Peking University Third Hospital
目的：探讨一种新的耳内镜下颞肌筋膜“四点固定”的方法修补鼓膜穿孔的临床疗效。 方法：选取北京大学第三医院耳鼻喉科2020年12月-2021年6月因鼓膜紧张部前方或中央型大穿孔的患者19人随机分为两组。观察组10人(12例)，行耳内镜下“四点固定”鼓膜修补术，注意前下鼓沟边缘，锤骨柄下方，后鼓沟和鼓索神经，前上部鼓环与鼓沟的裂隙四点的固定；对照组9人(9例)，采用带软骨膜的耳屏软骨进行耳内镜下鼓膜修补术。所有术后3个月分别采用耳内镜及纯音听力检查进行客观评估，采用汉化版苏黎世慢性中耳炎量表（ZCMEI）对患者进行包括中耳炎症状、术后主观听力水平、社会心理影响及医疗资源进行生活质量评估。 结果：观察组12例术后2周穿孔基本愈合，鼓膜的形态更接近于正常浅凹型。穿孔修复成功率100%，对照组有1例前方遗留裂隙样穿孔，穿孔修复成功率88.9%。采用四点固定的方法，术后听力PTA（ 22.5±7.5）dB，ABG （10.0±8.2）dB，较术前的(35.1±12.6)dB和（21.7±8.2）dB有明显提高（P=0.009, P=0.011）。与对照组相比，观察组在0.25k 、0.5k 、1kHz上术后气导较术前有显著性提高，而对照组仅在0.25kHz处有显著性提高。在生活质量评分方面，两组在中耳炎症状、术后主观听力水平、社会心理影响及医疗资源占用四个维度的评分上无明显差异（P>0.05）。 结论：耳内镜下采用颞肌筋膜“四点固定法”修补鼓膜，可以获得很高的修复成功率，且术后鼓膜形态更接近于自然的鼓膜形态，术后听力改善效果好，对于耳道宽敞、位于前方边缘的穿孔及对术后听力改善要求高的病例，可采用此方法进行鼓膜修补手术。
Objective: To explore a new method of “four-point fixation” endoscopic myringoplasty with temporal muscle fascia and to explore its clinical efficacy. Method: Patients with large anterior or central perforation of tympanic membrane underwent endoscopic myringoplasty at the Peking University Third Hospital from October 2020 to March 2021 were included in this study and divided into two groups. In observation group, 12 ears were repaired with temporal muscle fascia underwent "four-point fixation" method, and in the control group, 9 ears were repaired with tragus cartilage with perichondrium under endoscopy. Objective evaluation was carried out by endoscopy and pure tone audiometry were conducted 3 months postoperatively. Chinese version of the Zurich Chronic Middle Ear Invertory (ZCMEI) was used to evaluate the quality of life of this two groups from four aspects, including otitis media symptoms, postoperative subjective hearing level, psychosocial impact and medical resources occupation. Results: The graft success rate is 100% in observation group, and the shape of eardrum was closer to normal shallow concave shape. In the control group, there was 1 case left fissure perforation in front, and the success rate of perforation repair was 88.9%. In observation group, PTA and ABG were （22.5±7.5）dB and （10.0±8.2）dB respectively, which were significantly higher than （35.1±12.6）dB and （21.7±8.2）dB respectively (P=0.009, P=0.011). Compared with the control group, the postoperative air conductance of the observation group at 0.25k, 0.5k and 1kHz was significantly improved compared with that before surgery, while the control group was only significantly improved at 0.25kHz. In terms of quality of life score, there was no significant difference between the two groups in otitis media symptoms, postoperative subjective hearing level, psychosocial impact and medical resource occupation (P > 0.05). Conclusion: “Four-points fixation” endoscopic myringoplasty with temporal muscle fascia has the advantage of high graft success rate, natural shape of the postoperative eardrum and good audiometry improvement. This method can be used for tympanic membrane repair in patients with large ear canal, anterior tympanic membrane perforation and high requirements for postoperative hearing improvement.