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Title: [Revisional radical mastoidectomy surgeries--25 cases'experience].
Author: Li L, Xie J, Liu Y, Gong SS.
Journal: Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi; 2017 Oct 07; 52(10):766-770. PubMed ID: 29050095.
Abstract:
Objective: To analyze the risk factors of failure to dry ear after radical mastoidectomy and discuss key points in revisonal surgery. Methods: Clinical data of 25 patients(32 ears) with revisonal mastoidectomy were analyzed. The preoperative temporal bone CT findings, intra-operative findings, surgical procedures, postoperative operating cavities and aural abilities were recorded and analyzed. Results: All patients received preoperative temporal bone CT followed by revisonal radical mastoidectomy under microscope and general anesthesia. Among the revisonal surgeries, 19 ears(59.4%) presented cholesteatoma and 13 ears(40.6%) had no cholesteatoma. In addition, the inadequate opening for mastoid cavity and incompleted removal of the pathological tissues accounted for 90.6%(29/32), the insufficient drainage of surgical cavity for 90.6%(29/32), the lesions in tympanic ostium of eustachian tube for 31.2%(10/32), the improper operation procedures and selection of incision for 15.6%(5/32). As for the re-operation of the modified canal wall down mastoidectomy, tympanoplasty(Ⅱ) plus plastic repairing of cavity of concha were performed in 14 ears(43.8%), the modified canal wall down mastoidectomy, tympanoplasty(Ⅱ) plus reconstruction posterior bony wall of ear canal in 2 ears(6.2%); the modified canal wall down mastoidectomy, tympanoplasty(Ⅲ) plus plastic repairing of cavity of concha in 10 eras(31.3%), the modified canal wall down mastoidectomy, tympanoplasty(Ⅲ) plus reconstruction posterior boney wall of ear canal in 1 ear(3.1%); the radical mastoidectomy plus plastic repairing of cavity of concha in 5 ears(15.6%). Lodoform gauzes were packed in surgical cavity for 2 weeks and the antibiotic was used for 3 days after surgery. All patients had dressing of ears and their ears were dropped with ofloxacin regularly. The dry ear time ranged from 4 to 8 weeks, the average point was the 5th week. During a period of 6-18 months for follow-up, all patients got dried ears. The epithelialization of the operating cavity was well and the tympanic membranes were integrity. There was not pus in surgical cavities. Neither granulation tissue nor cholesteatoma was found to reoccur. Both pure tone air hearing thresholds and air-bone gap decreased in 27 ears after the revisional surgeries, with statistically significant different in comparison to those before the operation (P<0.05). Conclusions: There are many factors leading to the failure of radical mastoidectomy, including not fully opening of the surgical cavity , incomplete removal of the lesion tissue, poor drainage of surgical cavity, the lesions in the tympanic ostium of eustachian tube, and the improper operation procedures. Treatment strategies were taken according to above factors to obtain dry ear in revisional surgeries. 目的： 分析乳突根治术后不干耳的原因及乳突再根治术的手术要点。 方法： 回顾性分析25例(32耳)行乳突再根治术患者的临床资料，包括再手术前的颞骨CT表现、术中所见、手术方式及术后术腔状态、听力变化情况(采用SPSS 20.0软件对行鼓室成形术患者手术前后的气导平均听阈及气骨导差进行统计学分析)等。 结果： 25例(32耳)患者术前均行颞骨CT检查，全麻后在耳显微镜下行乳突再根治术。再手术时发现：19耳(59.4%)有胆脂瘤，13耳(40.6%)无胆脂瘤；术腔未完全开放、病灶清除不彻底者占90.6%(29/32)，术腔引流不畅者占90.6%(29/32)，咽鼓管鼓口存在病变者占31.2%(10/32)，前次手术方式选择不当者占15.6%(5/32)。再根治手术行改良乳突根治术＋鼓室成形术(Ⅱ型)＋耳甲腔成形术14耳(43.8%)，改良乳突根治术＋鼓室成形术(Ⅱ型)＋外耳道后壁重建术2耳(6.2%)，改良乳突根治术＋鼓室成形术(Ⅲ型)＋耳甲腔成形术10耳(31.3%)，改良乳突根治术＋鼓室成形术(Ⅲ型)＋外耳道后壁重建术1耳(3.1%)，乳突根治术＋耳甲腔成形术5耳(15.6%)。术后术腔碘仿纱条填塞2周，给予抗炎治疗3 d以及定期换药、滴耳等综合治疗。术后4～8周干耳，平均干耳时间5周。术后随访6～18个月，32耳均干耳，术腔上皮化良好，行鼓室成形术者鼓膜完整，未再出现穿孔、流脓，未发现肉芽增生及胆脂瘤复发。27耳(84.4%)行鼓室成形术，术后3个月的气导平均听阈较术前显著下降，气骨导差亦较术前显著缩小，差异均具有统计学意义(P值均<0.05)。 结论： 术腔未完全开放、病灶清除不彻底、术腔引流不畅、咽鼓管鼓口病变、手术方式选择不当等是乳突根治术后不干耳或胆脂瘤复发的常见原因，再次手术需明确不干耳原因，采取相应的治疗措施以达到干耳。.

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