复,痊愈时间1个月。听力资料完整的83例（67．5％,83/123）中,0．5、1、2 kHz气骨导差术前平均32．2±11．25 dB ,术后平均20．69±12．41 dB ,手术前后气骨导差缩小11．59±10．1 dB（P＜0．001）。结论乳突切开同时保留外耳道后壁使耳道形态得以保留,术后恢复时间短;切除上鼓室外侧壁能够更充分暴露病变,病灶清除彻底;上鼓室外侧壁软骨封闭重建可有效防止回缩袋的形成,避免胆脂瘤复发。     

中耳胆脂瘤行乳突根治术中保留外耳道后壁完整性的意义

目的 探讨中耳胆脂瘤行乳突根治术中保留外耳道后壁完整性的临床意义及技巧.方法 2016年1月～2019年1月对140例(140耳)中耳胆脂瘤患者行乳突根治术,术中切除上鼓室盾板及开放上鼓室,清除病灶后行全人工听小骨或部分听小骨听骨链重建,耳屏软骨-软骨膜修补鼓膜,以耳屏软骨及骨片重建上鼓室外侧壁及外耳道后壁,保持外耳道...     

乳突鼓室成形伴上鼓室切开重建技术治疗胆脂瘤性中耳炎

目的 探讨胆脂瘤性中耳炎的外科治疗方法.方法 本文介绍了2009年11月-2010年7月在我院接受乳突鼓室成形伴上鼓室切开重建(Mastoidotympanoplasty with epitympanoplasty,EMT)手术的56例(耳),即在保留外耳道后壁切开乳突的前提下,同时进行上鼓室外侧壁的切除以彻底清除病灶,最后进行上鼓室乳突填塞并重建听力.本文初步报告了这一技术并对与此相关的外科处理策略进行临床评价.结果全部病例术后随访时间1～9个月,1例术后疼痛再次手术,2例术后感染鼓膜穿孔未愈合,2例术后鼓膜紧张部后上微小穿孔,其余病例术后愈合良好,术后换药2～3次即完全愈合,术后随访56例中26例听力资料完整,0.5、1、2 kHz气骨导间距由术前平均31.9 dB HL缩短到19.6dB HL.结论 保留外耳道后壁乳突切开同时切除术上鼓室外侧壁并进行重建,简化了经典完壁式手术的复杂操作,易于掌握;同时,手术保留的外耳道后壁使耳道形态得以保留,术后恢复时间短,减少了术后换药次数;上鼓室软骨填塞可有效的防止回缩袋的形成,避免了胆脂瘤的复发.该术式为治疗中耳炎性疾病提供了一种新的选择.     

重建上鼓室外侧壁的保留骨桥乳突切开鼓室成形术

目的探讨完桥式乳突切开鼓室成形术(intact-bridge tympanomastoidectomy,IBM)并用自体骨片重建上鼓室外侧壁的临床疗效。方法对48例(50耳)慢性化脓性中耳炎和中耳胆脂瘤患者采用IBM术式,清除病变后自体外耳道后壁骨片重建上鼓室外侧壁及听力重建,观察鼓膜愈合情况及听力提高水平,总结手术技术要点和术后疗效。结果术后随访3-21个月,干耳时间3-14周,平均6.7周;鼓膜穿孔愈合率92%(46/50耳),3耳因术后感染及1耳胆脂瘤上皮残留导致鼓膜穿孔不愈,经再次手术愈合。患耳的气导平均纯音听力(pure tone average,PTA)由术前53.7±6.9 d BHL提高到术后36.3±9.1d BHL,气骨导差(air-bone gap,ABG)由术前26.4±7.3 d BHL缩小到术后15.0±4.2d BHL,手术听力提高成功率(术后PTA-ABG≤20d BHL)为72%(36/50耳)。结论 IBM术式保留的"骨桥"对重建上鼓室外侧壁的骨片和鼓膜移植物起到支撑作用,结合上鼓室外侧壁重建保持了中上鼓室含气腔和正常外耳道后壁形态结构,减少术后鼓膜内陷袋形成,是中耳乳突手术的理想选择。     

外耳道后壁和上鼓室外侧壁重建并鼓室成形术的临床应用

目的探讨外耳道后壁和上鼓室外侧壁同期重建在鼓室成形术中的意义。方法30例（31耳）慢性化脓性中耳炎患者,骨性外耳道预先取骨备用。清除病灶后进行外耳道后壁和上鼓室外侧壁重建,并行I期行鼓室成形术。结果术后随访3个月～1年,31耳均获得干耳;外耳道形态接近正常,保留含气乳突腔。术后平均气导听阈提高〉20dB以上者22耳,提高10-20dB者8耳,提高〈10dB者1耳。结论同期行外耳道后壁和上鼓室外侧壁重建并I期行鼓室成形术,有助于修复乳突根治术后遗留的乳突空腔或大外耳道,有助于改善听力。     

