软骨填塞封闭上鼓室缺损技术在中耳胆脂瘤手术中的应用

The surgical technique of obliterating attic defect with cartilage in the operation of middle ear cholesteatoma

目的 在中耳胆脂瘤手术中,为防止术后上鼓室胆脂瘤凹陷袋形成,以软骨封闭上鼓室回顾分析了这一临床技术、外科适应证及软骨在防止胆脂瘤复发中的应用价值。方法 本文回顾分析2014年4月~2019年12月因中耳胆脂瘤接受治疗的63例(63耳)患者。基本术式为乳突切开术,保留外耳道后壁但同时切除上鼓室外侧壁,以充分暴露并清理病变,缺损的上鼓室以软骨填塞封闭,防止术后上鼓室内陷袋形成,以避免胆脂瘤复发。软骨取自耳廓,切成条块状修复上鼓室缺损。本文术后随访检查包括软骨愈合情况、上鼓室回缩袋形成及胆脂瘤复发情况,不涉及听力。结果 全部病例术后随访时间1年以上。63例中,18例(28.6%)术后出现不同程度并发症,3例软骨缝隙过大,缝隙处局部胆脂瘤痂皮,门诊清理;6例术后检测咽鼓管功能不良,软骨缝隙处回缩局部胆脂瘤痂皮,但无内陷袋形成;3例上鼓室及中上鼓室交界处不同程度凹陷,胆脂瘤生成,但被软骨阻挡,未再发展;3例鼓膜边缘穿孔未愈合,鼓室内感染;3例术后胆脂瘤复发,由上鼓室向鼓窦和乳突方向发展。结论 在中耳乳突手术中,切除上鼓室充分暴露术区病变并彻底清除病灶后,缺损的上鼓室填塞封闭可有效防止回缩袋的形成,避免胆脂瘤复发。而软骨在术中取材、雕刻塑形、手术操作、术后抗感染能力、预防和阻止上鼓室处胆脂瘤的发生和发展均具有较强优势。

OBJECTIVE In order to prevent the formation of cholesteatoma retraction pocket in the epitympanum after the surgery,cartilage was used to obliterate the attic.The clinical technique,surgical indications and the value of cartilage in preventing recurrence of cholesteatoma were retrospectively analyzed.METHODS63 cases who underwent cholesteatoma surgery from April 2014 to December 2019 were retrospectively analyzed.The techniques include mastoidectomy with preservation of posterior canal but removal of attic.The attic defect was obliterated with cartilage.In order to prevent the formation of cholesteatoma retraction pocket,the cartilage was harvested from auricle then cut into pieces to block the epitympanum.RESULTS The period of postoperative observation is 1 to 6.6 years.In all 63 cases,18 cases(28.6%) had problem during the follow-up time.The postoperative problem includes local cholesteatoma matrix accumulation in the cartilage crack in 3 cases with normal eustachian tube function and in 6 cases with abnormal eustachian tube function,cholesteatoma formation in the attic but without retraction pocket formation due to resistance of the cartilage in 3 cases,delayed closure of tympanic membrane margin with infection in the middle cavity in 3cases.There were 3 cases with recurrence of cholesteatoma in the mastoid cavity.CONCLUSION In order to expose and clean up lession in the treatment of cholesteatoma,resection of the attic can be completed but obliteration of the attic should be done to prevent recurrence of cholesteatoma.Cartilage has more advantage in material harvesting,carving,operating and prevention of cholesteatoma recurrence.