Simple mastoidectomy for chronic otitis media

The incidence of middle ear mastoiditis is high, affecting not only hearing, but also serious intracranial and extracranial complications, and even life-threatening. Mastoid surgery is the main treatment for the treatment of middle ear and mastoid inflammation, including simple mastoid incision, mastoidectomy and modified mastoidectomy. In the case of the intact posterior wall of the external auditory canal, the simple mastoid incision removes all the air chambers and diseased tissues in the mastoid cavity, and does not touch the tympanic structure to maintain the original hearing operation. The purpose of the operation is to remove the purulent lesions at the entrance of the mastoid air chamber, the sinus sinus and the sinus sinus, and to establish a good drainage of the mastoid, sinus and tympanic cavity, which promotes the inflammation of the middle ear and mastoid and prevents complications. Treatment of diseases: chronic otitis media Indication Since the widespread use of antibiotics, acute suppurative otitis media has been controlled by non-surgical treatment, and few have to undergo mastoid incision. However, in the case of low patient resistance, strong bacterial virulence and untimely and incomplete treatment, acute mastoiditis still occurs and surgery is required. Simple mastoid incision should be considered in the following situations: 1. Acute suppurative middle ear mastoiditis After 3 weeks of treatment with broad-spectrum antibiotics, tympanic membrane incision, etc., there are still ear pus, ear deep or post-ear pain, fever, mastoid tenderness, X-ray or CT Scanning showed that the mastoid air chamber was blurred, and the number of white blood cells increased, suggesting that it is acute fusion mastoiditis. 2. Acute suppurative otitis media with epithelial subperiosteal abscess, facial paralysis, Bezold abscess and other complications. 3. Acute suppurative otitis media has been relieved after treatment. After several weeks, there are earaches, soft tissue swelling and tenderness in the mastoid area, and long-term thickening of the tympanic membrane, low fever, X-ray. A slice or CT scan showed that the mastoid air chamber was blurred or had bone destruction, suggesting atypical mastoiditis or recessive mastoiditis. 4. Cholesteatoma type of middle ear mastoiditis complicated with otogenic intracranial complications, if the general condition does not allow mastoidectomy, the first stage of simple mastoid incision, remove mastoid, sinus The lesions, and appropriate treatment of intracranial complications, the second phase of mastoidectomy. 5. Acute suppurative otitis media recurrent, X-ray or CT scan showed that the mastoid airway is blurred or bone destruction without detecting other causes, feasible exploration of simple mastoid incision. 6. Secretory otitis media or blue tympanic membrane, long-term unhealed after tympanic membrane incision treatment, consider the same lesion or cholesterol granuloma in the mastoid, feasible simple mastoid incision exploration. Contraindications 1. In the early stage of acute suppurative otitis media, non-surgical treatment should be used. Sufficient antibiotics should be used to control infection, or tympanic membrane incision should be performed at the same time for unobstructed drainage. It is not advisable to perform simple mastoid incision prematurely when inflammation has not been limited. 2. It is not suitable for surgery during various thermal diseases. Preoperative preparation 1. Intravenous antibiotics to control infection. Symptomatic treatment such as infusion according to the general condition of the patient. 2. Shave the hair in the 5cm area around the ear, and the female patient should crunch the hair and comb it to the opposite side. Clean and disinfect the auricle and periorbital skin with 75% ethanol. 3. Clear the secretions of the external auditory canal before surgery, and carry out bacterial culture and drug sensitivity test. 4. Oral pentobarbital 0.1 to 0.2 g or phenobarbital 0.06 to 0.09 g half an hour before surgery. General anesthesia is prepared and used according to general anesthesia. 5. Read X-ray or CT film carefully before operation to understand the degree of mastoid gasification, bone destruction and sigmoid sinus position. Surgical procedure 1. Incision: Generally, the incision is made in the ear, and one of the two incisions can be used in the adult. 1 conventional incision, the upper edge of the auricle attachment is placed, and the mastoid tip is obtained. The widest point of the posterior segment of the incision is 1.5 to 2.0 cm from the posterior auricle, and the upper and lower ends are 0.5 and 1.2 cm from the auricle, respectively. Subcutaneous tissue and periosteum, if the posterior musculoskeletal flap is made, only the skin is cut. 2 Cut into the back of the ear, or cut along the posterior sulcus to the lower wall of the external auditory canal to the lower back to the mastoid tip. Since the mastoid of infants and young children within 2 years of age has not yet developed, the facial nerve passes through the position of the stem of the stem, so the lower end of the infant incision should be slightly moved backwards to stop in the middle of the mastoid. If the patient has a subperiosteal abscess or has had a mastoid surgery before, the incision should be cut layer by layer. It is strictly forbidden to cut through too much to avoid damage to the exposed meninges or sigmoid sinus. 