RU2849864C1 - Method of surgical treatment of cholesteatoma of the temporal bone using a water jet hydrodissector - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: In the first stage, access to the lesion is provided. At the second stage, under visual microscopic control, the cholesteatoma is separated from the bone structures using a water jet dissector. The distance from the end of the nozzle to the working surface is 2 cm, the pressure for the nozzle is 50-80 bar, and the angle of the water jet is 45°. Then, the cholesteatoma matrix is separated from the vascular structures and the dura mater using the following parameters. When working in the area of the internal carotid artery wall and the dura mater, the nozzle pressure is 10-30 bar, the duration is 20 seconds, and the angle is 45°. When working in the area of the wall of the internal jugular vein, the pressure for the nozzle is 5-10 bar, the duration is 15 seconds, the angle is 35°, and the distance from the end of the nozzle to the working surface is 3-5 cm.

EFFECT: method reduces the risk of recurrence of cholesteatoma of the temporal bone in the postoperative period and minimises the degree of intraoperative damage to the vital structures of the middle and inner ear and the vascular-nerve structures.

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Description

The invention relates to the field of medicine, namely to otolaryngology, and can be used in the surgical treatment of cholesteatoma of the petrous bone and cholesteatoma of the middle ear.

Cholesteatoma is an epidermoid cyst that can develop in various parts of the temporal bone and can be either congenital or acquired. Acquired cholesteatoma is most often associated with a defect in the eardrum and is localized in the middle ear (affecting the tympanic cavity and mastoid cells). Congenital, and in some cases acquired, cholesteatoma extends into the supra- and infralabyrinthine cellular tracts, which can ultimately lead to damage to the petrous portion of the temporal bone and vascular-nerve structures (facial nerve, internal carotid artery, jugular bulb, internal auditory canal, and petrous apex) – the formation of petrous cholesteatoma (PTC). A petrous cholesteatoma tends to aggressively destroy the bony structures of the petrous ridge, clivus, sphenoid sinus, nasopharynx, and infratemporal fossa, sometimes with intradural spread. Symptoms of a petrous lesion are varied: hearing loss, ear fullness, dizziness, ear discharge, headaches, facial paralysis, earache, and tinnitus.

All patients with temporal bone cholesteatoma undergo a complete oto- and audiological examination. If extension into the supra- and infralabyrinthine cellular tracts and the formation of CPVC occurs, additional assessment of cranial nerve function (V-VIII) is required. Preoperative temporal bone imaging should be performed using additional imaging modalities, such as CT of the temporal bones and MRI of the temporal bones and brain, including NONEPIDWI.

Currently, the only treatment for temporal bone cholesteatoma is surgical. Surgery is usually elective, but necessary to prevent complications. The main stages of surgery are typically performed microscopically, but endoscopic assistance has become increasingly common in clinical practice over the past decade. Complete removal of the pathological process requires the use of appropriate surgical approaches that allow visualization of all involved areas of the surgical cavity. However, even this approach does not always allow for complete removal of the cholesteatoma matrix; there is a high risk of leaving residual cholesteatoma due to its high adhesive capacity.

A known method for removing cholesteatoma of the temporal bone using microscopic technology by mechanically removing the cholesteatoma matrix from the structures of the temporal bone with sharp microsurgical instruments and a drill (Glasscock ME 3rd, Miller GW, Drake FD, Kanok MM. Surgery of the skull base. Laryngoscope. 1978 Jun; 88 (6): 905-23. doi: 10.1288/00005537-197806000-00002. PMID: 651507), consists in the fact that with the help of cutting and diamond burs, the stages of access to the pathological process are performed by sawing off the bone. Next, mechanical removal of the pathological process from the bone and vital structures of the temporal bone is performed with the help of micro instruments. This method allows for rapid access to the lesion with the most optimal viewing angle of the affected area, elimination of cholesteatoma of the temporal bone, preservation of vital structures through manipulation and maneuvers with tissues, carrying out possible reconstruction, performing hemostasis, and completing the operation in its various variants.

Disadvantages of this technique include the fact that mechanical removal and manipulation of the cholesteatoma mass penetration zone is not always possible due to the limited accessibility of certain areas by vital structures (the geniculate ganglion, labyrinthine and tympanic portions of the facial nerve, the internal auditory canal with the acoustic-facial bundle from its base to the internal auditory opening, the microvascular center, and large vascular structures (ICA, CC, LAV). Furthermore, the use of sharp instruments required to remove epidermis from the surface of anatomical structures can lead to their trauma.

