endolymphatic sac mastoid cavity drainage

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. Endolymphatic cystic papillary drainage has a good effect on vertigo in the near future, 80% effective; the effect on tinnitus is poor, only 25% to 30% of patients with tinnitus disappeared; recent hearing decreased slightly, 1 to 2 months after hearing can be heard Return to preoperative levels and 30% of patients have improved hearing. The long-term effect is slightly worse, and only 65% of cases no longer have vertigo attacks. Due to a certain recurrence rate, the indication should be appropriate, suitable for typical Meniere's disease, unilateral low-frequency sensorineural hearing does not exceed 60dB, better hearing above 2kHz, volatility, positive re-vibration test, Ecoch G-SP /AP>0.37, suitable for endolymphatic decompression. Surgery is to remove the posterior fossa brain plate through the mastoid cavity, so that the endolymphatic sac can be exposed to reduce the pressure of the endolymphatic system, and can cut the outer wall of the endolymphatic sac, draining the endolymph to the mastoid cavity, and open the mouth. A permanent valve that ensures drainage when the pressure in the endolymph is increased. The surgical procedure is to expose the meninges of the endolymphatic sac to be widely exposed, and to expose the meninges of the posterior cranial fossa. The position of the posterior semicircular canal can be determined from the posterior lymphatic sac, and the posterior semicircular canal is not exposed, which can reduce the damage of the posterior semicircular canal. . 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. After incision of the endolymphatic sac to determine the location of the endolymphatic sac, use a small file to cut the lateral wall from the posterior anterior longitudinal direction, which can be extended to the underside of the posterior semicircular canal, and a small amount of lymph fluid can be seen from the endolymphatic sac. . In order to keep the drainage smooth and no longer closed, the incision is as large as possible, and a part of the outer wall of the endolymphatic sac is removed to cause a defect. The sigmoid sinus can also be made as a transverse incision, and the outer wall of the capsule can be turned forward. The hard bone of the posterior semicircular canal is pressed against the outer wall, so that it is not easy to return, keeping the circulation smooth, and the endolymph fluid continuously flows out to the mastoid cavity. , to achieve the purpose of endolymphatic decompression. 5. Indwelling T-type silicone tube inserted into the T-shaped silicone tube in the longitudinal incision of the outer wall of the endolymphatic sac, one end protrudes in the mastoid cavity (to form a permanent fistula, too much endolymph fluid flows into the mastoid cavity to reach drainage And the purpose of decompression. 6. Close the operating cavity with antibiotic solution to clean the cavity, put gelatin sponge and muscle flap pressure to fill the mastoid cavity, suture the soft tissue in two layers, subcutaneous rubber strip drainage, dressing, end the operation. 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.