RU2801214C1 - Method of ossiculoplasty - Google Patents

Abstract

FIELD: medicine, otorhinolaryngology.

SUBSTANCE: behind-the-ear approach is performed using the transmeatal route to reach the tympanic cavity. Tympanotomy and revision of the tympanic cavity are performed. After completion of the sanitizing stage of the operation, a complete ossicular prosthesis is installed and its stabilized. After reaching the tympanic cavity from the medial surface of the auricle in the surgical wound, a square-shaped cartilage flap is taken with sides of 1.0 cm and an oval-shaped autocartilaginous plate is made 0.3 mm thick, 3.5 mm long and 2.5 mm wide. The autocartilaginous plate overlaps the dimensions of the foot plate of the stirrup in length and width by 0.5 mm. Then, a hole with a diameter of 0.6 mm is made in the center of the autocartilaginous plate. After that, the following is determined: the length of a complete ossicular prosthesis containing a cap and a stem that consists of a rod and a sleeve with a diameter of 0.8 mm. The sleeve of the prosthesis leg is inserted into the hole made in the autocartilaginous plate with a diameter of 0.6 mm, setting it so that it protrudes 0.2 mm beyond the limits of the autocartilaginous plate along the vertical axis. Moreover, due to the difference in the diameters of these elements of 0.2 mm, the edges of the hole are bent, creating a seal on the prosthesis sleeve during the introduction. The position of the oval autocartilage plate and the position of the oval cap of the prosthesis are rotated relative to each other by 90 degrees in the horizontal plane. Then, a complete ossicular prosthesis, together with an oval autocartilaginous plate is placed on the foot plate of the stapes with an emphasis on the walls of the niche of the oval window.

EFFECT: method allows to improve the functional results of ossiculoplasty by ensuring the stability of the position of the complete ossicular prosthesis without losing its mobility.

1 cl, 3 dwg, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology, and can be used when performing sanitizing and hearing-improving operations in patients suffering from chronic purulent tubotympanic or epitympanic antral otitis media, with subtotal or total perforation of the tympanic membrane, retraction pocket, requiring ossiculoplasty.

When performing tympanoplasty, one of the key stages is ossiculoplasty - reconstruction of the ossicular chain through prosthetics.

During the operation, the surgeon needs to achieve balance, ensuring a secure position of the prosthesis connecting the neotympanic membrane and the preserved elements of the auditory ossicular chain, avoiding its instability on the one hand and fixation to the surrounding non-mobile anatomical elements on the other.

The surgeon encounters particular difficulties when installing a complete ossicular prosthesis that replaces the hammer, anvil and stapes superstructures, providing sound transmission according to the “columella” principle.

The difficulties lie in the fact that, unlike a partial ossicular prosthesis, which is securely attached by its proximal part - the "bell" prosthesis element - to the head of the stapes, the stem sleeve of the ossicular full prosthesis must be installed in the center of the foot plate of the stapes without the possibility of rigid fixation to this bone element.

The manipulation zone in the surgical field has rather limited dimensions. The diameter of the stem sleeve of a complete ossicular prosthesis varies depending on the model from 0.2 mm to 0.8 mm. The length of the foot plate of the stapes is 3.03 ± 0.331 mm, the width of the foot plate of the stirrup is 1.96 ± 0.108 mm.

Migration of the sleeve of the prosthesis stem to the edge of the stapes, or outside the oval window, which most often occurs at the stage of tympanic membrane plasty or in the early postoperative period in case of violation of the medical and protective regimen, leads to an unsatisfactory functional result of tympanoplasty with an air-bone interval of more than 30 dB.

The development of a method that prevents the migration of a complete ossicular prosthesis without limiting its mobility is an urgent task.

A known method of ossiculoplasty during reconstructive hearing-improving surgery, including behind-the-ear access, revision of the tympanic cavity, removal of the elements of the auditory ossicles affected by the carious process, installation of a complete ossicular prosthesis, plastic of the tympanic membrane, tamponade of the external auditory canal and suturing of the behind-the-ear wound (see copyright certificate SU No. 1792682 , IPC A61F 11/00, 1993).

When implementing this method, before mobilizing the stirrup, a hole is made in its head. The prosthesis is made from the cortical layer of the temporal bone in the form of a nail with a wide cap (4.0-5.0) and a thin (0.8-1.2 mm) stem 5.0-7.0 mm long, depending on the size of the stirrup and depth of the tympanic cavity.

