RU2850724C1 - Method of channel plasty in congenital atresia of membraneous-cartilaginous and bone sections of external auditory canal - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: incision is made behind the ear, and a skin-periosteal flap is separated anteriorly to the temporomandibular joint fossa. A temporal muscle fascia flap is prepared in the upper corner of the wound. An antrotomy is performed. Next, remove the atretic plate and form a trepanation cavity: anteriorly to the transparency of the temporomandibular joint capsule, upward to the transparency of the dura mater of the middle cranial fossa. A bone tympanic ring is formed. Myringoplasty is performed with an autofascial flap. The cartilage is excised in the projection of the auricle. A free displaced skin flap with a diameter of 0.8 mm is taken from the retroauricular region using a dermatome. In the area of the auricle, a tongue-shaped flap is cut out with its base in the area of the tragus of the auricle and brought down to the anterior wall of the formed external auditory canal. Free displaced skin flaps are placed on the exposed bone walls of the formed external auditory canal. The tongue-shaped skin flap is sutured to the periosteum of the anterior wall of the external auditory canal, 1 cm away from the formed bony tympanic ring. In doing so, the free end of the tongue-shaped flap is created in such a way that the autofascial flap remains uncovered by skin.

EFFECT: increased treatment effectiveness when performing canaloplasty in patients with congenital anomalies of the external ear.

2 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to otolaryngology, and can be used in performing canaloplasty in patients with congenital anomalies of the outer ear.

Congenital atresia of the external auditory canal is one of the most common malformations of the outer ear. It occurs in 1 in 10,000 to 20,000 newborns. In most cases, it is unilateral, affecting the right ear, and affects males 2.5 times more often than females.

Congenital atresia of the external auditory canal represents a clinical spectrum of anomalies affecting both the outer and middle ear, which can cause conductive hearing loss.

The population frequency of congenital ear anomalies is 3.5:1000 newborns, with atresia of the external auditory canal being the most common among them.

Reconstructive surgeries performed to form the external auditory canal are technically complex and not always successful due to the presence of anatomical features, the possible development of restenosis of the external auditory canal, and lateralization of the neotympanic membrane in the postoperative period.

When performing operations for atresia of the external auditory canal, three main approaches to the tympanic cavity are used: the posterior transcortical approach, the anterior approach, and a modification of the anterior approach. The choice of access is determined by the type of atresia of the external auditory canal (partial or complete), as well as the anatomical and topographic relationships of the outer and middle ear with the capsule of the temporomandibular joint, sigmoid sinus, middle cranial fossa and previously surgically formed auricle in case of anotia (Borisova, E.V. Congenital auricular atresia: clinical presentation and surgical treatment / E.V. Borisova // Science and practice in otolaryngology: materials of the 3rd Russian scientific and practical conference of otolaryngologists, Moscow, 2004. - pp. 244-247; Borisova, K.Z. Clinical evaluation of the results of surgical treatment of congenital auricular atresia / K.Z. Borisova, E.V. Borisova // Science and practice in otolaryngology: materials of the 3rd Russian scientific and practical conference otolaryngologists, Moscow, 2004. - pp. 173-174.).

A posterior bone approach is achieved by performing an antromastoidectomy followed by removal of the atretic plate in a posterior-to-anterior direction. This creates a large trepanation cavity, similar to a radical operation, which prolongs the patient's postoperative recovery period and requires lifelong restriction of ear contact with water and observation by an otolaryngologist (Balyasinskaya, G.L. Surgical Treatment of Congenital Malformations of the External and Middle Ear / G.L.Balyasinskaya, M.R.Bogomilsky, Yu.M.Ovchinnikov. - Moscow, 1999. - 126 p.).

The anterior bone approach creates a pathway to the tympanic cavity directly through the atretic mass. Sufficient distance between the temporomandibular joint capsule and the mastoid process is essential for this approach. This allows visualization of the tympanic cavity, which is necessary for controlled tympanoplasty. The mastoid process remains intact (Balyasinskaya, G.L. Surgical Treatment of Congenital Malformations of the External and Middle Ear / G.L.Balyasinskaya, M.R.Bogomilsky, Yu.M.Ovchinnikov. - Moscow, 1999. - 126 p.).