A known method for removing the pathological process of the temporal bone using piezoelectric technology (Lyutenski S, Lieder A, Bloching M. Piezoelectric ear surgery: a systematic review. HNO. 2023 Aug; 71 (Supp11):10-18. English, doi: 10.1007/s00106-022-01211-8. Epub 2022 Oct 7. PMID: 36205754), consists in the fact that, based on the piezoelectric effect, electrical energy is converted into ultrasonic vibrations at the tip of the instrument with a frequency of 25-30 kHz and an amplitude of 20-200 μm, which dissects mineralized tissue. Ultimately, mechanical shock waves cause microdisintegration of the bone surface and this method allows access to the lesion.

The disadvantages of this technique include slow bone removal, additional costs (it is necessary to have several different inserts on hand at the same time, since the inserts are intended for single use), and the incompletely studied effect of piezoelectric microvibrations on the inner ear.

The closest analogue of the claimed invention is a method for the surgical treatment of temporal bone cholesteatoma using a diode laser (Patent RU 2777241 C1), which consists in the fact that after surgical access, the cholesteatoma matrix is exposed to laser radiation by vaporization of a 445 nm wavelength, a power of 1-2 W, non-contact in a pulsed mode with a duration of 20-40 ms, the time between pulses is up to 100 ms. The advantages of this method include the ability to ensure the removal of the pathological process, prevent damage to the surrounding vascular and nerve structures, minimize the risk of recurrence of cholesteatoma of the petrous bone in the late period, improve the results of work with respect to hearing and the facial nerve, and reduce the patient's hospital stay due to the effect of laser radiation on the cholesteatoma by vaporization.

The disadvantages of this method include the use of laser radiation, which can have an adverse effect on the surgeon's retina. Vaporization of the cholesteatoma matrix from the vessel walls is an adjunct method for removing pathological tissue. The laser does not have sufficient penetrating power to remove the cholesteatoma matrix from the cellular structures of the temporal bone. Prolonged laser exposure to the anatomical structures of the temporal bone can lead to thermal injury to the inner ear structures, potentially leading to sensorineural hearing loss.

The objective of the invention is to develop a method for the surgical treatment of cholesteatoma of the temporal bone, in which the degree of intraoperative damage to the vital structures of the middle and inner ear, vascular and nerve structures is minimal.

To solve this problem, we propose a method for removing cholesteatoma of the petrous bone, which consists of the following: at the first stage, access to the lesion is achieved; at the second stage, under visual microscopic control, hydroseparation of the cholesteatoma from the bone structures is carried out using a water-jet dissector; the distance from the end of the nozzle to the working surface is 2 cm, the pressure for the nozzle is 50-80 bar, the angle of the water jet is 45°,

Then, the cholesteatoma matrix is separated from the vascular structures and the dura mater of the brain using the following parameters: when working in the area of the wall of the internal carotid artery and the dura mater, the nozzle pressure is 10-30 bar, the duration is 20 seconds, the angle is 45°; in the area of the wall of the internal jugular vein, the nozzle pressure is 5-10 bar, the duration is 15 s, the angle is 35°, the distance from the end of the nozzle to the working surface is 3-5 cm.

The technical result of the invention is as follows.

Our proposed method utilizes a portable waterjet dissector (the ERBEJET 2 Waterjet Dissector with accessories). The device is certified in the Russian Federation (RU FSZ 2008/02050, registry entry number 32972) and has the following technical specifications:

The dimensions of the device are no more than 410 * 130 * 370 mm, the weight of the device is no more than 11 kg, the monitor is not less than 110 × 60 mm, the pressure range for the nozzle is 1-80 bar (+ 20%), (100 - 8000 kPa), the flow rate of the medium is 1-55 (+ 10%) ml / min, pressure generation is possible using a sterile disposable two-piston pump, the cutting medium is sterile saline solution, there is an automatic adjustment of the suction system from -100 to -800 mbar (+ 50 mbar), sterile applicators, the diameter of the applicator nozzle is 120 μm.

The waterjet dissector system is simple and easy to use. It allows for customized settings for different tissues, adjustable cutting time, power, and distance, and program storage. Remote control is available via a footswitch with the ReMode function.

The applicators provide a clear view of the surgical field (the ergonomic shape and length of the tubes) and reduce surgical time due to irrigation and simultaneous aspiration. Due to the physical properties of biological tissue, the jet precisely and anatomically dissects the boundaries between different tissue structures. The kinetic energy of the water jet gently separates tissue layers, ensuring intact edges of healthy tissue in contact with the cholesteatoma due to the absence of heating and subsequent tissue necrosis.

The method is carried out as follows.

