RU2355369C2 - Mastoidoplasty technique - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: substance of the method consists in application of muscle pedicle flap to refill mastoid cavity after sanitising stage of middle ear surgery. Skin of temporal region is additionally dissected along the muscle fibres therethrough a pedicle flap is cut out from posterior one-third temporal muscle being sized as required by operative conditions and thereafter being unfolded to refill postoperative mastoid cavity. Then parotid and temporal wounds are closed completely.

EFFECT: complete closure of mastoid cavity, recurrence prevention and hearing improvement.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in the surgical treatment of mastoiditis and chronic purulent otitis media.

From the practice of otorhinolaryngology, many methods of surgical treatment of chronic purulent otitis media are known. The most common of them: radical surgery on the middle ear (Preobrazhensky Yu.B. Essays on the history of radical ear surgery (over a 100-year development) // West Otorhinolar. - 1992. - No. 4. - P.39-42), operations performed according to the "open method" - conservatively radical, modified radical, radical with tympanoplasty, etc. (Borisenko O.N. Clinical and experimental substantiation of surgical treatment methods for patients with chronic purulent otitis media: Abstract of thesis. Dr. med. Sciences. - Kiev, 2001), and performed by the "closed method" - and stroke channel mastidectomy (Atlas of operative otorhinolaryngology. / Ed. by prof. V.S. Pogosov. - M .: Medicine, 1983, 416 p.), separate atticoantrotomy with tympanoplasty, etc. (Gusakov A.D. Reconstruction of the sound-conducting apparatus with closed variants of functional reconstructive operations in patients with chronic purulent otitis media: Abstract of a thesis of a doctor of medical sciences. - Zaporozhye, 1985. - 42 p.).

Negative properties of large trepan cavities (long healing, difficulty in leaving, tendency to relapse, etc.) (Tolstov Yu.P., Anikin IA On the clinical significance of the state of a trephine cavity in patients undergoing radical surgery on the middle ear // Bulletin of otorinolar . - 1999. - No. 1. - P.44-46) prompted otosurgeons to develop "sparing" sanitizing operations with an endaural and behind-the-ear approach, preserving the posterior bone wall of the external auditory meatus (Korvyakov BC Surgical treatment of patients with inflammatory diseases cf closed ear // XYII Congress of Otorhinolaryngologists of the Russian Federation (abstracts). - Nizhny Novgorod, 2006. - S.315-316). However, practical experience has shown that the inflammatory process recurs in a poorly drained mastoid part of the cavity (Bystenin V.A., Bystenina L.V. Ensuring a complete and persistent sanitizing effect is the main requirement for operations performed with epitympanitis // Vestnik otorinolar. - 1999. - No. 3. - S.31-32). In addition, with primary tympanoplasty without reducing the mastoid cavity in closed operations, high functional and morphological results are preserved only in the near future after the operation. After 10-12 months, in 1/5 of the patients, due to atrophy of the soft tissues of the posterior wall of the external auditory meatus and neotympanic flap, retraction pockets begin to form. They depend on the size of the mastoid bone cavity included in the airway non-tympanic system, which is formed as a result of the carious process and measures to eliminate it (Melanyin V.D., Khorov O.G. Formation of the middle ear cavity in primary tympanoplasty // Bulletin of otorinolar. - 1999 . - No. 2. - S.46-47).

The desire to reduce the volume of the trepan wound led the surgeons to perform mastoidoplasty with filling the cavity with bone (Bogdanova T.V. The use of autobone in mastoidoplasty in patients with chronic otitis media // Vestnik otorinolar. - 1974. - No. 6. - P.33-35), cartilaginous (VD Melanyin, Long-term results of mastoidoplasty with formalized homogond cartilage // West. Otorhinolar. - 1975. - No. 5. - P.11-14), muscle tissue (Paparella MM, Kim CS Mastoidectomy Update // Laringoscope 1977; 87: 12: 1877-1988), alloplastic materials (Dragneva M.K. Antrit, mastoiditis and chronic otitis media. - Chisinau: “Štinza”, 1992. - 136 c).

The prototype of the proposed method can be considered an operation (Khorov O.G., Bulatsky A.V. Method of mastoidoplasty for the elimination of cavities in acute mastoiditis // Rat proposal of the Grodno Regional Clinical Hospital No. 1907 of 03/28/2000 / see http: // www. med.by/dn/book), which consists in the use of a muscular-periosteal flap in the form of a bridge on two legs, taken from the behind the ear, and allogeneic cartilage with combined mastoidoplasty of the bone cavity.

