Postoperative hearing in tympanoplasty preserving the manubrium of malleus and tensor tympani muscle tendon
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摘要: 目的 探讨鼓室成形术中保留锤骨柄及鼓膜张肌腱对术后听力重建效果的影响，为鼓室成形术中鼓膜张肌腱的处理提供参考。方法 分析2012年1月-2017年12月在北京大学第三医院进行鼓室成形术+人工听骨植入术的97例患者术后3个月~2年的听力情况，并与术前听力进行比较，计算听力的改善程度。根据术中是否保留锤骨柄及鼓膜张肌腱分为保留组(44例)和切除组(53例)，保留组保留锤骨柄及鼓膜张肌腱，切除组切除鼓膜张肌腱，保留或切除锤骨柄。采用t检验分析比较两组间所测频率气导听阈及气骨导差(ABG)的差异，以及较术前改善程度的差异。结果 保留组术后1年气导各频率听阈及ABG均低于切除组，其中在0.25、0.5及1.0 kHz的差异有统计学意义(P < 0.05)；保留组在上述频率听阈及ABG较术前的改善程度均优于切除组。在完壁术式及人工部分听骨赝复物(PORP)植入患者中，两组间上述差异仍存在(P < 0.05)；而在开放术式及全听骨赝复物(TORP)植入中，两组差异并无统计学意义(P>0.05)。结论 锤骨柄及鼓膜张肌腱的保留对鼓室成形术，尤其是完壁术式及PORP植入患者的术后听力改善有显著意义，应在术中注意尽量保留。Abstract: Objective To study the effect of retaining the manubrium of malleus and tensor tympani muscle tendon (TT) on postoperative hearing reconstruction in tympanoplasty.Methods Ninety-seven patients underwent tympanoplasty and ossiculoplasty in Peking University Third Hospital from January 2012 to December 2017, their postoperative results of audiometry were analyzed and compared with the preoperative results. The patients were divided into two groups according to retaining the manubrium of malleus and TT or not during the operation. Retention group include the cases with the manubrium of malleus and TT retained, resection group include the cases with TT resected with the manubrium retained or resected. T test was used to analyze and compare the differences of air conduction threshold air-bone gap (ABG) and the postoperative improvement between the two groups.Results One year after operation, the air conduction thresholds and ABG were lower in retention group (n= 44) than those in resection group (n= 53) at each frequency, and there were differences with statistically significant at 0.25, 0.5 and 1.0 kHz (P < 0.05); the postoperative improvement of hearing thresholds and ABG at above frequencies in retention group was better than that in resection group. In cases with canal-wall-up operations or partial ossicular prostheses implanted, the above differences still existed between the two groups with statistical significance (P < 0.05); while in cases with canal-wall-down operations or total ossicular prostheses implanted, there were no significant differences between the two groups (P>0.05).Conclusion The preservation of the manubrium of malleus and TT is significant for postoperative hearing improvement in tympanoplasty, especially in the canal-wall-up operation with partial ossicular prostheses.
