中华耳科学杂志
中華耳科學雜誌
중화이과학잡지
CHINESE JOURNAL OF OTOLOGY
2013年
2期
263-266
,共4页
单良%陈文文%童军%邓亚新%蔡勋华%杜丽君
單良%陳文文%童軍%鄧亞新%蔡勛華%杜麗君
단량%진문문%동군%산아신%채훈화%두려군
少年儿童%中耳炎%胆脂瘤%鼓室成形%听力重建%完壁法%去壁法
少年兒童%中耳炎%膽脂瘤%鼓室成形%聽力重建%完壁法%去壁法
소년인동%중이염%담지류%고실성형%은력중건%완벽법%거벽법
Juvenile and Children%otitismedia%cholesteatoma%tympanoplasty%haering reconstruction%canal-up%canal-down
[目的]探讨少年儿童中耳胆脂瘤手术的疗效以及采用“完壁法”的优点。方法25例。男18例，女7例。平均年龄15.74±3.97岁（范围4-19岁），随访66.75±38.32月（范围12-132月）。13例一次手术。12例有再次手术，平均再手术次数是3次，共计手术49次。其中6例初次手术在本院(可追溯到8-16年前，4例是去壁法的开放的技术,2例采用完壁技术,因残留疾病如鼓膜穿孔，鼓室积液，胆脂瘤复发等再手术)，19例本院初次手术中术前8例有1-12月以上流脓史,3例有紧张部穿孔，15例有松弛部袋凹或肉芽，1例鼓膜完好，有传导聋。另6例初次手术在外院，本次手术均有胆脂瘤复发。术前平均气骨导差（取0.5-2kHz均数，下同，37.16±15.52）dBHL，平均气导（46.45±17.45）dBHL，平均骨导（9.45±6.12）dBHL。完壁法技术包括：彻底清除胆脂瘤病灶“前后夹击法”：前卸盾板、后探孔，保留与外耳道后壁延续的上鼓室与鼓窦间骨桥，胆脂瘤从桥下完整掏出。用“自体骨回复技术”把卸下的盾板、探孔的耳道成块骨质修磨成听骨（臼柱或枪柱），和修复耳道壁（包括盾板）骨片，尽可能保留乳突腔内黏膜，使鼓室乳突再气化，鼓索神经弹压听骨，置入防粘连可吸收网片或注入透明质酸胶液。带钢芯塑管探察咽鼓管，必要时（术前有鼓室积液）给予鼓膜置管等多项综合技术]。以往已作去壁法手术的患者用自体耳道或乳突骨片作壁修复。取最后一次随访听力为结果，统计分析采用U检验。结果本院首次手术后复发的6例再手术中发现都有胆脂瘤皮囊存在,并伴有深部和周围的骨质侵蚀。残留复发率6/19=31%(完壁法复发率2/15=13%)。再手术后随访都超过12月，没有再复发迹象。有3例随访CT显示中耳气化良好，毫无胆脂瘤复发征象。25例术后平均气骨差（15.95±12.99）dBHL，与术前相比，U值5.13>u0.01=2.57，P<0.01.差异有极显著性意义。术后均气导（28.41±14.43）dBHL，与术前相比，u值3.90>u0.01=2.57，P<0.01,差异有极显著性意义。术后骨导（10.83±10.97）dBHL,与术前相比u值0.53，BC差异无显著性意义。20例气骨差在20dB以内，3例虽>20dB，但气导在40dB以内，23例为成功（92%），其中10例在10dB以内（40%）。平均气骨导差的差值为（20.45±14.29）dBHL。13例（52%）1次手术术后气骨差（10.61±9.28）dBHL，与再次手术的12例的术后气骨差（22.27±14.27）dBHL相比，u值2.23>u0.05=1.96,P<0.05,差异有显著性意义。结论完璧法综合技术治疗少年儿童胆脂瘤，虽仍有一定胆脂瘤复发率（13％左右）；但复发后再次采用同样方法仍能获很好效果，并预防再次复发以及去璧法所固有的各种术后麻烦，保持良好听力和正常耳道结构，综合效益十分明显。
[目的]探討少年兒童中耳膽脂瘤手術的療效以及採用“完壁法”的優點。方法25例。男18例，女7例。平均年齡15.74±3.97歲（範圍4-19歲），隨訪66.75±38.32月（範圍12-132月）。13例一次手術。12例有再次手術，平均再手術次數是3次，共計手術49次。其中6例初次手術在本院(可追溯到8-16年前，4例是去壁法的開放的技術,2例採用完壁技術,因殘留疾病如鼓膜穿孔，鼓室積液，膽脂瘤複髮等再手術)，19例本院初次手術中術前8例有1-12月以上流膿史,3例有緊張部穿孔，15例有鬆弛部袋凹或肉芽，1例鼓膜完好，有傳導聾。另6例初次手術在外院，本次手術均有膽脂瘤複髮。術前平均氣骨導差（取0.5-2kHz均數，下同，37.16±15.52）dBHL，平均氣導（46.45±17.45）dBHL，平均骨導（9.45±6.12）dBHL。完壁法技術包括：徹底清除膽脂瘤病竈“前後夾擊法”：前卸盾闆、後探孔，保留與外耳道後壁延續的上鼓室與鼓竇間骨橋，膽脂瘤從橋下完整掏齣。用“自體骨迴複技術”把卸下的盾闆、探孔的耳道成塊骨質脩磨成聽骨（臼柱或鎗柱），和脩複耳道壁（包括盾闆）骨片，儘可能保留乳突腔內黏膜，使鼓室乳突再氣化，鼓索神經彈壓聽骨，置入防粘連可吸收網片或註入透明質痠膠液。帶鋼芯塑管探察嚥鼓管，必要時（術前有鼓室積液）給予鼓膜置管等多項綜閤技術]。以往已作去壁法手術的患者用自體耳道或乳突骨片作壁脩複。取最後一次隨訪聽力為結果，統計分析採用U檢驗。結果本院首次手術後複髮的6例再手術中髮現都有膽脂瘤皮囊存在,併伴有深部和週圍的骨質侵蝕。殘留複髮率6/19=31%(完壁法複髮率2/15=13%)。再手術後隨訪都超過12月，沒有再複髮跡象。有3例隨訪CT顯示中耳氣化良好，毫無膽脂瘤複髮徵象。25例術後平均氣骨差（15.95±12.99）dBHL，與術前相比，U值5.13>u0.01=2.57，P<0.01.差異有極顯著性意義。術後均氣導（28.41±14.43）dBHL，與術前相比，u值3.90>u0.01=2.57，P<0.01,差異有極顯著性意義。術後骨導（10.83±10.97）dBHL,與術前相比u值0.53，BC差異無顯著性意義。20例氣骨差在20dB以內，3例雖>20dB，但氣導在40dB以內，23例為成功（92%），其中10例在10dB以內（40%）。平均氣骨導差的差值為（20.45±14.29）dBHL。13例（52%）1次手術術後氣骨差（10.61±9.28）dBHL，與再次手術的12例的術後氣骨差（22.27±14.27）dBHL相比，u值2.23>u0.05=1.96,P<0.05,差異有顯著性意義。結論完璧法綜閤技術治療少年兒童膽脂瘤，雖仍有一定膽脂瘤複髮率（13％左右）；但複髮後再次採用同樣方法仍能穫很好效果，併預防再次複髮以及去璧法所固有的各種術後痳煩，保持良好聽力和正常耳道結構，綜閤效益十分明顯。
