KISEP Otology Korean J Otolaryngol 2001;44:476-84 상고실성형술과유양동폐쇄술의결과분석 강명구 1 한치성 1 김부민 1 부성현 1 박헌수 1 허준 2 Results of Epitympanoplasty with Mastoid Obliteration Technique Myung-Koo Kang, MD 1, Chi-Sung Han, MD 1, Bu-Min Kim, MD 1, Sung-Hyun Boo, MD 1, Heon-Soo Park, MD 1 and Jun Hur, MD 2 1 Department of Otolaryngology and Head & Neck Surgery, College of Medicine, Dong-A University, Pusan; and 2 Department of Otolaryngology and Head Surgery, Dong-Eui Medical Center, Pusan, Korea ABSTRACT Background and ObjectivesThere have been heated controversies over the choice of the canal wall down mastoidectomy CWD and canal wall up mastoidectomy CWU, which are operational methods used to eliminate the lesion of chronic otitis media including cholesteatoma. The CWD method can secure a good operation field and remove the lesion easily, but it accompanies a cavity problem. The CWU method also has its shortcomings as it is difficult to eliminate cholesteatoma completely using this method. Combining the advantages of both methods, we invented a new operational method. The present study assesses the results of its use after a follow up of 55 months. Materials and MethodsFrom December of 1994 to March of 1997, epitympanoplasty with mastoid obliteration was conducted on 44 adults 42 patients. Of these, 38 cases were cholesteatomas, 2 cases adhesive otitis media and 4 cases chronic otitis media with poor E-tube function. The postoperative observation period ranged from 41 to 68 months, with the average period of 55.2 months. ResultsThere were 3 cases of residual cholesteatoma in the mastoid cavity and 3 cases in the middle ear cavity. All residual cholesteatomas in the mastoid cavity were treated with CWU, and there was no recurrent cholesteatoma or otorrhea, nor retraction pocket. ConclusionAlthough the observation period of the postoperative process was not long enough, there was no recurrence. We suggest that it is advantageous to operate on cholesteatoma using the new method. Korean J Otolaryngol 2001;44:476-84 KEY WORDSCholesteatoma Epitympanoplasty Mastoid obliteration. 476
477
상고실성형술과 유양동폐쇄술 A B C D E F G H Fig. 1. Intraoperative photographs. A After simple mastoidectomy. B After epitympanectomy. C One piece of temporalis muscle fascia was put into the mastoid antrum. D The mastoid antrum was filled with bone paste over the fascia. E Another piece of the fascia covered the epitympanum superior to the tympanic portion of facial nerve. F The space between the tegmen tympani and the second fascia was filled with bone paste. G All bone paste was covered with the fascia to prevent adhesion to the malleus handle in epitympanum. H A superficial part of the mastoid cavity was obliterated with inferior based flap. 478 Korean J Otolaryngol 2001 ;44 :476-84
강명구 외 Fig. 2. Schematic figures of operating technique. A Surgical view. B Axial view. While preserving the posterior wall, the EAC was widened up to the facial nerve canal (arrows). A wider tympanic membrane and shallower tympanic cavity was made due to the expansion of the EAC and epitympanoplasty. EAC external acoustic canal. C Coronal view. Epitympanectomy (thick dashed line) was executed up to the tegmen tympani to expose the whole epitympanum. The bone paste (hatched area) was stuffed into the space between the tegmen tympani and fascia to make a superior part of new bony annulus. All bone paste was covered with the fascia to prevent adhesion to the malleus handle. Consequently, only the mesotympanum and hypotympanum of the tympanic cavity remained as a space having air ventilation. And thus there is no possibility of occurrence of the attic retraction pocket, in addition to the reduction of the air burden of the E-tube. A B Fig. 4. Postoperative temporal bone CT shows reconstructed epitympanum with bone paste (arrow), well aerated and shallow tympanic cavity (white arrow), and obliterated mastoid cavity with bone Paste (asterisks). A coronal CT scan. B axial CT scan. 479