The first stage involves accessing the lesion. In the second stage, a waterjet dissector is used to separate the cholesteatoma matrix from healthy tissue using a water jet with adjustable water pressure at the interface. Sterile saline 0.9% NaCl is used as the separating medium, and a single-stage suction program is implemented using a separate module with pressure regulation up to 800 mbar. The cholesteatoma is separated from the bone structures in a contactless, continuous mode with an unlimited exposure time required for removal, and the cholesteatoma edges are visualized using microsurgical techniques. The distance from the nozzle tip to the working surface is 2 cm, the jet power is 50-80 bar, the angle of the water jet relative to the working surface is 45-90°, and the nozzle diameter is 120 μm. The maximum possible safe pressure value for a nozzle on a bone surface can reach 80 bar.

Then the cholesteatoma matrix is separated from the vascular structures and the meninges in a contactless, continuous mode with limited exposure time and a specified angle between the water jet and the working surface (on the wall of the internal carotid artery and the dura mater, the duration is 20 seconds, the angle is 45°; on the wall of the internal jugular vein, the duration is 15 seconds, the angle is 35°), the distance from the end of the nozzle to the cholesteatoma is from 3 to 5 cm, the power of the cutting jet depends on what the hydrodissector acts on (on the bulb of the jugular vein - 5-10 bar, on the internal carotid artery of the petrosal part - 10-40 bar, the dura mater of the posterior and middle cranial fossa - 10-30 bar). When working on vascular structures and the dura mater, in addition to the power, 2 additional factors are of great importance: exposure time, angle of action - which are inversely proportional to the power. Once the main stage of sanitation is completed, hydro-separation of hard-to-reach areas is carried out in a contactless, continuous mode, where the duration of exposure, distance, angle of exposure, and power are selected depending on which anatomical structures are the boundaries of a given area.

After complete removal of the cholesteatoma, the third stage is revision using endoscopic and microsurgical techniques, the fourth stage is reconstruction of the anatomical structures of the middle ear or obliteration of the middle ear cavity with autofat or automuscle, at the fifth stage, tympanoplasty is performed using autofascia using the underlay technique, the preserved skin of the external auditory canal is laid out over the fascia or suturing of the external auditory canal using the cull de sac technique.

Taking into account the factory parameters of the waterjet dissector, we selected settings (exposure time, distance from the end of the nozzle to the edge of the cholesteatoma and the working surface, water jet power, angle between the water jet and the working surface, nozzle diameter) that achieve a minimal degree of intraoperative damage to vital structures of the middle and inner ear, vascular-nerve structures, reducing the percentage of possible complications.

The developed method for removing cholesteatoma of the temporal bone (middle ear, with infra- and supralabyrinthine extension and cholesteatoma of the petrous temporal bone) is a minimally invasive microsurgical method that will reduce the percentage of recurrence of cholesteatoma of the temporal bone due to the possibility of sanitation of hard-to-reach areas.

The invention is illustrated by the following examples.

Clinical example No. 1

Patient M., 6 years old, was admitted to the otolaryngology (pediatric) department of the Federal Medical and Biological Agency of the National Medical Research Center of Oncology with a diagnosis of chronic bilateral purulent otitis media.

According to the legal guardian, the child has been under the care of an ENT specialist at his place of residence since 2023 with a diagnosis of chronic bilateral purulent otitis media. Conservative therapy has been ineffective.

Otoscopy reveals the retroauricular region and auricle are unremarkable. The external auditory canal is wide and filled with purulent discharge (a culture was taken and cleared). A polyp is obstructing the lumen of the external auditory canal. The eardrum is not visible. There are no signs of facial muscle paresis. There is no spontaneous nystagmus.

A CT scan of the temporal bones reveals signs of bilateral chronic otitis media. On the right: total opacification of the tympanic cavity and mastoid air cells.

Magnetic resonance imaging of the brain reveals signs of impaired pneumatization of the mastoid process cells and the tympanic cavity on the right and left sides due to inflammatory changes. Signs of cholesteatoma of the right temporal bone are also present.

According to the data of tonal audiometry, right-sided conductive hearing loss of the second degree is determined.