The disadvantage of the anterior bone approach is the lack of clear anatomical boundaries, which leads to a high risk of injury to such anatomical structures as the capsule of the temporomandibular joint and the middle cranial fossa.

The modified anterior approach begins with a traditional antromastoidectomy. After exposing the horizontal semicircular canal, the atretic mass is removed and a new auditory canal is formed, projecting onto the wide-open tympanic cavity. The anterior wall of the mastoid process (the posterior wall of the formed external auditory canal) is preserved at a thickness of 1-2 mm (Balyasinskaya, G.L. Surgical Treatment of Congenital Malformations of the External and Middle Ear / G.L.Balyasinskaya, M.R.Bogomilsky, Yu.M.Ovchinnikov. - Moscow, 1999. - 126 p.).

The presence of anatomical landmarks makes it possible to develop gentle methods of surgical treatment of congenital atresia of the external auditory canal.

A method of surgical treatment of congenital atresia of the external auditory canal is known (Gulya AJ, Minor LB Poe DS Glasscock - Shambaugh Surgery of the Ear, ^6th edition. Shelton, Connecticut: People's Medical Publishing House, 2010, pp. 435 - 445), including making a postauricular incision, separating the skin-periosteal flap to the fossa of the temporomandibular joint anteriorly, after which a flap of the fascia of the temporal muscle is prepared in the upper corner of the wound, then the atretic plate is removed with the formation of the canal of the external auditory canal: anteriorly until the temporomandibular joint bag is illuminated, upward until the dura mater of the middle cranial fossa is illuminated, myringoplasty is performed with an autofascial flap, excision of the cartilage is performed in Free, displaced skin flaps are placed on the exposed bony walls of the formed external auditory canal, using the projection of the auricle. This method is performed through a postauricular incision. The skin, atretic fibrous tissue, and periosteum are separated anteriorly to the temporomandibular joint fossa. The atretic plate is removed between the glenoid fossa anteriorly and the perforated area of the mastoid cortex posteriorly. The tympanic cavity is opened in the area of the epitympanum, removing the lateral wall of the attic until the body of the incus and head of the malleus are exposed. This serves as an anatomical landmark for further formation of the external auditory canal. The external auditory canal is formed anteriorly until the temporomandibular joint bursa is visible, posteriorly until individual cells of the mastoid process are exposed, superiorly until the dura mater of the middle cranial fossa is visible, and inferiorly until the ossicular chain and labyrinthine windows are fully visualized. If necessary, ossiculoplasty is performed with appropriate titanium prostheses. Myringoplasty is performed using autologous fascia of the temporalis muscle. Free, displaced skin flaps are placed on the walls of the newly formed external auditory canal.

The disadvantages of this method are:

- high risk of trauma to the structures of the tympanic cavity when removing the bony atretic plate without preliminary visualization of the anatomical landmarks of the middle ear;

- the use of only free displaced skin flaps, which are less resistant to necrosis than pedicled flaps, can lead to excessive exposure of the bone of the formed canal of the external auditory canal if they are rejected, which in turn can cause excessive growth of granulation tissue and increase the risk of restenosis.

Also known is a method for eliminating atresia of the bone portion of the external auditory canal (Method for eliminating atresia of the bone portion of the external auditory canal: patent RU2685638, Russian Federation, application RU2017138365, filed 02.11.2017, published 22.04.2019), including access by a behind-the-ear approach, separation of the skin of the external auditory canal, removal of atretic tissue, bone overhangs, placement of free displaced skin flaps on the exposed bone, characterized in that the separation of the skin is performed together with the atretic tissue in a single block, and after removal of the atretic tissue, the lumen of the external auditory canal is expanded by removing the bone mass of the lower, upper walls and the anterior wall until the first signs of the temporomandibular joint bag appear - thinning of the bone wall until the appearance bluish translucent tissue or point perforation of the bone wall with the formation of an anterior meatotympanic angle between the anterior wall and the eardrum, exceeding 90°, then a single flap of skin of the external auditory canal is formed on the feeding base from the upper and anterior walls and its anterior meatotympanic angle is lowered to the eardrum.

