RU2806740C1 - Method of surgical removal of formation of apex of temporal bone pyramid - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: formation of the apex of the temporal bone pyramid is removed using a modified transcanal infrapromontorial approach. At the first stage, the skin of the walls of the external auditory canal is separated with elevation and removal of the meatotympanic flap to the level of the cartilaginous part of the external auditory canal. The autocartilage of the medial surface of the auricle and the autofascia of the temporal muscle are collected. At the second stage, wide canaloplasty is performed to the level of the central cells of the facial nerve canal in the mastoid region. The lower wall of the external auditory canal (EA) is removed along with the tympanic ring to the level of the jugular vein bulb. The anterior wall of the joint is smoothed without opening the temporomandibular joint. At the third stage, skeletonization of the internal carotid artery (ICA) is performed in the vertical section and the knee area. Then the pericarotid cells, hypotympanum cells, and infralabyrinthine cell space are opened. The bone capsule of the basal curl of the cochlea is thinned. Afterwards the ICA is decanalized, mobilized and shifted anteriorly. At the fourth stage, the formation of the apex of the pyramid of the temporal bone is removed, followed by visualization, sanitation and revision of hard-to-reach areas of the apex of the pyramid and the area of the knee of the ICA, its anterior and medial walls, and the area of the anterior wall of the internal auditory canal. At the fifth stage, hemostatic material is placed in the postoperative cavity, a fragment of autocartilage is placed in the infrapromontorial space, completely covering the ICA, and autofascia is placed on the handle of the malleus using the underlay technique. The preserved NSP skin is laid over the fascia.

EFFECT: method allows to preserve the function of the facial nerve, as well as auditory function during surgical treatment of isolated lesions of the apex of the temporal bone.

1 cl, 15 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to otorhinolaryngology, and can be used in the surgical treatment of isolated lesions of the apex of the temporal bone pyramid.

The apex of the petrous temporal bone is difficult to access surgically due to its deep position at the base of the skull and the close proximity of surrounding vital anatomical structures. Symptoms of apex lesions are varied: hearing loss, ear congestion and dizziness due to compression of the eighth cranial nerve, headaches due to involvement of the trigeminal nerve, diplopia due to compression of the sixth cranial nerve and paresis of facial muscles associated with the seventh nerve.

The pathology of the apex of the pyramid according to its etiology is divided into extradural and intradural. Intradural pathology includes meningiomas and schwannomas. Extradural pathology includes cholesterol granulomas, mucoceles, cholesteatomas, osteomyelitis, effusion, chondromas, chondrosarcomas, metastases.

All patients with damage to the apex of the temporal bone are required to undergo a complete oto- and audiological examination and assessment of the function of the cranial nerves (V-VIII). Visualization of the temporal bone at the preoperative stage should be performed using additional research methods, such as CT of the temporal bones and MRI of the temporal bones and brain with intravenous contrast to determine the localization of the pathological process, the presence of bone destruction, the spread of the lesion of the apex of the pyramid and the involvement of the surrounding anatomical structures. structures, as well as lesions that arise outside the apex and grow into it for the second time.

There is a known method for removing pathology from the apex of the temporal bone pyramid using transcochlear access. This approach was first described by House and Hitselberger in 1976. The approach was developed to reach petroclival or large midline intradural lesions and cerebellopontine angle tumors. The approach involves removing the cochlea with expanding access to the apex of the temporal bone (see HouseW.F, DelaCruzA, HitselbergerW.E. “Surgeryoftheskullbase: transcochlear approachto the petrous apex and clivus” Otolaryngology, Vol. 86, No. 5, 1978, p. 770-779), which was subsequently modified by D.E. Brackmann, W. Pellet, M. Bappa. When using this method, a standard arcuate incision is made along the postauricular fold, the cortical layer of the mastoid process is widely removed, its cellular structure is almost completely drilled out, and the middle and posterior fossae of the dura mater are skeletonized to the sigmoid sinus. The facial nerve is identified and skeletonized to the level of the geniculate ganglion and greater petrosal nerve, allowing an open mastoidectomy to remove the superior and posterior walls of the external auditory canal. Then the jugular bulb is skeletonized, labyrinthectomy is performed, identification of the internal auditory canal (IAS), then complete decompression of the facial nerve is performed from the stylomastoid foramen to the labyrinthine part and its translocation posteriorly, removal of the cochlea with expansion towards the apex of the temporal bone pyramid. The upper limit of this approach is the superior petrosal sinus, the lower limit is the inferior petrosal sinus, in front is the region of the petrous part of the internal carotid artery (ICA), and the apex of the triangle is under the Meckel'scave.

