先天性外耳道狭窄与闭锁——远期疗效影响因素与手术策略

Management of congenital meatal stenosis and atresia-impact factors on long-term results and surgical strategy

目的对不同类型先天性外耳道狭窄与闭锁的患者,实施外耳道成形术重建外耳道改善听力。对新外耳道的状态、听力变化和并发症情况进行随访,对影响远期疗效的相关因素进行分析,为外耳道畸形手术适应症选择、手术方案制定与决策提供依据。材料与方法一般资料:本文收集07年9月—10年9月期间资料完整的73例先天性外耳道狭窄或闭锁行外耳道成形术者。入选标准依据Jahrsdoerfer的中耳评分法;术前伴难以控制的外耳道感染、胆脂瘤破坏鼓室者除外;平均随访时间22.0月、平均手术年龄12.8岁。治疗方法采用耳甲切口、上鼓室入路,常规替尔氏皮片外耳道植皮。新鼓膜采用颞肌筋膜或乳突骨膜外覆盖部分裂厚皮片,或小外耳道皮肤转位与小鼓膜形成新鼓膜;凡士林抗生素纱条紧密填塞固定外耳道植皮,如无感染发生3-4周后取出,取出后常规膨胀海绵或消毒棉球扩张。结果狭窄组19例(95.0%)达实用听力(ABG〈30dB),且长期结果稳定,外耳道并发症少。其中4例(20.0%)术后气骨导差小于10dB。新外耳道感染及耳甲腔耳周皮肤湿疹和鼓膜外移钝角化少见。闭锁组仅27例(50.9%)获实用听力(ABG〈30dB),并发症多。两组之间在听力改善、长期疗效和并发症发生率均有显著差异,闭锁组的效果较差。结论新外耳道状态、听力变化和并发症与是否伴有小鼓膜和正常外耳道皮肤密切相关,是影响远期疗效的重要因素;对完全闭锁者再造外耳道需要更慎重。

Purpose To analyze impact factors on long-term results following meatoplasty and tympanoplasty in terms of canal patency, post-surgery hearing and complications, and to determine surgical indications and protocol for such procedures in patients with congenital meatal stenosis and atresia. Materials and Methods： Seventy three patients with congenital stenosis or atresia seen between Sep. 2007 and Sep. 2010 were enrolled in this study. Inclusion was based on CT scores （greater than 6 on the Jahrsdoerfer ’ s scoring system）. Exclusion criteria included intractable infections and tympanic cavity destruction by cholesteatoma. The mean age of the 73 patients was 12.8 years and the mean follow-up time was 22.0 months .Surgical protocol： The endoaural incision was used to approach the canal and attic. The eardrum was reconstructed with temporal fascia or periosteum covered by Thiersch＇s skin graft. Skin translocation from canal was used in case of pre-existing small eardrum. The reconstructed canal was packed with Vaseline gauze with antibiotics for 3 to 4 weeks. After gauze removal, expansion foam or sterile cotton was used to maintain patency of the new canal for more than half year. Results In patients with meatal stenosis, 19 （95%） acquired stable and serviceable hearing with an air-bone gap （ABG） of less than 30 dB （less than 10 dB in 4 （20%）） and few complications. In patients with atresia, only 27 （50.9%） acquired similar results as in those with stenosis. There were also more complications in this group of patients. Post-operative hearing, long term outcomes and complications favored meatal stenosis when compared to atresia （p 0.05）.Conclusion The most important factor impacting prognosis was presence of an eardrum and ear canal skin. Indications for functional surgery should be stricter in atresia than in stenosis.