Caption:External acoustic canal is filled with radiopaque material
Acute otitis media
Pathophysiological features of the acute otitis media
Chronic otitis media
Tubo-tympanosclerosis and cholesteatoma as the effects of acute Evstahiit (tubootitis)
Pathophysiological features of the chronic otitis media
Variants of "Surgical Angle" of approach
to the Antrum
to the Antrum
Method of the "Antro-Dranage"
Method of "Slit-like" Antro-Atticotomy
Method Repair of the Hinged Mechanism of the Stapes
Correction of the Failures after Hinge-Like Stapedoplasty
Variants of Surgical Angle of approach to mastoid antrum.(16360-o)
Tarasov D.I., Fastovsky Y.A., Ulyanov Y.P., Itkin G.A: Age-related modifications of the surgical approach to the antrum. Journal "Vestnyc Otolaryngology". 1990:62-5 (In Russian).
Abstract:Nowadays, it is common knowledge that the minimally invasive and harmless method of surgical drainage for the mastoid antrum is named Antrodrainage (Russian Patent No. 306840 and 419219). It is more successful treatment mode for chronic suppurative otitis media with good preservation of the sound conductive system. During entry into the antrum by this method the precise drilling with safety is performing in a frontal plane of the skull from Henle spine and along a face of the mastoid-scaly seam, which is located under individual "surgical angle" to a level of the skull. This "surgical angle" of the approach to the antrum (SAAA) was measured on 500 patients in the age from five to 70. All patients were selected on 7 age-groups and over 100 patients were presented in each groups from the 2nd and until the 4th. Minimal "surgical angle" as minus 5 degree(dg) was detected in 1,4 % and maximal angle like plus of 55dg was found out in 0,6 %. The average-statistical of the "surgical angle" was increasing from 13,2dg in 5 age and up to 25,3dg in 40, with following lessening till 18dg in the 7th group. Therefore, during the all methods of exterior antro-mastoidotomy, otosurgeons should take into account these variants of the SAAA that will be able to help them to avoid many severe complications.
Introduction:Penetration into the mastoid antrum is the basic purpose of surgical intervention for treatment of chronic suppurative otitis media (CSOM). Approach to the mastoid cavity through the mastoid bone is the most retentive for a sound-conducting mechanism of the middle ear (ME). However, this surgical approach to the antrum is also the most dangerous, because numerous guileful variations of antrum locations could lead to many unpleasant complications. The most precise and minimally invasive surgical approach to the antrum through the mastoid was developed in 1970 [1,2] (Russian Patent Nos. 306840 and 419219) and named Antrodrainag.
Methods of Antrodrainage
Medical washing of the Antrum through drainage tube
This method was performing as direct drilling of an osteal canal through the mastoid till the antrum with subsequent insertion of a drainage tube into this canal, with next course of flushing the middle ear. During penetration into the mastoid cavity, the drilling is directing lengthways of a frontal plane of the skull from Henle spine and along a face of the mastoid-scaly seam, which is located under individual "surgical angle" to a (horizontal) level of the skull. Henle spine is an outside edge of the mastoid-scaly seam [1,2],
which passes through the external wall of the antrum, and accordingly, this spine is the most precise oriented point to find of the mastoid antrum. Consequently, this angle of the mastoid-scaly seam declination to a level of the skull was called as the "surgical angle" of the approach to the antrum (SAAA). In addition, we established that this part of the mastoid-scaly seam into a frontal plane of the skull is located in parallel with projection of the osteal part of the external auditory canal (EAC) [1,2].
Materials and methods:The SAAA was measured off in a quality of preparation to Antrodrainag on 500 patients with CSOM (200 patients of Republic Mali and 300 in Russia) at the age from five to 70 and in equal proportion of male to female (Tab.1).
Caption:Dynamics of the "surgical" angle of approach to the antrum in depending of the patients age Individual SAAA was determined over the contrast radiogram with filling of the EAC by radiopaque substance. This radiograph was made into the direct frontal X-ray projection of the skull (Fig1).
