Tympanic exploration for chronic otitis media

Tympanic exploration is a procedure for clearing the tympanic membrane and exposing the tympanic cavity for the purpose of diagnosing diagnosis and treatment. The scope of the tympanic exploration includes the upper, middle and lower tympanic chambers and the sinus sinus. The ossicular chain, the anterior and posterior ligaments of the hammer bone, the vestibular window, the round window, the tympanic membrane, the iliac crest muscle, the horizontal section of the facial nerve, the tympanic nerve, and the eustachian tube orifice should be seen. If the lesion is limited to the above range, it can be corrected at the same time. If it exceeds the above range, appropriate surgical approaches and methods can be selected for treatment. With the use of auditory brainstem response audiometry, acoustic impedance measurement, multi-body imaging, CT scanning and angiography, it provides important information for the diagnosis of various deafness and middle ear diseases, but some sounding, mixed sputum and some sudden sputum, clinical repeated examination is difficult to determine the cause, tympanic exploration is an important diagnostic and treatment. Treatment of diseases: chronic otitis media Indication 1. A tympanic membrane with normal tympanic membrane or abnormal tympanic membrane, or a mixed sputum with obvious qi and bone conduction. Suspected to be the following lesions: (1) Otosclerosis: Atypical patients with a history of sacral surgery after diagnosis. Tympanic sclerosis or adhesion otitis media. (2) ossicular chain fiber adhesion fixation, ossicular chain ossification straightening: remove the sclerosis or cut adhesion, place silicone membrane or tympanoplasty. (3) occlusion of small bone dislocation, fracture or interruption: osseointegration. (4) Congenital ossicular chain deformity: feasible tympanoplasty or humerus surgery. The vestibular window opens or the inner ear opens the window. 2. Patients with suspected external lymphatic leakage or labyrinth lesions: patients with sensorineural hearing loss, a history of head trauma, history of barotrauma and history of ear surgery. It is characterized by sudden onset, fluctuating sputum, dizziness or recurrent meningitis. 3. Suspected tympanic cholesteatoma or cholesterol granuloma: secretory otitis media or blood tympanic cavity (blue tympanic membrane) through the tympanic membrane incision for long-term unhealed, effusion thick or chocolate. 4. Suspected tympanic tumor: If the posterior tympanic membrane is bulging, it is pale yellow, with or without facial nerve palsy, suspected facial nerve sheath tumor; if the anterior and posterior tympanic membrane is bulging, the possibility of tympanic meningioma should be considered. In the eustachian tube, protruding toward the tympanic cavity. Explore the extent of the lesion and take a biopsy to confirm the diagnosis. Preoperative preparation 1. Clean the lateral external auditory canal with 75% ethanol 1 day before surgery. 2. The side of the ear was shaved 5 cm, 75% ethanol disinfected the auricle and the skin around the ear. 3. Before the operation and half an hour before surgery, take phenobarbital 0.06 ~ 0.09g or isobarbital 0.1 ~ 0.2g. 4. General anesthesia is prepared and used according to general anesthesia routine. 5. Penicillin allergy test. Surgical procedure Incision and tympanic exposure: commonly used incision path has three types in the ear canal, in the ear and behind the ear. 1. Incision in the ear canal and tympanic exposure: The incision in the ear canal is mainly used to expose the anvil joint, the vestibular window, the round window and the middle tympanic chamber. Currently used for sacral surgery incision, but the external auditory canal flap is slightly larger than the humerus surgery. The tympanic exploration usually makes the skin incision between the ear and the ear of the ear, extends to the full length of the cartilage segment in the ear canal, separates the subcutaneous tissue with the septal stripper, exposes the bone above the bone ear canal, and automatically pulls the visual field of the external auditory canal to make the operation It is convenient for hands to perform in-ear operation. The small bleeding point at the incision is electrocoagulated to stop bleeding, and then the incision is made in the ear canal. You can also put an appropriate size of the otoscope into the incision in the ear canal after local anesthesia. The upper part of the right ear incision starts from 1 to 2 o'clock on the short leg of the hammer bone, and the arc is outward and downward, 8 mm from the drum ring at 9 o'clock, and then goes down to the lower wall of the external auditory canal at 6 o'clock. At the ring. Use the external auditory canal stripe to separate the external auditory canal skin and periosteum as the tympanic membrane of the eardrum. Pay attention to the separation of the ear canal. If the fiber is stuck, it can be cut with a crocodile shear or cut with a knife. When separating, use a thin suction tube to attract the field. Clear. The adrenalin cotton ball or electrocoagulation was used to stop bleeding before entering the tympanic cavity, and then the fiber drum ring was separated from the tympanic membrane by the tympanic membrane. The skin of the posterior wall of the external auditory canal is turned forward together with the tympanic membrane of the posterior half to expose the posterior half of the tympanic cavity. The tympanic nerve may move forward with the flap of the ear canal, or may be hidden behind the bone of the drum ring. Generally, the circle should be visible. Window and hammer neck, if the vestibular window and the long bone of the anvil are not fully exposed, the anterior chamber window can be fully exposed by using a curette or a 2~3mm circle to remove the upper part of the bony drum ring and the posterior superior ear canal. And round window area. 2. Intraaural incision and tympanic cavity, upper tympanic cavity, sinus sinus exposure: mainly used for suspected lesions extending to the upper tympanic cavity, sinus sinus, such as anvil joint disease, upper tympanic cavity and sinus cholesterol granuloma, cholesteatoma. The incision in the ear includes two incisions: the first incision starts from the junction of the 12 o'clock bone and the cartilage at the upper wall of the external auditory canal, and the arc along the posterior wall of the external auditory canal down to the lower wall of the external auditory canal