耳内镜下分期手术治疗侵犯中耳的外耳道胆脂瘤

Staged Endoscopy Surgical Treatment of External Auditory Canal Cholesteatoma Involving the Middle Ear

摘要:

目的：外耳道胆脂瘤可破坏鼓室或乳突，通常伴有感染，目前尚无统一标准治疗方案。本文分析侵犯中耳的外耳道胆脂瘤采用分期手术治疗的疗效与安全性。 方法：纳入16例侵犯中耳的外耳道胆脂瘤的急性感染病例，患者均有急性耳痛，局部和全身抗生素治疗耳痛无明显改善，有外耳道环形肉芽增生，或者清理外耳道胆脂瘤时发现外耳道皮肤水肿易撕裂，均采用分期手术治疗。第一期在耳内镜下清除外耳道胆脂瘤，术后使用抗生素滴耳液控制感染。外耳道肉芽消退、皮肤肿胀消退后，第二期行相应的修复手术，如外耳道成形术、外耳道乳突瘘修补术、鼓室成形术等。 结果：初次手术后3个月内，所有患者均实现外耳道肉芽消退、皮肤肿胀消退，外耳道、鼓室无脓性分泌物。第二期手术中，有鼓膜穿孔外耳道深部扩大者，行鼓室成形术和外耳道成形术，有外耳道乳突瘘者行外耳道成形术、外耳道乳突瘘修补术。有鼓膜穿孔、外耳道乳突瘘者行外耳道成形术、外耳道乳突瘘修补术和鼓室成形术。第二次手术后所有患者均实现干耳状态，形成自净外耳道，平均干耳时间4.7周。未出现外耳道狭窄或者闭锁、感染、面瘫等并发症，与术前相比气导听力得到提高，气骨导差明显缩小。 结论：初步结果表明，侵犯中耳的外耳道胆脂瘤在急性感染，抗生素治疗无明显效果，且伴有外耳道有环形肉芽或者皮肤水肿的情况下，采用分期手术治疗，可能有助于保持外耳道后壁结构完整、维持其正常形态，术后恢复时间短，形成自我清洁功能的外耳道。

Abstract:

Objective: External auditory canal cholesteatoma can invade the tympanic cavity or mastoid process, often accompanied by infection, and there is currently no unified standard treatment protocol. This study analyzes the efficacy and safety of staged surgery for external auditory canal cholesteatoma invading the middle ear. Methods: A total of 16 cases of acute infection of external auditory canal cholesteatoma invading the middle ear were enrolled. All patients had acute ear pain that did not improve significantly with local and systemic antibiotic treatment, along with annular granulation hyperplasia in the external auditory canal or easily torn edematous skin during cholesteatoma debridement. All patients underwent staged surgery. The first stage involved clearing the cholesteatoma with otoscope, followed by topical antibiotic ear drops to control infection. After the granulation tissue and skin swelling had resolved, the second stage was performed, which included appropriate reconstructive procedures such as external auditory canalplasty, mastoid fistula repair, and tympanoplasty. Results: Within 3 months after the initial surgery, all patients showed complete resolution of granulation tissue and skin swelling, with no purulent discharge in the external auditory canal or tympanic cavity. During the second-stage surgeries, tympanoplasty and external auditory canalplasty were performed for those with tympanic membrane perforation and deep external auditory canal dilation; external auditory canalplasty and mastoid fistula repair were done for those with mastoid fistula; and a combination of these procedures was performed for those with both tympanic membrane perforation and mastoid fistula. All patients achieved a dry ear state after the second surgery, with the formation of a self-cleaning external auditory canal, and the average time to dry ear was 4.7 weeks. No complications such as external auditory canal stenosis/atresia, infection, or facial paralysis occurred. Air conduction hearing improved, and the air-bone gap narrowed significantly compared to preoperative levels. Conclusion: The preliminary results indicate that for external auditory canal cholesteatoma invading the middle ear presenting with acute infection unresponsive to antibiotics, accompanied by annular granulation or skin edema, staged surgery may help preserve the integrity and normal anatomy of the posterior wall of the external auditory canal. It is associated with a shorter postoperative recovery time and the formation of a functional, self-cleaning external auditory canal.