Surgery was performed under endotracheal anesthesia using the NIM 3.0 facial nerve monitoring system. The surgical field in the retroauricular area was prepared with an alcohol skin antiseptic. Under microsurgical control (Zeiss surgical microscope), an arcuate incision of the skin and subcutaneous tissue was made in the retroauricular area. Hemostasis was achieved. Next, an incision was made between the soft tissues and periosteum parallel to the first incision. The soft tissues and periosteum were separated with a raspater, and the soft tissues were spread apart with a retractor. Through the surgical approach, the fascia of the temporal muscle and a plate of autologous cartilage with perichondrium were harvested and prepared for the reconstructive stage of the surgery. The skin of the posterior wall of the external auditory canal was detached with a microraspater. Canaloplasty was performed with cutting and diamond burs, and the auditory canal was dilated (in the area of the anterior-superior wall, cells of the zygomatic tract filled with cholesteatoma were exposed). The skin of the ear canal was separated from the inferior, posterior, and superior walls of the bony portion of the external auditory canal down to the fibrous ring using a microraspater. The remnants of the tympanic membrane, along with the fibrous ring, were separated and retracted anteriorly. Examination of the tympanic cavity revealed that it was filled with cholesteatoma and was cleaned. A cholesteatoma surrounded the remnants of the malleus and incus, extending toward the attic. An atticotomy was performed using diamond burs. Next, a separate antromastoidectomy was performed from the cortical layer of the mastoid process. A bony defect in the roof of the mastoid cavity was present. The cells of the mastoid process, antrum, attic, and additus were filled with cholesteatoma. The cholesteatoma was removed from the attic and sent for histological examination. The remnants of the malleus and incus were removed along with the cholesteatoma mass. A posterior tympanotomy was performed, and the facial and tympanic sinuses were cleared of cholesteatoma. The stapes was lysed. Extension of the cholesteatoma into the infralabyrinthine tract was determined. Using a hydrodissector, the cholesteatoma mass, zygomatic process cells, perilabyrinthine cells, antrum, and mastoid cavity were removed under visual microscopic control, with simultaneous aspiration of the cholesteatoma masses. Next, using a contactless hydrodissector in a continuous mode with unlimited exposure time, the distance from the tip of the nozzle to the cholesteatoma was 2 cm, the nozzle pressure was 80 bar, the angle of the water jet and the working surface was 45°, the cholesteatoma masses were removed from the promontory wall of the tympanic cavity under visual microscopic control with simultaneous aspiration of the cholesteatoma masses. The footplate is intact and mobile. The cochlear window area is normal. Movement between the windows is preserved. The facial nerve canal was revised: the facial nerve is in the bony canal along its entire length. Next: an autochondral columella was installed on the footplate of the stapes; plastic surgery of the lateral wall of the attic and the smoothed posterior wall of the external auditory canal was performed with an autochondral plate; the defect of the middle cranial fossa was closed with a fragment of autochondral cartilage; The autologous fascia was placed under the fibrous layer of the eardrum using the underlay technique, and the separated skin of the external auditory canal was spread and placed over the fascia. The ear canal was tamponaded (hemostatic sponge with ceftriaxone + Merocel tampon). The postauricular wound was sutured layer by layer (Darwin 3-0, intradermal suture Darwin 4-0). An aseptic dressing was applied. There were no signs of bleeding.

A clinical example is illustrated in Fig. 1-4, where:

Fig. 1 - Stage of the performed separate atticoanthromastoidectomy and hydroseparation of the cholesteatoma matrix from the cells of the zygomatic tract: BP - tympanic cavity, ClSt - cells of the zygomatic tract, M - mastoid cavity, zsNSP - posterior wall of the external auditory canal, KpNSP - skin of the anterior wall of the external auditory canal.

Fig. 2 - Stage of hydroseparation of the cholesteatoma matrix from the perilabyrinthine cells of the mastoid cavity: PLC - perilabyrinthine cells, M - mastoid cavity, posterior wall of the external auditory canal.

Fig. 3 - Stage of hydroseparation of cholesteatoma matrix from infralabyrinthine tract cells: ICT - infralabyrinthine tract, TP - tympanic cavity, posterior wall of the external auditory canal (PACE) - posterior wall of the external auditory canal. A - the process of hydroseparation of cholesteatoma matrix from infralabyrinthine tract cells, B - view after removal of cholesteatoma matrix.

Fig. 4 - Stage of tympanoplasty and installation of autocartilaginous columella: F - autofascia, M - mastoid cavity, zsNSP - posterior wall of the external auditory canal, K - autocartilaginous columella.

Clinical example No. 2.

Patient M., 6 years old, was admitted to the pediatric otolaryngology department of the National Medical Research Center of Oncology and Biomedical Sciences (NMICO FMBA) with a diagnosis of chronic left-sided purulent otitis media. Infralabyrinthine cholesteatoma of the left petrous bone.

According to the legal guardian, the child has been experiencing hearing loss in the left ear and discharge from the left ear. Since 2021, the child has been seeing an ENT specialist with a diagnosis of chronic left-sided purulent otitis media. Conservative therapy has been ineffective.

Otoscopy: The external auditory canal is wide and clear, the eardrum is visible, and a defect in the lax portion is present, from which mucopurulent fluid is escaping. There are no signs of facial muscle paresis. There is no spontaneous nystagmus.

According to the data of computed tomography of the temporal bones, a violation of pneumatization of the mastoid process, tympanic cavity, and infralabyrinthine space on the left is determined due to pathological contents.