The disadvantages of the method using this access in any modification are the loss of residual hearing and decreased function of the facial nerve of varying degrees of severity (according to the House - Brackmarm scale), the possible development of complications in the postoperative period such as: vestibular disorders, otoliquorrhea or nasal liquorrhea, temporary cranial paresis -cerebral nerves (VII, IX, X, XI, XII), as well as general complications: inflammation, bleeding, cerebrovascular accidents.

There is a known method for removing pathology from the apex of the temporal bone pyramid through the middle cranial fossa (anterior transpetrosal approach). House first described an approach through the middle cranial fossa in 1963 for the treatment of petrositis (see HouseWF. Middle cranial fossa approach to the petrous pyramid. Report of 50 cases. ArchOtolaryngol.l963;78: 460e469). The access is the removal of a pathological process from the area of the apex of the pyramid of the temporal bone, the petroclival region by separating the dura mater (DRM) of the temporal lobe of the brain from the pyramid, removing the bone of the anterior surface of the pyramid of the temporal bone. This approach begins with a preauricular incision of about 7-8 cm, starting in front of the tragus, and a flap of the temporal muscle, the separated tissue is raised above the calvarium. The scales of the temporal bone are exposed and a craniotomy is performed above the zygomatic root, CSF drainage is formed, the media is coagulated, followed by anterior-posterior detachment of the dura mater from the temporal bone. The greater petrosal nerve and superior semicircular canal, namely the “blueline,” are then identified. The ICA canal is identified and the apex of the pyramid is exposed. At low speeds, cutting and diamond burs open the apex of the pyramid medial to C2 of the ICA, skeletonize and expose the medial wall of the ICA in the area of the knee and horizontal section. The pathological contents of the apex of the pyramid are removed.

The disadvantages of this approach include the need for retraction of the temporal lobe of the brain, the possible development of complications such as: liquorrhea, the frequency of which is up to 13%, paresis or paralysis of the facial nerve, meningitis, hydrocephalus and ataxia.

The closest analogue of the claimed invention is a method for surgical removal of the pathological process of the apex of the temporal bone pyramid - infracochlear access, which is used for cystic lesions and effusion affecting the lower apical cells (see ArriagaMA (2006) Petrous apex effusion: a clinical disorder. Laryngoscope 116 (8 ): 1349-1356.,cM.Ghorayeb BY, Jahrsdoerfer RA (1990) Subcochlear approach for cholesterol granulomas of the inferior petrous apex. OtolaryngolHeadNeckSurg 103(l):60-65). The infracochlear approach provides access to the perilabyrinthine and petrous apex cells by opening the perilabyrinthine cells below the cochlea between the jugular vein bulb (JV) and the vertical portion of the internal carotid artery (ICA).

The main disadvantage of the infracochlear approach is the narrow dissection field; there are also risks of hearing loss and liquorrhea, probably due to damage to the cochlear aqueduct. Facial palsy is another complication of infracochlear access.

The objective of the present invention is to develop a method for surgical removal of the pathological process of the apex of the temporal bone pyramid using a modified transcanal infrapromontorial approach to the apex of the temporal bone pyramid using microscopic and endoscopic techniques while preserving hearing.

