mastoidectomy

Mastoidectomy is the eradication of mastoid, sinus and tympanic lesions to form a cavity that covers the epithelium that communicates with the external auditory canal. The purpose of the operation is to completely remove the lesions of the mastoid, sinus sinus, tympanic cavity and eustachian tube, to stop pus, obtain dry ear, and prevent intracranial and extracranial complications. Classic mastoidectomy can cause hearing damage to a certain extent, and the general air conduction threshold can be reduced to 50-60 dB (HL). With the rapid development of ear microsurgery and tympanoplasty, in the past years, while clearing the middle ear mastoid lesions, try to retain the middle ear structure related to the sound transmission function, such as the small bone, residual tympanic membrane, eustachian tube mucosa, etc. Reconstructive hearing using a variety of procedures. Therefore, the choice of indications for mastoidectomy is more cautious, and the radical mastectomy has been reduced. Indication Mastoid radical surgery is applicable to: 1. The cholesteatoma otitis media has a wide range of damage and chronic suppurative otitis media with bone destruction has no reconstruction of hearing conditions, such as combined with sensorineural hearing loss and eustachian tube function can not be restored. 2. Cholesteatoma otitis media with otogenic intracranial complications, pyramidal inflammation, suppurative labyrinthitis, facial paralysis, etc., is not suitable for the implementation of hearing reconstruction. 3. Tuberculous middle ear mastoiditis with bone destruction or dead bone formation. 4. Middle ear mastoid tumors have not been completely eliminated, such as jugular spheroid tumor, facial nerve fibroma, middle ear cancer. Contraindications 1. Chronic suppurative otitis media simple type. 2. Allergic otitis media. 3. Secretory otitis media. 4. Acute suppurative otitis media. 5. Middle ear mastoid tuberculosis without bone destruction or dead bone Preoperative preparation 1. Intravenous antibiotics to control infection. Symptomatic treatment such as infusion according to the general condition of the patient. 2. Shave the hair in the 5cm area around the ear, and the female patient should crunch the hair and comb it to the opposite side. Clean and disinfect the auricle and periorbital skin with 75% ethanol. 3. Clear the secretions of the external auditory canal before surgery, and carry out bacterial culture and drug sensitivity test. 4. Oral pentobarbital 0.1 to 0.2 g or phenobarbital 0.06 to 0.09 g half an hour before surgery. General anesthesia is prepared and used according to general anesthesia. 5. Read X-ray or CT film carefully before operation to understand the degree of mastoid gasification, bone destruction and sigmoid sinus position. Surgical procedure 1. Incisions are generally commonly used in incisions in the ear, such as mastoid airway inflammation or bone destruction in a wide range, can also be performed in the posterior incision (see "single mastoid incision"). The incision in the ear includes two incisions. The first incision usually has two kinds of incision positions in the external auditory canal: one is in the external auditory canal, that is, at the junction of the external auditory canal and the cartilage, and is extended outward by about 0.5 cm at the bottom of the outer ear canal at the lower end of the incision, but is not cut through. Cartilage, this incision is also known as the Shambaugh incision. Another incision is in the external auditory canal, which cuts the skin and subcutaneous tissue to the bony ear or the mastoid cortex. The second incision is from the external ear canal 12 points, that is, the first incision starting point is cut up between the ear wheel and the tragus, and then the external auditory canal is about 3 mm in front of the front of the ear wheel, and the length is extended by 1.5 to 2.0 mm, and the skin and soft tissue are cut layer by layer. Directly to the periosteum, be careful not to cut to the temporalis fascia to reduce bleeding in the incision. Lempert designed the incision as a third incision in the auricular cavity to remove a crescent-shaped skin and cartilage, the purpose of which is to enlarge the external auditory canal to prevent the ear canal stenosis. However, at present, most of the strip cartilage is only removed, the flap is preserved, and a transverse incision is made in the middle of the subcutaneous flap, and the flap is inserted into the ear cavity to be sutured, that is, the external auditory canal. 