MRI of the temporal bones revealed diffusion restriction in the tympanic cavity, mastoid process and infralabyrinthine tract on the left in NonEpiDWI mode, with a hypointense signal in T1 at the level of the tympanic cavity and infralabyrinthine tract, an isointense signal in the mastoid cavity and a hyperintense signal in T2 modes in all parts of the middle ear and infralabyrinthine tract.

According to pure tone audiometry, left-sided conductive hearing loss of grade III.

The surgery was performed under endotracheal anesthesia using the NIM 3.0 facial nerve neuromonitoring system. The surgical field in the retroauricular area was prepared with an alcohol skin antiseptic. Sensors were inserted into the muscle in the nasolabial fold area and above the left eye. Under microsurgical guidance (Zeiss surgical microscope), an arcuate skin and subcutaneous tissue incision was made in the retroauricular area. Hemostasis was achieved. Next, an incision was made between the soft tissues and periosteum parallel to the first incision. A raspatory was used to separate the soft tissues and periosteum, and a retractor was used to spread the soft tissues apart. Autologous temporal muscle fascia and a plate of autologous cartilage with perichondrium were harvested through the surgical approach and prepared for the reconstructive stage of the surgery. A microraspatory device was used to detach the skin from the posterior, superior, and inferior walls of the external auditory canal, raising the meatotympanic flap anteriorly. A canaloplasty was performed using cutting and diamond burs, and the auditory canal was dilated. Examination of the tympanic cavity revealed that the cavity was filled with cholesteatoma. The malleus and incus were destroyed by the cholesteatoma. The stapes was not differentiated. An atticotomy was performed using diamond burs. Next, a separate antromastoidectomy was performed from the cortical layer of the mastoid process. The mastoid cells were filled with cholesteatoma. Cholesteatoma was found in the antrum, attic, and additus. The cholesteatoma was removed using the proposed method. The cholesteatoma was completely removed and sent for pathohistological examination. A posterior tympanotomy was performed. The cholesteatoma was removed from the protympanum, facial and tympanic sinuses, the niche of the vestibular window, and the cochlea. The remnants of the malleus and incus were removed. The extension of the cholesteatoma into the infracochlear tract was determined. Using a small-diameter diamond burr, the infracochlear tract was expanded without opening the basal helix. Using a hydrodissector, the cholesteatoma masses were removed from the infracochlear tract under visual microscopic control, in continuous mode with unlimited exposure time, at a distance of 2 cm from the nozzle tip to the cholesteatoma, a nozzle pressure of 50 bar, and a water jet and working surface angle of 45°. Cholesteatoma masses were removed from the infracochlear tract with simultaneous aspiration. The formed cavity in the infracochlear space is limited from above by the bony capsule of the basal turn of the cochlea, from below by the canal of the bulb of the jugular vein (the wall of which is preserved), from the front by the canal of the internal carotid artery (the wall of which is preserved), from behind by the mastoid segment of the canal of the facial nerve and the posterior tympanotomy, medial-bone massif.

Using a hydrodissector, we then separated the cholesteatoma matrix from these hard-to-reach areas of the formed cavity using a non-contact, continuous mode with an unlimited exposure time, a distance from the nozzle tip to the cholesteatoma of 3 cm, a nozzle pressure of 80 bar, a water jet angle, and a working surface of 90°. Next, we exenterated the mastoid cells and mastoid cavity using a waterjet dissector. The footplate is intact and mobile. The vestibular window niche is normal. The cochlear window area is normal. Movement between the windows is preserved. The facial nerve canal was examined: the facial nerve is devoid of a bony canal in the tympanic segment. Next, reconstruction of the anatomical structures of the middle ear was performed: autogenous fascia was placed under the remnants of the eardrum using the underlay technique, separated skin of the external auditory canal was straightened and placed over the fascia, an autogenous cartilaginous columella was placed on the footplate of the stapes; plastic surgery of the lateral wall of the attic and the posterior wall of the external auditory canal (EAC) with an autogenous cartilage plate; tamponade of the ear canal (hemostatic sponge + Merocel tampon). The retroauricular wound was sutured layer by layer. Aseptic dressing. There are no signs of bleeding. The outcome is favorable.

The sequence of performing the operation in clinical case No. 2 is shown in Fig. 5-10:

Fig. 5 - Stage of the performed separate atticoantromastoidectomy: BP - tympanic cavity, A - antrum, M - mastoid cavity, posterior wall of the external auditory canal, separated skin of the external auditory canal.

Fig. 6 - Stage of expansion of the boundaries of the infracochlear tract filled with cholesteatoma: Bp - tympanic cavity, Ik - infracochlear tract.

