耳内镜下分期手术治疗侵及中耳的外耳道胆脂瘤疗效分析

Staged otoendoscope surgical treatment of external auditory canal cholesteatoma involving the middle ear

摘要:

目的 探讨侵及中耳的外耳道胆脂瘤采用分期手术治疗的临床疗效与安全性。方法 纳入病变侵及中耳的外耳道胆脂瘤合并急性感染的患者16例，所有患者均以急性耳痛为主要临床症状，经局部联合全身抗生素治疗后耳痛症状无明显缓解；查体可见外耳道环形肉芽增生，清理外耳道胆脂瘤时发现外耳道皮肤肿胀、质地脆弱易撕裂。全部患者均采用分期手术治疗：一期耳内镜下彻底清除外耳道胆脂瘤病灶，术后予抗生素滴耳液局部控制感染；待外耳道肉芽消退、皮肤肿胀完全消退后，行二期手术，根据病变行相应的功能与结构修复手术，如外耳道成形术、外耳道乳突瘘修补术、鼓室成形术等。结果 所有患者一期术后3个月内，外耳道肉芽、皮肤肿胀均完全消退，外耳道、鼓室无脓性分泌物。二期手术根据患者具体病变情况采用个体化术式，合并鼓膜穿孔、外耳道深部扩大者，行鼓室成形术联合外耳道成形术；伴外耳道乳突瘘者，行外耳道成形术联合外耳道乳突瘘修补术；合并鼓膜穿孔、外耳道乳突瘘者行外耳道成形术联合外耳道乳突瘘修补术和鼓室成形术。所有患者二期术后均达到干耳状态，重建自净外耳道结构，平均干耳时间4.7周。术后随访患者均未出现外耳道狭窄或闭锁、感染、面瘫等并发症；与术前相比，患者气导听力显著提高，气骨导差明显缩小。结论 侵及中耳且合并急性感染的外耳道胆脂瘤，抗生素治疗无明显效果，且伴有外耳道环形肉芽增生及皮肤肿胀者，采用分期手术治疗效果明显。该术式有助于保留外耳道后壁解剖结构完整、维持其正常生理功能，术后恢复周期短，可重建具备自我清洁功能的外耳道，临床应用安全可行。

Abstract:

Objective External auditory canal cholesteatoma can erode and damage 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 the 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 an otoscope, followed by topical antibiotic ear drops to control infection. After the granulation tissue and skin swelling completely subsided, 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 surgery, 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 performed 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 with the preoperative levels. Conclusions For external auditory canal cholesteatoma invading the middle ear, when complicated by acute infection with poor response to antibiotic therapy and accompanied by circumferential granulation tissue proliferation and skin swelling in the external auditory canal, staged surgical treatment is effective. This surgical method helps preserve the anatomical integrity of the posterior wall of the external auditory canal, maintains its normal physiological structure, allows for a short postoperative recovery period, and enables reconstruction of an external auditory canal with self-cleaning function. It is clinically safe and feasible.