Acute otitis media
Pathophysiological features of the acute otitis media
Chronic otitis media
Pathophysiological features of the chronic otitis media
Variants of "Surgical Angle" of approach
to the Antrum Method of the "Antodrainage" Method of "Slit-like" Antro-Atticotomy Method Repair of the Hinged Mechanism of the Stapes
to the Antrum
Method of the "Antodrainage"
Method of "Slit-like" Antro-Atticotomy
Method Repair of the Hinged Mechanism of the StapesCorrection of the Failures after Hinge-Like Stapedoplasty
Treatment of caries in the atticoantral region of the middle ear with antrodrainage(Ulyanov Y.P.Treatment of caries in the atticoantral region of the middle ear with antrodrainage. XYI World Congr. Of Otolar. Head Neck Surg.(Sydney, Australia, 2-7 March, 1997: 1069-1072.)
SUMMARYA new minimally invasive method of surgical drainage of the an-trum is presented. The method, aimed at the treatment of patients with chronic suppurative otitis media, has been given a name of "antrodrainage". The method permits penetration into the antrum mas-toideum thanks to direct drilling with formation of an osseous channel in the temporal bone without injuring the areas which are at increased risk during surgery. A drainage tube is inserted into this osseous channel for a course of lavage of the middle ear with antibacterial solutions dur-ing two-three weeks until complete cure is achieved. The drainage tube is then removed and myringoplasty can be carried out as early as in six months. The security of the surgical approach to the antrum is provided through preoperative determination of the individual surgical angle of the approach to the antrum in each patient. This angle varies within 60o. Of over 1,000 surgical interventions, good results have been achieved in over 80% of cases. The follow-up period exceeds ten years. The method is also recommended for children after five.
INTRODUCTIONToday it is generally accepted (H.L.Wullstein, 1968) that treat-ment of chronic suppurative otitis media is aimed not only at elimina-tion of chronic inflammation in the middle ear, but also at the subse-quent recovery of the integrity of the membrana tympanica and the chain of the ossicula auditus (auditory ossicles) to restore the lost hear-ing. Therefore, during debridement of the middle ear aimed at elimi-nation of the focus of chronic inflammation in the atticoantral region, the middle-ear tissues should be spared as much as possible, as their good preservation secures both the results of subsequent reconstructive surgery and improvement of hearing. However, not all methods of surgi-cal debridement of the middle ear used nowadays meet these require-ments. Accordingly we have developed an up-to-date method of sparing surgical debridement of the middle ear, i.e. ANTRODRAINAGE (author's certificate of the USSR No 306840). To carry out direct drill-ing with formation of an osseous channel in the temporal bone without injuring the areas which are at increased risk during surgery, drilling is performed with due regard for the individual surgical angle of the ap-proach to the antrum in each patient as determined preoperatively by radiology imaging (author's certificate of the USSR No 419219).
PATIENTS AND METHODAntrodrainage, a new method of sparing drainage of the antrum, was used to treat 1,000 patients aged between five and 82 years with chronic suppurative otitis media. Surgery was indicated in the presence of chronic suppurative otitis media with caries in the atticoantral region. The endaural approach was applied (Fig. 1). Under local anesthesia the skin of the meatus acusticus is incised along the posterior and superior walls with going out to the front. After separation of soft tissues, the bone is drilled in the frontal plane of the skull (back of and upwards from Henle's spine) in the area of the mastoidal fossa with due regard for the individual surgical angle to the horizontal plane of the skull until penetration into the antrum with subsequent insertion of the drainage tube through this osseous channel into the cavity of the antrum (Fig. 2). At the last stage of the operation, cutaneous sutures are placed to con-nect the edges of the incision and the middle ear is washed with the medicinal solution through the drain to the antrum. The washing waters are discharged through a perforation of the ear drum and the tuba audi-tiva into the meatus acusticus externus and the nasopharynx. The dress-ing is removed the day after surgery. Thereafter, a course of lavage of the middle ear with antibacterial solutions is carried out every other day through the drain until the complete cure is achieved (during a period of two-three weeks on an average). The draining tube is then removed, with the drilled aperture being closed spontaneously in two-three days. We were surprised to find concealed small cholesteatomata which were washed out during lavage. As a rule, they were isolated and not danger-ous for subsequent closure of the middle ear. Our experiences with this method in patients with chronic sup-purative otitis media have shown its high efficiency as the focus of chronic infection in the atticoantral region was cured in over 80% of cases. Stable results were observed during more than ten years. Myrin-goplasty (reconstructive operation aimed at closure of the perforated membrana tympanica) was possible in six months after surgery. How-ever, before myringoplasty was considered, we carried out a provocative test to detect hidden foci of chronic suppurative inflammation in the middle ear. The test included insertion of the oiled cotton prosthesis into the dry perforation of the membrana tympanica for a week with subsequent examination. If the ear stayed dry and clean (without dis-charge), we carried out myringoplasty. In case any discharge was de-tected, complementary treatment of chronic inflammatory process was resorted to. As a result, after myringoplasty only single cases of suppura-tive inflammation were observed. It should be noted that the adhesions and scars were expressed very slightly in the tympanic cavity. This is probably related to the accelerated curing effect of antrodrainage. As a result, there is no sclerosing process, so that the chances for the possible success of hearing-improving interventions are increased. Stable long-term results (over ten years) confirm the high efficiency of the method. The individual surgical angle of the approach to the antrum was determined preoperatively with radiological technique by way of filling the meatus acusticus externus with a radiopaque substance, which al-lowed us to receive a straight X-ray picture of the skull. Using this pic-ture, the inclination of the longitudinal axis of the osseous part of the meatus acusticus externus to the horizontal plane of the scull was de-termined (Fig. 3). This angle of inclination varies from -5 to +55o to the horizontal plane of the scull and corresponds to the individual surgi-cal inclination of the plane of the squamomastoid suture to the hori-zontal plane of the scull. This angle increases with age to reach its maximum at 40, being decreased after 40. This finding was demonstrated to be significant through computer handling of 500 "surgical angles of the approach to the antrum" in patients (with an equal proportion of men to women) aged from five to 70 years (D.I.Tarasov, Y.A.Fastovsky, Y.P.ULyanov, G.A.Itkin, 1990). No complications are seen if the method requirements are strictly adhered to. Security and efficiency of this method have allowed us to apply it in treating children from 5 years up, as the meatus acusticus externus is formed enough in them to determine the individual surgical angle of the approach to the antrum. Contraindications for the method of antrodrainage:
1. Presence of intracranial complications;
2. Extended destructive alterations in the processus mastoideus;
3. Expressed alterations in the labyrinth and the fistula of the labyrinth;
4. Clear signs of the presence of a cholesteatoma;
5. Absence of Henle's spine.
REFERENCES1. Tarasov D.I., Fastovsky Y.A., Ulyanov Y.P., Itkin G.A. Age-related modifications of the surgical approach to the antrum (In Russian). - BOPL. - p.62-65. - 1990.
2. Ulyanov Y.P. Patent of the USSR No 306840.
3. Ulyanov Y.P., Fastovsky Y.A. Patent of the USSR No 412219.
4. Ulyanov Y.P. Antrodrainage in treatment of chronic suppurative otitis media (In Russian). - The thesis for the degree of MD.- Mos-cow, 1976. 5. Wullstein H.L. Operationen zur Verbesserung des Geh"res. Stutt-gart, 1968.
Fig. 1. Surgical separation of Henle's spine.
Fig. 2. Method of antrodrainage at the stage of lavage of the middle-ear cavities.
Fig. 3. Determination of the "surgical angle" of approach to