[목적]탐토소년인동중이담지류수술적료효이급채용“완벽법”적우점。방법25례。남18례，녀7례。평균년령15.74±3.97세（범위4-19세），수방66.75±38.32월（범위12-132월）。13례일차수술。12례유재차수술，평균재수술차수시3차，공계수술49차。기중6례초차수술재본원(가추소도8-16년전，4례시거벽법적개방적기술,2례채용완벽기술,인잔류질병여고막천공，고실적액，담지류복발등재수술)，19례본원초차수술중술전8례유1-12월이상류농사,3례유긴장부천공，15례유송이부대요혹육아，1례고막완호，유전도롱。령6례초차수술재외원，본차수술균유담지류복발。술전평균기골도차（취0.5-2kHz균수，하동，37.16±15.52）dBHL，평균기도（46.45±17.45）dBHL，평균골도（9.45±6.12）dBHL。완벽법기술포괄：철저청제담지류병조“전후협격법”：전사순판、후탐공，보류여외이도후벽연속적상고실여고두간골교，담지류종교하완정도출。용“자체골회복기술”파사하적순판、탐공적이도성괴골질수마성은골（구주혹창주），화수복이도벽（포괄순판）골편，진가능보류유돌강내점막，사고실유돌재기화，고색신경탄압은골，치입방점련가흡수망편혹주입투명질산효액。대강심소관탐찰인고관，필요시（술전유고실적액）급여고막치관등다항종합기술]。이왕이작거벽법수술적환자용자체이도혹유돌골편작벽수복。취최후일차수방은력위결과，통계분석채용U검험。결과본원수차수술후복발적6례재수술중발현도유담지류피낭존재,병반유심부화주위적골질침식。잔류복발솔6/19=31%(완벽법복발솔2/15=13%)。재수술후수방도초과12월，몰유재복발적상。유3례수방CT현시중이기화량호，호무담지류복발정상。25례술후평균기골차（15.95±12.99）dBHL，여술전상비，U치5.13>u0.01=2.57，P<0.01.차이유겁현저성의의。술후균기도（28.41±14.43）dBHL，여술전상비，u치3.90>u0.01=2.57，P<0.01,차이유겁현저성의의。술후골도（10.83±10.97）dBHL,여술전상비u치0.53，BC차이무현저성의의。20례기골차재20dB이내，3례수>20dB，단기도재40dB이내，23례위성공（92%），기중10례재10dB이내（40%）。평균기골도차적차치위（20.45±14.29）dBHL。13례（52%）1차수술술후기골차（10.61±9.28）dBHL，여재차수술적12례적술후기골차（22.27±14.27）dBHL상비，u치2.23>u0.05=1.96,P<0.05,차이유현저성의의。결론완벽법종합기술치료소년인동담지류，수잉유일정담지류복발솔（13％좌우）；단복발후재차채용동양방법잉능획흔호효과，병예방재차복발이급거벽법소고유적각충술후마번，보지량호은력화정상이도결구，종합효익십분명현。
Objective To report results of treatment of otitis media with cholesteatoma using the canal-up technique in pediat-ric patients. Methods Twenty five patients (18 boys and 7 girls, mean age=15.74±3.97 years ranging from 4 to 19 years)were in-cluded. Average follow up was 6.75±38.32 months (12-132 months). Thirteen patients received only one operation. Revision pro-cedures were performed in 12 patients (mean revision procedures=3), resulting in a total of 49 procedures. In 6 cases, the first oper-ation was performed in our hospital 8-16 years ago. Canal down technique was used in 4 of the 6 cases and canal up technique was used in,2 cases. Revision was needed,due to residual diseases including perforation of tympanic membrane, tympanic cavity effu-sion, and recurrence of cholesteatoma. Of the 19 cases in which the first operation was performed in our hospital, 8 presented with 1-12 months history of purulent