Fig. 7 - Stage of hydroseparation of cholesteatoma with a water-jet dissector from the infracochlear tract: M - mastoid cavity, Bp - tympanic cavity, Ik - infracochlear tract, Xc - cholesteatoma, zsNSC - posterior wall of the external auditory canal.

Fig. 8 - View of the tympanic cavity after complete sanitation using a hydrodissector: M - mastoid cavity, TP - tympanic cavity, ICT - infracochlear tract, PVEC - posterior wall of the external auditory canal.

Fig. 9 - Stage of laying autofascia using the underlay technique: f - autofascia, M - mastoid cavity, fn - facial nerve, ppwECM - posterior wall of the external auditory canal.

Fig. 10 - Stage of installation of autocartilaginous columella: f - autofascia, M - mastoid cavity, fn - facial nerve, posterior wall of the external auditory canal, K - autocartilaginous columella.

Clinical example No. 3.

Patient M., 54, was admitted to the Department of Ear and Skull Base Pathology at the National Medical Research Center of Oncology and Biomedical Sciences (NMICO FMBA) with a diagnosis of benign tumor of the left ear (infralabyrinthine-apical cholesteatoma of the left petrous bone). Postoperative status: 2012.

The patient reported complaints upon admission of intermittent purulent discharge from the left ear and deafness on the left. He has considered himself ill since childhood, having experienced pain in the left ear, purulent discharge, and increasing hearing loss on the left. In 2012, he underwent emergency surgery at his place of residence. He noted a recurrence of deterioration in 2022. He received outpatient treatment, which was ineffective. Otoscopy: the mastoid process area is unchanged. The scar shows no signs of hypertrophic growth. The auricle is unchanged. The ear canal is wide, with purulent discharge in the lumen of the external auditory canal, a defect of the neotympanic membrane in the lower sections, covered by a polyp. Facial muscle function is normal. There is no spontaneous nystagmus.

According to the computed tomography of the temporal bones, bone destruction of the left temporal bone with destruction of the horizontal and vertical sections of the internal carotid artery canal and the canal of the jugular bulb is determined.

An MRI of the temporal bones revealed a cholesteatoma of the left temporal bone. Postoperative changes in the left temporal bone and contents of the postoperative cavity.

According to the data of tonal threshold audiometry, there is right-sided sensorineural hearing loss of the 1st degree, left-sided deafness.

Surgery was performed under endotracheal anesthesia with placement of a fixed-position sensor in the oral cavity for electromagnetic navigation (Digi Poinceur). After treating the surgical field with an alcohol skin antiseptic, electrodes for facial nerve neuromonitoring (Medtronic) were placed. After tissue infiltration with a 2% Lidocaine + 0.9% NaCl solution, a linear skin and soft tissue incision was made behind the left ear with a scalpel down to the periosteum, 1.5 cm posterior to the scar. Subcutaneous fat was separated from the temporalis muscle fascia. Autologous temporalis muscle fascia was harvested. The soft tissues and periosteum were separated with a raspater. The temporal line and a small trepanation cavity were visualized. A cutting and diamond burr were used to further open the mastoid cells. The antrum was opened, revealing cholesteatoma masses, which were removed. The skin of the ear canal was separated from the inferior, posterior, and superior walls of the bony portion of the external auditory canal down to the fibrous ring using a microraspater. A tympanotomy was performed: the attic was filled with cholesteatoma, the auditory ossicles were destroyed, and their remnants were removed. An atticoanthrotomy was performed, preserving the posterior wall as a bony bridge. The skin of the tympanic membrane and the tympanic membrane was elevated using the underlay technique and peeled back to the cartilaginous portion. Extended canaloplasty was performed. The posterior wall of the external auditory canal was removed, the spur was smoothed using diamond burs, and the cog was smoothed. The internal carotid artery (ICA) canal in the vertical section and genu region was skeletonized using medium-diameter diamond burs, and the promontory wall of the cochlea was smoothed without opening its lumen. Considering the spread of cholesteatoma, a retrofacial approach was performed, the facial nerve canal was preserved, and perifacial cells were exposed. The cholesteatoma matrix was determined on the adventitia of the jugular bulb. Cholesteatoma was identified during skeletonization of the ICA and opening of the infracochlear cellular tract. Removal of cholesteatoma masses from the infracochlear tract was performed. Pericarotid cells were opened with diamond burs of different diameters, and the cholesteatoma matrix was determined on the petrous portion of the internal carotid artery. Then, in a contactless, continuous mode with a limited exposure time of 20 s and a set angle between the water jet and the working surface of 45°, a nozzle pressure of 30 bar, the cholesteatoma matrix was removed from the periosteal layer of the petrous portion of the internal carotid artery in horizontal and vertical segments using a waterjet dissector; Then, in a contactless, continuous mode, using a water-jet dissector with a limited exposure time of 15 s and a specified angle between the water jet and the working surface of 35°, a distance from the end of the nozzle to the working surface of 5 cm and a nozzle pressure of 10 bar, the cholesteatoma matrix was removed from the adventitia of the jugular bulb.