The leg of the prosthesis becomes thinner from the proximal end to the distal one and departs from the cap of the prosthesis at an angle, which, depending on the position of the stirrup, can vary from 90 to 60 degrees.

The prosthesis is installed so that the leg passes through the hole in the stirrup and rests against its base, while the prosthesis is stabilized.

The disadvantages of this method are:

- limitations in the application of the method, since it can only be used if the stirrup superstructures are preserved;

- high risk of vibration-acoustic injury of the inner ear when creating a perforation in the stirrup head;

- high risk of lysis of the prosthesis stem, deprived of blood supply;

- mobilization of the foot plate gives satisfactory functional results only in the early postoperative period.

The closest in technical essence to the claimed solution is the method of ossiculoplasty, including the implementation of behind-the-ear access using the transmeatal route to reach the tympanic cavity, the implementation of tympanotomy and the revision of the tympanic cavity, while after completion of the sanitizing stage of the operation, a complete ossicular prosthesis is installed and its stabilization is carried out (see Patent No. RU No. 2469657, IPC А61В 17/00, A61F 11/00, 2012).

The method consists in restoring sound-conducting structures. At the same time, the stabilization of the prosthesis is performed with a clot of platelet-rich plasma (hereinafter - PRP) from autologous blood taken from the patient immediately before the operation.

The densely elastic consistency of the clot prevents the displacement of the prosthesis during the operation and in the postoperative period. At the same time, the elements included in the PRP clot undergo biodegradation (absorbed) in the postoperative period, like the blood itself.

Due to the stabilization of the prosthesis in the early postoperative period, the functional result of the surgical intervention is improved.

The disadvantages of this method are:

- the probability of an uncontrolled cicatricial process in the niche of the oval window, provoked by the placement of platelet-rich plasma in the tympanic cavity;

- at the stage of tympanic membrane defect repair, there is a high risk of displacement of the stem of a complete ossicular prosthesis along with a clot of platelet-rich plasma that has not completed polymerization.

The technical result of the proposed solution is to improve the functional results of ossiculoplasty by ensuring the stability of the position of the complete ossicular prosthesis without losing its mobility.

To achieve the specified technical result in the method of ossiculoplasty, including the implementation of behind-the-ear access using the transmeatal path to reach the tympanic cavity, the implementation of tympanotomy and the revision of the tympanic cavity, while after completing the sanitizing stage of the operation, a complete ossicular prosthesis is installed and its stabilization is carried out, according to the invention, after reaching the tympanic cavity from the medial surface of the auricle in the operating wound, a square-shaped autocartilaginous flap is taken, with sides measuring 1.0 cm, and an oval-shaped autocartilage plate is made from it, 0.3 mm thick, 3.5 mm long and 2.5 mm wide overlapping the dimensions of the footplate of the stapes in length and width by 0.5 mm, then a hole with a diameter of 0.6 mm is made in its center, after which the length of the complete ossicular prosthesis is determined, containing a hat and a leg, which consists of a rod and a sleeve with a diameter of 0.8 mm, which is inserted into the hole made in the autocartilaginous plate with a diameter of 0.6 mm, setting it so that it protrudes 0.2 mm along the vertical axis beyond the limits of the autocartilaginous plate, and due to the difference in the diameters of these elements at 0, 2 mm edges of the hole are bent, creating a seal on the prosthesis sleeve during insertion, while the position of the oval autocartilaginous plate and the position of the oval cap of the prosthesis are rotated relative to each other by 90 degrees in the horizontal plane, then the complete ossicular prosthesis, together with the oval autocartilaginous plate, is installed on the footplate stirrup with an emphasis on the walls of the niche of the oval window.

The combination of all essential features in one technical solution allows to ensure contact and reliable fixation of the proximal part of the complete ossicular prosthesis to the footplate of the stapes without losing its mobility properties.

The presence of an oval autocartilage plate, fixed by means of a seal on the sleeve of the stem of a complete ossicular prosthesis, prevents the migration of the stem of the prosthesis along the foot plate of the stapes due to its size matching with the size of the niche of the oval window and acting on the principle of a spacer with an emphasis on the facial nerve canal and the promontory of the medial wall of the tympanic cavities that form the walls of the oval window.

The presence of an oval autocartilaginous plate allows you to maintain contact between the prosthesis sleeve and the foot plate of the stapes during the tympanic membrane repair and in the postoperative period, due to the fixation of the sleeve of the prosthesis stem in the thickness of the cartilage.