2. Isolation: soft tissue, exposed to the full-thickness incision of the mastoid cortex, and the periosteum was separated along the bone surface with a bone stripper. If the posterior musculoskeletal flap is made, the subcutaneous tissue is sharply separated by a blade, and the auricle attachment edge is placed so that the pedicle is on the anterior side, the upper edge of the valve is flat, the lower edge is near the mastoid tip, and the posterior margin is near the skin incision. The base is slightly wider, and the entire flap is transversely trapezoidal. If the incision is made in the posterior sulcus, the soft tissue on the mastoid side is separated forward to the posterior wall of the bony external auditory canal, and is above and above the bony external auditory canal. The periosteum was dissected and cut along the posterior edge of the bony external auditory canal and extended posteriorly to the tip of the mastoid to form a periosteal flap of the posterior border of the pedicle. The periosteal stripper separates the periosteum or separates it from the soft tissue, and advances to the posterior edge of the external auditory canal of the bone. Try to avoid peeling the periosteum and skin of the upper and posterior wall of the external auditory canal, down to the tip of the mastoid, and cut off the sternocleidasis muscle fibers attached to the tip of the mastoid. Fully expose the mastoid cortex and open the incision with the mastoid retractor. Identify the anatomical landmarks of the mastoid cortex: the linea temporalis, the suprameatal spine, and the cribriform area are important markers of sinus positioning. The three sides of the upper ear canal (also known as the Macewen triangle) are: 1 a horizontal tangent to the upper edge of the bony external auditory canal; 2 a vertical line at the trailing edge; 3 the line formed by the upper edge of the outer ear canal as the baseline The triangular area formed by the third side, thus entering the sinus of the drum, is a sign of the positioning of the sinus. 3. Grinding (chiseling) the sinus sinus, clearing the mastoid air chamber using a cutting drill (round chisel) to remove the mastoid cortex and exposing the shallow cavity of the mastoid. The upper boundary is the sacral line, the front boundary is the posterior edge of the external auditory canal and the leading edge of the mastoid, and the posterior border is the oblique line connecting the mastoid tip with the posterior part of the sacral line, showing a broad triangle. Look for the sinus: at the screen area behind the upper ear canal of the external auditory canal, grind (chisel) the mastoid air chamber or use a large curette to track the air chamber. Remember that the sinus is located in the posterior superior part of the inner surface of the external auditory canal, that is, the deep part of the upper ear canal. The adult sinus is about 1.0 to 1.5 cm deep from the surface of the mastoid. Therefore, the direction of the grinding (chiseling) should be toward the upper rear of the upper wall of the outer ear canal, and the wound edge should be sloped or funnel shaped. Sometimes there is a petrosquamous lamina in the well-developed rock-bone air chamber and the squamous air chamber. A partition is formed on the surface of the sinus sinus. It is called K?rner septum (K?rner septum), which is easy to be mistaken for "drum sinus". It is necessary to grind (chisel) through the partition to pass into the sinus. After exposing the sinus, the fine-bend probe can slide forward into the entrance of the sinus without any hindrance. Carefully enlarge the entrance of the sinus with a small curette, fine-grain drill or diamond drill bit to expose the short leg of the anvil. And outer semi-regulators. If the mastoid cortex has a pupil, under the guidance of the probe, use the electric drill or osteotome, rongeur, curette to expand the overhanging bone of the cortical bone around the pupil and the mastoid air chamber to enter the sinus. Clear the mastoid air chamber. Starting from the sinus sinus, the ventral sinus is first removed to the air chamber at the tip of the mastoid, forming a so-called "initial groove", taking care to avoid the vertical section of the facial nerve. Remove the air chamber at the tip of the mastoid, which is usually one or several atmosphere chambers. Remove the outer wall of the mastoid tip and expose the digastric ridge. Be careful not to damage the stem of the stem at the front end. The facial nerve was scraped off with a small curette at the posterior side of the second abdominal muscle and the sigmoid sinus and the gas chamber at the proximal jugular vein. At this time, the air chamber in the lower half of the mastoid was removed. Then remove the airway septum above the sigmoid sinus until the sinus plate is exposed and connected to the outer layer of the mastoid cortex, taking care not to damage the sigmoid sinus wall and the mastoid blood vessels. Returning to the sinus sinus, removing the sacral sacral stenosis, revealing the bone plate, and sometimes inadvertently