상고실성형술과 유양동폐쇄술 일차수술에서 tympanization을 시행하였던 30예 중 중이강 결 내 등골주위나 고실동 등에 잔존 진주종이 의심되는 8예에 과 서는 평균 9개월 뒤 이차수술을 시행하여 재발 혹은 잔존 병변을 확인하고 PORP 4예, TORP 4예를 시행하였다. 술후 평균 입원 치료기간은 1주일이었고, 외래 치료기간 은 3 4주였다. 모든 례를 외래에서 양안현미경으로 추적관 찰하였다. 진주종성 중이염 환자 중에서 재발성 진주종은 없었고 유양동내 잔존 진주종이 3예, 중이강내 잔존 진주종 이 3예 있었고 고막천공이 2예, 이개후부 창상감염이 3예 있었다. 일차수술시 tympanization을 시행했던 2예와 PORP를 시 행했던 1예에서 모두 술 후 1년 이내 이루와 함께 외이도 후 벽으로 터져나오는 각질(keratin debri)을 통해 유양동내 잔 존성 진주종이 발견되어 CWD을 시행받았다. 또 중이강내 잔존 진주종 2예는 추적관찰 중 keratoma로 고막을 통해 터 져나와 외래에서 제거되었으며 나머지 1예는 이차수술 중 Fig. 3. Intraoperative view of the tympanic cavity. The tympanic portion of facial nerve ( ), oval window ( ), sinus tympani (*), and round window (arrow) are seen. 발견되어 제거되었다. 비진주종성 중이염 환자 중에서는 1예에서 PORP의 탈출 Fig. 5. Postoperative tympanic membrane findings. During the trace observation, there was some difference from patient to patient in the absorption of the bone pate used for the epitympanum reconstruction. But there was no otorrhea or retraction pocket. 480 Korean J Otolaryngol 2001 ;44 :476-84
481
482 Korean J Otolaryngol 2001;44:476-84
483
REFERENCES 1) Birzgalis AR, Farrington WT, O Keefe L. Reconstruction of discharging mastoid cavities using the temporalis myofacial flap. Clinical Otolaryngol 1994;19:70-2. 2) Meuser W. The exenterated mastoid: A problem of ear surgery. Am J Otol 1985;6:323-5. 3) Sade J. Treatment of retraction pockets and cholesteatoma. J Laryngol Otol 1982;96:685-704. 4) Kang MK, Hur J, Kim LS. Epitympanoplasty with mastoid obliteration in attic cholesteatoma. In: Sanna M, Editor. Cholesteatoma and Mastoid Surgery. Proceeding of the Fifth International Conference on Cholseteatoma and Mastoid surgery; 1996 September 1-6; Alghero-Sardinia, Italy. CIC edizioni internationali;1997. p. 567-70. 5) Park HS, Kang MK. Epitympanoplasty and Mastoid Obliteration in Cholesteatoma with Attic Destruction: New Method. The Dong-A J of Med 1998;10:95-101. 6) Mercke U. The cholesteatomatous ear one year after surgery with obliteration technique. Am J Otol 1987;8:534-6. 7) Yanagihara N, Gyo K, Sasaki Y, Hinohira Y. Prevention of recurrence of cholesteaoma in intact canal wall tympanoplasty. The Am J Otol 1993;14:590-4. 8) Edelstein DR, Parisier SC. Surgical techniques and recidivism in cholesteatoma. Otolaryngol Clin North Am 1989;22:1029-40. 9) Sanna M, Zini C, Gamoletti R, Delogu P, Scandellari R, Russo A, et al. Prevention of recurrent cholesteatoma in closed tympanoplasty. Ann Otol Rhinol Laryngol 1987;96:273-5. 10) Sakai M, Shinkawa A, Miyake H, Fujii K. Reconstruction of scutum defects (scutumplasty) for attic cholesteatoma. Am J Otol 1986;7:188-92. 11) Black B. Prevention of recurrent cholesteatoma: use of hydroxyapatite plates and composite grafts. Am J Otol 1992;13:273-8. 12) Heermann J. Autograft tragal and conchal palisade cartilage and perichondrium in tympanomastoid reconstruction. Ear Nose Throat J 1992;71:344-9. 13) Wehrs RE. Results of reconstructive mastoidectomy with homograft knee cartilage. Laryngoscope 1978;88:1912-7. 14) Solomons NB, Robinson JM. Obliteration of mastoid cavities using bone pate. J Laryngol Otol 1988;102:783-4. 15) Palva T. Surgical control of the mastoid segment in chronic ear disease in 1988. Arch Otorhinolaryngol 1989;246:274-6. 16) Jahn AF. Experimental applications of porous (coralline) hydroxylapatite in middle ear and mastoid reconstruction. Laryngoscope 1992;102:289-99. 17) Estrem SA, Highfill G. Hydroxyapatite canal wall reconstruction/mastoid obliteration. Otolaryngol Head Neck Surg 1999; 120:345-9. 18) Park K, Chun YM, Kang JW, Kwon OH, Kim MS. Healing Process of Mastoid Obliteration Using Cortical Bone Chips: Anaysis of 90 cases. Korean J Otolaryngol 1995;38:345-52. 19) Kwon YW, Wang DY, Lee SD, Nam SY, Lee YB, Park JH. The Effect of the Mastoid Obliteration using Palva Flap and Cortical Bone Dust. Korean J Otolaryngol 1993;36:1155-61. 20) Roland PS, Meyerhoff WL. Open-cavity tympanomastoidectomy. Otolar-yngol Clin North Am 1999;32:525-46. 21) Whittemore KR, Merchant SN, Rosowski JJ. Acoustic mechanisms: canal wall-up versus canal wall-down mastoidectomy. Otolaryngol Head Neck Surg 1998;118:751-61. 484 Korean J Otolaryngol 2001;44:476-84