The placement of the oval autocartilaginous plate in the niche of the oval window does not interfere with the ventilation of the middle ear. Having the main importance in the migration of air from the auditory tube into the cellular structure of the mastoid process, the posterior way of ventilation of the middle ear, passing in the normal tympanic cavity around the anvil, does not receive additional obstacles.

This is due to the fact that the entire autocartilaginous plate is located in the niche of the oval window and has no contact with the sinuses of the retrotympanum, with the tendon of the muscle stretching the tympanic membrane, with the pyramidal process, which is a prevention of the development of disventilation syndrome and the development of retraction pockets.

The specified position of the oval autocartilaginous plate with a seal on the sleeve of the prosthesis stem limits the movement of the prosthesis in the horizontal plane relative to the foot plate of the stapes, due to the emphasis on the walls of the niche of the oval window, at the same time, without affecting the vertical mobility of the prosthesis, while maintaining the columella principle.

The perpendicular direction of the cap of the complete ossicular prosthesis to the position of the oval autocartilaginous plate when the prosthesis is placed in the tympanic cavity avoids contact of the prosthesis with the fixed anatomical elements of the middle ear, primarily with areas of the bony tympanic ring. In the presence of this contact, the vertical mobility of the prosthesis is lost, which does not allow to achieve a functional result of the surgical intervention.

From the foregoing, it follows that the introduced distinctive features affect the specified technical result, are in a causal relationship with it.

The method is illustrated by drawings, where:

- in Fig. 1 shows a complete ossicular prosthesis with an oval autocartilaginous plate attached to the stem sleeve, side view;

- fig. 2 - the same, top view;

- in Fig. 3 schematically shows the functional position of a complete ossicular prosthesis with an oval autocartilaginous plate in the tympanic cavity.

The following positions are used in the drawings: 1 - oval autocartilaginous plate; 2 - foot plate of the stirrup; 3 - cap of a complete ossicular prosthesis; 4 - sleeve of the leg of a complete ossicular prosthesis; 5 - canal of the facial nerve; 6 - cape of the medial wall of the tympanic cavity; 7 - remains of stirrup legs; 8 - circular ligament of the stirrup; 9 - combined autocartilaginous-autofascial flap.

The method is carried out as follows.

Stage 1

Surgical intervention is carried out under conditions of combined endotracheal anesthesia. The position of the patient on the table is typical - lying on his back with his head turned towards the opposite ear. Behind the ear access and transmeatal way to reach the tympanic cavity.

From the medial surface of the auricle, in the operating wound, a cartilage flap of a flat plane, square shape, with sides 1.0 cm in size, is taken.

Next, use the Kurz Precise Cartilage Cutter (8000 155, registration number of the medical product, FS No. 2006/1297).

At the same time, an oval-shaped autocartilaginous plate 1 0.3 mm thick, 3.5 mm long and 2.5 mm wide is made on a micromanipulation slide. Moreover, the area of the specified plate overlaps the standard dimensions of the foot plate 2 stirrup by 0.5 mm in length and 0.5 mm in width.

Further, with the help of a microsuction, a hole with a diameter of 0.6 mm is made in the center of the oval autocartilaginous plate 1.

Stage 2

After that, tympanotomy is performed and the tympanic cavity is inspected. They remove scars, ingrown epidermis, foci of tympanosclerosis, polyposis-altered mucosa.

Then the anvil affected by the inflammatory process is removed. Separate the remnants of the tympanic membrane from the handle of the malleus. The tendon of the muscle stretching the eardrum is dissected, the malleus is removed.

Then, with the help of scissors-krurotome, the remains of the stirrup superstructures are removed. With the help of microneedles, the foot plate of the stirrup 2 is cleaned from cicatricial adhesions and foci of tympanosclerosis.

Stage 3

Next, using a calliper, measure the distance from the footplate 2 of the stirrup to the bone tympanic ring.

In accordance with the measurements obtained, the length of the complete ossicular prosthesis is determined, namely the titanium prosthesis KURTS with adjustable length, registration certificate RZN 2016/5004 dated 04/14/2020.

A complete ossicular prosthesis includes a cap 3 and a stem, which consists of a rod with a diameter of 0.2 mm and a sleeve 4 with a diameter of 0.8 mm.

The sleeve 4 of the prosthesis leg is inserted into the hole made in the autocartilaginous plate 1, setting it so that it protrudes 0.2 mm beyond the limits of the autocartilaginous plate 1 along the vertical axis.