An endoscopic cavity revision was performed. Under endoscopic assistance, a nasal rasp was used to debride hard-to-reach areas, including the medial genu of the ICA, the apex, and the posterior borders of the cavity at the level of the ICA. Cholesteatoma matrix was removed from the dura mater of the middle cranial fossa (MCF) using a hydrodissector at a nozzle pressure of 10 bar. The distance from the nozzle tip to the working surface was 3 cm, the exposure time was 20 seconds, and the angle was 35°. All pathological tissue was removed and sent for histological examination. The cavity was irrigated three times with saline. Neuromonitoring of the facial nerve was performed (Medtronic NIM Response - 3.0 facial nerve monitoring system): with stimulation from 0.5 to 3.0 mA in the tympanic segment, contractions from the orbicularis oculi muscle (zygomatic nerve) and orbicularis oris muscle (buccal nerve) were recorded. After treating the surgical field with an alcohol skin antiseptic and infiltrating tissues with a 2% Lidocaine + 0.9% NaCl solution, autofat was collected from the right iliac region. The postoperative wound was sutured in layers. One rubber drain was installed in the distal part of the wound. The eardrum and skin from the bony part of the ESP were removed. Autofascia was placed on the bottom of the postoperative cavity. The postoperative cavity was filled with autofat. The external auditory canal was sutured using the cull de sac technique with individual interrupted Monocryl 6.0 sutures. The postoperative wound was closed layer by layer with interrupted 3.0 Vicryl sutures. An aseptic dressing was applied to the area behind the ear. The surgery was uneventful.

The sequence of performing the operation in clinical case No. 3 is presented in Figures 11-16

Fig. 11 - Stage of the completed radical cavity: Tp - tympanic cavity, Mp - mastoid cavity, psNSP - anterior wall of the external auditory canal, mlN - mastoid section of the facial nerve in the bone canal.

Fig. 12 - Stage of opening of pericarotid cells and skeletonization of the ICA: PC - pericarotid cells, ICA - petrous part of the internal carotid artery in the vertical segment, Mx - cholesteatoma matrix.

Fig. 13, Fig. 14 - Stages of hydroseparation of cholesteatoma with a water-jet dissector from the periosteal layer of the internal carotid artery: ICA - petrous part of the internal carotid artery in the vertical segment, Tp - tympanic cavity, mlN - mastoid part of the facial nerve in the bone canal, MP - mastoid cavity, Ksp - end of the nozzle.

Fig. 15 - Stage of hydroseparation of cholesteatoma with a water-jet dissector from the adventitia of the ICA: ICA - jugular vein bulb, Tp - tympanic cavity, mlN - mastoid part of the facial nerve in the bone canal, Mp - mastoid cavity, Ksp - end of nozzle, ICA - petrous part of the internal carotid artery in the vertical segment.

Fig. 16 - Stage of the performed sanitation, where it is possible to visualize: ICA - petrous part of the internal carotid artery in the vertical segment, TP - tympanic cavity, MLN - mastoid part of the facial nerve in the bone canal, MP - mastoid cavity, LBJ - bulb of the jugular vein.

Clinical example No. 4.

Patient M., 53, was admitted to the Ear and Skull Base Pathology Department of the National Medical Research Center of Oncology and the Federal Medical and Biological Agency with a diagnosis of chronic bilateral purulent otitis media. His condition post-operatively was on the right ear in 1983, on the left ear in 1997, and on June 5, 2023. Chronic bilateral sensorineural hearing loss, grade IV.

According to the patient, upon admission, he complained of hearing loss in both ears, and periodic discharge from the right ear. According to the patient, he has had the above complaints since childhood. Surgical treatment of the right ear was in 1983, the left ear in 1997. A hearing aid was fitted in the left ear. On June 5, 2023, the operation was performed at the Federal Medical and Biological Agency of the National Medical Research Center of Oncology of Russia. He was under dynamic observation and examination. Hospitalization for surgical treatment was recommended. Otoscopy: the mastoid process area is unchanged. In the retroauricular area, there is a scar without signs of inflammation. The auricle is unchanged. The auditory canal is narrow. There is mucous discharge in the external auditory canal. The postoperative cavity is filled with epithelial masses. The neotympanic membrane is incompetent. The function of the facial muscles is normal. There is no spontaneous nystagmus.