drainage, 3 with pars tensa perforation, 15 with pars flaccida pockets or granulation, and 1 with in- tact tympanic membrane but conductive deafness. Canal down technique was used in the other 6 cases whose primary operation was performed by other hospitals, all with recurrence of cholesteatoma. Pre-operative average air-bone gap (GAP) over 0.5-2 kHz was 37.16±15.52 dB HL in 25 cases and mean air and bone conduction (AC and BC)thresholds were 46.45±17.45 dB HL and 9.45±6.12 dB HL respectively. Surgical treatments included eradication of cholesteatoma using a canal-up technique, with the bony bridge or posterior canal wall preserved. The mucosa in mastoid cavity was preserved for possible re-pneumatization. The tympani corda was preserved to support the POPE or TOPE. A tube was left in place in cases with pre-operative tympani cavity effusion. The U test was used in outcomes assessment. Results Drum perforation, effusion and recurrent cholesteatoma were seen during revision in the 6 cases originally operated in our hospital, with cholesteatoma pockets and bone erosion. The recurrent rate was 31%(6/19), com-pared to 13%(2/15) when the cananl up technique was used. There was no recurrence durng the 12 months or longer followed up af-ter revision. In the 25 cases, post-operative mean GAP (15.95±12.99 dB HL) showed improvement compared with pre-operative GAP, (U=5.13>u0.01=2.57,P<0.01):while the mean post-operative AC(28.41±14.43 dB HL) also showed improvement compared with pre-operative AC (U=3.90>u0.01=2.57,P<0.01). There was no change in post-operative BC(10.83±10.97dB HL,U=0.53). Postoperative GAP was less than 20 dB in 20 cases. While it was>20 dB in 3 cases, their AC was less than 40 dB HL. Treatment was considered successful in 23 cases (92%), with. GAP at 10 dB or less in 10 cases (40%) and mean GAP at 20.45±14.29 dB for the 25 cases. Post-operative CT scans at 3-9 years in 3 case indicated no recurrent cholesteatoma. Post-GAP (10.61±9.28 dB) after the primary procedures in13 cases (52%) was better than that (22.27±14.27 dB) after revision procedures in 12 cases (U=2.23>u0.05=1.96, P<0.05). Conclusion Although treatment with canal up technique for cholesteatoma does not completely prevent recurrence in pediatric patients (about 13%), revision with the same canal up technique may still yield good results while reducing future recur-rence,andotherproblemsassociatedwiththecanal-down techniqueandpreservinggoodhearingandearcanalanatomy.
