Combined approach tympanoplasty

Mastoid surgery and tympanoplasty that preserve the posterior wall of the external auditory canal are also known as closed techniques or a combined approach typanoplasty (CAT) that preserves the posterior wall of the external auditory canal, by Jansen (1963) and Sheehy. (1965) and so on. The primary goal of CAT is to remove chronic inflammatory lesions and cholesteatoma in the middle ear and mastoids while retaining the external auditory canal and sulcus structure. This has the advantage of avoiding the left open mastoid cavity and facilitating the reconstruction of the acoustic structure in the middle ear cavity of near normal size. Treatment of diseases: cholesteatoma otitis media tuberculous otitis media Indication 1. Chronic cholesteatoma otitis media and chronic otitis media. It is especially suitable for the upper tympanic pocket-like recessive cholesteatoma invading the entrance of the sinus and the sinus cavity, while the mastoid of the distal side of the cholesteatoma is well vaporized. 2. Eustachian tube function is good. Contraindications 1. Irreversible obstruction of the eustachian tube. 2. There is acute upper respiratory tract inflammation. 3. There are serious systemic diseases such as hypertension, heart disease, diabetes and coagulopathy. 4. Severe sensorineural hearing loss. Preoperative preparation 1. According to the preoperative examination results, introduce the patient to the purpose of the operation and its brief surgical procedure. At the same time, the possible situation during the operation and the prognosis of the operation can be proposed so that the patient's understanding and cooperation can be obtained. 2. Shave the ear and ear hair before surgery; for the posterior auricular approach or the removal of the temporalis fascia as a transplanter, the range of the ear skin preparation should be widened accordingly. 3. 1d before surgery, the ear canal was removed from the cartilage segment of the external auditory canal, and the internal auditory canal and suede were removed. Then wipe the skin of the external auditory canal and the outer side of the auricle with a 3% boric acid ethanol or 70% ethanol cotton swab. However, the disinfectant is prevented from flowing into the tympanic cavity to avoid earache, reactive hyperemia of the tympanic mucosa, and increased secretion. 4. Systemic antibiotics were applied 1 day before surgery. Adults received oral phenobarbital 0.09g 1 hour before surgery. 5. Perform bacterial culture and drug sensitivity test on the secretion of external auditory canal. 6. X-ray of the mastoid, to determine the extent of the mastoid lesions and mastoid gasification. Surgical procedure 1. Incision: Take the upper incision after the ear, and make a 1.5-2.0 cm arc-shaped incision along the posterior groove of the ear. 2. Sharply separate the subcutaneous tissue, forward to the attachment of the auricle, and then make a U-shaped periosteal flap anterior to the anterior side between the sacral line and the mastoid tip. The periosteal flap was exfoliated from the bone surface with a periosteal stripper and forwarded to the opening of the external ear canal. Then, the posterior wall of the ear canal is incision according to the method of posterior tympanic membrane repair, and the skin of the upper, lower and posterior wall of the external auditory canal is separated inwardly to the drum ring. At this time, the exposed bone faces up to the sacral line and the sacral root, down to the mastoid tip, and then reaches the sigmoid sinus projection line, and reaches the posterior wall of the external auditory canal inward. 3. Use the cutting drill to remove the mastoid cortical bone and the mastoid air chamber, and complete the simple mastoidectomy. The bone wall after the external auditory canal is completely preserved, and the thickness is preferably 0.3 mm. 4. Separate the fiber drum ring from the upper part of the tympanic membrane with a small stripper, and turn the tympanic membrane of the external auditory canal forward to reveal the anvil joint. If the ossicular chain is intact, the anvil joint is separated by a hook to prevent the hammer and the anvil from being removed when the upper tympanic lesion is removed, causing dislocation or hyperactivity of the humerus. 5. The anvil bone can be seen after removing the lesions such as cholesteat and cholesteat at the entrance of the sinus. The long legs of the anvil are often corroded by necrotic lesions such as cholesteatoma. After the anvil is removed, the upper tympanic chamber is opened to expose the hammer bone and its surrounding cholesteat tissue. When peeling off the cholesteat stromal epithelium expressed by the outer semicircular canal, pay attention to the presence or absence of the fistula, and do not wear it. If a fistula has been formed, the fistula can be closed with a fascia cut near the incision. 