Method of plastic surgery of postoperative cavity in treatment of chronic purulent otitis media in patients with sclerotic type of mastoid process structure

Abstract

FIELD: otolaryngology.SUBSTANCE: incision is made along the transitional fold in the area behind the ear. Soft tissues are separated. Using a drill, bone chips are taken from the mastoid process area in the volume required for plastic surgery of the postoperative cavity. Next, an antrotomy is performed through the posterior bony wall of the external auditory canal. In this case, a “bridge” is left from the back wall of the external auditory canal. The pathological contents of the tympanic cavity, attic and antrum are removed. The mucous membrane of the postoperative cavity is removed. Using an individually selected plate of auricular cartilage with the perichondrium left on one side at the level of the “bridge”, the postoperative cavity is separated from the attic in such a way that the perichondrium is directed towards the attic. Bone chips soaked in an antibiotic solution are placed into the postoperative cavity up to the level of the previously removed posterior bone wall of the external auditory canal. On top of the bone chips, plates of cartilage of the auricle are laid like tiles and the temporal fascia. Next, tympanoplasty and ossiculoplasty are performed. The external auditory canal is tamponed with a hemostatic sponge. The wound in the area behind the ear is sutured.EFFECT: increasing the effectiveness of surgical treatment of chronic purulent otitis media in patients with a sclerotic type of mastoid process structure due to the optimal technique of plastic surgery of the postoperative cavity after sanitizing surgery on the middle ear.1 cl, 4 dwg, 1 ex

Description

[0001] The invention relates to medicine, namely otolaryngology, and can be used for plastic surgery of the postoperative cavity in the treatment of chronic suppurative otitis media (hereinafter referred to as CSOM) in patients with a sclerotic type of mastoid process structure.

[0002] There are several types of mammillary process structure, depending on their structure: pneumatic, diploic, and sclerotic. In the pneumatic type, the air cells fill the entire process and extend to the squama of the temporal bone, the zygomatic process, and the petrous bone. The diploic (spongy, spongy) type is characterized by a small number of air cells, predominantly around the antrum. The sclerotic (compact) type is formed by dense bone tissue; air cells are absent or very few in number, and the antrum is preserved but reduced in size. Patients with chronic sclerotic osteomyelitis and a sclerotic type of mastoid process structure have a long history of the disease, a sluggish subacute course of inflammation, which leads to disruption of metabolic processes and microcirculation in tissues, atrophy of the mucous membrane of the periantral cells, sclerosis, increased bone density and a decrease in the size of the mastoid process.

[0003] There is no consensus among otolaryngologists regarding the surgical approach for treating patients with chronic sclerotic otitis media and a sclerotic mastoid process. Performing a closed procedure with preservation of the posterior wall of the ear canal presents technical challenges due to bone density and the depth of the antrum, as well as the difficulty of visualizing the attic when using a surgical burr in the narrow space between the posterior wall of the ear canal and the middle cranial fossa. Good visualization requires a wide approach, which leads to the removal of a large volume of mastoid bone and the walls of the external auditory canal, creating a large postoperative cavity, the size of which significantly exceeds the size of the antrum in cases of a sclerotic mastoid process, requiring more material for reconstruction.The technical difficulties of this type of operation, the duration of the surgical intervention, the difficult to predict result of reconstruction in conditions of impaired microcirculation and the absence of cells with a mucous membrane in the mastoid process that perform a gas-forming function, contribute to the choice of an "open" type of sanitizing operation with the initial formation of a radical cavity, the size of which will slightly exceed the size of the antrum in the sclerotic type of structure of the mastoid process.

[0004] The presence of even a small postoperative cavity following open surgery can lead to the development of so-called "operated ear disease," which significantly reduces patients' quality of life due to chronic inflammation caused by incomplete epidermal closure of the cavity walls, mucositis with epidermal accumulation, and the possible development of cholesteatoma. With an aggressive course of inflammation, erosive changes in the bony walls of the cavity itself, the lateral semicircular canal, and the facial nerve canal can occur, potentially leading to complications. A radical cavity requires constant care from both the patient and the involvement of an otolaryngologist. However, obliteration and plastic surgery of the radical cavity significantly improves patients' quality of life.

[0005] The optimal material for obliterating the postoperative cavity after performing antromastoidectomy is bone autochips, the collection of which does not cause difficulties, and its quantity in the case of the sclerotic type of structure of the mastoid process exceeds the volume of the antrum and the size of the access zone to it, while the volume of surgical trauma and the duration of the operation do not increase.