The position of the oval autocartilaginous plate 1 and the position of the oval cap 3 of the prosthesis are rotated relative to each other by 90 degrees in the horizontal plane in which they are located.

The perpendicular direction of the cap 3 of the complete ossicular prosthesis to the position of the oval autocartilaginous plate 1 when the prosthesis is placed in the tympanic cavity avoids contact of the prosthesis with areas of the bone tympanic ring, which could limit the mobility of the prosthesis.

Due to the difference in the diameters of the sleeve 4 with a diameter of 0.8 mm to 0.2 mm and the hole in the center of the oval autocartilage plate 1 with a diameter of 0.6 mm, the edges of the hole are bent, creating a seal on the sleeve 4 of the prosthesis during insertion, which further prevents the migration of the leg prosthesis along the footplate 2 stirrup.

Next, a complete ossicular prosthesis with an oval autocartilaginous plate 1 on the sleeve 4 of the prosthesis is installed on the footplate 2 of the stirrup.

In this case, the oval autocartilaginous plate 1 coincides with the size of the niche of the oval window, adjacent to the canal of the facial nerve 5 and the adjacent part of the promontory 6 of the medial wall of the tympanic cavity, covering the remains of the legs 7 of the stapes and the circular ligament 8 of the stapes.

The emphasis of the oval autocartilaginous plate 1 in the walls of the niche of the oval window ensures a stable position of the complete ossicular prosthesis in the horizontal plane.

Next, the plastic of the tympanic membrane is performed with a combined autocartilaginous-autofascial flap 9, compared with the cap 3 of the prosthesis, oriented perpendicular to the axis of the footplate 2 of the stirrup.

Thus, the oval autocartilaginous plate 1, fixed on the sleeve 4 of the leg of a complete ossicular prosthesis, placed in the niche of the oval window, serves as a support, prevents horizontal displacement of the prosthesis without losing its properties for vertical mobility and does not create additional volume in the middle ear ventilation pathways.

At the same time, the cap 3 of the complete ossicular prosthesis, placed perpendicular to the plane of position of the oval autocartilaginous plate 1, does not come into contact with the fixed anatomical elements of the middle ear.

Stage 4

Tamponade of the external auditory canal is performed with fragments of a highly purified gelatin sponge. Stitches are applied to the incision and a gauze bandage.

The method is illustrated by the following example.

Patient N., born in 1987 was admitted to the clinic of surgical treatment for adults of the Federal State Budgetary Institution "SPb Research Institute of ENT" of the Ministry of Health of the Russian Federation with a diagnosis of right-sided chronic tubotympanal purulent otitis media, conductive hearing loss of the 3rd degree on the right.

Upon admission, the patient noted hearing loss in the right ear, periodic suppuration from the right ear, not more than one episode within six months. These complaints disturb the patient from childhood.

On examination:

AD - external auditory canal is wide, free. Tympanic membrane with a total defect. Whispered speech 0 m, colloquial speech - 3.0 m. Weber's test - lateralization to the right. Rinne's test is negative. Jelly test is negative.

AS - external auditory canal is wide, free. The tympanic membrane is gray, the contours are clear. Whispered speech is 6 m, colloquial speech is more than 6 m. Rinne's test is positive. Jelly test is positive.

The mucous membrane of the nose is pink, moist. Septum of the nose in the midline. The nasal passages are free. The vault of the nasopharynx is free. Nasal breathing is satisfactory. The mucous membrane of the pharynx is pink, moist. The palatine tonsils are pink, behind the arches, there are no raids, the lacunae are clear. The mucous membrane of the larynx is pink, moist. The vocal folds are white, their movement is in full. The glottis is wide and symmetrical.

The results of tone threshold audiometry: Right-sided conductive hearing loss 3 with sound conduction thresholds in the speech frequency zone of 55-60 dB in the presence of an air-bone interval of 40 dB.

On a CT scan of the temporal bones: on the right, the external auditory meatus is free, the mastoid cavern is airy, the cellular system of the mastoid process is sclerotic, the tympanic cavity is airy, the ossicular chain with multiple defects - the long process of the incus and the head of the stapes are missing.

Stage 1

Surgical intervention was performed under conditions of combined endotracheal anesthesia. The position of the patient on the table is typical - lying on her back with her head turned towards the opposite ear. Performed behind the ear access and transmeatal path, reaching the tympanic cavity.