2. Isolation of the periosteum, exposure of the mastoid cortex and the upper and posterior orthodontic bone wall with a slightly thicker bone stripper to fully separate the mastoid periosteum from the incision, exposing the papillary cortex, up to the iliac line, the posterior root of the iliac crest, down to The tip of the mastoid, the anterior to the posterior wall of the external auditory canal, and the posterior wall of the posterior wall 2cm, reveals the surface of the mastoid, with the "single mastoid incision". 3. Remove bone, enter the sinus and upper tympanic cavity into the sinus sinus usually have three ways, according to preoperative mastoid X-ray film or CT showed mastoid gasification, degree of sclerosis, mastoid bone destruction range, Whether the sigmoid sinus is pre-positioned, whether the meninges of the middle cranial fossa are low, etc., whether there are loosening perforation in the otoscope, bone defect in the upper tympanic cavity, collapse of the upper wall after the external auditory canal, and the technique and equipment conditions of the operator are selected. The sinus approach (the posterior approach of the superior ear canal) is a routine approach. For detailed procedures, see "Single mastoidectomy". Then, under the exploration of the fine-bend probe, the entrance of the sinus sinus is enlarged, and the outer wall of the upper drum or the upper wall of the external auditory canal is removed by the entrance of the sinus sinus, and the outer side wall of the upper drum is removed into the upper tympanic chamber. After the sinus and upper tympanic cavity are exposed, the anvil bone and the short bone of the anvil in the anvil bone socket, the outer semicircular canal protuberance above the short foot of the anvil, the hammer bone, and the facial nerve are visible. Marks to avoid damage to these structures when handling bone bridges later. This approach is suitable for cases with better mastoid gasification, large cholesteatoma, and extensive bone destruction. Sclerosing mastoid, anterior sigmoid sinus, and meningeal lower, can be difficult to operate, and easy to damage the sigmoid sinus wall and meninges. The upper tympanic approach, also known as the inner-outward approach, has become a widely used approach. Commonly used incision in the ear canal, the separated external auditory canal flap and residual tympanic membrane are gently pushed to the front and the lower part of the ear canal, exposing the white scaly, residual hammer and anvil bone exposed on the outer side wall of the drum and below, and are bent at any time. The probe is inserted into the upper tympanic cavity just below the drum notch to understand the depth and width range. The small cutting or polishing drill (or small round chisel) gradually advances upwards, forwards and backwards from the drum cutting edge. From the inside to the outside, grinding (chiseling) the upper bone wall of the upper drum, so that the upper tympanic chamber is completely open. Under probe exploration, through the entrance of the sinus sinus, grinding (chiseling) in addition to the external papillary cortex and air chamber of the sinus sinus, after completely opening the sinus sinus, the short leg of the anvil, the anvil bone, and the outer semicircular canal can be seen. The mastoid airway lesions are then removed based on the extent of the lesion. This approach is suitable for cholesteatoma otitis media, otitis media with otitis media, which is limited to the upper tympanic cavity. It is also suitable for cases of sclerosing mastoid, anterior sigmoid sinus and meningeal hypochalemia in chronic suppurative otitis media. This procedure starts at the bone bridge and follows the approach of the upper tympanic cavity, the sinus sinus entrance, and the sinus sinus. It is not difficult to find the sinus sinus. For example, the perforation of the tympanic membrane and the bone defect of the upper tympanic membrane are much easier to operate. As long as you enter the sinus sinus, the operation can be performed safely later, and the scope of the operation can be determined according to the degree of the lesion. The disadvantage is that the field of view from the upper tympanic cavity is small and deep, which is difficult for beginners to grasp, and adjacent to the facial nerve level and flexion Structures such as the outer semicircular canal, the tibia, and the anvil can cause damage to the above structure if handled inadvertently. Subcortical external auditory canal approach: The inner side of the superior spine after the external auditory canal is about 5 mm, that is, the angle between the posterior wall of the external auditory canal and the upper wall, so that it enters inward and backward, generally no more than 3 to 4 mm, and can enter the sinus. Use the hook-shaped probe to probe the upper, lower and outer borders of the sinus sinus, remove the cortical bone and air chamber of the external tympanic sinus, and gradually enlarge the entrance of the sinus to the lower side. The following surgical steps are the same as the sinus approach. This method is suitable for patients with sclerosing mastoids, enlarged sinus sinus, and cholesteatoma. 