Ear developmental abnormalities: treatment

Objectives of treatment of anomalies of ear development

Improvement of auditory function, elimination of cosmetic defect.

Non-pharmacological treatment of ear anomalies

When bilateral kanduktivnoy hearing loss to normal speech development of the child helps to wear a hearing aid with a bone vibrator. Where there is an external auditory meatus, a standard hearing aid can be used.

A child with a microtia has the same probability of developing otitis media as in a healthy child, since the nasopharyngeal mucosa continues into the auditory tube, the middle ear and the mastoid process. There are cases of mastoiditis in children with a microtia and atresia of the external auditory canal (surgical treatment is necessary).

Surgical treatment of ear anomalies

Treatment of patients with congenital malformations of the external and middle ear, as a rule, surgical, and severe cases of hearing loss perform auditory prosthetics. With congenital defects of the inner ear - hearing aid. Below are ways to treat the most frequently observed anomalies of the external and middle ear.

Anomalies in the development of the auricle that result from excessive growth (macro-onset) are manifested by an increase in the entire auricle or part of it. Macrothia usually does not entail functional disorders; it is removed surgically.

Auriculoplasty for microstations of the 1st degree. The peculiarity of the ingrown auricle is its location under the skin of the temporal region. During surgery, the upper part of the auricle from under the skin should be released and the skin defect closed. To do this, perform operations in the manner of F.Burian or G. Kruchinsky.

The F.Burian method involves cutting the skin over the ingrown part of the auricle. The resulting wound of the skull is covered with a displaced skin flap cut from the scalp and fixed with sutures. On the back surface of the auricle, a free skin flap is transplanted.

The way of Kruchinsky Gruzdevoy. On the back surface of the preserved part of the auricle, a tongue-shaped incision is made so that the long axis of the flap is located along the bovine fold. Dissect the area of cartilage at the base and fix it in the form of a spacer between the restored part of the ear and the temporal region. Defect of the skin is restored with a previously cut flap and a free skin graft. The contours of the auricle are formed by gauze rollers.

With a pronounced anti-malignancy (Stahl's ear), deformity is eliminated by wedge excision of the lateral pedicle.

Normally, the angle between the upper pole of the auricle and the lateral surface of the skull is 30 degrees, and the angle between the rook and the ear shell is 40 degrees. In patients with protruding ears, these angles increase to 90 and 120-160 degrees, respectively. To correct the protruding ears, a variety of methods have been proposed. The most common and convenient way to Convert Tanser.

Produce an S-shaped incision of the skin along the back surface of the auricle, retreating 1.5 cm from the free edge. Exude the posterior surface of the cartilage of the auricle. Through the front surface of the needles, the boundaries of the anti-curvature and a hundred lateral pedicles are applied. Cut the cartilage of the auricle, then thin its antiflora and its leg is formed by continuous or nodal sutures in the form of a "cornucopia."

In addition, from the groove of the auricle, a cartilage area of 0.3 x 2 cm is cut out, the edges of the cut are sewn. Two U-shaped sutures fix the auricle to the soft tissues of the mastoid process. Then, the seams are applied to the cutaneous wound and the contours of the auricle form by gauze bandages.

Operation on Barsky. On the back surface of the auricle, a skin flap of ellipsoidal shape is excised. Expose the cartilage, apply two parallel incisions, forming a cartilaginous strip, which is turned toward the front surface of the auricle. Then, the seams are applied, and when tightening, a countercurrent is formed. The skin of the posterior surface is sutured.

Method K. Sibilova. On the back surface of the auricle, a skin flap of ellipsoidal shape is excised, the lower incision is made along the bovine fold. Paint and needles inflict contours of the anti-curvature and its lateral pedicle. Cut the cartilage strips along the planned lines 1-2 mm wide for 3-4 mm stretches. Additionally, a number of incisions are applied to the cartilage by parallel incisions. On the edges of the incisions of the cartilage, a continuous mattress suture and a number of mattress sutures are applied, having retreated from the first line by 3-4 mm.

