Variants of "Surgical Angle" of approach
to the Antrum Method of "Slit-Like" Antro-Atticotomy
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Possibilities of "slit-like" antroatticotomy(Uliyanov Y.P Possibilities of «slit-like» antroatticotomy. XYI World Congr. Of Otolar. Head Neck Surg.Sydney, Australia, 2-7 March, 1997: 1073-1076.) |
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SUMMARYTo cure chronic suppurative otitis media complicated by cholesteatoma or impassibility of the aditus ad antrum, a minimally invasive method of antroatticotomy was developed. The method was named "slit-like" antroatticotomy. The method permits revision of the atticoantral region through a slit-like cut (with a width of 2 to 2.5mm) in the pars lateralis with removal of the cholesteatoma together with the matrix. The method also corrects obstruction of the region, which makes it possible to carry out postoperatively a course of lavages with antibacterial solutions through the draining tube placed into the antrum. The method was applied to treat 200 patients with a positive long-term result achieved in 70% of cases. Myringoplasty is possible to be performed successfully in six months after surgery.INTRODUCTIONThe aim of modern otological surgery to recover hearing of patients while treating them for chronic suppurative otitis media prompts the otological surgeons to search for as sparing as possible methods of surgical debridement of the attico-antral region. Various methods have been developed to avoid destruction of the osseous structures of the middle ear as much as possible during antrotomy. As of today, the most sparing method of antrotomy is the method of antrodrainage (patents of the USSR No 1802161 and 306840). This method permits antrotomy with drilling a direct osseous channel into the antrum mastoideum, whereas a course of lavage with antibacterial solutions through the draining tube leads to a complete cure of the chronic suppurative focus in the atticoantral region in two-three weeks. Therefore, all structures of the middle ear and the meatus acusticus externus are retained, which makes it possible to carry out myringoplasty in only six months after this operation. However, this method is inefficient in cholesteatoma, when it is necessary to remove the matrix of cholesteatoma, and in case an impasse of the aditus ad antrum is present, when the retrograde lavage of the middle ear becomes impossible. In these cases, direct revision of the atticoantral region is unavoidable, i.e. a more extended surgical intervention of antroatticotomy type is necessary. This method of antrodrainage has turned out to be the most suitable one also as a component in developing a new sparing method of antroatticotomy. As is known, the most sparing method of atticotomy consists in drilling a fenestrated aperture in the exterior wall of the attic, which preserves the osseous edge of the tympanic membrane and is sufficient for a revision of the attic cavity, the size of which is determined during surgery. This method of sparing atticotomy was also chosen by us as a component in developing a new sparing method of antroatticotomy. Descriptive anatomy and embryogeny indicate that the atticoantral region is formed in the space of the fissura mastoidea squamosa, whose rests are retained as the sutura mastoidea squamosa in the pars lateralis of the atticoantral region. This fact is to take into consideration, as the surgical approach in the plane of the osseous suture is the safest one. It is this approach that is used in performing antrodrainage, which includes direct drilling of the osseous channel into the antrum exactly in the plane of this suture. Being situated in the pars lateralis of the atticoantral region, the plane of the squamomastoid suture is just between the osseous channel of antrodrainage and the aperture of fenestrated atticotomy. Therefore, the direct slit-like saw cut of the exterior wall of the atticoantral region between the already existing antrotomy and atticotomy goes just through the plane of the squamomastoid suture, i.e. in the safest area. Tentative saw cuts in this area in 50 cadavera have completely confirmed the correctness of our preliminary expectations, having given grounds for performing these operations in treating patients with chronic suppurative otitis media. Consequently, this method of antroatticotomy was patented in Russia (claim No 95116292).PATIENTS AND METHODThe method of the slit-like antroatticotomy was applied by us to treat 200 patients with chronic suppurative otitis media complicated by caries, including 130 patients in whom this method of surgery was indicated due to an impasse of the aditus ad antrum detected during antrodrainage, with cholesteatoma being found in 36 patients. In other cases, antroatticotomy was indicated because of the presence of cholesteatoma filling the atticoantral region, but in the absence of osseous destructions