Causes analysis of mastoid cavity infection after mastoidectomy and key techniques of revision mastoidectomy
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摘要: 目的 分析乳突术后不干耳的原因, 探讨乳突翻修手术的关键技术。方法 回顾性分析因乳突术后不干耳行乳突翻修手术的患者92例。前次手术行完壁式乳突切开+鼓室成形术者56例, 开放式乳突切开+鼓室成形术者36例。前次手术至本次翻修手术时间为7个月至50年, 中位时间9年。通过其一般病例资料、术前颞骨高分辨率CT及手术发现, 对前次手术的缺陷、本次病变所在区域进行分析及统计。结果 92例患者中, 乙状窦前移及脑板低垂共7例(7.6%), 面神经骨管缺失45例(48.9%)。在36例前次手术行开放式乳突切开术的患者中, 未行乳突轮廓化者36例(100.0%), 面神经嵴高者26例(72.2%)。前次手术缺陷包括: 外耳道口狭窄65例(70.7%), 咽鼓管口阻塞11例(12.0%), 管鼓室炎2例(2.2%)。乳突翻修手术中观察病变残留或复发的部位, 最常见于乳突及鼓窦(50/92, 54.3%), 其次为上鼓室及上鼓室前腔(44/92, 47.8%)、后鼓室(29/92, 31.5%)、迷路周围气房(13/92, 14.1%)、窦脑膜角(13/92, 14.1%)、面后气房及面神经周围(12/92, 13.0%)、咽鼓管(10/92, 10.9%)、下鼓室(9/92, 9.8%)。结论 乳突术后不干耳的主要原因包括病变清除不彻底和没有建立良好的通畅引流条件。乳突翻修手术的关键技术包括碟形术腔、乳突轮廓化、削低面神经嵴、处理咽鼓管及耳甲腔成形术。以上技术也是初次手术时需要注意的要点, 以期提高一次手术的成功率, 避免翻修手术。Abstract: Objective To analyze the causes of infected mastoid cavity after mastoidectomy and explore the key techniques of revision mastoidectomy.Methods Ninety-two patients, who underwent revision mastoidectomy due to mastoid cavity infection after mastoidectomy were retrospectively analyzed. There were 56 cases of canal wall up mastoidectomy plus tympanoplasty and 36 cases of canal wall down mastoidectomy plus tympanoplasty in previous surgery. The interval between the previous operation and this revision ranged from 7 months to 50 years, with a median of 9 years. By reviewing the general clinical data, preoperative HRCT scan of temporal bone and intraoperative findings, the defects of the previous operation and the region of the lesion were analyzed and counted.Results Out of the 92 cases, 7 cases(7.6%) had sigmoid sinus antedisplacement and low-lying middle cranial fossa, and 45 cases(48.9%) with facial nerve canal loss. Among the 36 patients who underwent canal wall down mastoidectomy and tympanoplasty, mastoid cells were removed in completely; 26 patients had high facial ridge, accounting for 72.2%(26/36). The defects of the previous operation included: stenosis of external auditory meatus(65/92, 70.7%), obstruction of Eustachian tube(11/92, 12.0%), and tympanitis(2/92, 2.2%). Residual or recurrent lesions were most common in mastoid process and tympanic sinus(50/92, 54.3%), followed by attic cell and anterior cavity(44/92, 47.8%), posterior tympanic cavity(29/92, 31.5%), perilabyrinthine cells(13/92, 14.1%), sinus meningeal angle(13/92, 14.1%), cells behind the facial nerve(12/92, 13.0%), Eustachian tube(10/92, 10.9%), and hypotympanum(9/92, 9.8%).Conclusion The main causes of mastoid cavity infecion after mastoidectomy include incomplete removal of the lesion and inadequate drainage conditions. The key techniques of revisional mastoidectomy include disc-shaped operative cavity, skeletonization of mastoid process, reduction of facial nerve ridge, management of Eustachian tube and conchaplasty. The above techniques are also key in the first operation in order to improve the success rate of operation and avoid revision operation.
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