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
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摘要
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.
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.
引文
1 Westerberg J,M?ki-Torkko E.Cholesteatoma Surgery with The Canal Wall up Technique Combined with Mastoid Obliteration:Results from Primary Surgery in 230 Consecutive Cases[J].Acta oto-laryngologica,2018,():e1-6.
2 Tomlin J,Chang D,Mc Cutcheon B,et al.Surgical Technique and Recurrence in Cholesteatoma:a Meta-analysis.Audiol Neurootol.2013;18(3):135-142.
3 van der Toom HFE,van der Schroeff MP.Single-Stage Mastoid Obliteration in Cholesteatoma Surgery and Recurrent and Residual Disease Rates:A Systematic Review[J].JAMA otolaryngology--head&neck surgery,2018,():e1-8.
4龙瑞清,阮标,刘卓慧,等.保留部分外耳道后壁上鼓室切开软壁重建术治疗中耳胆脂瘤[J].临床耳鼻咽喉头颈外科杂志,2018,32(01):23-27.Long RQ,Ruan B,Liu ZH,et al.The Technique of Retaining Part of The External Auditory Canal Posterior Wall with Epitymnoplasty in Soft Wall Reconstruction Treating Middle Ear Cholesteatoma[J].J Clin Otorhinolaryngol Head Neck Surg(China),2018,32(01):23-27.
5 Kerckhoffs KGP,Kommer MBJ,Van Strien THL,et al.The Disease Recurrence Rate after The Canal Wall Up or Canal Wall Down Technique in Adults.Laryngoscope.2016;126:980-987.
6 Trinidade A,Skingsley A,Yung MW.Mastoid Obliteration Surgery for Cholesteatoma in 183 Adult Ears-a 5-year Prospective Cohort Study:Our Experience.Clin Otolaryngol.2015;40:721-726.
7布莱克曼(美)著,孙建军编译.耳外科学第3版[M].北京大学医学出版社.2013,P.190.ISBN:978-7-5659-0514-8.Blackman(USA)Original Author,Sun JJ(China)Compiling.Audiosurgery,Third Edition[M].Peking University Medical Publishing House.2013,P.190.ISBN:978-7-5659-0514-8.
8钟笑,陈文文,殷国华.传导性聋的诊断及手术治疗的临床分析[J].听力学及言语疾病杂志,2008,16:235.Zhong X,Chen WW,Yin GH.Clinical Analysis of The Diagnosis and Surgical Treatment of Conductive Deafness[J].Journal of Audiology and Speech Pathology(China),2008,16:235.
9邵永良,周永靑,李晓明,等.耳屏软骨加颞肌筋膜重建上鼓室外侧壁的临床应用[J].临床耳鼻咽喉头颈外科杂志,2015,29(22):1981-1984.Shao YL,Zhou YQ,Li XM,et al.The Lateral Attic Wall Reconstruction with Tragal Cartilage and Temporalis Fascia Graft[J].JClin Otorhinolaryngol Head Neck Surg(China),2015,29(22):1981-1984.
10兰龙江,徐珏.上鼓室外侧壁软骨重建技术在乳突根治鼓室成形术中的应用[J].听力学及言语疾病杂志,2014,22(06):647-648.Lan LJ,Xu Y.The Application of Cartilage Reconstruction in the Attic Lateral Wall in Radical Mastoid Tympanoplasty[J].Journal of Audiology and Speech Pathology(China),2014,22(06):647-648.
11刘阳,孙建军,林勇生.保留骨桥的乳突鼓室成形术(IBM)远期疗效与相关技术再探讨[J].中华耳科学杂志,2007(02):148-151.Liu Y,Sun JJ,Lin YS.Intact-bridge Mastoitympanoplasty(IBM)-The Long Term Effect and Related Techniques[J].Chinese Journal of Otology,2007,5(02):148-151.
12杨名保,赵海亮,柴福,等.重建上鼓室外侧壁的保留骨桥乳突切开鼓室成形术[J].中华耳科学杂志,2016,14(05):625-628.Yang MB,Zhao HL,Chai F,et al.Epitympanoplasty with Autologous Cortical Bone in Intact-bridge Tympanomastoidectom[J].Chinese Journal of Otology,2016,14(05):625-628.
13 Csakanyi Z,Katona G,Konya D,et al.Middle Ear Gas Pressure Regulation:The Relevance of Mastoid Obliteration.Otol Neurotol.2014;35(6):944-953.
