乳突根治术后不干耳的原因及再根治手术要点分析

目的研究中耳炎患者乳突根治术后不干耳的原因，并分析乳突再根治手术的注意要点。 方法回顾性分析北京大学第三医院2013年9月至2020年1月收治的35例乳突根治术后不干耳患者的临床资料，包括详细病史、影像学资料、听力资料、手术情况、术后术腔和听力恢复等情况。 结果35例乳突术后不干耳患者全部行术前颞骨CT检查及纯音测听检查。34例患者（97.1%）本次手术行开放式乳突再根治术+鼓室成形术，1例（2.9%）行完壁式乳突再根治术+鼓室成形术，30例（85.7%）行耳甲腔成形术。术中发现所有患者前次手术均存在不同程度的乳突术腔开放不完全、病灶清除不彻底。有25例（71.4%）存在胆脂瘤复发，26例（74.3%）存在面神经嵴偏高。病变残留或复发位置主要位于上鼓室或上鼓室前腔、后鼓室、镫骨底板周围、圆窗膜或圆窗龛周围、中鼓室、鼓窦或鼓窦入口、面后气房、迷路周围气房等部位。所有35例患者术后均达到干耳，未再复发。 结论乳突根治术后不干耳的主要原因为：耳甲腔未成形，乳突术腔与外耳道口未形成合适的比例；前次手术为避免手术并发症，重要部位解剖暴露不充分，导致隐匿部位的胆脂瘤残留。乳突再根治手术应首选开放术式，轮廓化乳突形成碟形术腔，彻底清理隐匿部位的病变，磨低面神经嵴。

Infected mastoid cavity after radical mastoidectomy for otitis media: causes and key points in revisional radical mastoidectomy

Objective To investigate the causes of infected mastoid cavity after radical mastoidectomy in patients with otitis media,and to explore the key points in revisional radical mastoidectomy.Methods The clinical data of 35 patients with infected mastoid cavity after radical mastoidectomy for otitis media were retrospectively analyzed,including detailed medical history,imaging data,audiological data,surgical data,and postoperative recovery of the mastoid cavity and hearing.Results Among the 35 patients with infected mastoid cavity after radical mastoidectomy,34(97.1%)underwent canal wall down mastoidectomy and tympanoplasty,and 30(85.7%)underwent conchoplasty.During the operation,it was found that all patients had different degrees of incomplete mastoid profile and incomplete clearance of the lesions in the previous operation.There were 25(71.4%)cases of cholesteatoma recurrence and 26(74.3%)cases of high facial nerve ridge.The lesions were mainly located in the upper tympanum or the anterior tympanum space,in the posterior tympanum,around the base of the stapes,around the round window membrane or round window ridge,in the middle tympanum,in the tympanic antrum or the entrance,in the posterior air cells of facial nerve,and in the air cells around the labyrinth.After surgery,all the 35 patients had a dry mastoid cavity without recurrence.Conclusion The main reasons for infected mastoid cavity after radical mastoidectomy are:conchoplasty has not been performed in the previous operation,leading to a small ostium of the external auditory canal relative to the big mastoid cavity;some important anatomic areas are not exposed sufficiently for the purpose of avoiding surgical complications in the previous operation,leading to cholesteatoma residues in hidden areas.Canal wall down mastoidectomy is the first choice for revisional cases.The surgeon should profile the mastoid to form a saucer-shape cavity,thoroughly clean the lesions in hidden areas,and grind down the facial crest.