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Key words:
- tympanoplasty /
- tensor tympani muscle tendon /
- manubrium of malleus
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表 1 保留组与切除组手术前后各频率气导听阈比较
频率/kHz 保留组(n=44) 切除组(n=53) t P 术前 0.25 52.8±16.6 54.2±17.3 -0.378 0.706 0.5 54.5±16.7 54.0±18.4 0.162 0.872 1.0 54.7±18.8 54.8±18.7 -0.040 0.968 2.0 45.6±22.9 48.2±20.8 -0.594 0.554 4.0 52.8±26.3 51.0±22.9 0.360 0.719 术后 0.25 33.9±15.5 44.6±18.8 -3.041 0.003 0.5 32.4±15.3 45.9±19.0 -3.806 0.000 1.0 35.6±18.7 47.4±21.1 -2.881 0.005 2.0 32.4±19.8 40.3±25.1 -1.702 0.092 4.0 44.5±24.8 49.3±27.0 -0.903 0.369 手术前后差值 0.25 19.0±16.8 9.5±18.4 2.616 0.010 0.5 22.2±18.3 8.0±18.4 3.784 0.000 1.0 19.1±18.7 7.5±18.2 3.093 0.003 2.0 13.2±19.0 7.9±18.1 1.398 0.165 4.0 8.3±19.0 1.7±20.1 1.648 0.103 
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表 2 鼓膜张肌腱保留组与切除组术后各频率ABG比较
频率/kHz 保留组(n=44) 切除组(n=53) t P 术前 0.25 43.4±16.3 44.2±15.1 -0.232 0.817 0.5 39.0±16.8 35.0±16.1 1.190 0.237 1.0 38.9±15.1 37.4±14.3 0.503 0.616 2.0 19.5±14.1 22.5±11.9 -1.139 0.258 4.0 29.3±15.3 28.2±13.9 0.374 0.710 术后 0.25 28.3±15.1 36.3±17.5 -2.385 0.019 0.5 17.4±14.1 28.9±16.1 -3.703 0.000 1.0 22.2±14.8 32.5±15.3 -3.343 0.001 2.0 11.9±11.7 15.1±13.5 -1.228 0.223 4.0 20.1±16.7 22.0±15.6 -0.569 0.571 手术前后差值 0.25 15.1±20.7 7.8±19.4 1.783 0.078 0.5 21.6±20.9 6.1±18.1 3.906 0.000 1.0 16.7±17.3 4.9±18.1 3.263 0.002 2.0 7.6±14.3 7.5±15.6 0.060 0.952 4.0 9.2±20.0 6.2±18.4 0.763 0.447
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表 3 完壁术式鼓膜张肌腱保留组与切除组手术前后各频率气导听阈比较
频率/kHz 保留组(n=29) 切除组(n=24) t P 术前 0.25 56.0±17.0 52.5±20.1 0.693 0.491 0.5 56.6±17.2 52.7±18.4 0.785 0.436 1.0 55.7±19.8 54.0±19.3 0.321 0.750 2.0 47.9±24.6 46.3±21.9 0.260 0.796 4.0 54.5±26.8 48.5±23.3 0.852 0.398 术后 0.25 32.6±16.8 47.9±21.4 -2.919 0.005 0.5 30.9±16.7 49.4±21.2 -3.559 0.001 1.0 33.6±19.1 49.0±22.3 -2.698 0.009 2.0 33.1±20.4 42.9±26.7 -1.517 0.135 4.0 45.9±23.5 54.2±27.9 -1.176 0.245 手术前后差值 0.25 23.4±16.5 4.6±16.9 4.097 0.000 0.5 25.7±19.5 3.3±16.5 4.441 0.000 1.0 22.1±18.3 5.0±16.8 3.500 0.001 2.0 14.8±20.4 3.3±16.7 2.217 0.031 4.0 8.6±20.0 -5.6±19.7 2.593 0.012
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表 4 完壁术式鼓膜张肌腱保留组与切除组术后各频率ABG比较