4. Clear the mastoid air chamber and cholesteatoma and other lesions thoroughly and step by step to remove the mastoid airway lesions. See the "single mastoid incision" procedure. Radical mastectomy is mainly for the treatment of mastoid cholesteatoma and its pathological changes. Remove the cannula on the cholesteat cavity to fully expose the range of cholesteatoma. The cholesteatoma presents a white, smooth, thin capsule with extra-thick connective tissue and adjacent bone wall or The organization is closely linked. After the capsule is broken, the contents of the odor and the bean curd residue can be absorbed by the suction device or scraped with a large curette. The stripper is peeled off from the breast surface after the mastoid and the lower direction of the sinus, and the cholesteat membrane bottom is removed. And the surrounding bone may be soft due to osteitis, easy to bleed, and the hardened bone resembling ivory is obviously different, and should be ground or scraped to a white hard bone. In cholesteatoma otitis media, long-term inflammation, mastoids are mostly sclerosing type, the bone cavity after clearing cholesteatoma is smooth, no extended air chamber, but some gasified mastoid cholesteatoma epithelium can be extended to the surrounding air chamber. , should be traced to the end and completely removed. In the following areas, special care should be taken when removing the cholesteatoma epithelium, and the preservation should be considered: the cholesteatoma epithelium covered on the semicircular canal is generally not removed, so as to avoid getting lost infection and greater damage. If it is accidentally removed, it should not be At the mouth of the fistula, a thin layer of temporalis fascia should be covered immediately on the fistula; the cholesteat epithelium firmly adhered to the exposed sigmoid sinus, meninges and facial nerves can be preserved to avoid damage to these important structures; The cholesteatoma epithelium covering the humeral foot plate can be retained during the first surgery and will be considered for removal during the second surgery. The cleared mastoid cavity should be contoured, and the sigmoid sinus wall, Trautmann triangle, sinodural angle, outer semicircular canal, sinus entrance, anvil short leg, and second abdomen can be seen. Tendon and other signs. 5. After the thinning and fractured bridge mastoid and sinus cholesteatoma are removed, the bone bridge or the sinus entrance and the upper tympanic cavity across the drum incision between the entrance of the sinus and the upper tympanic cavity and the middle tympanic cavity can be seen. The bone bridge between the bones of the outer ear canal is thinned and bitten by a cutting or polishing drill (osteotomy, fine-headed rongeur) to form a bone across the entrance of the drum or the entrance of the sinus. bridge. If the tympanic approach is performed, the bone bridge is removed at the beginning of the operation. Grind (chisel or bite) the broken bone bridge with a diamond drill or a polished drill (small flat chisel, fine-headed rongeur). Because the inner side of the bone bridge has a facial nerve tube and an outer semicircular canal, the operation should be particularly careful. The electric drill or the chisel should be stabilized to avoid slippage and deepening. The facial nerve protector or small sliver can be placed under the bone bridge, and the facial nerve is flexed. The bone tube is located deep in front of the short foot of the anvil, so the short position of the normal anvil bone can also play a certain protective role. First remove the front half of the arch bridge (ie, at the top of the upper tympanic cavity), then carefully remove the posterior half of the bone bridge and the cantilever protruding from the outer lower wall of the posterior arch or the entrance of the sinus sinus (also known as "the eagle mouth" "), this step can be carried out together with the removal of the posterior wall of the external auditory canal and the reduction of facial nerve spasm. 