[0006] There are known methods of mastoidoplasty using bone autograft:

[0007] - a method of reconstructive hearing-improving surgery (USSR Author's Certificate No. 1802706, IPC A61F 11 / 00, published 03 / 15 / 1993), in which mastoidoplasty is performed using crushed bone from the apex of the mastoid process;

[0008] - a method of mastoidoplasty (Patent No. 2074688 C1 RF, IPC A61F 11 / 00, published 03 / 10 / 1997) by closing the trepanation cavity with a transplant from the ilium, the material is collected in the area of ​​the anterior-superior iliac crest, a fragment of the ilium of 1-2 cm is knocked off with a chisel 3 and the spongy bone tissue is taken, the trepanation cavity is filled with a transplant from the iliac crest, which is irrigated with a suspension of activated autologous lymphocytes, then the wound is sutured tightly in layers, and 1 ml of the same suspension is subcutaneously injected into the retroauricular region, a turunda moistened with a supernatant containing mediators of immunocompetent cells is inserted into the external auditory canal;

[0009] The main disadvantages of using free bone grafts or bone chips include the high risk of their complete or partial resorption, especially when they are not tightly adhered to the bone walls of the radical cavity and when in contact with highly vascular muscle tissue. Furthermore, bone chips can be actively destroyed by mucin and mucous membranes, cholesteatoma, epithelium, and perilymphatic fluid in the presence of a semicircular canal fistula, as well as inflammation in the middle ear. Therefore, to achieve maximum results, the bone graft and bone chips must be completely isolated from the tympanic cavity, external auditory canal, and the soft tissues of the retroauricular region with additional connective tissue material, creating optimal conditions for osseointegration. Partial resorption of the bone graft can lead to the formation of cavities and retraction pockets, requiring reoperation.

[0010] Thus, there is a need for a method of plastic surgery of the postoperative cavity in the treatment of chronic purulent otitis media in patients with a sclerotic type of mastoid process structure.

[0011] The prototype of the proposed method is the "Method of mastoidoplasty in repeated sanitizing operations on the ear" (Patent No. 2593898 C1, IPC A61F 11 / 00, published 10.08.2016, Bulletin No. 22), which consists in using autogenous bone for obliteration of the mastoid cavity, in which an incision is made in the postauricular region along the old postoperative scar with its continuation at the upper edge of the attachment of the auricle backwards and upwards by 1.5 cm parallel to the temporal line, and the soft tissues of the postauricular region are exfoliated to the bone with exposure of the temporal line with subsequent taking of autogenous bone shavings for mastoidoplasty, then tympanoplasty is performed with the creation of a small tympanic cavity, then with autogenous bone shavings obtained from the temporal line area and mixed with an antibiotic, The trepanation cavity is obliterated, and the plastic material is closed from the side of the external auditory canal using a two-layer collagen membrane “Bio-Gide”.The Bio-Gide collagen membrane is resorbable, thus precluding contact between the external auditory canal epithelium and bone chips after complete resorption of the material. Furthermore, the method proposes creating a low-functional, small tympanic cavity, the boundaries of which are not clearly defined, as is the obliteration zone in the upper portions of the trephination cavity, which includes the epitympanic sinus.

[0012] According to the latest scientific data, the mucous membrane of the anterior epitympanic sinus in its morphological structure in the overwhelming majority of cases is close to the mucous membrane of the mastoid process, which has a pronounced gas-absorbing function due to the flattened epithelium, organized by its own lamina, which ensures the smallest distance between the surface of the mucous membrane and the center of the capillary lumen (Komarov M.V. Modern approaches to surgical treatment of chronic suppurative otitis media: dissertation for the degree of Doctor of Medical Sciences. - St. Petersburg, 2024. - 458 p.). Thus, for patients with chronic suppurative otitis media and a sclerotic type of mastoid process structure, an operating method with preservation of the communication between the tympanic cavity and the anterior epitympanic sinus, which contains the gas-forming epithelium, can improve the functional and anatomical results.

[0013] The technical result of the proposed method is to increase the effectiveness of surgical treatment of chronic otitis media due to the optimal technique of plastic surgery of the postoperative cavity after sanitizing surgery on the middle ear in patients with a sclerotic type of mastoid process structure.

