Clinical analysis of 21 cases of cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty
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摘要: 目的 分析完壁式乳突切开鼓室成形术后胆脂瘤复发患者的特征, 探讨其复发原因。方法 回顾性分析21例完壁式乳突切开鼓室成形术后胆脂瘤复发患者的临床资料, 包括术前术腔检查、颞骨高分辨CT及术中所见等。结果 其中19例(90.5%)患者为内陷囊袋再次形成的复发病变。在有前次手术资料的12例患者中, 前次术中见胆脂瘤范围广泛(超出上鼓室)者8例(66.7%)。21例再行手术患者中, 重建的上鼓室外侧壁塌陷、盾板破坏者4例(19.0%); 锤骨头未剪除者4例(19.0%); 隐匿部位发现胆脂瘤者3例(14.3%); 咽鼓管不通者8例(38.1%); 硬化型乳突9例(42.9%); 存在颞骨解剖结构变异者3例(14.3%); 外耳道瘢痕闭锁1例(4.8%)。结论 本组完壁式术后复发患者前次手术时胆脂瘤范围多较广泛, 该因素可能导致清理病变时损失过多黏膜、术后出现鼓峡通气不良, 促使胆脂瘤囊袋再次形成。此外, 本组患者存在咽鼓管功能不良、重建的上鼓室外侧壁不牢固、适应证掌握不当等现象, 亦会增加复发风险。因此, 完壁式手术应注意适应证把握严格、术前评估全面、术中清除病灶彻底、关键部位重建牢固, 以减少胆脂瘤复发。Abstract: Objective To discuss the possible reasons for cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty by analyzing clinical characteristics of patients.Methods Data of 21 cases who suffered from cholesteatoma recidivism after canal-wall-up surgery were retrospectively reviewed, including preoperative examination, high resolution temporal bone CT, and intraoperative findings.Results 90.5%(19/21) cases had recurrent cholesteatoma with retraction pockets. Among 12 cases with previous operative notes, 66.7%(8/12) had extensive cholesteatoma which was not limited to attic in the original surgery. The intraoperative features of revision surgery in 21 patients including the destruction of reconstructive lateral attic wall and scutumwere found in 19.0%(4/21) cases, the head of malleus left in 19.0%(4/21) cases, the cholesteatoma found in hidden part in 14.3%(3/21) cases, the hadeustachian tube dysfunction in 38.1%(8/21)cases. the sclerotic mastoid in 42.9%(9/21) cases. hadanatomic variations of the temporal bone in 14.3%(3/21) cases and atresia of external auditory canal in 4.8%(1/21) cases.Conclusion In this group of recidivism cases, most patients had extensive cholesteatoma, which may lead to excessive mucosa loss during lesion clearance, poor ventilation of tympanic isthmus after surgery, and promote the formation of retraction pocket. In addition, some cases had eustachian tube dysfunction, unstable reconstruction of attic lateral wall, and improper selection of the indications, which may also increase the risk of recurrence. Therefore, in order to reduce cholesteatoma recidivism after canal-wall-up surgery, attention should be paid to the striction of surgical indications, comprehensive preoperative evaluation, thorough clearance of lesions and firm reconstruction.
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Key words:
- cholesteatoma /
- recurrence /
- tympanic isthmus ventilation /
- canal-wall-up surgery
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表 1 21例患者特征分析
特征 例数/% 病变类型(n=21) 复发 19(90.5) 残留 0(0) 无法判断 2(9.5) 前次手术病变范围(n=12) 局限(局限于上鼓室) 4(33.3) 广泛(超出上鼓室) 8(66.7) 再次手术(n=21) 上鼓室外侧壁塌陷、盾板破坏 4(19.0) 锤骨头未剪除 4(19.0) 隐匿部位存在胆脂瘤 3(14.3) 咽鼓管不通 8(38.1) 硬化型乳突 9(42.9) 解剖结构变异(乙状窦前移、颈静脉球高位、中颅窝脑板低位) 3(14.3) 耳道瘢痕闭锁 1(4.8) 
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