利用自体耳屏软骨外耳道后壁重建术

目的　探讨开放式乳突根治术后外耳道后壁重建方法,寻找一种既能彻底清除病变,又能获得符合生理功能的外耳道及良好的术后听力的手术方式。方法　常规开放式乳突根治术后,利用自体耳屏软骨重建外耳道后壁,并行一期鼓室成形术。结果　随访1年以上,25耳外耳道形状及功能接近正常,2耳外耳道后上壁及上鼓室外侧壁部分塌陷及粘连;听力情况显效6耳,有效14耳,无效7耳,总有效率为74.1%。复发情况术后1例病变复发,复发率为3.7%。结论　开放式乳突根治术后利用自体耳屏软骨重建外耳道后壁,并行一期鼓室成形术,既能彻底清除病变,又能获得符合生理功能的外耳道及良好的术后听力,是一种治疗胆脂瘤型及骨疡型中耳炎比较合理的手术方式。     

改良完壁式鼓室成形术治疗上鼓室局限性阻塞性病变

目的探讨上鼓室局限性阻塞性病变的手术方法与疗效。方法 75例(88耳)上鼓室局限性阻塞性病变,其中胆脂瘤及内陷袋46耳,肉芽肿42耳。经上鼓室外侧壁进路,在颞线下自后上嵴至颧弓后根磨开骨壁,保留菲薄的外耳道后上骨壁和完好天盖,于后拱柱开放面神经隐窝,清除病变组织,修复或重建听骨链,疏通中、上鼓室气流通道,保留鼓窦乳突,完成改良完壁式鼓室成形术。结果术后鼓膜和外耳道完整。局限性上鼓室胆脂瘤及内陷袋患者平均语頻听力较术前提高15-25d BHL;慢性中耳炎上鼓室肉芽患者平均语频听力较术前提高15-30d BHL。随访5.0年未见胆脂瘤复发。结论改良完壁式鼓室成形术,进路便捷,再通气道,疗效满意。     

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.     

上鼓室胆脂瘤的临床治疗分析

目的分析胆脂瘤型中耳炎局限于上鼓室的临床表现与治疗方法。方法对186例(186耳)局限性上鼓室胆脂瘤型中耳炎行上鼓室开放术,据胆脂瘤侵蚀范围和听骨链受累情况分别进行处理。胆脂瘤未累及锤、砧关节,单纯去除胆脂瘤,保留听骨链完整性共89例。胆脂瘤侵蚀锤、砧关节共97例,清除胆脂瘤后,还要切除病变的锤骨头或砧骨,用人工听小骨架桥于锤骨柄与镫骨头之间重建听骨链。97例患者均用乳突皮质骨重建上鼓室外侧壁,颞筋膜修复鼓膜松弛部穿孔。结果 186例患者随诊1～3年,所有病例上鼓室外侧壁及鼓膜松弛部愈合良好。术后气骨导差<10 dB者32例,<20 dB者108例,<30 dB者39例,30 dB以上5例。该组病例声音传导功能基本保留或恢复,术后随访听力基本稳定,无胆脂瘤复发。结论上鼓室胆脂瘤在早期治疗的同时,据听骨链的受损情况进行听骨链重建手术,既可彻底清除病灶,又能保留和恢复听觉功能。     

钛网应用于开放式鼓室成形术32例

目的 探讨应用钛网重建外耳道后壁并上鼓室外侧壁开放式鼓室成形术中的手术疗效。方法 胆脂瘤型及骨疡型中耳炎患者32例（32耳）根治病灶后,均应用钛网重建外耳道后壁并上鼓室外侧壁,同期行开放式鼓室成形术。结果 术后30耳外耳道形态接近正常生理状态,29耳鼓膜移植物生长良好,干耳率90.62%,干耳时间平均（15.89±4.02）d。术后气导听力提高在15dBHL以上者27耳,区骨导差＜20dBHL者22耳。结论 应用钛网重建外耳道后壁并上鼓室外侧壁的开放式鼓室成形术,可较好地恢复外耳道和中耳的解剖结构和生理功能,患者听力提高远期效果显著。     

Epitympanoplasty with cartilage obliteration in the preservation of posterior canal wall: a technique for surgical treatment of attic cholesteatoma

