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摘要: 目的 探讨全耳内镜中耳手术后恢复不良发生情况及对策。方法 对2020年6月至2021年6月在中山大学附属第三医院耳鼻咽喉头颈外科行全耳内镜中耳手术302例(315耳)患者，术后1、3、6个月及1年分别进行疗效评估，了解鼓膜愈合不良、听力恢复不良等情况的发生率、可能原因、处理对策及效果。结果 随访恢复不良患者共28例。鼓膜愈合不良14例，门诊耳内镜鼓膜贴补治疗后10例愈合，成功率约71.4%。中耳胆脂瘤或粘连性中耳炎术后鼓膜再发内陷粘连4例，自行咽鼓管吹张后1例内陷袋完全恢复，2例患者维持鼓膜内陷程度未再进展，1例无效者选择再次手术治疗，有效率为75.0%。听力下降无改善或加重8例，均进行二次手术探查，7例二次手术后听力改善，有效率为87.5%；8例术后存在听力下降无改善或加重的患者中：有4例术后一直为C型或B型鼓室图，经咽鼓管吹张后听力不能提高进行二次手术探查，二次手术后听力改善；2例听骨方位调整后听力改善；1例鼓膜外移者，手术将鼓膜内移后听力改善；1例鼓室硬化进行二次手术但仍再发硬化，听力改善不佳。术后外耳道再发瘢痕闭锁1例，患者不愿再次手术。术后迟发性面瘫1例，予以药物保守治疗后面瘫恢复。结论 鼓膜贴补及咽鼓管吹张是简易而有效的早期门诊处理方法。对于部分预后不良的患者，及时的二次手术探查是安全、有效的。全耳内镜下中耳手术后规律复查有利于及时发现并处理恢复不良的病例。Abstract: Objective To investigate the occurrence and managements of poor recovery after total endoscopic middle ear surgery.Methods A total of 302 cases(315 ears) who underwent endoscopic middle ear surgery in our hospital from June 2020 to June 2021 were collected. Follow up by means of endoscopy, pure tone hearing threshold, tympanogram was conducted at 1 month, 3 months, 6 months and 1 year after surgery to analyze the incidence, possible causes, treatment strategies and effects of poor results tympanic membrane healing and hearing recovery.Results Among 302 patients(315 ears) followed up, there were 28 cases with poor recovery. There were fourteen cases of poor eardrum healing, of which 10 cases achieved healing of eardrum after tympanic membrane patching in the outpatient department, with a success rate of about 71.4%. TM recurrence adhesion occurred in 4 cases after surgeries of cholesteatoma and adhesive otitis media. One case completely recovered after self eustachian tube insufflation, while 2 cases maintained the degree of eardrum subsidence, and one ineffective patient chose resurgical treatment, with an effective rate was 75.0%. Failure in hearing improvement occurred in 8 cases, all of which underwent second surgical exploration, and seven cases were improved after the second surgery, with an effective rate of 87.5%. Among the 8 patients with no improvement or aggravation of hearing loss after surgery, four cases had postoperative B-type or C-type of tympanogram, and the hearing could not improve after self eustachian tube insufflation for secondary surgical exploration. and the hearing improved after the secondary surgery. Incorrect orientation of ossicular prosthesis was accounted for another 2 cases, the hearing was improved after the ossicular orientation adjustment. One patient with lateral healing of TM and failed hearing recovery was corrected by a second operation. One case of tympanosclerosis underwent stapes release surgery, but hearing recovery still failed. One patient had recurrent postoperative cicatricial atresia of external auditory canal, and the patient was reluctant to undergo reoperation. Postoperative delayed facial paralysis occurred in 1 case, and the facial paralysis recovered recovered after conservative treatments.Conclusion Eardrum patch and eustachian tube autoflation are simple and effective early outpatient treatment for patient with poor recovery. For those who failed with conservative treatments such as eardrum patch or eustachian tube and poor hearing recovery, the second surgical exploration is safe and effective. Regular follow up after endoscopic middle ear surgery is necessary for the managements of poor recovery.