6. After lowering the external auditory canal, the bone wall and facial nerve paralysis remove the posterior wall of the external auditory canal and reduce the facial nerve spasm, so that a large cavity is formed between the mastoid cavity, the sinus sinus, the tympanic cavity and the external auditory canal, and the drainage is smooth, which is convenient for dressing and observation. The important steps of mastoidectomy are also the most problematic parts of the operation. Due to the inadvertent operation of the facial nerve and the external semicircular canal, some surgeons dare not cut the facial nerve spasm and form a higher "door", which affects the curative effect. Therefore, to recognize the anatomical landmarks, first find the outer semicircular canal protuberance and the anvil short leg or the anvil fossa, the upper end of the facial nerve flexion and vertical section is located in front of the lower part, and the anatomical landmark of the lower part of the vertical section of the facial nerve is the posterior inferior wall of the external auditory canal. The second abdominal muscle spasm of the nipple and the mastoid tip. Therefore, it should be borne in mind that the medial segment of the facial nerve spasm cannot be lower than the outer semicircular canal and the anvil socket. The outer end of the posterior wall of the external auditory canal can be cut parallel to the lower wall of the external auditory canal. If the mastoid cavity extends to the mastoid tip, the outer end of the lower ear canal can also be removed, so that the posterior wall flap can be flattened into the mastoid cavity. Usually, the ingot is taken out first, and the incus is mostly surrounded by granulation or cholesteatoma, and the anvil has a long foot defect, which is easy to be loosened by a crochet. Under the operating microscope, use a diamond drill or a polished drill to carefully cut down the facial nerves, including the medial section "eagle" and the posterior arch. It is necessary to flush the water at any time to prevent the superheat caused by the electric drill from damaging the facial nerve; it can also be cut with a flat bone chisel and carefully. The operation must be parallel to the direction of the facial nerve. The lateral wall of the facial nerve canal often has a small artery running in parallel. If the bone wall is cut down, the bone is more likely to bleed, indicating that it is close to the facial nerve canal, and should not be further ground (chiseled). Sometimes you can see the pink facial nerve under the thin bone shell. If it is not necessary, you should not expose the facial nerve to avoid facial paralysis. 7. Remove the tympanic lesions and remove the anterior arch bones, and remove the lesions hidden in the anterior crypt of the upper tympanic cavity. The anterior crypt of the upper tympanic cavity is the air chamber presented by the thin layer of semi-membrane and semi-membrane thin wall in front of the open hammer bone. It is easy to hide the cholesteatoma matrix. The air chamber of the sacral root often hides the lesion and must be removed. Remove the residual ossicles, but the tibia cannot move. Usually the bone is removed before the facial nerve is removed. If it has not been removed, first use the sharp needle to touch the short foot of the anvil, separate the tissue or granulation between the hammer, the anvil and the anvil, the tibia, and then remove the residual ossicle ( Do not use force to pull, so as not to dislocate the humeral floor or take out the tibia. Carefully remove the granulation, cholesteatoma epithelium, and swelling mucosa in the tympanic cavity under a surgical microscope. The granulation of the humerus and the oval window should be removed from the cone ridge, and the anterior parallel to the iliac tendon should be removed and removed, and the difficult residual granules should be removed, and the patella dislocation should be avoided. Some facial nerve tubes are naturally damaged or destroyed, facial nerves are exposed, and when the granulation is separated, the assistants observe the patient's facial muscle twitch while gently separating, or use the facial nerve detector to find the position of the facial nerve, such as the patient's facial muscle. With twitching, separation should be stopped. Note that the lesions hidden in the tympanic sinus including the facial nerve crypt are removed one by one. The tympanic sinus is located in the medial space of the bulge between the vestibular window and the round window. These parts are easy to hide the granulation, cholesteatoma matrix, should be carefully scraped. In the classic mastoidectomy, residual tympanic membrane, tympanic membrane and pelvic sulcus need to be removed. The excised tympanic membrane tendon is pulled out from the osseous half tube, and the curette is pressed against the spatula to cause a fracture from the facial