From the medial surface of the auricle, in the operating wound, a cartilage flap of a flat plane, square shape, with sides 1.0 cm in size, was taken.

Next, using a cartilage cutter, a 0.3 mm thick plate of autocartilage was made. An oval-shaped autocartilaginous plate 3.5 mm long and 2.5 mm wide was fabricated on a micromanipulation slide. Further, a hole was formed in the center of the oval autocartilaginous plate using a microsuction with an outer diameter of 0.6 mm.

Stage 2

Then performed tympanotomy and made a revision of the tympanic cavity. Removed scars and foci of tympanosclerosis.

Then the body of the anvil was removed. The remnants of the tympanic membrane were separated from the handle of the malleus. The tendon of the tensile eardrum muscle was dissected and the malleus was removed. After that, the remnants of the stirrup superstructures were removed with the help of scissors-krurotome. Using microneedles, the footplate of the stapes was cleaned from cicatricial adhesions and foci of tympanosclerosis.

Stage 3

Next, using a calliper, we measured the distance from the footplate of the stapes to the bony tympanic ring. In accordance with the measurements obtained, the length of the complete ossicular prosthesis was set to 4.5 mm.

Then the sleeve of the prosthesis stem was inserted into the hole in the oval autocartilaginous plate, so that the sleeve protruded beyond the limits of the autocartilaginous plate by 0.2 mm, and the orientation of the oval autocartilaginous plate and the oval cap of the prosthesis differed by 90 degrees. Thus, a seal was created on the sleeve of the prosthesis.

Next, a complete ossicular prosthesis was placed on the footplate of the stapes. The cartilaginous skirt was compared between the canal of the facial nerve and the adjacent part of the promontory of the medial wall of the tympanic cavity.

Next, tympanic membrane plasty was performed with a combined autocartilaginous-autofascial flap, matching it with the cap of the prosthesis, oriented perpendicular to the axis of the footplate of the stapes, radially to the center of the neotympanic membrane.

Stage 4

The external auditory canal was loosely plugged using fragments of a highly purified cubic gelatin sponge.

The access was closed by placing four U-shaped sutures on the behind the ear incision. They put on a bandage.

To prevent bacterial infections, antibiotic prophylaxis was carried out for 7 days. The postoperative period proceeded without complications. The sutures were removed on the 7th day. Tampons from the external auditory canal are removed on the 21st day.

At the control examination on the 21st day after the operation: AD - the external auditory canal is wide, free, the neotympanic membrane is rich, pale pink, well vascularized, without granulation tissue.

At the control examination 12 months after the operation: AD - the external auditory meatus is wide free, the tympanic membrane is without defects, gray, transparent, the contours are preserved, the anterior meatotympanic angle is without blunting.

According to the results of the control tone threshold audiometry: AD - sound conduction thresholds in the speech frequency zone of 5-10 dB in the presence of a bone-air interval of up to 5 dB.

Claims (1)

A method for ossiculoplasty, which includes performing a behind-the-ear approach using a transmeatal route to reach the tympanic cavity, performing tympanotomy and performing a revision of the tympanic cavity, wherein after the sanitizing stage of the operation is completed, a complete ossicular prosthesis is installed and its stabilization is carried out, characterized in that after reaching the tympanic cavity with a medial surface of the auricle in the operating wound, a square-shaped autocartilaginous flap with side dimensions of 1.0 cm is taken and an oval-shaped autocartilaginous plate 0.3 mm thick, 3.5 mm long and 2.5 mm wide is made from it, overlapping the size of the foot stirrup plates in length and width by 0.5 mm, then a hole with a diameter of 0.6 mm is made in its center, after which the length of a complete ossicular prosthesis is determined, containing a cap and a leg, which consists of a rod and a sleeve with a diameter of 0.8 mm, which is inserted into the hole made in the autocartilaginous plate with a diameter of 0.6 mm, setting it so that it protrudes 0.2 mm beyond the limits of the autocartilaginous plate along the vertical axis, and due to the difference in the diameters of these elements of 0.2 mm, the edges of the hole are bent, creating a seal on the prosthesis sleeve during insertion, while the position of the oval autocartilaginous plate and the position of the oval cap of the prosthesis are rotated relative to each other by 90 degrees in the horizontal plane, then the complete ossicular prosthesis, together with the oval autocartilaginous plate, is installed on the foot plate of the stirrup with emphasis on the walls of the niche oval window.