局限性上鼓室胆脂瘤的临床分型与治疗初探

目的：探讨局限性上鼓室胆脂瘤型中耳炎临床分型与治疗方法。方法：对21例（21耳）局限性上鼓室胆脂瘤型中耳炎行上鼓室凿开术，根据胆脂瘤侵蚀范围和锤、砧关节是否受累分型处理。胆脂瘤范围仅达锤、砧关节表面，而未累及锤、砧关节为Ⅰ型共5例患者，仅彻底去除胆脂瘤，保留完整的听骨链。胆脂瘤侵蚀范围超过锤、砧关节达上鼓室前间隙且锤、砧关节受累者为Ⅱ型共16例，除彻底清除胆脂瘤外，还要切除病变的锤骨头及砧骨，用人工听小骨（PORP）架桥于锤骨柄与镫骨头之间重建听骨链。21例患者均用带软骨膜的耳屏软骨重建上鼓室外侧壁，其软骨膜修复穿孔的鼓膜松弛部。观察术后上鼓室外侧壁和鼓膜愈合及听力恢复情况。结果：21例患者随诊1～5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 10例，〈20 dB 7例，〈30 dB 3例，30 dB以上1例。该组病例的传音功能基本保留和恢复，术后随访听力基本稳定，无眩晕及耳鸣等并发症。结论：局限性上鼓室胆脂瘤需早期诊断，再分型处理，既可彻底清除病灶，又能保留和恢复传音功能，值得探讨。

Clinical classification and treatment of localized attic cholesteatoma

OBJECTIVE: To investigate the clinical classification and treatment of localized attic cholesteatoma through surgical management. METHOD: Twenty-one patients (21 ears) of localized attic cholesteatoma accepted atticotomy. Then different surgical managements were carried out according to the extent of cholesteatoma and whether the malleo-incudal joint was destroyed or not. If the cholesteatoma has only reached the surface of the malleo-incudal joint, it was regarded as type I (5 patients). To this type, the cholesteatoma was removed and the ossicular chain was preserved. If the cholesteatoma has entered the anterior attic space and destroyed the malleo-incudal joint, it was regarded as type II (16 patients). Besides the removing of cholesteatoma, the head of malleus and incus should be removed also in this condition. Then reconstruction of the ossicular chain was performed by putting PORP artificial auditory ossicles between the manubrium mallei and stape. In all these 21 patients, the lateral wall of attic was reconstructed with the cartilage of tragus. The perichondrium of the cartilage was used to repair the perforation in the non-vibrans membrane. Healing of the lateral wall of attic and the tympanic membrane and recovery of hearing level were investigated after the operation. RESULT: The follow-up period lasted 1 year to 5 years. Healing of the lateral wall of attic and the tympanic membrane were satisfying in all 21 patients. According to the pure tone audiometry after the operation, A-B gap was less than 10 decibel in 10 patients,less than 20 decibel in 7 patients, less than 30 decibel in 3 patients, and over 30 decibel in only 1 patient. Acoustic transmission function was preserved or reconstructed. No vertigo or tinnitus happened after operation. CONCLUSION:Diagnosis of localized attic cholesteatoma should be made early. If it can be treated by clinical classification properly, not only the removing of clolesteatoma, but also the reservation and recovery of acoustic transmission fanction can be obtained. It is worthy of further discussion.