完壁加盾板修复等多种技术治疗中耳胆脂瘤效果分析

Effect of multi-technique of intact canal and scute rebuilding in treatment of middle ear cholesteatoma

目的分析观察完壁法加盾板修复等多种技术治疗中耳胆脂瘤的效果。方法 2001年9月至2006年1月手术的113例中耳胆脂瘤患者,男60例,女53例;双耳11例,共124耳。其中11耳经2次手术,1耳经3次,共137耳次手术。手术采取耳内切口,保留外耳道后壁,综合采用气钻铣切割耳道整块取骨、自体骨制臼柱枪柱听骨、鼓索弹压听骨、透明质酸酯膜防粘连、轮廓化清除病灶、耳道壁(盾板)重建、上鼓室乳突再气化、早期咽鼓管吹张等多种技术。平均随访(36.58±20.47)个月。术后随访的气骨导差<20 dB,或术后气骨导差虽>20 dB,但气导<40 dB 者为手术成功。术后气骨导差<10 dB,或气骨导差虽>10 dB 但手术前后气骨导差的差值>30 dR 为显效;其余为有效。结果术后118耳(95.2%)没有胆脂瘤复发,112耳(90.3%)具有正常耳道,鼓膜愈合。胆脂瘤复发6耳、听力下降5耳、鼓膜再穿孔1耳共计12耳再手术并随访>12个月。112耳只经一次手术者术前气骨导差为(33.61±12.35)dB,术后气骨导差为(13.58±9.27)dB,差异有统计学意义(t=18.35,p<0.01)。12耳再手术者首次术前的气骨导差(38.83±12.43)dB,最后随访的气骨导差(10.38±8.99)dB,与首次术前相比,差异有极显著统计学意义(t=5.38,P<0.001)。手术有效47耳(37.9%),手术显效59耳(47.6%)。手术成功共106耳(85.5%)。骨导变化:术前平均骨导阈为(17.3±13)dB,与随访平均骨导阈(15.15±11.79)dB 比较,差异统计学意义(t=4.77,P<0.01)。其中骨导阈上升21耳(16.93%),不变42耳(33.87%),下降6l耳(49.19%)。10例19岁以下患者术后气骨导差为(8.80±5.27)dB,听力全部达到成功。结论完壁法加盾板修复等多种技术治疗中耳胆脂瘤,术后大多数不仅可以获得安全、干耳和正常的耳道,绝大多数听力可改善甚至恢复正常。复发率低,且复发后用同样的治疗方法仍能获得很好效果。对少年儿童能保持生理的耳道和听力,尤其有益。多种技术采用对骨导亦是安全的。

Objective To assess the results of muhi-technique with intact canal and scute rebuild operation for meddle ear cholesteatoma. Methods Analysis of 113 cases （ males 60, females 53, with mean 42.7 years old）, of which with double ears of 11 cases, and totally 124 ears （ 11 ears for one review, an ear for third time review, and totally 137 operations） was retrospectively performed. Ten cases less than 19 years old were operated from September 2001 to January 2006 for middle ear cholesteatoma as well as ossiculoplasty with intact canal and scute rebuild etc multi-technique. All cases were followed up for a mean （ 36. 58 ± 20. 47） months. Results There were 118 ears （95.2%） without cholesteatoma recurrence. Six ears were found cholesteatoma recurrence. Other 6 post-operation ears with drum re-perforation and hearing drop were re-operated. The pre-operation air-bone gap （ABG, average of 0.5,1,2 kHz） of 124 ears, with in initial 112 ears, was （33.61 ±12. 35 ） dB, while that of post-operation ABG was （ 13.58 ＋ 9.27） dB, by partnership t test, t = 18. 35, P 〈 0.01. The pre-operation ABG in reviewed 12 ears at the first pre-operation was （38.83 ± 12.43 ） dB, but post-operation ABG （10. 38 ± 8.99） dB, by partnership t test, t = 5.38, P = 0. 00022. The ABG closure to within 20 dB was tested in 100 ears while ABG over 20 dB but air conduct （AC） in 40 dB was in 6 ears, and then as succeed was in 106 ears（85.5% ）. ABG closure within 10 dB was in 50 ears and though ABG over 10 dB but ABG reduced over 30 dB was in 9 ears （59/124,47. 6% ） as which as best result. Bone conduct （BC） threshold was tested of 21 ears（ 16. 93% ） with raise 1-9 dB, of 42 ears （33.9%） with no change and of 61 ears （49. 2% ） with descend 1 -28 dB. Of 10 cases less than 19 years old post-operation ABG was （8. 80 ± 5.27 ）dB, which indicated that all cases was as succeed. Conclusions Using intact canal and scute rebuild etc multi-technique a normal canal, hearing improvement and very low recurrent could be gained for middle ear cholesteatoma, especially in juvenile and children. The multi- technique should be almost no damage for heating bone conduct.