频率/kHz 保留组(n=29) 切除组(n=24) t P 术前 0.25 47.2±17.0 41.3±16.6 1.290 0.203 0.5 41.9±18.0 31.3±17.5 2.169 0.035 1.0 39.5±16.0 33.3±14.9 1.435 0.157 2.0 21.0±14.0 20.6±11.4 0.115 0.909 4.0 30.9±14.8 26.0±12.8 1.257 0.215 术后 0.25 26.6±16.5 38.1±19.5 -2.339 0.023 0.5 16.7±14.7 29.6±17.3 -2.929 0.005 1.0 21.2±14.9 32.9±14.4 -2.892 0.006 2.0 12.4±11.4 15.6±14.7 -0.896 0.374 4.0 20.5±17.1 26.0±16.7 -1.185 0.242 手术前后差值 0.25 20.7±21.1 3.1±19.7 3.109 0.003 0.5 25.2±23.1 1.7±17.9 4.073 0.000 1.0 18.3±18.1 0.4±15.6 3.798 0.000 2.0 8.6±16.4 5.0±14.0 0.856 0.396 4.0 10.3±20.9 0.0±19.2 1.861 0.069
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表 5 开放术式鼓膜张肌腱保留组与切除组手术前后各频率气导听阈比较
频率/kHz 保留组(n=15) 切除组(n=29) t P 术前 0.25 46.7±14.2 55.5±14.8 -1.901 0.064 0.5 50.7±15.3 55.0±18.8 -0.770 0.445 1.0 52.7±17.0 55.5±18.4 -0.499 0.621 2.0 41.0±19.2 49.8±20.2 -1.399 0.169 4.0 49.7±26.0 53.1±22.9 -0.451 0.654 术后 0.25 36.3±12.6 41.9±16.1 -1.163 0.251 0.5 35.3±12.3 43.1±16.9 -1.572 0.123 1.0 39.3±17.8 46.0±20.5 -1.074 0.289 2.0 30.9±19.1 38.1±23.9 -1.006 0.320 4.0 42.0±27.7 45.3±26.1 -0.395 0.695 手术前后差值 0.25 10.3±14.3 13.6±18.8 -0.592 0.557 0.5 15.3±13.7 11.9±19.2 0.617 0.541 1.0 13.3±18.7 9.5±19.4 0.632 0.531 2.0 10.1±16.3 11.7±18.6 -0.292 0.772 4.0 7.7±17.6 7.8±18.6 -0.016 0.987
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表 6 开放术式鼓膜张肌腱保留组与切除组术后各频率ABG比较
频率/kHz 保留组(n=15) 切除组(n=29) t P 术前 0.25 36.0±12.1 46.6±13.6 -2.531 0.015 0.5 33.3±12.6 38.1±14.4 -1.083 0.285 1.0 37.7±13.6 40.7±13.1 -0.715 0.479 2.0 16.7±14.4 24.1±12.3 -1.808 0.078 4.0 26.3±16.5 30.0±14.8 -0.750 0.457 术后 0.25 31.7±11.8 34.8±16.0 -0.677 0.502 0.5 18.7±13.3 28.3±15.3 -2.065 0.045 1.0 24.0±15.0 32.1±16.3 -1.598 0.118 2.0 10.9±12.7 14.7±12.7 -0.924 0.361 4.0 19.3±16.6 18.6±14.0 0.150 0.881 手术前后差值 0.25 4.3±15.5 11.7±18.7 -1.315 0.195 0.5 14.7±13.9 9.8±17.7 0.920 0.363 1.0 13.7±15.5 8.6±19.5 0.870 0.389 2.0 5.7±9.3 9.5±16.9 -0.797 0.430 4.0 7.0±18.5 11.4±16.4 -0.805 0.425
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表 7 PORP植入中鼓膜张肌腱保留组与切除组手术前后各频率气导听阈比较
频率/kHz 保留组(n=32) 切除组(n=31) t P 术前 0.25 53.0±16.2 50.8±19.0 0.487 0.628 0.5 54.7±16.2 50.5±18.5 0.960 0.341 1.0 55.8±19.0 51.6±20.4 0.840 0.404 2.0 44.7±22.7 47.1±23.4 -0.415 0.680 4.0 51.6±27.3 49.4±25.0 0.335 0.739 术后 0.25 31.7±15.0 38.2±20.8 -1.418 0.162 0.5 30.6±15.4 41.6±20.8 -2.393 0.020 1.0 35.6±18.8 44.2±22.0 -1.662 0.102 2.0 34.4±19.2 38.7±26.6 -0.742 0.461 4.0 45.3±25.6 48.5±28.4 -0.475 0.636 手术前后差值 0.25 21.3±13.0 12.6±20.0 2.030 0.045 0.5 24.1±16.5 8.9±18.5 3.447 0.001 1.0 20.2±18.1 7.4±19.8 2.666 0.010 2.0 10.3±17.6 8.4±18.4 0.424 0.673 4.0 6.3±18.7 0.8±18.1 1.175 0.244