The disadvantages of this method include the long-term epidermization of the trepanation cavity due to its large size, as well as the high risk of lateralization or fusion of the anterior meatotympanic angle, which ultimately leads to conductive hearing loss in the patient.

The closest to the claimed invention is a method of surgery for atresia of the external auditory canal (Method of surgery for atresia of the external auditory canal: patent RU2426500, Russian Federation, application RU2009145977, declared 02.12.2009, published 20.08.2011), including making a postauricular incision, after which a flap of the fascia of the temporal muscle is prepared in the upper corner of the wound, then an anthromatoidotomy is performed, the atretic plate is removed with the formation of the canal of the external auditory canal: anteriorly until the temporomandibular joint bag is illuminated, upward until the dura mater of the middle cranial fossa is illuminated, myringoplasty is performed with an autofascial flap, cartilage is excised in the projection of the auricular cup, from the preserved skin of the cup A tongue-shaped flap with an anterior base is formed from the auricle and lowered onto the anterior wall of the formed canal of the external auditory canal. Free, displaced skin flaps are placed on the exposed bony walls of the formed canal of the external auditory canal. This method involves a postauricular approach. A cutting bur is used to shape the bony portion of the external auditory canal and the tympanic cavity, focusing on the protrusion of the lateral semicircular canal and the wall of the capsule of the horizontal portion of the facial nerve. Next, the tympanic portion of the tympanic cavity is expanded anteriorly to the opening of the auditory tube, inferiorly to the hypotympanum, and posteriorly to the vertical portion of the canal of the facial nerve. The lateral portion of the external auditory canal is widened as widely as possible: superiorly to the dura mater of the middle cranial fossa, anteriorly to the temporomandibular joint. The atretic plate is completely removed, creating a bony tympanic ring that leaves a gap of at least 1 mm between it and the auditory ossicles. If necessary, ossiculoplasty is performed with an appropriate titanium prosthesis. Seven to nine holes are made in the cortical plate along the periphery of the created bony portion of the external auditory canal for subsequent fixation of the skin flap. In addition, two to three holes are made in the formed bony ring with a fine diamond bur to secure the neotympanic membrane and prevent its lateralization. The fascial flap is then placed on the reconstructed ossicular structure (mobilized incus and malleus, or a titanium prosthesis). A tongue-shaped skin incision is then made parallel to the helix, creating a skin flap on an anterior pedicle. The cartilage and fibrous tissue from the base of the auricle are completely removed. The flap skin is mobilized and sutured laterally to the edges of the bony portion of the external auditory canal through the previously created openings. The flap is then brought down into the trephine cavity, covering its anterior wall. Next, a split-thickness free skin flap, taken from the inner surface of the arm with a dermatome, is placed circumferentially on the inner surface of the newly created external auditory canal, with the outer edge of the flap also secured with sutures to the edge of the external auditory canal through the aforementioned openings. At the final stage, the same flap is used to cover the fascial flap. A gauze pad soaked in iodoform and petroleum jelly is inserted into the external auditory canal. The primary incision is sutured layer by layer. Postoperatively, sutures are removed on the 9th-10th day. Tampons from the external auditory canal are removed on the 10th-11th day, while the external auditory canal is tamponed weekly for a month with a hemostatic sponge soaked in iodoform and 4% Na-CMC (sodium carboxymethyl cellulose) gel.

The disadvantages of this method are:

- formation of a large trepanation cavity, which prolongs the patient’s recovery time after surgery and requires lifelong medical care for the periodic cleaning of this cavity;

- when placing skin flaps on the autofascia and the effect of prolonged postoperative inflammation, it is possible that a massive neotympanic membrane will form, followed by its lateralization or closure of the anterior meatotympanic angle, which in turn can lead to conductive hearing loss in the patient.