Operation by G. Kruchinsky. On the back surface of the auricle, cut the skin flap S-shaped, deviating from the edge of the curl by 1.5 cm. Using the paint and needles, the direction of the future antiflora is marked and the ear cartilage is dissected. Outside the first incision, two more parallel incisions are made, and one additional one is medial. The auricle is folded, forming a counter-curvature. In addition, a strip of cartilage along the edge of the auricle deepening is excised. The wound is sewn up. Anti-inoculum is strengthened with two or three through mattress sutures on gauze rollers. The threads are held below the striae of the cartilage without sewing it.

Operation by D. Andreeva. On the back surface of the auricle, the skin flap is spindle-shaped. Two parallel incisions designate a sickle-shaped strip of cartilage 3 mm wide. Two or three U-shaped seams are applied to the free edges and stretch them, forming a relief of the anti-curvature. With the same threads, the auricle is fixed to the periosteum of the mastoid process.

Operation on A. Gruzdeva. On the back surface of the auricle, an S-shaped cut of the skin is produced, retracting from the edge of the curl by 1.5 cm. Mobilize the skin of the posterior surface to the edge of the curl and the bovine fold. Needles inflict the boundaries of the anti-curvature and the lateral leg of the anti-malignancy. The edges of the dissected cartilage are mobilized, thinned and sewn in the form of a tube (the body of a counter-cuff) and a gutter (a leg of a counter-cushion). In addition, a wedge-shaped area of the cartilage is excised from the lower leg of the curl. The antiviral is fixed to the cavum choncha cartilage. Excess skin on the back surface of the auricle is excised in the form of a strip. On the edge of the wound, a continuous seam is applied. The contours of the anti-cushion are strengthened with gauze bandages, fixed mattress seams.

Meatotympanoplasty

The goal of rehabilitation of patients with severe developmental anomalies is to form a cosmetically acceptable and functional external auditory canal for transferring sounds from the ear to the cochlea while preserving the function of the facial nerve and labyrinth. The first task to be solved when developing a rehabilitation program for a patient with a microtia is to determine the feasibility and timing of meatotympanoplasty.

Selection of patients for an auditory operation. The decisive factors in the selection of patients should be considered the results of KT temporal bones. HA Mileshina has developed a 26-point evaluation system for KT data of the temporal bone in children with atresia of the external auditory canal. The protocol adds data to each ear separately.

For example, patients with a microtia of any degree and conductive hearing loss of II-III degree, with a slightly reduced (or normal size) pneumatized drum cavity, mastoid cave, differentiated and physiologically located hammer and anvil in the absence of pathology of the labyrinth, inner ear and facial nerve, or the number of points equal to 18 or more, it is possible to perform an auditory improvement operation - meatotympanoplasty.

In patients with microtia and conductive hearing loss of III-IV degree, accompanied by a rough congenital pathology of the auditory ossicles, maze windows, the third part of the facial nerve channel, with a score of 17 or less, a hearing improving the stage of the operation will not be effective. These patients are rational to carry out only a plastic surgery to reconstruct the auricle.

Patients with stenosis of the external auditory canal are shown dynamic observation with CT of temporal bones to exclude the cholestasoma of the external auditory canal and the cavities of the middle ear. When identifying signs of cholesteatoma, the patient should undergo surgical treatment aimed at removing the cholesteatoma and correcting the stenosis of the external auditory canal.

Meatotimpanoplasty in patients with microtia and atresia of the external auditory canal. Lapchenko. After hydropreparation, a cut of the skin and soft tissues along the posterior edge of the rudiment is made in the BTE area, the mastoid process is exposed, bark uncovers the cortical and periantral cells of the mastoid process, the cave, the cave entrance to the wide exposure of the anvil, and forms a 15 mm diameter external deafness passage.

From the temporal fascia cut out a free flap and lay it on the anvil and the bottom of the formed auditory canal, the rudiment of the auricle is transferred behind the auditory canal. Prolong the BTE incision downward and cut out the skin flap on the upper leg. The soft tissues and cutaneous edges of the wound are sutured to the level of the earlobe, the distal incision of the rudiment is fixed to the edge of the tail wound near the hair growth zone, the proximal edge of the flap is lowered and the auditory passage in the form of a tube to completely cover the bone walls of the auditory canal, which provides good healing in the postoperative period . The formed ear canal is covered with turundas with iodoform.