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表 8 PORP植入中鼓膜张肌腱保留组与切除组术后各频率ABG比较
频率/kHz 保留组(n=32) 切除组(n=31) t P 术前 0.25 41.0±15.9 43.0±15.6 0.504 0.616 0.5 30.0±16.3 38.6±15.9 2.121 0.038 1.0 33.2±15.1 39.1±14.2 1.584 0.118 2.0 21.0±12.2 18.1±11.1 -0.969 0.336 4.0 25.5±14.0 27.3±15.5 0.499 0.620 术后 0.25 32.1±18.1 26.9±13.8 -1.290 0.202 0.5 24.8±14.3 15.9±13.1 -2.573 0.013 1.0 30.0±13.8 22.7±13.1 -2.160 0.035 2.0 12.3±11.4 12.5±9.3 0.092 0.927 0.4 19.8±15.7 21.6±15.4 0.440 0.662 手术前后差值 0.25 8.9±21.0 16.1±17.4 1.490 0.141 0.5 5.2±17.9 22.7±19.8 3.683 0.000 1.0 3.2±20.0 16.4±17.4 2.790 0.007 2.0 8.7±14.9 5.6±11.5 -0.921 0.361 4.0 5.6±18.0 5.8±19.1 0..029 0.977
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表 9 TORP植入中鼓膜张肌腱保留组与切除组手术前后各频率气导听阈比较
频率/kHz 保留组(n=7) 切除组(n=18) t P 术前 0.25 47.9±16.8 60.0±14.2 -1.823 0..081 0.5 47.1±15.5 60.0±18.8 -1.605 0.122 1.0 47.9±20.0 61.1±15.7 -1.760 0.092 2.0 41.4±24.8 51.9±18.1 -1.178 0.251 4.0 52.9±26.7 57.8±19.3 -0.513 0.613 术后 0.25 38.6±14.4 54.4±9.4 -3.271 0.003 0.5 36.4±16.0 52.8±13.9 -2.542 0.018 1.0 32.9±19.5 53.1±19.8 -2.299 0.031 2.0 20.0±18.7 43.3±25.0 -2.225 0.036 4.0 38.6±20.1 51.9±27.8 -1.153 0.261 手术前后差值 0.25 9.3±19.7 5.6±15.9 0.494 0.626 0.5 10.7±19.2 7.2±19.3 0.407 0.688 1.0 15.0±23.1 8.1±16.7 0.838 0.411 2.0 21.4±24.3 8.6±19.2 1.392 0.177 4.0 14.3±20.7 5.8±23.4 0.835 0.412
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表 10 TORP植入中鼓膜张肌腱保留组与切除组术后各频率ABG比较
频率/kHz 保留组(n=7) 切除组(n=18) t P 术前 0.25 37.9±13.8 48.9±13.5 -1.828 0.081 0.5 32.9±13.2 42.2±13.9 -1.537 0.138 1.0 37.9±17.3 41.9±11.4 -0.696 0.494 2.0 19.3±16.4 25.3±11.9 -1.014 0.321 4.0 34.3±14.8 35.3±12.1 -0.173 0.864 术后 0.25 30.0±19.1 43.1±16.1 -1.729 0.097 0.5 16.4±17.0 35.3±17.6 -2.424 0.024 1.0 15.0±19.1 35.8±17.9 -2.562 0.017 2.0 7.9±17.5 18.9±16.5 -1.477 0.153 4.0 10.0±20.2 25.3±16.8 -1.935 0.065 手术前后差值 0.25 7.9±22.1 5.8±18.6 0.232 0.819 0.5 16.4±21.4 6.9±20.1 1.043 0.308 1.0 22.9±16.5 6.1±16.2 2.305 0.031 2.0 11.4±22.1 6.4±18.4 0.583 0.566 4.0 24.3±21.5 10.0±20.2 1.560 0.132
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