The disadvantages of the prototype include:

- the small thickness of the formed flap does not allow to fill the mastoid cavity of a large volume;

- lack of muscle tissue requires additional filling of the mastoid cavity with allogeneic cartilage, which does not exclude its sequestration and relapse of inflammation at a new qualitative level;

- the presence of two feeding legs makes the formed flap rigid, poorly displaceable, which makes it difficult to fit into the cavity of the mastoid process with incomplete filling and the formation of unnecessary voids.

The aim of the invention is the prevention of relapse and improving hearing in the surgical treatment of mastoiditis and chronic suppurative otitis media.

The goal of the invention is achieved by the fact that after the sanitizing stage of the operation on the skin of the temporal region, an additional incision is made along the muscle fibers, through which a flap on the leg of the size that is required by the surgical situation is cut out from the back 1/3 of the temporal muscle, and then deployed and they fill the postoperative mastoid cavity, after which the wounds in the behind-the-ear and temporal areas are sutured tightly.

To study the possibility of forming a flap from the temporal muscle and applying it to mastoidoplasty, we studied the anatomical features of the muscle on sectional material, depending on the structure of the skull. The length, width and blood supply of the formed flap were assessed for 17 cadavers: 4 brachycephalus, 8 normocephalus and 5 dolichocephalus. It was established that the maximum possible length of the muscle flap formed ranged from 6.9 to 8.1 cm and depended not on the type of structure of the skull, but on gender and age. Even with a minimal flap length, it was enough with a margin to completely fill the mastoid cavity. In addition, in more than 70% of cases, a major blood vessel a.temporalis profudae was found in the posterior 1/3 of the muscle, topographically corresponding to the formed leg.

The essence of the invention is illustrated in figures 1, 2, where:

1. Skin wound in the temporal region

2. The temporal muscle

3. Flap on the feeding leg, formed from the back 1/3 of the temporal muscle

4. Feeding foot

5. Aditus and posterior tympanum

6. Postoperative mastoid cavity

The proposed method is performed as follows: under intubation anesthesia, an incision is made in the skin and soft tissues in the behind-the-ear area at the place of attachment of the auricle. Soft tissues are separated, the site of the mastoid is exposed. A mastoid process is performed. The sanitizing stage of the operation is performed with the removal of pathologically changed tissues, the formation of a mastoid postoperative cavity (6) and preservation of the posterior wall of the ear canal ("closed" version of the sanitizing operation) (Fig. 1). Through the aditus (5), an audit of the tympanic cavity and the sound-conducting circuit is carried out. Doubts about the usefulness of the rehabilitation of the tympanic cavity are interpreted in favor of endaural tympanotomy. The rehabilitation phase ends with one of the types of tympanoplasty. Next, a linear skin incision is made in the projection of the temporal muscle along its fibers, 1.5-2.0 cm higher than the behind-the-ear incision, about 4-5 cm long (1). Under the superficial fascia, both sections are combined. A flap (3) is formed from the back 1/3 of the temporal muscle (2) on the feeding leg (4) 5-7 cm long, depending on the operating situation and the width corresponding to the width of the mastoid cavity. The flap is deployed, held under the superficial fascia and fits into the mastoid cavity (figure 2). To prevent it from “popping up”, a muscle flap is sutured with catgut to the soft tissues of the ear region. Wounds are sutured in layers tightly (1).

Thus, due to the sufficient thickness and length of the formed muscle flap, it is possible to completely close even the voluminous mastoid cavity. The flap from the temporal muscle, having good blood supply, does not undergo resorption and retains its physiological activity, starting to contract during chewing, squeezing the wound exudate into the auditory tube. This circumstance allows the sound-conducting cavities of the middle ear to quickly cleanse of exudate, preventing the development of relapse of inflammation and pathological scarring with the development of tympanofibrosis. This is especially important in the treatment of patients from remote rural areas, the dynamic monitoring of which is difficult, and the preservation of the mastoid cavity due to the inability to control it determines the development of "diseases of the operated ear."

Our proposed method was introduced into the work of the ENT department of the Alexander Mariinsky Regional Clinical Hospital in Astrakhan and was used in the treatment and rehabilitation of 7 patients with chronic purulent otitis media. The following are examples of testing.