14 Komori M,Yanagihara N,Hyodo J,et al.Five-year Postoperative Outcomes of Modified Staged Canal Wall Up Tympanoplasty for Primary Acquired Cholesteatoma.Eur Arch Otorhinolaryngol2018;275:691-698.
15张浩亮,于锋,王瑞娴.胆脂瘤型中耳炎软性外耳道后壁重建24例疗效分析[J].中华耳科学杂志,2011,9(3):315-317.Zhang HL,Yu F,Wang RX.Soft Tissue Ear Canal Wall Reconstruction Following Mastoidectomy[J].Chinese Journal of Otology,2011,9(3):315-317.
16 Kim JH,Choi SH,Chung JW.Clinical Results of Atticoantrotomy with Attic Reconstruction or Attic Obliteration for Patients with an Attic Cholesteatoma[J].Clin Exp Otorhinolaryngol,2009,2(1):39-43.
17 Rosowski JJ,Merchant SN.Mechanical and Acoustic Analysis of Middle Ear Reconstruction.Am J Otol,1995,16:486-497.
18 Hinohira Y,Gyo K,Yanagihara N,Bredberg G,et al.Effects of Mastoid Cavity Obliteration on The Growth of Experimentally Produced Residual Cholesteatoma.Acta Otolaryngol.1998;118(1):101-104.
19 Hinohira Y,Yanagihara N.Improvements to Staged Canal Wall Up Tympanoplasty for Middle Ear Cholesteatoma[J].Otolaryngology--head and Neck Surgery:Official Journal of American Academy of Otolaryngology-Head and Neck Surgery,2007,137(6):913-917.
20卜行宽.做好婴幼儿听力损失的诊断工作[J].中华医学杂志,2003,17(83):1550-1552.Pu XK.Diagnosis of Hearing Loss in Infants[J].Chinese Journal of Medicine,2003,17(83):1550-1552.
21 Edfeldt L,Stromback K,Kinnefors A,et al.Surgical Treatment of Adult Cholesteatoma:Long-term Follow-up Using Total Reconstruction Procedure Without Staging.Acta Otolaryngol.2013;133:28-34.
22 Obholzer R,Ahmed J,Warburton F,et al.Hearing and Ossicular Chain Preservation in Cholesteatoma Surgery.J Laryngol Otol.2011;125:147-152.
2 Tomlin J,Chang D,Mc Cutcheon B,et al.Surgical Technique and Recurrence in Cholesteatoma:a Meta-analysis.Audiol Neurootol.2013;18(3):135-142.
3 van der Toom HFE,van der Schroeff MP.Single-Stage Mastoid Obliteration in Cholesteatoma Surgery and Recurrent and Residual Disease Rates:A Systematic Review[J].JAMA otolaryngology--head&neck surgery,2018,():e1-8.
4龙瑞清,阮标,刘卓慧,等.保留部分外耳道后壁上鼓室切开软壁重建术治疗中耳胆脂瘤[J].临床耳鼻咽喉头颈外科杂志,2018,32(01):23-27.Long RQ,Ruan B,Liu ZH,et al.The Technique of Retaining Part of The External Auditory Canal Posterior Wall with Epitymnoplasty in Soft Wall Reconstruction Treating Middle Ear Cholesteatoma[J].J Clin Otorhinolaryngol Head Neck Surg(China),2018,32(01):23-27.
5 Kerckhoffs KGP,Kommer MBJ,Van Strien THL,et al.The Disease Recurrence Rate after The Canal Wall Up or Canal Wall Down Technique in Adults.Laryngoscope.2016;126:980-987.
6 Trinidade A,Skingsley A,Yung MW.Mastoid Obliteration Surgery for Cholesteatoma in 183 Adult Ears-a 5-year Prospective Cohort Study:Our Experience.Clin Otolaryngol.2015;40:721-726.
7布莱克曼(美)著,孙建军编译.耳外科学第3版[M].北京大学医学出版社.2013,P.190.ISBN:978-7-5659-0514-8.Blackman(USA)Original Author,Sun JJ(China)Compiling.Audiosurgery,Third Edition[M].Peking University Medical Publishing House.2013,P.190.ISBN:978-7-5659-0514-8.