nerve tube, and the muscle and tendon are taken out. In the inner wall of the drum, the spatula, the humeral foot plate and the round window are three important structures, 1.5mm from the humeral foot plate to the spatula, 1.52mm from the humeral foot plate to the round window, after understanding the distance between the three As long as one of the three is found during surgery, the other two markers can be found according to the distance. The mucosa inside the drum should be completely removed. Use the eustachian tube to reach the eustachian tube, repeatedly scrape the mucosa inside the tube, or close the eustachian tube with the tympanic membrane tendon or broken bones, because the eustachian tube and the internal carotid artery are separated by a thin bone wall or bone. Wall defect, therefore, the operation should be gentle, do not apply force to the back (inside), so as not to damage the internal carotid artery. Use a power drill (curette) to grind (scrape) to remove the tympanic chamber, and grind (scrape) the lower wall of the external auditory canal, so that the middle ear cavity is widely exposed, the external auditory canal is enlarged, but care should be taken to avoid damage to the jugular bulb, and some tympanic wall defects The jugular bulb is exposed or the high position protrudes into the lower tympanic cavity. If it is injured, it may cause severe bleeding. After the classic mastoidectomy is completed, the drum is removed from the tibia, the hammer and the anvil are removed, the residual tympanic membrane, the drum ring and the sulcus are removed, the tympanic membrane of the tympanic membrane is removed, the upper eustachian tube is exposed, the upper tympanic cavity is exposed. The lower tympanic cavity is completely open and the lesion is removed, the posterior wall of the external auditory canal is removed, the facial nerve is reduced, the facial crypt and the sinus sinus lesion are removed, and the middle ear, mastoid, sinus sinus and external auditory canal are opened into a large cavity. With the progress of ear microsurgery and tympanoplasty, in the radical mastectomy, attention has been paid to the complete eradication of lesions, according to the different conditions of the lesions, careful operation, as far as possible to retain the healthier and possibly recovering tissue . For example, the sclerosing mastoid does not necessarily enlarge the cavity of the hardened bone, so as to avoid the large cavity left after the operation, it is necessary to clean up the epithelium, and the signs of the second abdominal muscle tendon are not necessarily seen. The case also does not close the eustachian tube. The granulation tissue in the vestibular window and the round window area is only slightly removed. Considering the removal of the main source of infection and the smooth flow of the sinus, the swelling mucosa and The granulation may gradually subside, and the hearing reconstruction will be possible if conditions permit. 8. The external auditory canal flap was performed, and the intraoperative skin grafting procedure was performed with warm saline. After the surgical cavity lesions were completely removed, an appropriate amount of 1 adrenaline cotton sheet or small gauze was placed to stop bleeding. If the incision is made in the ear, the flap is cut at the junction of the anterior wall and the upper wall of the external auditory canal or cut outward from the drum ring with a sharp knife, and the flap is flipped back over the facial nerve sac and the mastoid cavity. If the incision is made behind the ear, another incision should be made in the external auditory canal. If the flap is too thick, it should be thinned. All the cartilage on the posterior wall of the external auditory canal should be removed. Otherwise, the flap should be lifted up and not easy to be flattened. Because the external auditory canal flap can not cover the surgical cavity, such as no osteitis, acute infection and intracranial complications, the split skin can be taken from the ear or the thigh, the leather surface is attached to the Vaseline gauze, and the wound is placed on the sinus. The bridge area, the upper tympanic chamber, the tympanic cavity and the mastoid cavity make the accelerated surgery cavity epithelial and dry the ear as soon as possible. The leather supply area covers Vaseline gauze and disinfectant dressing. 9. Fill the surgical cavity, suture the incision and cut the segmented fine iodoform gauze (about 2.0 cm long) into the surgical cavity, fix the external auditory canal flap and the implanted skin, and suture the ear incision.

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