中耳胆脂瘤并发迷路瘘管的临床特征  

Clinical Features of Middle Ear Cholesteatoma Complicated with Labyrinthine Fistula

作　　者：韩亮[1] 吴贤敏[1] 陈晓云[1] 方练 黄益灯[1] HAN Liang;WU Xianmin;CHEN Xiaoyun;FANG Lian;HUANG Yideng(Department of Otorhinolaryngology Head and Neck Surgery,First Affiliated Hospital of Wenzhou Medical University)

机构地区：[1]温州医科大学附属第一医院耳鼻咽喉科,浙江省温州市325000

出　　处：《中华耳科学杂志》2021年第1期11-15,共5页Chinese Journal of Otology

基　　金：浙江省自然科学基金资助,项目编号为:LY19H130003、LY19H130004;温州市基础性科研项目,项目编号:Y20180091联合资助。

摘　　要：目的探讨中耳胆脂瘤并发迷路瘘管的诊断和处理方法。方法回顾分析2012年9月至2018年9月在我院住院行中耳胆脂瘤手术患者658例,其中并发迷路瘘管52例(7.9%),收集其术前临床表现、纯音听阈结果、影像学表现,术中探查所见及处理方式,术后恢复情况等结果进行统计学分析。结果 52例迷路瘘管患者术前有眩晕症状32例(61.5%),周围性面瘫2例(House-Brackman分级分别为3级和4级),薄层颞骨CT扫描发现迷路瘘管29例(55.8%),29例CT确诊瘘管患者行瘘管试验,阳性为20例。术中探查发现外半规管瘘49例,上半规管瘘2例,后半规管1例。术中探查所见面神经骨管缺损30例。参照Dornhoffer的分型标准,52例中瘘管Ⅰ型20例,Ⅱ型22例,Ⅲ型10例,Ⅰ型和Ⅱ型患者行自体骨粉+颞肌筋膜瘘口修补术,Ⅲ型瘘管行颞肌筋膜半规管堵塞+瘘管内置入软骨+颞肌筋膜及自体骨粉瘘口修补术,所有患者均行乳突根治术,术后的骨导听阈和术前比较,差异无统计学意义(ZⅠ=72.50,PⅠ=0.816,ZⅡ=59.00,PⅡ=0.147,ZⅢ=10.00,PⅢ=0.260,Z总=364.00,P总=0.188)。23例患者行鼓室成形术,术后气骨导差和术前比较,差异有显著性统计学意义(Z=-3.879,P<0.001)。术前2例面瘫患者术后3个月面神经功能恢复为2级。结论迷路瘘管为中耳胆脂瘤常见并发症,外半规管为好发位置,中耳胆脂瘤患者出现眩晕症状首先要考虑迷路瘘管可能,颞骨薄层CT及瘘管试验阳性有助于诊断,但是很大一部分病史不典型、检查阴性患者术中仔细探查可以确诊,术中确诊迷路瘘管后,应先处理鼓室、乳突的病变,最后处理瘘管,对于Ⅱ型和Ⅲ型迷路瘘管,高倍显微镜下仔细完整清理瘘管内的肉芽及胆脂瘤组织,瘘管内滴入地塞米松,快速行瘘口封闭,可以保存或改善现有的骨导听力,对于有条件行听力重建的患者,术后可以改善患者气骨导差,提高患者听力。Objective To report diagnosis and management of middle ear cholesteatoma complicated with labyrinthine fistula. Methods This retrospective analysis of 658 patients surgically treated for middle ear cholesteatoma from September 2012 to September 2018 at Wenzhou Medical University included 52 patients(6.9%) with labyrinth fistula.Preoperative clinical manifestations, pure tone thresholds, imaging findings, intraoperative findings and treatment, and postoperative recovery in these patients were analyzed. Results Among the 52 patients with labyrinthine fistula, 32(61.5%) had vertigo before surgery, 2 had peripheral facial paralysis(House-Brackman grade Ⅲ and ⅠV, respectively)and 29(55.8 %) showed labyrinthine fistula on CT scan, which was confirmed by positive fistula test in 20 patients. Ⅰntraoperative exploration revealed fistula in the lateral semicircular canal in 49 cases, in the superior semicircular canal in2 cases and in the posterior semicircular canal in 1 case. The facial nerve canal was involved in 30 cases. According to the Dornhoffer classification criteria, fistula was type Ⅰ in 20 of the 52 cases, type Ⅱ in 22 cases and type Ⅲ in 10 cases.Patients with type Ⅰ and Ⅱ fistulas underwent temporalis fascia + autologous bone powder fistula repair, while those with type Ⅲ fistulas received fascia canal plugging + intra-canal cartilage grafting + fistula repair with temporalis fascia and autologous bone powder. Mastoidectomy was performed in all cases. Postoperative bone conduction thresholds remained unchanged(Z=364.00, P=0.188). Air-bone gap improved in the 23 patients who received tympanoplasty(Z=-3.879,P<0.001). Facial nerve function in the 2 patients with facial paralysis recovered to H-B grade Ⅱ. Conclusion The lateral semicircular canal is commonly involved in fistula as a common complication of middle ear cholesteatoma,which should be suspected in middle ear cholesteastoma patients complaining of vertigo. High resolution CT scans and fistula test can facilitate diagnosis, while fis

关 键 词：胆脂瘤 中耳炎 迷路瘘管 并发症 

分 类 号：R764[医药卫生—耳鼻咽喉科]