再次Ⅰ型鼓室成形术经验分析  

Experiences of second typeⅠtympanoplasty

作　　者：李惠[1] 杨霞[1] 陆玲[1] 陈杰[1] 戴艳红[1] LI Hui;YANG Xia;LU Ling;CHEN Jie;DAI Yanhong(Department of Otolaryngology Head and Neck Surgery,Affiliated Drum Tower Hospital of Nanjing University Medical School,Jiangsu Provincial Key Medical Discipline（Laboratory;Research Institute of Otolaryngology,Drum Tower Hospital,Nanjing,210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院耳鼻咽喉头颈外科 江苏省医学重点学科 南京鼓楼医院耳鼻咽喉研究所,南京210008

出　　处：《临床耳鼻咽喉头颈外科杂志》2018年第22期1703-1706,共4页Journal of Clinical Otorhinolaryngology Head And Neck Surgery

基　　金：江苏省科教强卫工程项目(No：ZDXKB2016015); 江苏省第十四批“六大人才高峰”高层次人才项目(No：WSW-075); 国家自然科学基金项目(No：81700913)

摘　　要：目的:分析Ⅰ型鼓室成形术的失败原因,总结再次手术的成功经验。方法:回顾性分析2007-2017年收治的再次行Ⅰ型鼓室成形术的病例。通过复习患者病史、再次手术前鼓膜穿孔大小和部位、再次手术前后纯音听阈、再次手术术中所见及术后鼓膜愈合等,分析初次手术的失败原因,总结再次手术的手术技巧和成功经验。结果:42例(42耳)再次行Ⅰ型鼓室成形术,均采用耳后沟切口,取同侧颞肌筋膜为修补材料。术中常规扩大骨性外耳道,鼓膜钙化12例,鼓室内硬化灶6例,锤骨柄与鼓岬相贴或粘连7例,残余鼓膜内侧与鼓岬粘连10例。再次手术前平均气骨导差为(26.4±8.7)dB HL。再次手术后3个月,鼓膜全部成功愈合,术后气骨导差为(14.0±7.3)dB HL,与术前相比明显缩小(P=0.000),其中气骨导差≤20dB HL者35例(83.3%)。结论:Ⅰ型鼓室成形术是一项较为精细的操作,术中受视野限制致穿孔前缘重叠不良,术中鼓岬黏膜损伤和(或)鼓室填塞明胶海绵不够造成移植膜与鼓岬粘连等,是导致鼓膜修补失败的常见原因。耳后沟切口Ⅰ型鼓室成形术(内植法),术中扩大了骨性外耳道使之平直,可提供清晰的手术视野,从容松解鼓室粘连,确保穿孔前缘充分重叠,可提高再次手术的鼓膜愈合率并改善听力。Objective：To analyze the failure reasons of the typeⅠtympanoplasty and to summarize the successful experiences of the reoperation.Method：A retrospective clinical study of 42 patients undergoing second typeⅠtympanoplasty in the ENT department of Nanjing Drum Tower Hospital from 2007 to 2017 was performed.By reviewing the perioperative clinical data and by following up the patients for 3 months to summarize the failure reasons of the first tympanoplasty and successful experiences of the second tympanoplasty.Result：All of the 42 patients received second tympanoplasty under general anesthesia using the post auricular approach,harvesting the temporalis fascia as the graft material,enlarging the external canal to optimize of the operation vision and using underlay tympanoplasty technique.During the operation calcification was found in 12 cases,tympanosclerosis in 6 cases,handle of malleus attached to promontorium tympani in 7 cases,and remnant tympanic membrane adhered to promontorium tympani in 10 cases.Three months after the second tympanoplasty all of the perforations were closed.The air-bone gap（ABG）between 0.5-4.0 kHz before and after the second tympanoplasty were（26.4±8.7）dB HL and（14.0±7.3）dB HL,respectively.The difference is statistically significant（P=0.000）.ABG less than 20 dB HL was found in 35 cases（83.3%）after the second tympanoplasty.Conclusion：TypeⅠtympanoplasty is a delicate operation.Poor surgical outcomes of the first operation was due to inadequate exposure,mucosal lesion of the promontory,and inadequate gelatin sponge filling in the middle cavity.Post auricular approach,enlarged and straight external canal could optimize the operation vision,resolve the adhesion of the tympanum easily and acquire the adequate anterior overlap,which are benefit for success closure of the perforation and better hearing after surgery.

关 键 词：化脓性中耳炎 鼓室成形术 鼓膜穿孔 

分 类 号：R764.2[医药卫生—耳鼻咽喉科]