To solve this problem, we propose a method for removing the pathological process of the apex of the pyramid using a modified transcanal infrapromontorial approach, which consists in the fact that at the first stage, the skin of the walls of the external auditory canal is separated with elevation and removal of the meatotympanic flap to the level of the cartilaginous part of the external auditory canal, autocartilage is collected from the medial surface of the auricle and autofascia of the temporal muscle,

at the second stage, wide canaloplasty is carried out to the level of the central cells of the facial nerve canal in the mastoid region, the lower wall of the external auditory canal (EAC) is removed along with the tympanic ring to the level of the jugular vein bulb, the anterior wall of the ECA is smoothed without opening the temporomandibular joint,

at the third stage, the internal carotid artery (ICA) is skeletonized in the vertical section and the knee area, then the pericarotid cells, hypotympanum cells, and infralabyrinthine cell space are opened, and the bone capsule of the basal turn of the cochlea is thinned; after which the ICA is decanalized, mobilized and shifted anteriorly,

at the fourth stage, the formation of the apex of the pyramid of the temporal bone is removed, followed by visualization, sanitation and revision of hard-to-reach areas of the apex of the pyramid and the area of the knee of the ICA, its anterior and medial walls, the area of the anterior wall of the internal auditory canal,

at the fifth stage, hemostatic material is placed in the postoperative cavity, a fragment of autocartilage is placed in the infrapromontorial space, completely covering the ICA, autofascia is placed on the handle of the malleus using the underlay technique, and the preserved ESP skin is laid out on top of the fascia.

The technical result of the claimed invention is the ability to preserve the function of the facial nerve due to the fact that the surgeon leaves it in the bone canal, the ability to preserve hearing in the postoperative period due to leaving the chain of auditory ossicles intact, smoothing the promontorial wall without opening the lumen of the cochlear capsule, and this access also makes it possible to expand overview of the surgical field (expand the internal window of the corridor to the apex of the pyramid) and thereby remove the pathological process of the apex of the pyramid by mobilizing and displacing the internal carotid artery.

The developed method for removing the pathological process of the apex of the temporal bone pyramid is a minimally invasive microsurgical approach, which made it possible to minimize postoperative hearing loss and preserve the function of the facial nerve.

Brief description of explanatory materials.

The sequence of the operation is schematically presented in Figures 1-6.

Fig. 1 - elevation and removal of the meatotympanic flap to the level of the cartilaginous part of the external auditory canal;

Fig. 2 - view of the surgical field after extended canaloplasty;

Fig. 3 - opening of cells lateral to the canal of the internal carotid artery, infracochlear space, smoothing of the promontorial wall;

Fig. 4 - opening of the anterior pericarotid cells;

Fig. 5 - expansion of the internal window of the corridor to the apex of the pyramid due to anterior displacement of the ICA;

Fig. 6 - stage of endoscopic revision of the area of the apex of the pyramid medial from the ICA.

The sequence of operations for Example 1 is presented in Figures 7-15.

Fig.7 - Extended canaloplasty is performed, the posterior and anterior and lower bone walls of the auditory canal are thinned circularly with a diamond bur;

Fig. 8 - view of the tympanic cavity (endoscopic photo);

Fig. 9 - Stage of opening the pericarotide cells, skeletonization of the ICA C1 canal and in the knee area, smoothing the promontorial wall of the cochlea without opening its lumen, opening the infracochlear cellular tract, during which the pathological contents of the apex of the temporal bone pyramid - cholesteatoma - were identified;

Fig. 10 - Stage of decanalization of the ICA in the knee area and the upper part of the vertical section, expanding the boundaries of the internal window of surgical access with mobilization of the ICA;

Fig. 11 - Stage of removal of cholesteatoma of the temporal bone pyramid due to the expansion of the internal window of the corridor by retracting the ICA anteriorly;

Fig. 12 - Stage of complete sanitation of the apex of the pyramid using a combined method (microscopic photo);

Fig. 13 - Stage of complete sanitation of the apex of the pyramid using a combined method (endoscopic photo);