Computed tomography of the temporal bones reveals signs of chronic otitis media on both sides. Postoperative conditions: Partial ossification of the left otic chamber and bilateral otic chamber.

MRI of the temporal bones reveals postoperative changes in the temporal bones on both sides. Signs of cholesteatoma are present on the right and left sides. Partial loss of bright signal from the lateral semicircular canals on both sides and the superior semicircular canal on the left.

Based on pure-tone audiometry, signs of deafness are present bilaterally. ABR: peak V is not visualized at a 100 dB stimulus bilaterally. ASSR: hearing thresholds are not detectable bilaterally.

The surgical intervention was performed under endotracheal anesthesia using the NIM 3.0 facial nerve neuromonitoring system. After treating the surgical field with an alcohol skin antiseptic under endotracheal anesthesia and additional infiltration anesthesia with 0.4% Certacaine solution - 10 ml behind the right ear, an S-shaped incision of the skin and subcutaneous tissue was made with a scalpel along the old scar with a scalpel under the control of an operating microscope with Carl Zeiss optics. An incision of the soft tissues and periosteum was made along the old scar. The mastoid portion of the cavity filled with cholesteatoma masses was visualized. They were partially removed from the cavity, and the material was sent for histology. Circular dissection was made at the border of the osteochondral portion. The cartilage of the esophageal plexus was isolated, and the external auditory canal was sutured using the cul de sac technique. The skin of the external auditory canal was completely removed. Large cutting and diamond burs were used to smooth the edges of the trephination cavity, expose the sinodural, epidural, perifacial, and perilabyrinthine cells, and smooth the spur. A defect of the sinodural fiber was identified at the level of the mastoid cavity, with the epidermis partially overlapping the dura mater. In the tympanic region, the ossicular chain is absent, the remnants of the neotympanic membrane prolapse, and the facial nerve is partially exposed in the tympanic region. Diamond burs were used to remove a large overhang, smooth the anterior wall of the neotympanic membrane, and create the infracochlear tract. The facial nerve was cleaned (reductions were obtained), and the stapes footplate was intact and preserved. Using a hydrodissector, the cholesteatoma matrix was separated from the promontorial wall and in the infracochlear space in a non-contact, continuous mode with an unlimited exposure time, a distance of 2 cm from the nozzle tip to the cholesteatoma, a nozzle pressure of 80 bar, a water jet angle to the working surface of 45°, and a nozzle diameter of 120 μm. Then, using a water-jet dissector, the cholesteatoma matrix was separated from the dura mater of the middle cranial fossa in a non-contact, continuous mode with a limited exposure time (20 s), a specified angle between the water jet and the working surface (45°), a distance of 3 cm, a nozzle pressure of 30 bar, and a nozzle diameter of 120 μm. The epidermis was completely removed, and debridement was performed. The cavity was repeatedly irrigated with saline. The cavity was obliterated with autologous fat. The wound was sutured layer by layer. There are no complications.

The sequence of performing the operation in clinical case No. 4 is shown in Figures 17-20:

Fig. 17 - Stage of execution of the radical cavity: Tp - tympanic cavity, Mp - mastoid cavity, Shp - spur, MCF - middle cranial fossa.

Fig. 18 - Stage of work with a water-jet dissector on the bone in the infracochlear tract: inK - infracochlear tract.

Fig. 19 - Stage of work with a waterjet dissector on the dura mater of the middle cranial fossa (DM MCF).

Fig. 20 - Stage of completion of the operation: obliteration of the cavity with automuscle(aM).

Five patients with temporal bone cholesteatoma were operated on using the proposed method. Using a waterjet dissector system, complete sanitation of the cholesteatoma was achieved, thereby reducing the risk of recurrence of temporal bone cholesteatoma in the postoperative period. Computed tomography, MRI, and otoscopic examination revealed no evidence of pathological progression in this area. The follow-up period was 12 months.

Claims (3)

A method of surgical treatment of cholesteatoma of the temporal bone, which consists in the fact that at the first stage access is gained to the lesion, At the second stage, under visual microscopic control, hydroseparation of the cholesteatoma from the bone structures is carried out using a water-jet dissector, the distance from the end of the nozzle to the working surface is 2 cm, the pressure for the nozzle is 50-80 bar, the angle of the water jet is 45°, Then, the cholesteatoma matrix is separated from the vascular structures and the dura mater of the brain using the following parameters: when working in the area of the wall of the internal carotid artery and the dura mater, the nozzle pressure is 10-30 bar, duration is 20 s, angle is 45°; in the area of the wall of the internal jugular vein, the nozzle pressure is 5-10 bar, duration is 15 s, angle is 35°, the distance from the end of the nozzle to the working surface is 3-5 cm.