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Key words:
- endoscopic middle ear surgery /
- poor results /
- managements
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表 1 术后恢复不良患者临床信息列表
类型 性别 年龄/岁 临床诊断 术前咽鼓管功能 手术方式 术后不良事件 处理措施 处理效果 鼓膜愈合不良(14例) 女 21 慢性化脓性中耳炎(左) 正常 左耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 男 23 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 42 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 鼓膜贴补后穿孔未愈合，二次手术后愈合 女 46 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 45 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 29 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 27 慢性化脓性中耳炎(右) 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 男 65 慢性化脓性中耳炎(左) 正常 左耳鼓室成形术(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 鼓膜贴补后穿孔未愈合，二次手术后愈合 男 35 中耳胆脂瘤(左) 正常 左耳鼓室成形术(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 鼓膜贴补后穿孔未愈合，二次手术后愈合 女 29 慢性化脓性中耳炎(左) 正常 左耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 鼓膜贴补后穿孔未愈合，二次手术后愈合 男 18 慢性化脓性中耳炎(右)，变应性鼻炎 正常 右耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 男 51 慢性化脓性中耳炎(左) 异常 左耳鼓室成形(Ⅰ型)+左侧咽鼓管球囊扩张术 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 34 慢性化脓性中耳炎(双) 正常 双耳鼓室成形(Ⅰ型) 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 女 30 慢性化脓性中耳炎(左) 异常 左耳鼓室成形(Ⅰ型)+经鼓室咽鼓管球囊扩张术 鼓膜愈合不良 门诊耳内镜下鼓膜贴补治疗 贴补治疗后愈合 胆脂瘤或粘连性中耳炎术后鼓膜再发内陷粘连(4例) 女 27 粘连性中耳炎(左) 异常 左耳鼓室成形(Ⅲ型)+鼓膜切开置管+经鼓室咽鼓管球囊扩张术 术后鼓膜再发内陷粘连 自行咽鼓管吹张 内陷袋完全恢复 女 51 粘连性中耳炎(左) 异常 左耳鼓室成形(Ⅲ型)+经鼓室咽鼓管球囊扩张术 术后鼓膜再发内陷粘连 自行咽鼓管吹张 无效再次手术并鼓膜置管后恢复 男 27 中耳胆脂瘤(右) 异常 右耳鼓室成形(Ⅲ型)+乳突切开+外耳道后上壁重建成形+鼓膜切开置管+经鼓室咽鼓管球囊扩张 术后鼓膜再发内陷粘连 自行咽鼓管吹张 内陷袋维持稳定 男 20 中耳胆脂瘤(左) 异常 左耳鼓室成形(Ⅲ型)+乳突切开鼓室探查+外耳道后上壁重建成形+鼓膜切开置管+左侧咽鼓管球囊扩张术 术后鼓膜再发内陷粘连 自行咽鼓管吹张 内陷袋维持稳定 听力效果不佳(8例) 男 63 慢性化脓性中耳炎(左) 正常 耳内镜下左耳鼓室成形(Ⅲ型) 鼓膜外移 二次手术将鼓膜内移 听力改善 女 51 粘连性中耳炎(左) 异常 左耳鼓室成形(Ⅲ型)+经鼓室咽鼓管球囊扩张术 咽鼓管功能不良 吹张无效后二次手术松解鼓室粘连 听力改善 女 25 中耳胆脂瘤(左)，鼻后孔闭锁(术后) 异常 左耳鼓室成形(Ⅲ型)+鼓膜切开置管术 咽鼓管功能不良 吹张无效后二次手术松解鼓室粘连，并鼓膜置管 听力改善 女 25 中耳胆脂瘤(左)，先天性听骨畸形(左) 正常 左耳鼓室成形(Ⅲ型)+外耳道后上壁重建成形 人工听骨方位不良 二次手术重置人工听骨 听力改善 女 36 慢性化脓性中耳炎(右) 异常 右耳鼓室成形(Ⅲ型) +镫骨撼动+鼓膜切开置管+经鼓室咽鼓管球囊扩张术 镫骨再发硬化 二次手术松解固定的镫骨 听力改善不佳 男 31 慢性化脓性中耳炎(双) 异常 左耳鼓室成形(Ⅲ型) +经鼓室咽鼓管球囊扩张术 咽鼓管功能不良 吹张无效后二次手术松解鼓室粘连 听力改善 女 28 慢性化脓性中耳炎(左) 正常 左耳鼓室成形(Ⅲ型) 人工听骨方位不良 二次手术重置人工听骨 听力改善 女 52 粘连性中耳炎(左) 异常 左耳鼓室成形(Ⅰ型) +鼓膜切开置管+经鼓室咽鼓管球囊扩张术 咽鼓管功能不良 吹张无效后二次手术松解鼓室粘连，并鼓膜置管 听力改善 术后外耳道再发瘢痕闭锁(1例) 女 26 慢性化脓性中耳炎(双)；后天性外耳道闭锁(双) 正常 左耳鼓室成形术(Ⅰ型)+外耳道瘢痕切除术 术后外耳道再发瘢痕闭锁 门诊耳内镜下松解瘢痕并涂抹激素软膏 瘢痕仍增生，患者未同意再次手术治疗 术后迟发性面瘫(1例) 男 41 中耳胆脂瘤(左)，原发性高血压(Ⅲ级) 异常 左耳鼓室成形术(Ⅲ型)+乳突切开+外耳道后上壁重建+经鼓室咽鼓管球囊扩张术 术后迟发性面瘫 足量激素冲击治疗 面瘫完全恢复 
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