[0014] The said technical result is achieved by the fact that in the method of plastic surgery of the postoperative cavity during the treatment of chronic otitis media in patients with a sclerotic type of mastoid process structure, an incision is made along the transitional fold in the postauricular region, soft tissues are separated, bone chips are taken from the surface of the mastoid process using a burr, then an antrotomy is performed through the posterior bony wall of the external auditory canal, while a “bridge” is left from the posterior wall, the pathological contents of the tympanic cavity and antrum are removed, the postoperative cavity is delimited from the attic with an individually selected plate of cartilage of the auricle with the perichondrium left on one side at the level of the “bridge” in such a way that the perichondrium remains on the side of the attic.The mucous membrane of the postoperative cavity is removed, bone chips soaked in an antibiotic solution are placed into the postoperative cavity up to the level of the previously removed posterior bony wall of the external auditory canal. Auricular cartilage plates and the temporal fascia are placed over the bone chips. Tympanoplasty and ossiculoplasty are performed, the external auditory canal is packed with a hemostatic sponge, and the wound in the retroauricular area is sutured. If the bone "bridge" is destroyed by the pathological process, this area is reconstructed with a cartilage plate.

[0015] This method allows preserving the tympanic cavity, the attic with gas-forming epithelium, and the area of ​​the antrum entrance, and prevents the formation of the tympanic cavity wall at the level of the facial nerve; the cartilage plate with the perichondrium prevents contact of the bone chips with the mucous membrane secretion of the attic and tympanic cavity; laying cartilage plates on top of the chips in a tile-like pattern completes the formation of a bed for the bone chips and eliminates the likelihood of the formation of retraction pockets by the epithelium of the external auditory canal; mastoidoplasty with bone chips eliminates the need for the formation of a radical cavity and a small tympanic cavity.

[0016] The claimed method is performed as follows. The surgical stage is performed under general anesthesia, with the patient in the supine position. An incision is made along the mucosal fold in the retroauricular region, the soft tissues are separated, and a burr is used to remove bone chips from the mastoid process in the volume necessary for the plastic surgery of the postoperative cavity. An antrotomy is then performed through the posterior bony wall of the external auditory canal, leaving a "bridge" from the posterior wall of the external auditory canal. Pathological contents of the tympanic cavity, attic, and antrum are removed, as is the mucous membrane of the postoperative cavity (Fig. 1). Using an individually selected plate of auricular cartilage with the perichondrium left on one side at the level of the “bridge”, the postoperative cavity is separated from the attic in such a way that the perichondrium is directed towards the attic (Fig. 2).Bone chips soaked in an antibiotic solution are placed in the postoperative cavity up to the level of the previously removed posterior bone wall of the external auditory canal (Fig. 3); plates of cartilage of the auricle are placed on top of the bone chips like tiles (Fig. 4) and the temporal fascia; if the bone “bridge” is destroyed by the pathological process, the given area is reconstructed with a cartilage plate; then tympanoplasty and ossiculoplasty are performed; the external auditory canal is tamponed with a hemostatic sponge; the wound in the retroauricular region is sutured.

[0017] Brief description of the drawings. Fig. 1 shows a diagram depicting the prepared postoperative radical cavity (with the patient in a supine position, as on the operating table):

[0018] 1 - postoperative cavity (borders are outlined with a continuous line), 2 - zone where the attic and postoperative cavity are delineated (borders are outlined with a dotted line), 3 - bone “bridge”, 4 - tympanic cavity (borders are outlined with a continuous line);

[0019] Fig. 2 shows a diagram showing the postoperative radical cavity, which is partially filled with bone chips: 3 - bone "bridge", 4 - tympanic cavity (borders are outlined with a continuous line), 5 - postoperative cavity (borders are outlined with a continuous line) partially filled with bone chips, 6 - cartilage plate that delimits the attic and the postoperative cavity (borders are outlined with a dotted line);

[0020] Fig. 3 shows a diagram showing the postoperative radical cavity, which is completely filled with bone chips:

[0021] 4 - tympanic cavity (borders are outlined with a continuous line), 7 - postoperative cavity (borders are outlined with a continuous line) is completely filled with bone chips;

[0022] Fig. 4 shows a diagram showing the postoperative radical cavity filled with bone chips, which is covered with cartilaginous plates:

[0023] 4 - tympanic cavity (borders are outlined by a continuous line), 8 - cartilaginous plates.

[0024] Thus, the proposed method achieves the desired technical result of obliterating the postoperative cavity with bone chips and preventing "disease of the operated ear," which improves the effectiveness of surgical treatment for chronic suppurative otitis media and improves patients' quality of life. Forty-five patients have been operated using the proposed method.

[0025] Clinical example. Patient X. (44 years old). Clinical diagnosis (ICD 10 - H66.0): Chronic right-sided suppurative otitis media. Right-sided mixed hearing loss of grade 2. Admitted to the clinic with complaints of hearing loss, episodes of suppuration up to 2 times a year. Chronic suppurative otitis media since age 15. Conservative treatment without long-term positive effect.