To report and evaluate the surgical outcomes of the treatment of attic cholesteatoma using epitympanoplasty with cartilage obliteration in the preservation of the posterior canal wall. Our study group consists of 138 subjects with attic cholesteatoma who underwent surgery of the mastoidectomy of the intact posterior canal wall and epitympanoplasty with cartilage obliteration, from November 2008 to November 2010. The major techniques employed included the following: (1) mastoidectomy with the preservation of the posterior canal; (2) removal of the scutum; (3) epitympanum obliteration with cartilage, and (4) mastoid obliteration with bone dust. The post-operative observation period was between 2 and 4 years. All patients were examined via microscopy and oto-endoscopy. Of these 138 subjects, 91 subjects have a follow up period of more than 3 years. There was no retraction pocket formation in the epitympanum in all cases. However, in two subjects, there was a recurrence of cholesteatoma within the mesotympanum. Other observable post-surgery complications were also recorded. For hearing results, 64 of the 138 subjects underwent post-operative audiometric testing for 2 to 3 years and 3 to 4 years consecutively. The average pre- and post-operative air-bone gap closure was found to be 11.97 ± 11.02 dB for the 2 to 3 year period, and 10.08 ± 10.34 dB for the 3 to 4 year period. Based on the results of our study group, epitympanoplasty with cartilage obliteration in the preservation of the posterior canal wall is a better alternative treatment technique for attic cholesteatoma.     

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.     

耳软骨在中耳手术中的应用

目的 探讨软骨在中耳手术中的应用,以拓展手术范围,改善手术疗效。方法 (1)用自体软骨进行鼓膜修补;(2)在乳突根治术后应用软骨重建外耳道后壁;(3)治疗粘连性中耳炎。结果 (1)软骨组的鼓膜愈合率为93.4％,颞肌筋膜组为80％。两组的听力结果无显著性差异。(2)应用软骨重建外耳道后壁的43耳中有40耳一期愈合(93％),干耳时间平均为4.19+1.00周。对照组干耳时间平均为5.54+1.83周。二者有显著性差异。(3)41耳粘连性中耳炎术后平均骨气导差为27.9+10.7dB。共有18耳(43.9％)术后骨气导差<20dB。有26耳术后提高>15dB。术后24耳(56％)的鼓室接近正常。结论 (1)软骨是修补鼓膜穿孔的一种好材料。(2)应用软骨同时修补鼓膜并重建外耳道后壁,不仅能够缩短干耳时间,改善听力,而且免除了二次手术,明显改善了病人的生活质量。(3)应用软骨治疗粘连性中耳炎疗效有所提高,但要严格选择手术适应症。     

Reconstruction of the radical mastoid.

Open cavity techniques (radical mastoidectomy, canal wall down tympanomastoidectomy, modified radical mastoidectomy) are well established surgical procedures for the treatment of chronic otitis media. Despite their effectiveness in exteriorizing cholesteatoma, they are associated with a 20 to 60 percent incidence of persistent intermittent drainage. In an effort to eliminate this problem, we have employed a Palva flap and medial graft technique to reconstruct the mastoid cavity and middle ear space in those patients with chronically draining ears. Between 1987 and 1990, 28 patients underwent this procedure. Twenty-six of these (93%) had complete obliteration of the mastoid cavity and successful tympanic membrane reconstruction. Two of 28 (7%) had a persistent tympanic membrane perforation and intermittent drainage following their surgery. Based on these results, this procedure is effective in eliminating intermittent drainage associated with the open cavity techniques. The indications for this procedure, the specifics of the surgical technique, and the postoperative results are discussed.     

中耳乳突炎性改变对人工耳蜗置入的影响

目的：探讨中耳乳突炎性改变对人工耳蜗置入术的影响。方法：9例行人工耳蜗置入术患者均伴有中耳乳突炎性改变。1例乳突根治术后Ⅱ期行人工耳蜗置入及应用耳廓软骨一软骨膜复合物重建并加强后鼓室外侧壁及外耳道后壁;1例慢性中耳炎伴鼓膜穿孔Ⅰ期行人工耳蜗置入及应用耳廓软骨一软骨膜复合物重建鼓膜;3例隐性中耳乳突炎,Ⅰ期行改良乳突开放术并人工耳蜗置入术;3例硬化型乳突伴鼓室粘连,Ⅰ期行鼓室探查并人工耳蜗置入术;1例慢性中耳乳突炎伴松弛部内陷袋形成,Ⅰ期行上鼓室开放及软骨一软骨膜复合物重建上鼓室外侧壁并人工耳蜗置入术。结果：术中所有的电极均顺利置入,并经术中检测电极完好,电阻测试效果满意。术后伤口均甲级愈合,1个月后均开机成功。随访无并发症。结论：对于慢性中耳乳突炎的患者,若欲行Ⅱ期人工耳蜗置入术,Ⅰ期中耳乳突手术应尽可能保留相关解剖结构。对于隐性中耳乳突炎的患者在确保鼓窦乳突、上鼓室、咽鼓管口三处引流均通畅的前提下可行Ⅰ期人工耳蜗置入。对于病变局限的上鼓室胆脂瘤,有经验的术者可以选择Ⅰ期手术,但一定要慎重。感染因素很可能在乳突汽化不良及不明原因先天性感音神经性聋的发病中起着重要的作用。对于乳突硬化、乙状窦前移严重的患者可选择经外耳道鼓岬开窗。对于人工耳蜗置入术时的鼓膜修补术,上鼓室外侧壁或外耳道后壁重建选择软骨一软骨膜复合物可以提高成功率,加固鼓膜避免内陷及电极脱出。     