Caption:Schematic drawing of the surgical angle(SA) of approach to antrum on the contrast radiogram of the skull Legends:
Over such radiogram, the SAAA was sized up by the inclination of a longitudinal axis of the EAC to a level of the skull. Particular attention was made to detecting of SAAA variants and to possible regularities of their objective manifestations. Equalization of the variational line was conducted by the method of the slipping medium for averaging-out of the received results.
The discovered regularities of SAAA variants were processed statistically for support of their authenticity.
Results:All patients were selected on 7 age groups (5-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70 years) and over 100 patients were presented in the each group from the 2nd and till the 4th, but in the 7th group of elderly people was 17 (Tab.1) . More frequent the SAAA equalled to 18-20dg, while minimal "surgical angle" as minus 5(dg) was sized in 1,4 % and solely in the first four groups (Fig.1A), and maximal SAAA like plus 55dg was found out in the 2nd and the 3th groups together in 0,6 % (Fig.1B).
Caption:The diagram of dependence arithmetical mean of the surgical angle of approach to the antrum (SAAA)from the age into 500 patients with CSOM. Legends:
Average-statistical "surgical angle" was rising from 13,2dg in 5 age and up to 25,3dg in 40, with following lessening towards the 7th group till 18dg.
Statistically reliable average arithmetic of SAAA in the 1th group was 13,2dg, in the 2nd group 13,2dg, in the 3th - 23,8dg and in the 4th group 25,3dg, that confirmed depending of increasing of the EAC slope to a level of the skull owing to the growing of patient's age.
However, the purely surprise for us was to find the subsequent statistically valid decreasing of the SAAA after the age of 41, that was marked in the 5th, 6th and the 7th groups.
The age's changes of the SAAA were statistically reliable, because p < 0,001 was in the 1th and up to the 6th group, while p < 0,005 was in the 7th group.
The first statistical regularity of EAC declination changes to a level of the skull was detected in the form of increasing of the "surgical angle" from 5 age and up to 40 and the second regularity was as following decreasing of the "surgical angle" after the age of 41 (Fig. 2).
Apparently, these age's variations of EAC declination could depend because of the growth of the age activity of the breast-clavicle-mastoid muscle, which one is reinforcing with development of the organism, but after the age 41 the activity of this muscle was gradually weakening, like all organism, with gradual dominance of destructive-sclerotic process of the skull-bones.
Knowledge of these features of the mastoid cavity locations allows to perform the precise and harmless direct drilling through the mastoid into the antrum. That provides the real using of such minimally invasive and safe method antrotomy as Antrodrainag or "Slit-like" antro-atticotomy . And also, it will help and allow to otosurgeons to avoid of dangerous complications during the performing of any other surgical interventions into the antrum through mastoid like antro-mastoidotomy, mastoidectomy, antro-atticotomy, radical operations on the middle ear and others.
1. The most precise, minimal invasive and safety surgical penetration into the antrum through the mastoid can be warranted solely in a frontal plane of the skull, from Henle spine and lengthwise of the mastoid-scaly seam, which face is located under individual "surgical angle" to a level of the skull.
2. Individual "surgical angle" of approach to the antrum can be defined by the declination of the external auditory canal projection, which in a frontal plane of the skull is disposed in parallel with the mastoid-scaly seam.
3. More frequent "surgical angle" of the approach to the antrum equals to 18-20o, but there are also individual variants from minus 5dg and up to plus 55dg, and it is growing from the age of 5 and till 40 with the following particularly decreasing to 70 years.
. Uliyanov Y.P.. The method of "Antrodrainage" in the treatment of Chronic Suppurative Otitis Media. . The report of thesis for a Scientific Doctor's degree-Doctor of Medicine, M.D. (Moscow) 1976; 24. (In Russian).
. Uliyanov Y.P.. Treatment of caries in the atticoantral region of the middle ear with antrodrainage. XVI World Congress of Otolaryng. Head and Neck Surg. 1997; 2.p.1069-72.
. Uliyanov Y.P.. Possibilities of "slit-like" antroatticotomy. XVI World Congress of Otolaryng. Head and Neck Surg. 1997; 2.p.1073-6.
Tarasov D.I., Fastovsky Y.A., Ulyanov Y.P., Itkin G.A: Age-related modifications of the surgical approach to the antrum. Vestnyc Otolaryngol. 1990; 62-5 (In Russian).