[0026] On examination: the right ear - the parotid region is unchanged, there are traces of mucopurulent discharge in the ear canal, the eardrum is retracted, cicatricially changed, perforation in the relaxed part of the eardrum, scant mucopurulent discharge. Hearing Sh.R. - 0 m. Left ear: the eardrum is gray, mobile. Hearing - Sh.R. - 6 m. No vestibular disorders. According to the computed tomography of the temporal bones: sclerotic type of mastoid process structure, single periantral cells, antrum and tympanic cavity are filled with pathological soft tissue contents, the auditory ossicles are destroyed by the inflammatory process, the bony canal of the facial nerve is without pathological changes. According to audiometry data, left-sided mixed hearing loss of the 2nd degree was detected, with an air-bone interval of 35-45 dB.

[0027] Surgical treatment was performed under general combined anesthesia using the proposed method. After a skin incision in the right retroauricular area and separation of soft tissue, the temporal fascia and fragments of auricular cartilage were harvested, and bone chips were collected from the surface of the mastoid process using a bur. An antrotomy was performed through the posterior bone wall; the anrum was filled with cholesteatoma, and the area of ​​the bony "bridge" was destroyed by the cholesteatoma. The cholesteatoma was removed, the remnants of the carious malleus and incus were removed, the stapes was preserved, a partial titanium prosthesis was installed on the head of the stapes, a cartilage plate was laid on the prosthesis plate, and a neotympanic membrane was formed from the temporal fascia. The bony walls of the postoperative cavity were polished with a diamond bur, and the mucous membrane was completely removed.A custom-selected fragment of cartilage, with the perichondrium retained on one side, was placed in the antrum to separate it from the postoperative cavity. The perichondrium was positioned toward the attic, and the area of ​​the bridge destroyed by the cholesteatoma was reconstructed with a cartilage plate. The postoperative cavity was filled with bone chips soaked in an antibiotic solution, over which cartilage plates were laid in a tile-like pattern. The temporal fascia was placed over the cartilages. Silicone strips were placed on the walls of the external auditory canal and the reconstructed area, and the external auditory canal was packed with a hemostatic sponge soaked in an antibiotic solution. The wound in the retroauricular area was sutured. Postoperatively, the patient received anti-inflammatory and antibacterial therapy; the silicone plates were removed after 3 weeks. The skin of the external auditory canal showed no signs of inflammation, and the grafts were adequate.One year after surgery, upon examination, the external auditory canal was wide and clear, the reconstructed area was free of pathological changes, the eardrum was gray, scarred, and mobile during the Valsalva and Toynbee maneuvers. According to audiometry, the air-bone interval had decreased to 10-15 dB. According to MSCT of the temporal bones and magnetic resonance imaging of the head, no pathological changes or middle ear cholesteatoma were detected, the bone graft volume had not decreased, and the reconstruction was satisfactory.

[0028] A method for postoperative cavity reconstruction in the treatment of chronic suppurative otitis media in patients with a sclerotic mastoid process, according to the invention, allows for the maximal restoration of the acquired tissue defect of the middle ear and external auditory canal using a bone autograft and an optimal combined technique for its application, which represents a major technical and economic improvement. The proposed method has improved the effectiveness of surgical treatment for patients with chronic suppurative otitis media and a sclerotic mastoid process and eliminated the formation of an open radical cavity. Conducted studies indicate that the advantages of the developed method allow for safe and minimal surgical risks in achieving lasting clinical results and significantly improving the quality of life of these patients.

Claims

1. A method for plastic surgery of the postoperative cavity in the treatment of chronic purulent otitis media in patients with a sclerotic type of mastoid process structure, characterized by the fact that an incision is made along the transitional fold in the retroauricular region, soft tissues are separated, bone chips are taken from the mastoid process area using a bur in the volume necessary for plastic surgery of the postoperative cavity, then an antrotomy is performed through the posterior bony wall of the external auditory canal, while a "bridge" is left from the posterior wall of the external auditory canal, pathological contents of the tympanic cavity, attic and antrum are removed, the mucous membrane of the postoperative cavity is removed;an individually selected plate of cartilage of the auricle with the perichondrium left on one side at the level of the "bridge" is used to separate the postoperative cavity from the attic in such a way that the perichondrium is directed towards the attic; bone chips soaked in an antibiotic solution are placed in the postoperative cavity up to the level of the previously removed posterior bone wall of the external auditory canal; plates of cartilage of the auricle are placed on top of the bone chips in a tile-like pattern and the temporal fascia; then tympanoplasty and ossiculoplasty are performed, the external auditory canal is tamponed with a hemostatic sponge, the wound in the retroauricular region is sutured.

2. The method according to paragraph 1, characterized in that in the case where the bone “bridge” is destroyed by a pathological process, the given zone is reconstructed with a cartilage plate.

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