软骨嵌合修复上鼓室外侧壁在乳突切开鼓室成形中的应用

Application of Cartilage in Repairing the Attic Lateral Wall in the Canal Wall Up Tympanoplasty

目的探讨在完壁式乳突切开鼓室成形术(CWU)中取用大块完整耳甲腔软骨行嵌入式方法修复上鼓室外侧壁缺损治疗外耳道后壁及/或上鼓室外侧壁明显破坏的中耳胆脂瘤疗效。方法 35例(共37耳)伴有外耳道后壁及/或上鼓室外侧壁明显破坏的中耳胆脂瘤在CWU术中取用大块完整耳甲腔软骨修复盾板缺损且同期行鼓室成形。总结手术技术要点,观察术后干耳时间、鼓膜愈合等相关情况;纯音测听检查比较手术前后言语相关频率平均听阈(PTA)及气骨导差(ABG)值;声导抗检查统计分析外耳道容积值、声顺值以及A型曲线鼓室导抗图出现率。结果术后平均随访时间19.3±7.5月。术后相关情况:平均干耳时间(23.47±11.76)d;鼓膜完全愈合34耳(34/37,91.89%),3例未愈合者中央性穿孔1耳,前下象限边缘性裂隙状愈合不良2耳;面瘫(0/37,0.00%);外耳道狭窄(0/37,0.00%);未发生上鼓室内陷袋(0/37,0.00%)。术后12月,0.5、1、2kHz平均气导听阈较术前比较有明显统计学意义(44.13±6.82dBHL,57.72±10.37dBHL,P=0.000, P<0.01),ABG值较术前比较有明显统计学意义(13.57±7.59dBHL,27.46±6.35dBHL,P=0.000, P<0.01);共有23耳行声导抗检查,平均外耳道容积1.73±0.61ml,平均声顺值为0.76±0.49ml,共计A型曲线鼓室导抗图15耳(15/23,65.22%),C型曲线4耳(4/23,17.39%),B型曲线4耳(4/23,17.39%。结论 CWU术中尽量保存和利用残存硬壁结构,采用大块完整的耳甲腔软骨嵌于上鼓室外侧壁修复缺损,能更好地维持外耳道及中耳解剖及生理功能,防止上鼓室内陷袋形成,是中耳乳突手术的理想选择。

Objective To report efficacy of usage of large auricular cartilage for repairing attic lateral wall defect in canal wall up(CWU) tympanoplasty for treatment of middle ear cholesteatoma with erosion to the posterior wall of the external auditory canal(EAC) and/or the attic lateral wall. Methods A total of 35 patients(37 ears) with middle ear cholesteatoma and significant erosion of the posterior EAC wall and/or the attic lateral wall, underwent CWU tympanoplasty with the erosion repaired using large auricular cartilage. The technique and outcomes(time to dry ear, rate of tympanic membrane healing, etc.) were reported. The average air conduction threshold(pure tone average, PTA) and average air-bone gap(ABG) before and after operation were compared. Acoustic immittance test was used to assess EAC volume, ear drum compliance and the rate of type A tympanograms. Results The average follow-up time after operation was 19.3±7.5 months. Average time to dry ear was 23.47±11.76 days. The rate of tympanic membrane healing was91.89%(34/37 ears). Of the 3 unhealed ear drums, one showed central perforation and 2 showed marginal irregular perforation in the inferoanterior quadrant. There was no facial paralysis, EAC stenosis or attic retraction pocket observed.At 12 months after operation, the average air conduction threshold(0.5, 1 and 2 kHz) improved from 57.72±10.37 dB HL to 44.13±6.82 d B HL(P=0.000, P<0.01), while average air-bone gap decreased from 27.46±6.35 dB to 13.57±7.59 dB(P=0.000, P<0.01). Acoustic immittance test was conducted in 23 ears, showing an average EAC volume of 1.73±0.61 ml and compliance of 0.76±0.49 ml. Tympanogram was type A in 65.22%(n=15), type C in 17.39%(n=4) and type B in 17.39%(n=4) of the 23 ears. Conclusion In CWU tympanoplasty, the preservation and utilization of residual bony wall structures combined with repair using large auricular cartilage provide improved anatomy and function of the EAC and middle ear, while helping prevent formation of attic retraction pockets. The technique is therefore ideal for the treatment of middle ear cholesteatoma.