Fig. 14 - Stage of closure of the internal carotid artery with a fragment of autocartilage;

Fig. 15 Underlay tympanoplasty was performed using a fragment of autofascia,

where for Fig. 1-6, 9-14 the following designations are used:

1 - skin of the anterior wall of the external auditory canal,

2 - anterior wall of the external auditory canal,

3 - internal carotid artery,

4 - round window of the cochlea,

5 - pyramidal elevation,

6 - incus-stapedius joint,

7 - anterior pericarotide cells,

8 - snail,

9 - apex of the pyramid of the temporal bone,

10 - internal carotid artery segment C2,

11 - internal carotid artery segment C3,

12 - dura mater,

13 - infrapromontorial space,

14 - stirrup,

15 - anvil,

16 - hammer,

17 - vertical section of the stony part of the internal carotid artery (segment C1),

18 - cholesteatoma,

19 - fragment of autocartilage.

Carrying out the invention

Removal of the pathological process of the apex of the pyramid using a modified transcanal infrapromontorial approach using microscopic and endoscopic techniques, intended for patients with preserved hearing, is performed under general intubation anesthesia, under the control of neuromonitoring of the facial nerve. Access begins with an arcuate incision of the skin and soft tissues of the postauricular area, sampling of the autofascia of the temporal muscle of a size sufficient to close the surgical area using the underlay technique, a fragment of the cartilaginous plate of the medial surface of the auricle of a size sufficient to close the vertical segment of the internal carotid artery (ICA), and skin separation walls of the external auditory canal (EA) with complete elevation and removal of the meatotympanic flap to the level of the cartilaginous part of the external auditory canal. Next, wide canaloplasty is performed, namely: by circularly smoothing the walls of the external auditory canal, the posterior wall of the external auditory canal is removed with burs to the level of the central cells of the facial nerve canal in the mastoid region; the lower wall of the EAS together with the tympanic ring to the level of the jugular vein bulb; smoothing the anterior wall of the EJJ without opening the temporomandibular joint, removing a large overhang, identifying the canal of the internal carotid artery (ICA) in the vertical segment. Then, with the help of medium-diameter diamond burs, skeletonization of the ICA is performed in the vertical section, the knee area, opening of the pericarotid cells (special attention is paid to the removal of cells anterior to the ICA canal), cells (cells) of the hypotympanum, and infralabyrinthine cell space. The ICA is completely decanalized (the remains of the bone canal are removed) with its mobilization and displacement anteriorly using microinstruments or an endoscope tube.

The presented access option has 2 bounding windows (the entrance access window, accesswindow, and the internal window, innerwindow). In this case, the main stage of the work is performed in the lower floor of the tympanic cavity; the chain of auditory ossicles remains intact and does not interfere with the performance of surgical maneuvers. External window boundaries:

The posterior border of the entrance access window is the mastoid segment of the facial nerve (preserved in the bone canal), the lower border is the bulb of the jugular vein, the anterior border is the temporomandibular joint (TMJ); upper - middle cranial fossa (MCF).

The posterior border of the internal access window is the promontorial wall, the cochlear aqueduct; anterior - vertical segment of the ICA), lower border - bulb of the jugular vein; top - SCHYA.

The internal window of the corridor to the apex of the pyramid can be expanded by the maneuver of retracting the ICA anteriorly, thinning the bone capsule of the basal turn of the cochlea.

Removal of the pathological process is carried out using both microscopic and endoscopic techniques. After sanitation of the main volume of the pathological process, endoscopic attachments with viewing angles of 30°, 45°, 70° are used, allowing for review, sanitation and revision of hard-to-reach areas of the apex of the pyramid, the area of the knee of the ICA from the inside (in front), its medial wall, the area of the anterior wall of the internal auditory aisle (rear) (figure 1-6).