8钟笑,陈文文,殷国华.传导性聋的诊断及手术治疗的临床分析[J].听力学及言语疾病杂志,2008,16:235.Zhong X,Chen WW,Yin GH.Clinical Analysis of The Diagnosis and Surgical Treatment of Conductive Deafness[J].Journal of Audiology and Speech Pathology(China),2008,16:235.
9邵永良,周永靑,李晓明,等.耳屏软骨加颞肌筋膜重建上鼓室外侧壁的临床应用[J].临床耳鼻咽喉头颈外科杂志,2015,29(22):1981-1984.Shao YL,Zhou YQ,Li XM,et al.The Lateral Attic Wall Reconstruction with Tragal Cartilage and Temporalis Fascia Graft[J].JClin Otorhinolaryngol Head Neck Surg(China),2015,29(22):1981-1984.
10兰龙江,徐珏.上鼓室外侧壁软骨重建技术在乳突根治鼓室成形术中的应用[J].听力学及言语疾病杂志,2014,22(06):647-648.Lan LJ,Xu Y.The Application of Cartilage Reconstruction in the Attic Lateral Wall in Radical Mastoid Tympanoplasty[J].Journal of Audiology and Speech Pathology(China),2014,22(06):647-648.
11刘阳,孙建军,林勇生.保留骨桥的乳突鼓室成形术(IBM)远期疗效与相关技术再探讨[J].中华耳科学杂志,2007(02):148-151.Liu Y,Sun JJ,Lin YS.Intact-bridge Mastoitympanoplasty(IBM)-The Long Term Effect and Related Techniques[J].Chinese Journal of Otology,2007,5(02):148-151.
12杨名保,赵海亮,柴福,等.重建上鼓室外侧壁的保留骨桥乳突切开鼓室成形术[J].中华耳科学杂志,2016,14(05):625-628.Yang MB,Zhao HL,Chai F,et al.Epitympanoplasty with Autologous Cortical Bone in Intact-bridge Tympanomastoidectom[J].Chinese Journal of Otology,2016,14(05):625-628.
13 Csakanyi Z,Katona G,Konya D,et al.Middle Ear Gas Pressure Regulation:The Relevance of Mastoid Obliteration.Otol Neurotol.2014;35(6):944-953.
14 Komori M,Yanagihara N,Hyodo J,et al.Five-year Postoperative Outcomes of Modified Staged Canal Wall Up Tympanoplasty for Primary Acquired Cholesteatoma.Eur Arch Otorhinolaryngol2018;275:691-698.
15张浩亮,于锋,王瑞娴.胆脂瘤型中耳炎软性外耳道后壁重建24例疗效分析[J].中华耳科学杂志,2011,9(3):315-317.Zhang HL,Yu F,Wang RX.Soft Tissue Ear Canal Wall Reconstruction Following Mastoidectomy[J].Chinese Journal of Otology,2011,9(3):315-317.
16 Kim JH,Choi SH,Chung JW.Clinical Results of Atticoantrotomy with Attic Reconstruction or Attic Obliteration for Patients with an Attic Cholesteatoma[J].Clin Exp Otorhinolaryngol,2009,2(1):39-43.
17 Rosowski JJ,Merchant SN.Mechanical and Acoustic Analysis of Middle Ear Reconstruction.Am J Otol,1995,16:486-497.
18 Hinohira Y,Gyo K,Yanagihara N,Bredberg G,et al.Effects of Mastoid Cavity Obliteration on The Growth of Experimentally Produced Residual Cholesteatoma.Acta Otolaryngol.1998;118(1):101-104.
19 Hinohira Y,Yanagihara N.Improvements to Staged Canal Wall Up Tympanoplasty for Middle Ear Cholesteatoma[J].Otolaryngology--head and Neck Surgery:Official Journal of American Academy of Otolaryngology-Head and Neck Surgery,2007,137(6):913-917.
20卜行宽.做好婴幼儿听力损失的诊断工作[J].中华医学杂志,2003,17(83):1550-1552.Pu XK.Diagnosis of Hearing Loss in Infants[J].Chinese Journal of Medicine,2003,17(83):1550-1552.
21 Edfeldt L,Stromback K,Kinnefors A,et al.Surgical Treatment of Adult Cholesteatoma:Long-term Follow-up Using Total Reconstruction Procedure Without Staging.Acta Otolaryngol.2013;133:28-34.
22 Obholzer R,Ahmed J,Warburton F,et al.Hearing and Ossicular Chain Preservation in Cholesteatoma Surgery.J Laryngol Otol.2011;125:147-152.