Example 1. Patient K., 23 years old, a resident of the Ikryaninsky district, was admitted to the ENT department of the Alexander Mariinsky Regional Clinical Hospital on November 24, 2005 (No. history 19200) with DS: Exacerbation of left-sided chronic purulent mesotympanitis. When otoscopy: in the left ear canal, moderate mucopurulent discharge, the eardrum is brightly hyperemic, infiltrated, a central defect of up to 2 mm in diameter is determined. CT scan: against the background of the sclerotic type of the structure of the mastoid process, a destructive cavity with sequestration was determined. On the audiogram - hearing loss in the left ear as a violation of sound conduction with conductive discontinuity at conversational frequencies of 15-25 dB. Whispering speech on the left ear 2.5 m, conversational -5 m. Considering objective and CT data on December 1, 2005, a sanitizing operation was performed on the left middle ear with tympanoplasty type I (the defect is covered by the fascia of the temporal muscle) and mastoidoplasty according to the method described above . Formed flap on the leg of the temporal muscle completely filled the mastoid cavity. The postoperative period is smooth, the sutures are removed on the 8th day, wound healing by primary intention. The perforation of the eardrum is completely closed. It was observed in dynamics for 6 months. The inflammatory process did not recur, in place of the former defect of the tympanic membrane, scar tissue. On the audiogram, hearing improvement in colloquial frequencies by 5-15 dB, whispering began to be perceived from 4.5 meters, colloquial speech from 6 meters. During the control X-ray of the temporal bones according to Schuller and Mayer, the mastoid cavity is filled with homogeneous homogeneous tissue, its bone walls without signs of inflammatory destruction.

Example 2. Patient T., born in 1949, resident of the Liman region, was hospitalized on a planned basis on November 14, 2005 (No. of source. 18448) with DS: Left-sided chronic epithympanitis. With otoscopy in the left ear canal, a slight purulent discharge, in the posterior upper quadrant, an edge defect of up to 2 mm in diameter. An X-ray examination against the background of a small, sclerotic type of structure of the mastoid process revealed a destructive cavity with destruction of the upper wall of the antrum. On the audiogram, hearing loss in the left ear as a violation of sound conduction by 15-20 dB, whispering in the left ear 3 meters. On November 22, 2005, according to the method described above, under anesthesia, a sanitizing operation was performed on the left middle ear with mastoidoplasty and tympanoplasty. Operational findings - a destructive mastoid cavity with extensive destruction of the roof of the antrum and exposure of the dura mater in an area of 1.5 × 1.0 cm.The formed muscle flap on the leg filled the entire mastoid cavity to the antrum and completely covered the exposed dura mater. The postoperative period is smooth. Dynamic observation for six months. The eardrum defect was closed, there was no recurrence of epithympanitis, and hearing in whispered speech on the operated ear improved by 1 meter. During X-ray control in the mastoid cavity, no signs of bone inflammatory destruction were noted, the cavity was filled with homogeneous homogeneous tissue.

When performing our proposed surgical intervention, it is possible to achieve:

- complete filling of the mastoid cavity with the temporal muscle on the feeding leg, which does not require additional mastoidoplasty techniques using allogeneic tissues;

- the muscle flap on the feeding leg is mobile, easily unfolds and fits into the formed postoperative cavity;

- anatomical and topographic parameters allow you to cut a muscle flap of any thickness and length, as required by the operating situation;

- good nutrition of the flap provides its functionality and good adaptation;

- a muscle flap, like a well-vascularized tissue, significantly improves microcirculation in the operated ear, which creates favorable conditions for regeneration and microbiocenosis;

- chewing activity of the temporal muscle allows the flap to contract and push the wound exudate into the tympanic cavity, and then, through the auditory tube, into the nasopharynx, thus preventing stagnation of the exudate and the possibility of inflammation;

- the possibility of covering with a muscle flap bone destructive defects that expose the lining of the brain, and preventing the formation of meningeal hernias.

Claims (1)

Method of mastoidoplasty, consisting in the use of a muscle flap on the leg to fill the cavity of the mastoid process after the sanitizing stage of the operation on the middle ear, characterized in that an additional incision is made along the muscle fibers on the skin of the temporal region, through which a flap is cut from the back 1/3 of the temporal muscle on a leg, of such sizes as the operating situation requires, which is then deployed and filled with a postoperative mastoid cavity, after which I suture the wounds in the behind-the-ear and temporal areas t tightly.

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