exposing the dura mater in the cranial fossa, such as the dura mater without damage, generally hindering. The air chamber in the intercostal space between the mastoid and the sigmoid sinus is removed, so that the sky cover and the sigmoid sinus plate meet at an acute angle - the sinusal angle. If the scales and ankles have inflammation, extend up to the scales and forward to the roots of the condyle, but do not enter the upper tympanic cavity. Finally, use a small curette or a diamond drill bit to carefully remove the air chamber inside the drum sinus, including the residual air chamber around the semicircular canal, around the facial nerve, and the posterior wall of the external auditory canal. Generally, the contours of the three semicircular canals are not exposed, but the exact position should be understood to avoid damage. Bone semicircular canal, facial nerve and anvil. The surgical cavity that has completed the simple mastoidectomy should be contoured or skeletalized, that is, the mastoid sigmoid and the sigmoid sinus have only a thin layer of bone wall protection, which can be seen through the thin bone plate. To the pink meninges and small blood vessels or blue-violet sigmoid sinus, the sinus meninges have an acute angle and the Trautmann triangle and the second abdominal muscles are clearly distinguishable. 4. Thoroughly remove the diseased tissue: After the mastoid cavity is completely open, the mastoid cavity, sinus cholesteatoma, granulation, polyps and diseased mucosa and bone should be carefully examined and removed under the operating microscope. Such as near the sinus, semicircular canal and facial nerve canal containing chocolate-colored secretions and granulation, suggesting that the sinus entrance or the upper tympanic cavity has obstructive lesions, use small curettes, nippers, crochet to carefully remove the granulation, be careful not to damage the anvil bone. When removing bone, if there is osteoporosis and easy bleeding, it indicates that there is localized osteitis or osteomyelitis. The bone should be removed until the white bone is hard. If the mastoid has a fusion cavity, check it carefully. Whether there is damage to the bones of the mastoid wall. If the mastoid or sigmoid sinus wall is found to have bone destruction and local granulation is formed, the defect bone wall should be enlarged until the healthy tissue is exposed, and the granulation surface is lightly scraped. There are no pupils or epidural abscesses. Such as mastoid metatarsal destruction, pay attention to the presence or absence of deep neck abscess, if any, should be adequate drainage. 5. Suture incision: After washing the cavity with warm saline, fill the iodoform gauze. One end of the gauze is loosely placed at the entrance of the sinus, and the end is extended from the lower end of the incision. There is no secretion in the external auditory canal, and it is gradually extracted. The periosteum, subcutaneous tissue and skin of the incision were sutured. Iodine gauze is packed in the external auditory canal to prevent stenosis. Apply a sterile dressing and bandage the bandage. complication 1. Postoperative pus discharge: Because the lesions in the mastoid air chamber have not been completely removed, especially in the outer semicircular canal and facial nerve tube around the air chamber, sinus meningeal horn gas chamber, sinus sinus entrance, upper tympanic membrane, residual disease tissue, Causes continuous pus after surgery. Surgery should be performed again to completely remove the lesion. 2. Bleeding: Intraoperative injury to the sigmoid sinus wall or the anterior sigmoid sinus may result in fierce venous bleeding, which should be immediately filled with gelatin sponge and iodoform gauze. If you have a mastoid vein, you will have more bleeding. You can use bone wax to stop bleeding. During the operation, the bone surface is oozing, and the diamond is drilled. Hemorrhage during incision and musculoskeletal flap can be performed by electrocoagulation or ligation. 3. Cerebrospinal fluid leakage or meningitis: intraoperative chisel (grinding) open mastoid upper boundary position is too high or cranial fossa is drooping, improper use of osteotome, resulting in dural tear damage, cerebrospinal fluid leakage, should immediately use fine needle thread The dura mater is sutured, or repaired with the temporalis fascia, and the fibrin glue is applied. In the case of cerebrospinal fluid leakage, meningitis is easy to occur, and a sufficient amount of antibiotics through the blood-brain barrier should be used to prevent meningitis. 4. Facial paralysis: facial paralysis occurs immediately during surgery. One possibility is that the local anesthetic infiltrates into the facial nerve, and a temporary facial paralysis occurs. It can be recovered spontaneously. If the nerve chamber around the facial nerve is removed during surgery, the facial nerve is exposed and damaged. Face nerve exploration, decompression. Facial paralysis occurs several days after surgery, which may be facial nerve edema and recover spontaneously after a few days. 5. Conductive sputum: due to inadvertent operation during operation, the anvil is dislocated. The tympanoplasty can be performed in the second phase to reconstruct the hearing.