The technical problem is the need to develop a method of canaloplasty in congenital atresia of the membranous-cartilaginous and bony sections of the external auditory canal, devoid of the above-mentioned disadvantages.

The technical result consists in increasing the effectiveness of surgery in patients with congenital anomalies of the outer ear.

The technical result is achieved by the fact that in the method of canaloplasty in case of congenital atresia of the bone and membranous-cartilaginous parts of the external auditory canal, including the performance of a postauricular incision, separation of the skin-periosteal flap to the fossa of the temporomandibular joint anteriorly (2), after which a flap of the fascia of the temporal muscle is prepared in the upper corner of the wound, then antrotomies are performed (1), then the atretic plate is removed with the formation of the canal of the external auditory canal: anteriorly until the bursa of the temporomandibular joint is illuminated (2), upward until the dura mater of the middle cranial fossa is illuminated, myringoplasty is performed with an autofascial flap (12), excision of the cartilage is performed in the projection of the cup of the auricle (10), from the preserved skin of the cup of the auricle a tongue-shaped flap is formed with the base in front and lowered onto the anterior wall of the formed canal of the external auditory canal (11), free displaced skin flaps are placed onto the exposed bone walls of the formed canal of the external auditory canal, according to the invention , the tongue-shaped skin flap is sutured to the periosteum of the anterior wall of the external auditory canal, retreating 1 cm from the formed bony tympanic ring (9), creating a free end of the tongue-shaped flap in such a way that the autofascial flap remains uncovered by skin.

In a preferred embodiment of the invention, autochondral plates (13) are placed in the trepanation cavity, filling the mastoid segment of the trepanation cavity to the level of the descending part of the facial nerve canal (8), without making contact with the long leg of the incus (6), after which these autochondral plates are covered with freely displaced skin flaps.

The claimed method increases the effectiveness of surgery in patients with congenital malformations of the outer ear by reducing the risk of postoperative restenosis of the external auditory canal and creating a small trepanation cavity, which, along with a simultaneous improvement in the patient's hearing, leads to a shortening of the healing period in the postoperative period.

The claimed method is intended for patients with congenital atresia of the bony and membranous-cartilaginous parts of the external auditory canal in the presence of an auricle or one previously formed surgically.

The formation of a tongue-shaped skin flap on a pedicle covering the anterior wall of the formed canal of the external auditory canal, which has a free distal end, as well as the absence of skin on the autofascial flap allows for the creation of a thin neotympanic membrane that adequately conducts sound vibrations and prevents restenosis of the formed external auditory canal.

The placement of autologous cartilaginous plates in the mastoid section of the trepanation cavity allows for a reduction in its volume, which subsequently accelerates postoperative healing and avoids the excessive accumulation of sulfur-epidermal masses requiring removal, which, in turn, improves the patient's quality of life.

The claimed invention is further explained by images (Figs. 1-5), which illustrate various stages of the operation and provide the following positions:

1- atresia in the membranous-cartilaginous part of the external auditory canal;

2- capsule of the temporomandibular joint;

3- bone atretic plate;

4- stage of performing antrotomy;

5-hammer;

6- anvil;

7- stirrup;

8- descending part of the facial nerve canal;

9- formed bone tympanic ring;

10 - stage of excision of cartilage in the area of atresia of the membranous-cartilaginous part of the external auditory canal;

11- anterior tongue-shaped skin flap;

12- autofascial flap of the temporal muscle;

13- autocartilaginous plate.

The method is carried out as follows.

The procedure is performed under multicomponent anesthesia and monitored by a facial nerve monitor. A retroauricular incision is made from the level of the lamellar temporalis to the apex of the mastoid process. A periosteal flap is separated to the anterior aspect of the temporomandibular joint fossa (2). A temporalis muscle fascia flap is prepared in the superior aspect of the wound.

Under the control of an operating microscope, an antrotomy (1) is performed with a 3.0 mm diameter cutting bur in the projection of the perforated zone of the cortical plate of the mastoid process until the lateral semicircular canal and the short leg of the incus in the aditus ad antrum are fully visualized.