Mastoid obliteration with silicone blocks after canal wall down mastoidectomy

Objectives

To evaluate the usefulness of silicone blocks as graft material for mastoid cavity obliteration in the prevention of problematic mastoid cavities after canal wall down mastoidectomies.

Methods

Retrospective evaluation of 20 patients who underwent mastoid obliteration with silicone blocks between 2002 and 2009 at the Chonnam National University Hospital. The cases consisted of 17 patients with chronic otitis media with cholesteatoma and 3 patients with adhesive otitis media. The postoperative follow-up period was an average 49 months (range, 6 to 90 months). The surgical technique used at our institution composed four major steps: First, the canal wall down mastoidectomy was performed and the middle ear procedure was completed. The silicone blocks were used to fill up the mastoidectomized cavity. Then, a cortical bone pate was used to cover the surface of the silicone blocks. Finally, temporalis fascia and a split musculoperiosteal flap were used to surround the bone pate for reinforcement of the reconstructed canal wall. We examined postoperative success rate and hearing outcomes.

Results

In 19 cases (95%), the reconstructed canal wall maintained a cylindrical shape and the ear drum healed without perforation. In only 1 case (5%), the reconstructed canal wall was destroyed with ear drum perforation. The mean improvement in air-bone gap was about 12 dB (P<0.05), and the mean improvement in air-conduction was about 16 dB (P<0.05).

Conclusion

We suggest that silicone blocks could be valuable resources as graft materials for mastoid obliteration after canal wall down mastoidectomies.     

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...     

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。     

Surgical treatment of acquired external auditory canal atresia

Acquired atresia of the external auditory canal is a relatively rare disease, that can be the result of the recurrent external otitis, chronic media otitis, ear trauma, neoplasms or iatrogenic complications. The surgical treatment results after operation in the 7 patients with acquired external auditory canal atresia were presented. The mean age of the patients was 34.1 and the female to male ratio was 2:5. In 6 cases we performed transcanal operation. The meatus atresia was removed and then the stenotic canal was widened by removing the skin and fibrous tissue. We especially focused our attention on the state of the anterior angle of the tympanic membrane. The bony canal was widened by burr in cases with bony overhangs. The bony canal walls were lined with pediculate or free skin grafts. In cases of tympanic membrane perforation we performed myringoplasty with temporal muscle fascia or tragus perichondrium. The follow-up period was from 8 to 39 months. The hearing improvement with primary closure of air bone gap within 20 dB was achieved in 43% of cases. In 28% of the patients recurrent atresia developed. The early surgical treatment is recommended in all the cases because cholesteatoma behind the atresia was found in 28% of patients.     

角化细胞生长因子及受体在鼓膜穿孔邻近皮肤的研究

目的观察鼓膜穿孔部位邻近皮肤中角化细胞生长因子（keratinocyte growth factor,KGF）及其受体角化细胞生长因子受体（keratinocyte growth factor receptor,KGFR）的表达情况,分析其在慢性化脓性中耳炎不同转归中的作用。方法应用免疫组化SP染色方法和多媒体图像分析系统,观察20例继发性胆脂瘤型中耳炎鼓膜穿孔部位邻近皮肤、胆脂瘤上皮以及耳道深部正常皮肤的KGF和KGFR表达,并和20例非胆脂瘤型中耳炎鼓膜穿孔部位邻近皮肤作对比。结果胆脂瘤型中耳炎鼓膜穿孔邻近皮肤KGF和KGFR的阳性表达率分别为（33.135±6.364）%和（19.965±10.570）%,介于胆脂瘤上皮与耳道正常皮肤之间,明显高于非胆脂瘤型中耳炎患者相应部位（19.380±2.827）%和（13.145±7.935）%。结论KGF和KGFR在慢性化脓性中耳炎不同部位的表达依次上升,在胆脂瘤型中耳炎鼓膜穿孔邻近皮肤的表达明显高于非胆脂瘤型中耳炎,说明胆脂瘤型中耳炎该处皮肤增生更活跃。