耳内镜下儿童中耳胆脂瘤的处理及疗效分析

Transcanal endoscopic ear surgery for childhood middle ear cholesteatoma

摘要:

目的 探讨耳内镜下经耳道径路切除儿童中耳胆脂瘤的手术适应证及临床疗效，为该类疾病的处理提供临床参考。方法 回顾性分析2017年9月-2020年10月上海交通大学医学院耳科学研究所耳内镜下经耳道径路处理的20例中耳胆脂瘤患儿临床资料，患者年龄3~14岁，平均年龄为（7±0.5）岁。根据术前影像学评估，病变范围均在中耳范围内，手术方案为耳内镜经耳道径路中耳切除胆脂瘤，对于听骨链破坏者同期行人工听骨链重建。分析患者术后的临床疗效。结果 结合病史、耳内镜检查、术前CT及术中发现，20例患者中18例（90%）为先天性胆脂瘤，其中Potsic II期3例，Potsic III期15例。；2例（10%）为后天继发性局限性中耳胆脂瘤，病变主要位于上鼓室。所有患者均顺利完成手术，术后3个月均干耳。19例（95%）患者无复发。患者均随访1年以上，平均随访（34±8）个月，1例（5%）III期先天性胆脂瘤复发，再次行耳内镜经耳道径路手术，随访26个月未见复发。术前患者平均气导听阈（37.3±9.3）dB，术后平均气导听阈（29.8±6.3）dB，术后听力明显改善（P<0.05）。结论 儿童中耳胆脂瘤以先天性胆脂瘤常见。对于术前评估为局限性的中耳胆脂瘤患儿（Potsic分期I-III期），耳内镜下经耳道径路手术可提供清晰广角视野，在少量骨质切除的情况下，能更加微创地处理胆脂瘤并进行听骨链重建，病变残留复发率少，手术效果佳，是值得提倡的治疗方案。

Abstract:

Objective To analyze the clinical characteristics of childhood cholesteatoma, explore the surgical indications and clinical efficacy of transcanal endoscopic ear surgery for childhood cholesteatoma, and provide clinical reference for the treatment of these diseases.Methods Clinical data of 20 children with middle ear cholesteatoma treated via transcanal endoscopic approach from Sept 2017 to Oct 2020 in our institute were retrospectively analyzed. Their age ranged from 3 to 14 years old with an average of 7±0.5. Preoperative high-resolution computed tomography (HRCT) of temporal bone revealed that their lesions were all within the middle ear. Transcanal endoscopic approach was adopted to resect the cholesteatoma in all cases and simultaneous artificial ossicle reconstruction was performed for the patients with destruction of auditory ossicular chain. The therapeutic effect was evaluated.Results Medical history, preoperative endoscopic and audiologic examinations as well as intraoperative findings showed congenital cholesteatoma in 18 cases (90%) (including 3 of Potsic stage II and 15 of Potsic stage III) and secondary local cholesteatoma in 2 (10%). Transcanal endoscopic ear surgery was performed successfully in all the children. They had been followed up for more than one year with an average of 34±8.0 months. Dry ear was achieved in all cases 3 months after surgery. Follow-up found no recurrence except one case (5%, 1/20) with Potsic stage III congenital cholesteatoma. This patient received reoperation under otoendoscope, and no recurrence was found for the next 26 months with follow-up visit. The preoperative average air conducted pure-tone auditory threshold was (37.3±9.3) dB and the postoperative one was (29.8±6.3) dB, which indicated significant improvement of postoperative hearing.Conclusions Congenital cholesteatoma in children is common, often invades auditory ossicular chain and needs exhaustive preoperative evaluation. With advantages of good surgical effect and low recurrence rate by providing a clear wide-angle vision, minimally invasive treatment of cholesteatoma and reconstruction of the auditory ossicular chain with a small amount of bone resection, transcanal endoscopic ear surgery is a promising remedy to treat localized cholesteatoma (Postic stage I-III) in children.