established before surgery. Intracranial complications and extended osseous destructions surpassing the atticoantral region were seen as a contraindication to surgery. The age of patients varied within from 9 to 68 years. There were 86 men. The first stage of slit-like antroatticotomy consisted in antrodrainage. Under infiltration anesthesia the skin of the meatus acusticus is incised along the posterior and superior walls with going out to the front above the tragus. After separation of soft tissues, the area of Henle's spine and the mastoidal fossa situated behind the latter were exposed. Because the fossa mastoidea, as was shown by our studies of 1976, is the exterior edge of the sutura mastoidea squamosa, and it is through this fossa that the osseous channel is drilled in the temporal bone into the cavity of the antrum. The bone is drilled strictly in the frontal plane of the skull with due regard for the individual surgical angle to the horizontal plane of the skull to provide for the exact passing of the drill in the plane of the sutura mastoidea squamosa. The diameter of the osseous channel is 4mm (Fig.1-4). After additional separation of the skin of the meatus acusticus along its posterior and superior walls until the fibrous ring of the membrana tympanica, the pars lateralis of the atticoantral region and the superior edge of the osseous tympanic ring (1) were exposed. A cutter was then applied to make an orifice (6) in the pars lateralis of the atticoantral region with retention of the osseous edge of the membrana tympani. This permitted a revision of the attic (recessus epitympanicus - 3). Then a saw cut was made with a cutter in the pars lateralis of the atticoantral region directly backwards (7) to reach the osseous channel of antrodrainage (5) by cutting the latter along its anterior wall. The cut in the bone (7) may have a width of 2 to 2.5mm. As a result, the whole atticoantral region (2, 3, 4) is open and accessible for revision and removal of the cholesteatoma or granulations of the scar tissue to recover the aditus ad antrum - 4). In case the cholesteatomatous process is present, cholesteatoma together with the matrix can be removed through this saw cut. However, in case cholesteatoma is extended into the depressions of the atticoantral region, complete removal of the cholesteatoma necessitates making supplementary cuts of the funnel type in deeper areas of the osseous slit. This permits complete removal of the matrix of cholesteatoma without outward extending of the osseous slit. This is very important for consequent closure of the slit with a soft-tissue flap of the superior and posterior walls of the meatus acusticus, which has been formed and shifted forwards and below in the beginning of the operation. After a revision of the atticoantral region, a plastic draining tube is inserted through the osseous channel into the antrum mastoideum with a tough fit. Then the soft-tissue flap of the superior and posterior walls of the meatus acusticus externus is laid in its initial place, whereas catgut sutures are placed on the edges of the skin incision around the draining tube. Postoperatively, a retrograde lavage with the antibacterial solution is carried out through the draining tube, with the solution being poured out through the perforation of the membrana tympani and the tuba auditiva. Lavages are usually performed twice a week. During the first days, mucus is profusely discharged from the draining tube and the meatus acusticus externus. Later the quantity of the effluent is reduced, so that in two-three weeks the draining tube is clean and dry at the next session of lavage. This means that the tube can be removed after the last lavage, with the aperture for the draining tube being closed spontaneously in two-three days. General and local antibacterial and anti-inflammatory treatment is continued for two or three weeks more until all reactions in the ear subside and the ear becomes dry. Positive results like that were achieved in over 84% of cases. Failures were mainly related to chronic inflammation of the tuba auditiva complicated by chronic rhinosinusitis. There were no complications due to the technique of surgery. At six months, the results were stable in 74% of cases. These patients were subjected to myringoplasty. The postoperative course was usually free from suppurative complications. Our experiences with slit-like antroatticotomy show that this method can be recommended for a wide use in otological surgery.REFERENCESUlyanov Y.P. Antrodrainage in treatment of chronic suppurative otitis media. A dissertation for a degree of MD. - Moscow, 1976.Ulyanov Y.P. Patent of the USSR No 306840. Ulyanov Y.P., Fastovsky I.A. Patent of the USSR No 412219. Ulyanov Y.P. Patent of the Russian Federation No 028215. Fig. 1. Method of slit-like antroatticotomy.
1 - Membrana tympani with perforation.
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