耳内镜下中耳乳突胆脂瘤手术55例

Otoendoscopic Surgery for Cholesteatoma of Middle Ear Mastoid Process: Report of 55 Cases

目的探讨经外耳道耳内镜下中耳乳突部胆脂瘤切除术的效果。方法外耳道内C形切口,分离外耳道皮瓣,暴露鼓环,若松弛部穿孔,掀开鼓环;若紧张部大穿孔,保留前下方鼓环,暴露鼓室,清除鼓室内肉芽组织。持续灌流模式下磨除上鼓室外侧壁骨质,清除上鼓室胆脂瘤、听小骨周围病变,磨除乳突表面骨质,清除乳突腔胆脂瘤。内置明胶海绵支撑,视听小骨破坏程度置入不同类型人工听骨,乳突腔及上鼓室表面放置耳屏软骨,外覆软骨膜或生物膜。耳屏软骨膜内置法或耳屏软骨-软骨膜夹层法修补鼓膜,铺平外耳道皮瓣,术腔填塞。结果术前气导听阈中位数52.0(33.8~67.5)dB HL,显著高于术后6个月25.0(15.0~50.0)dB HL(Z=-6.454,P=0.000);术前气骨导距中位数35.0(21.2~52.5)dB HL,显著高于术后6个月15.0(3.8~27.5)dB HL(Z=-6.453,P=0.000)。55例术后2周,1、3、6个月复诊,以后每隔3个月进行一次复诊,随访24个月,55例鼓膜愈合良好,2例术后1年复发,均无面瘫、感音神经性耳聋等并发症。结论结合持续与非持续灌流模式,耳内镜下经外耳道入路行中耳乳突部胆脂瘤手术,鼓膜愈合良好,并发症少,术后患者听力改善明显,是一种微创、安全有效的手术方式。

Objective To investigate the clinical value of otoendoscopic surgery for cholesteatoma of middle ear mastoid process through external auditory canal.Methods A C-shaped incision was made in the external auditory canal and then the external auditory canal flap was separated to expose the tympanic anulus.If the flaccid part of the eardrum was perforated,the tympanic anulus was lifted.If the pars tensa membranae tympani was perforated,the anterior inferior tympanic anulus was preserved to expose the tympanic cavity,and the granulation tissue was removed within the tympanic cavity.Under the continuous perfusion,the bone of the lateral wall of the upper tympanic cavity was grinded,the cholesteatoma around the attic and auditory ossicles was removed,the bone of the mastoid was grinded,and the mastoid cavity cholesteatoma was removed.Gelatin sponge support was placed in mastoid cavity and tympanic cavity.According to the degree of destruction of the auditory ossicles,different types of artificial ossicles were placed.Tragus cartilage covered with perichondrium or biofilm was placed on the surface of mastoid cavity and attic.The tympanic membrane was repaired by tragus perichondrium built-in method or tragus cartilage-perichondrium dissection method.Finally,the external auditory canal flap was paved and the surgical cavity was filled.Results The median threshold of airway hearing was 52.0 dB HL(range,33.8-67.5 dB HL)before surgery,which was significantly higher than that at 6 months after surgery[25.0 dB HL(range,15.0-50.0 dB HL),Z=-6.454,P=0.000].The median threshold of airway bone conduction hearing before the operation was 35.0 dB HL(range,21.2-52.5 dB HL),which was significantly higher than that at 6 months after surgery[15.0 dB HL(range,3.8-27.5 dB HL),Z=-6.453,P=0.000].All the patients were followed up at 2 weeks,and 1,3,and 6 months after surgery.Afterwards,follow-ups were performed every 3 months until 24 months after surgery.All the patients had good tympanum healing,and 2 patients had recurrence at 1 year after surgery.All the patients had no complications such as facial paralysis or sensorineural deafness.Conclusions Combining continuous and non-continuous perfusion,otoendoscopic surgery for cholesteatoma of middle ear mastoid process through external auditory canal has a high healing rate of eardrum,few complications,and significant postoperative hearing improvement.It is a minimally invasive,safe,and effective surgical method.