at 6 o'clock, and then extends outward by 0.5 cm. But the cartilage is not cut through; the second incision is from the upper wall of the external auditory canal at 12 o'clock, that is, the starting point of the first incision is upward and the skin and soft tissue are cut layer by layer between the ear and the tragus to the front of the ear wheel, taking care not to injure the cartilage. , diaphragm and superficial temporal artery. The mastoid cortex was separated from the incision, and the skin and periosteum of the upper and lower ear canal were separated, and the drum incision and the drum ring were directly reached. The outer side wall of the upper drum is removed from the bottom of the drum by a 2 to 3 mm cutting drill (round chisel) from the bottom of the drum. Fully expose the upper tympanic cavity, and expose the sinus sinus area from the upper tympanic cavity through the entrance of the sinus sinus. The lesions of the hammer bone, the anvil bone, the anvil joint, the facial nerve tympanic chamber, the surrounding tissue and the bone wall can be explored. 3. Post-incision incision and exposure of the sinus, upper tympanic cavity, and posterior tympanic cavity: one of two incisions can be used in adults. 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. Under the operating microscope, a 1 to 2 mm cutting bit is used to advance the outer wall of the upper drum from the entrance of the drum sinus, and the outer wall of the outer ear canal is ground as much as possible (about 1 mm), so that the upper tympanic chamber is fully opened. For example, after the tympanic cavity is opened, the tympanic cavity is opened. The simple mastoid sclerotomy is performed first, and the posterior wall of the external auditory canal is ground from the direction of the mastoid to form a thin layer of eggshell-like bone wall, and a 1 mm cutting bit is placed under the anvil. From the top to the bottom, from the back to the front to open the facial nerve crypt into the middle tympanic cavity. The facial nerve crypt has a triangular fissure, the upper boundary is the anvil bone, the outside is the tympanic nerve, and the inner side is the upper part of the vertical section of the facial nerve. In patients with good development in the mastoid air chamber, the air chamber group around the facial nerve can be opened into the posterior tympanic cavity. The long bones of the anvil, the anvil joint, the humerus, the round window, the lower tympanic cavity, and the tympanic membrane can be seen. Try to keep the posterior arch intact during the operation to avoid dislocation of the incision. 4. According to the different lesions seen in the exploration, different surgical treatments are used. The fixation of the ossicular chain due to inflammation of the middle ear, the interruption of the ossicular chain, the ossification of the ossicular chain caused by tympanosclerosis, and the feasibility of ossicular chain reconstruction, see "tympanplasty." Congenital ossicular chain malformation: the hammer bone, neck and anvil bones are from the first zygomatic arch, the hammer shank and the anvil bone are from the second zygomatic arch, and the humerus structure is from the second zygomatic arch. If the embryo has a developmental disorder of the first and/or second zygomatic arch 12 weeks ago, it may form a single or two or three ossicular deformities, which may be unilateral or bilateral, with or without external ear malformation, and other parts of the body. Traumatic perilymphatic paralysis: refers to the perilymphatic sputum caused by the rupture of two windows caused by outward violence and inward violence. There is a clear history of labor and barotrauma before or at the same time. Patients with sudden vertigo, deafness, tinnitus, varying degrees of neurological paralysis, or rhinorrhea. Incision in the ear, flip the ear canal flap. The vestibular area was exposed and the anvil joint, the tibial foot plate and the ligament of the ankle were examined. The presence or absence of perilymph was observed from the anterior edge of the window, the ligament of the ring, the foot plate and the round window. If there is a fiber mesh around the arch, the round window film has a sticky fiber strip, suggesting that there may be a fistula and should be cleaned. The footplate fistula is mostly micro-cracked. It can be seen that the lymph fluid still leaks out after being absorbed (active type), or it is pressed against the jugular vein and leaked after forced coughing (passive type). For the pupil of the round window film, you can gently touch the tibia, see the round window film spot reflection, help identify. Since the round window film is blocked by the overhanging round window, the film must be ground to a thickness of about 0.4 to 0.9 mm (average 0.65 mm), and 40% of the cornice is covered with a film. Do not mistake the round window film. Be careful. Remove the film, observe the round window film with or without cracks and holes. Normally, the round window film is mostly kidney-shaped. The size is about 2.2mm×1.5mm, the thickness is about 0.51mm, the middle is slightly thin, and the front part of the round window film is vertical. The rear part is horizontal, and its intersection angle is curved upward and upward. Make a 0.05mm wide transplant bed around the round window membrane, or scrape the mucosa around the pupil of the foot plate, put the fascia or subcutaneous tissue, cartilage, fat, and press the gelatin sponge to repair the pupil. complication 1. Tympanic membrane wear: due to intraoperative injury or postoperative puncture, surgical repair is feasible. 2. Blood tympanic cavity: Due to the incomplete hemostasis during surgery, most of them can be eliminated through the eustachian tube, and a few days later, the blood can be formed, which can cause adhesion in the tympanic cavity. 3. Facial nerve injury: due to unskilled anatomy, inadvertent operation, congenital malformation of the middle ear ossicular chain, and some with facial nerve malformation, therefore, careful operation under the operating microscope to avoid damage to the facial nerve. 4. Membrane labyrinth injury, labyrinth: humeral foot plate fixation deformity or vestibular window atresia sacral surgery has a certain difficulty, such as surgical injury and infection, can cause long-term severe vertigo. 5. Sensorineural hearing loss: severe labyrinthine inflammation and membrane labyrinth damage can lead to irreversible sensorineural hearing loss, or even total paralysis.