重建上鼓室外侧壁的保留骨桥乳突切开鼓室成形术

摘要

目的：探讨完桥式乳突切开鼓室成形术（intact-bridge tympanomastoidectomy,IBM）并用自体骨片重建上鼓室外侧壁的临床疗效。方法对48例(50耳)慢性化脓性中耳炎和中耳胆脂瘤患者采用IBM术式，清除病变后自体外耳道后壁骨片重建上鼓室外侧壁及听力重建，观察鼓膜愈合情况及听力提高水平，总结手术技术要点和术后疗效。结果术后随访3-21个月，干耳时间3-14周，平均6.7周；鼓膜穿孔愈合率92%（46/50耳），3耳因术后感染及1耳胆脂瘤上皮残留导致鼓膜穿孔不愈，经再次手术愈合。患耳的气导平均纯音听力（pure tone average,PTA）由术前53.7±6.9 dBHL提高到术后36.3±9.1dBHL，气骨导差（air-bone gap，ABG）由术前26.4±7.3 dBHL缩小到术后15.0±4.2dBHL，手术听力提高成功率（术后PTA-ABG≤20dBHL）为72%（36/50耳）。结论 IBM术式保留的“骨桥”对重建上鼓室外侧壁的骨片和鼓膜移植物起到支撑作用，结合上鼓室外侧壁重建保持了中上鼓室含气腔和正常外耳道后壁形态结构，减少术后鼓膜内陷袋形成，是中耳乳突手术的理想选择。%Objective To report outcomes of epitympanoplasty with autologous cortical bone in intact-bridge tympa-nomastoidectomy (IBM) for the treatment of chronic suppurative otitis media or middle ear cholesteatoma. Methods In 48 patients (50 ears) who underwent IBM, the lateral wall of the attic was reconstructed with autologous cortical bone. The technique and outcomes were reported. Results Cases were followed up 3-21 months. The ears became dry between 3 to 14 weeks (average 6.7 weeks). Tympanic membrane healing rate was 92%(46/50 ears). In 4 cases, revision operation was need-ed because of postoperative infection (n=3) and tympanic membrane perforation related to residual cholesteatoma epitheli-um (n=1). The average air conduction threshold over 0.5, 1 and 2 kHz improved from 53.7 ± 6.9 dBHL to 36.3 ± 9.1 dBHL, while average air-bone gap decreased from 26.4±7.3 dB to 15.0±4.2 dB. The success rate (postoperative PTA-ABG≤20 dB HL) was 72%(36/50). Conclusion The preserved"bone bridge"in IBM plays a supporting role to cortical bone and tym-panic membrane grafts. IBM combined with epitympanoplasty with autologous cortical bone preserves the air space in the attic or mesotympanum, as well as the morphology of the external auditory canal wall, and helps prevent retraction pocket formation. This technique provides an ideal solution of treating otitis media for otologists.