At the end of the operation, a revision of the chain of auditory ossicles is carried out, a hemostatic material (surgicell) is placed in the postoperative cavity, a large fragment of autocartilage is placed in the infrapromontorial space, completely covering the ICA, then pre-prepared autofascia is placed using the underlay technique with lateralization of the flap on the handle of the malleus, the preserved skin of the ESP is laid out on top fascia, the external auditory canal is tamponed with hemostatic tampons.

Clinical example.

Patient M., 63 years old, was admitted to the Department of Pathology of the Ear and Skull Base of the National Medical Research and Clinical Center of the Federal Medical and Biological Agency with a diagnosis of a benign neoplasm of the apex of the temporal bone pyramid on the left.

He complained of dizziness, double vision, decreased hearing in the left ear, noise in the head and left ear for 2 years.

Otoscopy - the external auditory canal is narrow and free, the eardrum is gray, there are no defects. There is no spontaneous or pressor nystagmus.

According to computed tomography of the temporal bones, the formation of the apex of the temporal bone pyramid is determined with destruction of the clivus on the left, C2 of the horizontal section of the ICA on the left.

MRI of the brain revealed diffusion restriction in the petroclival area on the left in NonEpiDWI mode, with a hypointense signal in T1 and hyperintense signal in T2 modes.

According to pure tone threshold audiometry, bilateral sensorineural hearing loss of the 1st degree.

Surgical intervention was performed under endotracheal anesthesia using the NIM 3.0 facial nerve neuromonitoring system. Sensors are installed in the muscle in the area of the nasolabial fold and above the eye on the right. A postauricular incision was made in the skin and soft tissue to the periosteum. The autofascia of the temporalis muscle and a fragment of cartilage were collected. The platform of the mastoid process is exposed, and the spine of Henle is visualized. Using a microraspatter, the skin of the auditory canal is separated from the lower, posterior and upper walls of the bony part of the external auditory canal to the fibrous ring. Tympanotomy was performed: the tympanic cavity is free, the chain of auditory ossicles is intact, mobile, and motion is transmitted to the cochlear window. The skin of the external auditory canal (EA) with the eardrum is raised using the underlay technique, peeled off to the cartilaginous section. Extended canaloplasty was performed. The mastoid process is of a pneumatic type of structure, the posterior wall of the ESP is smoothed to the level of the central cells of the facial nerve canal in the mastoid region. The anterior wall of the joint was smoothed without opening the temporomandibular joint (TMJ). Using diamond burs of medium diameter, the ICA canal in the vertical section and the knee area was skeletonized, the promontorial wall was smoothed without opening its lumen of the cochlea. Upon skeletonization of the ICA and opening of the infralabyrinthine cell tract, a cholesteatoma was identified. Partial removal of cholesteatoma masses was performed, during which a large cavity was visualized, occupying the apex of the pyramid of the temporal bone (posterior border - VSP, lateral border - ICA in the horizontal section and the knee area, cochlea; medial wall - dura mater, lining the projection middle and upper sections of the clivus, anterior - the edge of the apex of the pyramid and the region of the sphenoid sinus; upper - the dura mater of the middle cranial fossa; lower - the anterior parts of the jugular foramen). Diamond burs of different diameters were used to decanalize the ICA in the area of the knee and the upper part of the vertical section, and the surgical corridor to the apex of the temporal bone pyramid was expanded. The cholesteatoma masses were removed bluntly. The cavity was inspected using endoscopic techniques. Under endoscopic assistance, using the maneuver of retracting the ICA anteriorly with the help of a nasal raspator, it was possible to expand the internal window of the corridor to the apex of the pyramid, which made it possible to sanitize hard-to-reach places: the knee area of the ICA on the medial side, the apex, the posterior borders of the cavity at the level of the VSP. The cholesteatoma matrix was removed from the walls of the ICA and dura mater. All pathological formations were removed and sent for histological examination. The cavity is washed with saline. solution three times. During revision of the tympanic cavity, the incus and malleus are preserved, the stirrup is preserved, and transmission to the cochlear window is positive. Neuromonitoring of the facial nerve was performed (Medtronic NIMResponse-3.0 facial nerve monitoring system): with stimulation from 0.5 to 3.0 mA, contractions from the orbicularis oculi muscle (zygomatic nerve) and the orbicularis oris muscle (buccal nerve) were recorded in the tympanic segment. Reconstructive stage of the operation: Surgicell is placed in the cavity, the ICA is completely covered with a large fragment of autocartilage. The infralabyrinthine tract was additionally tamponed with Surgicell; there were no signs of active liquorrhea. An underlay tympanoplasty was performed using a fragment of autofascia with lateralization of the flap onto the handle of the malleus. The preserved skin is laid over the fascia. The external auditory canal is tamponed with Spangostan, a Merocel Medtronic tampon with Ceftriaxone. The postoperative wound is sutured in layers with separate interrupted sutures of Vicryl 3.0. An aseptic bandage was applied to the area behind the ear. The operation was completed without complications.