Using a 2.0 mm diameter cutting burr, the atretic plate is removed, creating a trephination cavity: anteriorly until the temporomandibular joint capsule (2) is visible, and superiorly until the dura mater of the middle cranial fossa is visible. Next, the tympanic cavity and ossicular chain (5, 6, 7) are inspected.

Myringoplasty is performed using an autofascial flap (12) on a pre-formed bone ring (9) with a diameter of 1.5 mm. A free, advanced skin flap with a diameter of 0.8 mm is taken from the retroauricular area using a dermatome. In the area of the auricle, a tongue-shaped flap (11) is dissected with a base in the area of the tragus of the auricle, the cartilages of the auricle (10) are partially excised, and the flap is lowered onto the anterior wall of the formed external auditory canal (11), suturing it to the periosteum of the formed canal of the external auditory canal, retreating by 1 cm in order to create a free distal end of the tongue-shaped flap. The free distal end of the tongue-shaped flap reduces the risks of lateralization of the neotympanic membrane and blunting of the anterior meatotympal angle. To reduce the volume of the trepanation cavity (and to reduce the time it takes for epidermization and healing), mastoidoplasty is performed by placing a strip of autologous cartilage (13), partially filling the mastoid segment of the trepanation cavity to the level of the descending part of the facial nerve canal (8), without contacting the long pedicle of the incus (6). These autologous cartilaginous plates are then covered with a fascial flap and then with free displaced skin flaps. Free displaced skin flaps are placed on the exposed bony walls of the formed canal of the external auditory canal, without covering the autologous fascial flap.

The surgery continues as usual: a silicone protector is placed on the autofascial flap, and the newly formed external auditory canal is packed with a hemostatic sponge. The postauricular wound is sutured layer by layer. An aseptic dressing is applied.

The method is explained with an example.

Patient K., 6 years old, was admitted to the pediatric surgical department with a diagnosis of: Congenital anomaly of the outer ear: atresia of the external auditory canal on the right.

Upon admission, the patient complained of hearing loss in his right ear. His medical history revealed no history of ear inflammation, temporal bone trauma, or surgery.

On examination: the nose – the mucous membrane is pink and moist. The nasal septum is in the midline. The nasal passages and the vault of the nasopharynx are free. Nasal breathing is not obstructed. The mucous membrane of the pharynx is pink and moist. The mucous membrane of the larynx is pink and moist. The vocal folds are gray, the edges are smooth, and they are fully mobile during phonation. The interfold space is wide. The voice is clear, and breathing is free.

Otomicroscopy revealed: AS – the external auditory canal is wide and free. The eardrum is gray, contoured, and free of defects. Whispered speech is 6.0 m, spoken speech is greater than 6.0 m; AD – the auricle is formed, with complete atresia of the external auditory canal. The eardrum is not visible. Whispered speech is 2 m, spoken speech is greater than 3 m.

The data from additional examination methods are presented below.

Pure-tone audiometry reveals stage 1 conductive hearing loss on the right side. Computed tomography of the temporal bones reveals a mixed mastoid process structure. Congenital malformation of the outer ear is evident. The external auditory canal is absent (atresia in the membranous-cartilaginous and bony sections).

The atretic plate is visible in the membranous-cartilaginous and bony regions. The bony bed of the sigmoid sinus, the superior facet of the pyramid, and the bony capsule of the labyrinth are intact. The ossicular chain shows no signs of carious changes. The patient underwent surgery on the right ear.

The surgical intervention was performed under multicomponent anesthesia with tracheal intubation, under the control of facial nerve monitoring.

An incision was made in the right retroauricular region. The periosteal flap was separated to the anterior temporomandibular joint fossa. A temporalis muscle fascia flap was prepared in the superior angle of the incision.

Under the control of an operating microscope, an antrotomy was performed with a 3.0 mm diameter cutting bur in the projection of the perforated zone of the cortical plate of the mastoid process until the lateral semicircular canal and the short leg of the incus in the aditus ad antrum were fully visualized.