6. When removing the upper tympanic cholesteatoma, the hammer neck should be cut and the head removed to facilitate the complete removal of the lesion. To remove the lesion, the tympanic membrane tendon should be preserved to maintain the normal position of the hammer stem. Then use a small diamond drill to remove the bone between the short leg of the anvil, the vertical line between the tympanic nerve and the facial nerve, and reveal the facial nerve crypt. To clear the lesions in the posterior tympanic cavity, facial nerve horizontal section and vestibular window. When clearing the surface of the facial nerve cholesteatoma and squamous epithelium, pay attention to the presence or absence of bone defects. If there is a facial nerve tube defect, the epithelium is carefully peeled off along the surface of the nerve sheath with a small peel. Fully separate all adhesions and membranes between the middle and lower tympanic chambers. 7. Thoroughly remove the lesions in the middle and upper tympanic cavity, sinus sinus and mastoid cavity, prepare the transplanted bed according to the method of "tympanicplasty", and then perform ossicular chain reconstruction and tympanic membrane repair according to the residual bone. If the tympanic membrane is missing, the graft fascia is lining the inner side surface of the upper edge of the residual tympanic membrane. If the perforation of the tympanic membrane is large, the fascia is lining the inner surface of the residual tympanic membrane and the external auditory canal flap, and the tympanic membrane is repaired by "planting". Because of the corrosion of cholesteatoma, the upper ear wall has more bone defects, and can be repaired with cartilage pieces. The fascia and the external auditory canal tympanic membrane are covered on the outer side of the grafted cartilage piece. The reconstruction of the ossicular chain can be completed in the first phase, or the second phase can be performed after half a year. The cholesteatoma caused by sinus sinus invagination is concealed due to the lesion, and the upper part of the tympanic membrane is prone to invagination. It is a difficult lesion in tympanoplasty. The method of tympanoplasty for this lesion is to remove the cholesteat epithelium involving the facial nerve crypt, the humerus, the facial nerve and the tympanic sinus through the posterior mastoid and facial nerve crypt pathways, with a scored otolary cartilage block. Close the tympanic sinus ostium Specifically, a rectangular cartilage block with a cartilage coat is taken from the tragus, and the blade is intermittently cut on the side without the cartilage coat, and the depth is not more than the contralateral cartilage coat. There is tension on the side of the cartilage coat, and the scoring side forms a convex surface. The skin of the ear canal and the tympanic membrane which have been separated and lifted are sent into the middle ear cavity, and placed behind the vestibular window sill and the round window sill to close the tympanic ostium. When the cartilage is placed, the scored surface faces the drumstick. Later, the bone chain reconstruction and tympanoplasty should be performed as needed. The purpose of the occludal cartilage to seal the tympanic ostium of the tympanic cavity is to prevent post-inferior tympanic membrane retraction. 8. Close the operating cavity: Fix the transplanted tympanic membrane and the external auditory canal flap with gelatin sponge and iodoform gauze. Make a small incision 1 cm from the incision behind the ear. Since then, a small plastic tube for intravenous infusion has been introduced into the mastoid cavity for drainage. If the eustachian tube function is good, the tube can be removed 2 to 3 days after the operation. If the eustachian tube is dysfunctional, the tube can be placed for 3 weeks after operation for drainage and ventilating. The skin incision was sutured intermittently with a silk thread, and the ear was wrapped with a gauze bandage. complication 1. Transplantation of the sacral invagination of the tympanic membrane: The main reasons are as follows: 1 The outer wall of the upper drum is too much, and it is not repaired with hard tissue (such as bone piece or cartilage piece). 2 The passage between the middle tympanic cavity and the upper tympanic cavity is not fully opened, so that the upper tympanic cavity cannot be fully ventilated through the tympanic cavity and the eustachian tube. 2. Recurrence of cholesteatoma: The reasons are as follows: 1 the outer wall defect of the upper drum, the upper quadrant of the tympanic membrane, and the formation of invaginated capsular cholesteatoma. 2 failed to completely remove the lesion. It is generally believed that residual cholesteatoma growth rate is faster in children than in adults. Symptoms and signs of recurrence of cholesteatoma are related to the original site, and those who relapsed in the sinus and mastoids were later than those who relapsed in the tympanic cavity. It is not easy to find in the early stage. This is the main reason why some authors do not advocate such closed surgery. Some people think that after this operation, the recurrence rate of lipoma is high, and the imaging of the middle ear and mastoid (CT) should be followed up regularly. 3. Facial paralysis: more common in the operation of the open facial nerve crypt or the treatment of the tympanic epithelium on the facial surface of the tympanic membrane when the facial nerve is damaged. 4. Lost sputum: caused by intraoperative open facial nerve crypts or removal of semicircular canals when removing semicircular canal surface lesions.