In the postoperative period, antibacterial, anti-inflammatory and desensitizing therapy and treatment of surgical sutures behind the ear were carried out. The ear tampons were removed on the 7th day. Postoperative sutures were removed on the 7th day. The patient was discharged on the 10th day after surgery in satisfactory condition for further outpatient monitoring by an otolaryngologist. Otomicroscopic picture at discharge: left ear - postoperative wound in the postauricular area without signs of inflammation, healed by primary intention. In the external auditory canal there is scant wound discharge, the skin of the walls is edematous, the neotympanic flap is pasty and rich. There are no signs of paresis of facial muscles, no spontaneous or pressor nystagmus. Histological examination confirmed cholesteatoma. Discharged with recommendations.

The patient is under observation for 12 months. Upon re-examination, a good anatomical result was obtained in the form of a consistent neotympanic membrane; after 6 months, an MRI of the temporal bones was performed, including in the NONEPIDWI mode - there was no evidence of cholesteatoma, the function of the facial muscles was not impaired, and the hearing function was preserved.

15 patients with pathological processes in the area of the apex of the temporal bone were operated on using the claimed method. Using the maneuver of retracting the ICA anteriorly with the help of a nasal raspator, it was possible to expand the internal window of the corridor to the apex of the pyramid, which made it possible to sanitize hard-to-reach areas. In the postoperative observation period, no hearing impairment was detected, the function of the facial nerve was preserved. According to computed tomography, MPT and otoscopic images in the postoperative period, no evidence of a pathological process in this area was identified. The observation period is 12 months.

Claims (1)

A method for removing the formation of the apex of the pyramid using a modified transcanal infrapromontorial approach, which consists in the fact that at the first stage, the skin of the walls of the external auditory canal is separated with elevation and removal of the meatotympanic flap to the level of the cartilaginous part of the external auditory canal, autocartilage is collected from the medial surface of the auricle and the autofascia of the temporal muscle , at the second stage, a wide canaloplasty is performed to the level of the central cells of the facial nerve canal in the mastoid region, the lower wall of the external auditory canal (EAC) is removed along with the tympanic ring to the level of the jugular vein bulb, the anterior wall of the ECA is smoothed without opening the temporomandibular joint, at the third stage stage, the internal carotid artery (ICA) is skeletonized in the vertical section and the knee area, then the pericarotid cells, hypotympanum cells, infralabyrinthine cell space are opened, the bone capsule of the basal curl of the cochlea is thinned, after which the ICA is decanalized, mobilized and shifted anteriorly, at the fourth stage removal of the formation of the apex of the pyramid of the temporal bone, followed by visualization, sanitation and revision of hard-to-reach areas of the apex of the pyramid and the knee area of the ICA, its anterior and medial walls, the area of the anterior wall of the internal auditory canal, at the fifth stage, hemostatic material is placed in the postoperative cavity, a fragment is placed in the infrapromontorial space autocartilage, completely covering the ICA, autofascia is placed on the handle of the malleus using the underlay technique, the preserved skin of the ICA is laid out on top of the fascia.