A 2.0 mm diameter cutting burr was used to remove the atretic plate, creating a trephination cavity: anteriorly until the temporomandibular joint capsule was visible, and superiorly until the dura mater of the middle cranial fossa was visible. Next, the tympanic cavity and ossicular chain were inspected. No pathological tissue was detected during the tympanic cavity inspection. The ossicular chain was abnormally altered and mobile. Khilov's sign was positive.

Next, myringoplasty was performed using an autofascial flap on a pre-formed 1.5 mm diameter bone ring. A free, advanced 0.8 mm diameter skin flap was taken from the retroauricular area using a dermatome. A tongue-shaped flap was dissected in the auricular cup, with its base at the tragus. The auricular cartilage was partially excised, and the flap was lowered onto the anterior wall of the formed external auditory canal, sutured to the periosteum of the formed external auditory canal, leaving a 1 cm margin to create a free distal end of the tongue-shaped flap. Strips of autologous cartilage were placed in the mastoid portion of the trephination cavity to the level of the descending facial nerve canal, avoiding contact with the long pedicle of the incus. Free displaced skin flaps are placed on the exposed bone walls of the formed canal of the external auditory canal, without covering the autofascial flap.

The surgery continued as usual: a silicone protector was placed on the autologous fascial flap, and the newly formed external auditory canal was packed with a hemostatic sponge. The postauricular wound was sutured layer by layer. An aseptic dressing was applied.

No complications were observed in the postoperative period. The sutures were removed on the seventh postoperative day. The patient was discharged on the 12th postoperative day with packing in the newly formed right external auditory canal. The packing was initially removed 12 days after surgery, followed by retamponade with a hemostatic sponge for 10 days.

Otomicroscopy after removal of tampons after 22 days: AD: the external auditory canal is wide, free, the trepanation cavity is small, the mastoid region is partially epidermized, fascial, skin flaps are moderately edematous, there are no defects.

According to the control tonal audiometry data after removal of the tampons, hearing was normal, with a decrease in the air-bone gap of 15 dB compared to the preoperative examination.

Follow-up examination after 6 months. AD: the external auditory canal is wide and clear, the trepanation cavity is small, the mastoid region is epidermized, the neotympanic membrane is gray, and there are no defects.

Thus, the claimed method results in a shorter healing period in the postoperative period, while simultaneously improving the patient’s hearing.

Claims (2)

1. A method of canaloplasty in congenital atresia of the bone and membranous-cartilaginous parts of the external auditory canal, including making a postauricular incision, separating the skin-periosteal flap to the temporomandibular joint fossa anteriorly, after which a flap of the fascia of the temporal muscle is prepared in the upper corner of the wound, then an antrotomy is performed, then the atretic plate is removed with the formation of a trepanation cavity: anteriorly until the temporomandibular joint bag is illuminated, upward until the dura mater of the middle cranial fossa is illuminated, myringoplasty is performed with an autofascial flap, cartilage is excised in the projection of the auricular cup, a free displaced skin flap with a diameter of 0.8 mm is taken from the postauricular region using a dermatome, in the area of the auricular cup A tongue-shaped flap is cut out with a base in the area of the tragus of the auricle and lowered onto the anterior wall of the formed canal of the external auditory canal; free displaced skin flaps are placed onto the exposed bone walls of the formed canal of the external auditory canal, characterized in that a bony tympanic ring is formed; the tongue-shaped skin flap is sutured to the periosteum of the anterior wall of the external auditory canal, retreating 1 cm from the formed bony tympanic ring, creating a free end of the tongue-shaped flap in such a way that the autofascial flap remains uncovered by skin. 2. The method according to paragraph 1, characterized in that autochondral plates are placed in the trepanation cavity, filling the mastoid segment of the trepanation cavity to the level of the descending part of the facial nerve canal, without making contact with the long leg of the incus, after which these autochondral plates are covered with fascial and then freely displaced skin flaps.