endolymphatic sac valve implantation

Portmann (1926) first reported intraductal lymphocytic decompression for Meniere's disease, and House (1962) reported an effective effect of intraductal lymphatic sac-subarachnoid shunt; Shea reported that the intralymphatic cystic papillary drainage was effective and No complicated meningitis; Shambaugh (1966) reported that simply removing the meninges of the posterior cranial fossa exposed to the endolymphatic sac area, even if the endolymphatic sac is not recognized, can also be satisfactory, called endolymphatic decompression, effective Up to 80%, this surgery has been widely carried out in China to treat Meniere's disease. The pedicled iliac muscle flap or prosthetic valve is placed in the endolymphatic sac, and the endolymph can be drained continuously without causing endolymphatic hydrops. Treating diseases: Meniere's disease Indication 1. Patients who have failed medical treatment still cannot control dizziness and progressive hearing loss after symptomatic treatment with diuretics, vestibular sedatives, vasodilators and other drugs. Generally, after more than one year of conservative treatment is invalid, surgery can be considered. 2. In the early stage of the disease, the hearing function and vestibular function damage are not serious, but the seizures are frequent and can not adhere to normal work. Conservative surgery can be considered to control the onset of vertigo. 3. Although the number of episodes is not much, it is accompanied by a significant decrease in hearing, and the hearing is not recovered after the episode. Contraindications 1. During acute exacerbation or acute infectious diseases, it is not suitable for surgery, and then consider surgery after remission. 2. Women's menstrual period is not suitable for surgery. 3. Cardiopulmonary function can not bear the operator. 4. Hyperglycemia, electrolyte imbalance, surgery can be corrected. Surgical procedure 1. According to the "single mastoidistomy" step, after the sinus sinus exposure, the mastoid air chamber is removed, and the mastoid cavity is contoured, and the outer semicircular canal, sigmoid sinus and cranial fossa brain plate and sinus membrane are recognized. angle. In the sinus cavity, the sigmoid sinus and the semicircular canal are the Trautmann triangle, and the deep triangle is the meningeal cranial membrane. The mastoid gas chamber was removed downward, and the second abdominal muscle spasm was exposed to complete the "single mastoid sclerotomy". 2. After removing the open endosperm cavity of the endolymphatic sac surface, the outer semicircular canal is exposed, and the bone surface of the posterior semicircular canal is further removed from the posterior to the deep. The blue line is not required to be exposed, and the endolymphatic sac is located in the posterior semicircular canal. Before the lower sigmoid sinus, under the Donaldson imaginary line, the bone of the endolymphatic sac is rubbed with a small grindstone in the posterior cranial fossa plate to remove about 1 cm × 2 cm of bone. 3. After the endolymphatic sac is removed from the bone plate in the Trautmann triangle area, the meninges on the posterior side of the rock cone are separated inward and upward by a stripper for 3 to 4 mm, and the white endolymphatic sac is exposed to the pale blue meninges. The meninges of the wall are thickened, no blood vessels are running, and the sclerosing needle is used to make the endolymphatic sac protruding, to determine the upper and lower boundaries, the foremost part of the endolymphatic sac, remove a small amount of bone, and further separate the dura mater. Here, the dura mater and the rock cone are tightly adhered, and there is a bony bulge, which is the outlet of the vestibular water tube, and the position of the endolymphatic sac can be further determined. Patients with Meniere's disease often have poor mastoid gasification, and the sigmoid sinus shifts forward, limiting the exposure of the posterior margin of the endolymphatic sac. The sigmoid sinus bone wall should be thinned or the bone wall removed to enlarge the area of the Trautmann triangle. Use brain cotton to protect the sigmoid sinus from injury. 4. The posterior cranial fossa has been resected, and the endolymphatic sac and the meninges above and below are exposed, and an L-shaped incision is made on the outer wall of the endolymphatic sac In some patients, the lymphatic sac often has adhesions and fibroproliferation. The outer wall of the endolymphatic sac can be pulled by a hook. Then the sac is used to open and loosen the sac adhesion. The middle ear stripper is separated from the meninges in parallel, and the adhesion is completely loosened. Meninges. 5. After the endolymphatic cyst is fully separated, the posterior edge of the outer wall of the endolymphatic sac is cut, and the scissor head extending into the sac is spherical, so as not to damage the inner wall of the capsule and the meninges. The outer wall of the endolymphatic sac can be turned up, and then enters the endolymphatic vessel through the cystic cavity with a 0.58 mm blunt probe, which can both loosen the adhesion in the tube and make the valve have a proper position, which is an important step in the operation. 6. Implantation of the valve with a valvular forceps to implant a one-way endolymphatic balloon valve. The size of the forceps needs to match the size of the valve head. The valve head is held while implanting without affecting the field of view, so that the valve head fits into the endolymphatic tube. 7. After suturing the lymphatic sac in the outer wall of the endolymphatic sac, the outer wall of the endolymphatic sac was sutured and sutured with a 5-0 to 7-0 nylon thread. The valve should be covered as much as possible, but there is often a fissure after suturing. The small type III endolymphatic sac is more obvious. When suturing, the fissure should be reduced as much as possible to prevent the valve from sliding backwards. The sigmoid sinus of the valve tail is not Covered by the endolymphatic wall, it can cause permanent endolymphatic fistula. 8. After filling the outer wall of the lymphatic sac of the gelatin sponge, the gelatin sponge is used to cover and fill the mastoid cavity, and the skin and subcutaneous tissue are sutured according to the layer, and the wound is wrapped. complication 1. Deafness: In a few cases, the hearing loss temporarily, may be due to hemorrhage in the mastoid or middle ear cavity, transmission disturbance, blood absorption or excretion 1 to 2 months after surgery, hearing can be restored. If it is a permanent decline, it may be the semi-circular canal during surgery and injury, or it may develop for the disease itself. If the operation is not controlled and the hearing is further reduced, it is a sensorineural hearing loss. 2. Cerebrospinal fluid sputum: A few cerebrospinal fluid leaked from the wound after 3 to 4 days after surgery. After the wound healed, it can stop itself. About 2% of patients continue to have cerebrospinal fluid otorrhea. The wound can be opened under local anesthesia and can be cured with sacral muscle filling. 3. Meningitis: Due to poor disinfection or surgical trauma, postoperative meningitis can be prevented by intravenous infusion of a large number of broad-spectrum antibiotics. 4. Facial paralysis: When the mastoid gasification is poor, the distance between the sigmoid sinus and the posterior semicircular canal is too small. When the posterior sinus space of the anterior sinus is removed, the vertical section of the facial nerve is easily damaged. The mild injury can be recovered by itself, causing serious damage. It should be handled accordingly. 5. Intracranial hematoma: After removal of the posterior cranial fossa plate, intracranial hematoma can be formed when hemostasis is not complete, and complete hemostasis during operation can prevent the formation of intracranial hematoma. 6. Dizziness does not reduce or relapse: In the late stage of Meniere's disease, the hair cells have degenerated, or the vestibular membrane is pushed to the frontal wall and loses its elasticity and cannot be restored. Although the lymphatic sac decompression is performed, the vertigo is not relieved. Within a few months after surgery, the lymphatic incision scar was narrowed or blocked, and the endolymphatic hydrops were again formed and dizzy. Other operations could be performed.