陈旧乳突腔粘连性中耳炎重建听力的效果观察

The results following reconstuction of old radical cavities with adhesive otitis media

目的总结采用多种技术治疗陈旧乳突根治腔合并中耳粘连的效果。方法回顾1999年6月—2004年5月间乳突根治后再手术共48例(49耳),男28例(29耳),女20例(耳),平均年龄44.9岁(25～65岁),平均随访15.69月(范围12～59月),并与以往的胆脂瘤再手术研究作对比分析。术前气导(AC)水平59.69dBHL,术前气骨导差(40.63±13.65)dB。40耳因为开放的乳突腔和/或中鼓室感染再发、9耳为提高听力前来要求手术。18耳(37%)用自体乳突碎骨或髂骨填塞陈旧的乳突腔,13耳(27%)用自体骨作耳道、盾板修复,18耳(37%)根治腔未填塞。用自体骨枪柱法重建听骨的23耳(47%),臼柱法24耳(49%),保留原有听骨的2耳(4%)。16耳(33%)用施美德-美敦力公司提供的MeroGel透明质酸膜片,12耳(24%)用强生公司提供的羟基乳酸聚合物网片预防再粘连。39耳(80%)用残留的鼓膜紧张部和鼓索神经弹压新听骨。2耳(4%)存在鼓室积液作鼓膜置管。49耳全部在2周后自行捏鼻通气或导管法行咽鼓管通气。结果47耳保持干耳,1耳(2%,未填塞)乳突腔炎性肉芽生长耳漏再发,经治疗干愈。另1耳(未填塞)1年后耵聍栓塞伴少量分泌物,取后干愈。术后平均气骨导差(ABG)为(19.84±11.80)dB,与术前比,t为8.07,t0.01=2.63,P<0.01,差异有极显著性意义。其中术后ABG缩小30dB以上的显效者17耳(35%),缩小15dB以上的有效者35耳(71%),有5耳ABG缩小虽不足15dB,但气导水平达到40dBHL实用水平以内(10%),两者相加,有效率为40耳(81%)。术后ABG缩小10dB以上为38耳(78%),另有5耳(10%)气导水平达到40dBHL实用水平以内,二者相加为43耳(88%)。如以ABG缩小到20dB以内为成功者是28耳(57%),另有4耳(8%)虽ABG略大于20dB,但AC已达40dBHL以内,两者相加为32耳(65%)。术后AC小于40dBHL实用水平的总共31耳(63%)。再穿孔4耳(8%),3耳重新手术修补。再次发生粘连或钙化致听力下降9耳(18%),没有术后感音功能受损的病例。结论按实际情况采取多种措施可提高以往胆脂瘤手术遗留乳突腔伴粘连性中耳炎的鼓室成形手术效果。本组获得ABG缩小10dB以上或保持气导在40dB以内43耳(88%),与作者以往的结果(43/66耳,65%)相比已有很大改进。

Objective To assess the results following reconstruction of old radical cavities with adhesive otitis media with a multi-technique approach. Methods A retrospective study was performed on 48 patients, 28 male （ 29 ears ） and 20 female （ total： 49 ears ）, mean age 44.9 years （ range 25 - 65 years ）, who underwent reconstruction of old radical mastoid cavities for infection and conductive deafness from June 1999 to May 2004 and were followed up for a mean of 15.69 months （ range 12 - 59 months ）. The mean preoperative air conduction （ AC ） threshold and air-bone gap（ ABG ） were 59.69 dB and 40.63 dB, respectively. Of the 49 ears operated on, 18 ears （ 37% ） had obliteration of mastoid cavities, 13 ears （ 27% ） had scutumplasty with autogenous bone graft, and the 18 remaining ears with a dry, small mastoid cavity were left alone. Ossicular chain reconstruction was performed using L-shaped, autogenous bone graft in 24 ears （ 49% ） and rod-like autogenous bone graft in 23 ears （ 47% ）, and in the 2 remaining ears（ 4% ） the ossicular chains were preserved intact. MemGel, an absorbable hyaluronic acid membrane, and Vicryl, a polyglactin mesh, were used in 16 （ 33% ） and 12 （ 24% ） ears for preventing adhesion reformation, respectively. In 36 ears （ 73% ）, the chorda nerve or the pars tensa of tympanic membranes were stretched over the grafts. Ventilating tubes were inserted in 2 middle ear effusion cases （4%）. In all patients, middle ears were inflated by Valsalva＇s method or catheterization two weeks after operation. Results Of 49 ears operated on, 47 were dry at the final examination while other 2 had inflammatory granulation tissue and otorrhoea, and were cured conservatively. The postoperative mean ABG 19.84 dB （ SD 11.80 dB ） was statistically batter than the preoperative one （ P 〈 0.01 ）. An air-bone gap reduction of 〉 30 dB and 〉 15 dB was achieved in 17 ears （ 35% ） and in 35ears （ 71% ）, respectively; there was an ABG reduction of 〈 15 dB in 5 ears （ 10% ）, their AC thresholds, however, were less than 40 dB HL and were considered as improvement, for a total improvement rate of 81%. Postoperative hearing results showed an excellent （ ABG 〈 10 dB ） or a good （ ABG 〈 20 dB ） ABG closure in 10 ears （ 20% ） and 28 ears （ 57% ）, respectively. Re-perforation occurred in 4 ears and among them 3 were cured by re-operation. Conclusion A muti-technique approach was adopted for reconstruction of old radical mastoid cavities and good results were obtained.