In cases of sufficient dermal plasty, the postoperative period proceeds smoothly. Tampons after surgery are removed for 7 days, then changed 2-3 times a week for 1-2 months, using ointments with glucocorticoids (hydrocortisone).

In the early postoperative period with pronounced reactive processes, one can conduct a course (6-8 procedures) of magnetolaser irradiation. It is also recommended to apply bandages with heparin or traume ointment, applying traumel C inside at an age-related dose for 10 days. On average, the hospitalization period is 16-21 days, followed by outpatient treatment up to 2 months.

Meatotimpanoplasty with isolated atresia of the external auditory meatus by Jarsdofer. The author uses direct access to the middle ear, which avoids the formation of a large mastoid cavity and the problems of healing, but recommends it only to an experienced otosurgeon. The auricle is removed anteriorly, a neotympanal flap is extracted from the temporal fascia, the incision of the periosteum is made closer to the temporomandibular joint. If it is possible to detect a rudimentary tympanal part of the temporal bone, begin to work boron at this site forward and upward (as a rule, the middle ear is located directly medially). A common wall is formed between the temporomandibular joint and the mastoid process, which will later be the anterior wall of the new auditory canal. Then gradually approach the plate of atresia, thin with diamond cutters. If the middle ear is not found at a depth of 2 cm, the surgeon should change direction.

After removing the plate of atresia, the elements of the middle ear become well-visible. The body of the anvil and the head of the malleus are usually fused, the handle of the malleus is absent, the neck of the malleus is fused with the zone of atresia. The long leg of the anvil can be thinned, crimped and positioned vertically or medially with respect to the hammer. The stirrup is also variable. The best situation is finding deformed auditory ossicles, but working as a single mechanism for sound transmission. In this case, the fascial flap is laid on the auditory ossicles without additional supports from the cartilage. When working with boron should leave a small bone canopy over the auditory ossicles, which allows you to form a cavity (the auditory ossicles at the same time are in the central position).

Before the fascia application phase, the anesthetist should reduce the oxygen pressure to 25% or switch to ventilation with room air to avoid "inflating" the fascia. If the neck of the malleus is fixed to the area of atresia, the bridge should be demolished, but at the last moment, using a diamond cutter and a low boron frequency, to avoid injury to the inner ear.

In 15-20% of cases, prostheses are used, as with conventional types of ossiculoplasty. In cases of fixation of the stapes, it is recommended to stop the operation by forming an auditory meatus and neomembranes, and ossicoloplasty should be postponed for 6 months in order to avoid the creation of two unstable membranes (neomembrane and oval window membrane), and the likelihood of displacement of the prosthesis and injury of the inner ear.

A new ear canal should be covered with skin, otherwise scar tissue develops very quickly in the postoperative period. A split skin flap can be taken from the inner surface of the baby's shoulder by dermatome, a thiner part of the skin flap is placed on the neomembrane, a thicker one is fixed to the edges of the auditory canal. The location of the skin flap is the hardest part of the operation. Then the silicone protector is inserted into the auditory canal to neomembranes, which prevents the displacement of both the skin flap and the non -impactal and forms the canal of the auditory canal.

The auditory canal can be formed only in one direction, in connection with which it is necessary to adapt the soft tissue part of it in a new position. To do this, the auricle can be displaced upwards or backwards and up to 4 cm. A cutaneous C-shaped incision is made along the border of the ear shell. The tragus zone is left intact, using it to close the front wall. After combining the bone and soft tissue parts of the ear canal, the auricle is returned to its original position and fixed with non-absorbable sutures. At the border of the parts of the auditory canal, absorbable sutures are applied. The posterolateral incision is sutured.

On average, the hospitalization period is also 16-21 days, followed by outpatient treatment up to 2 months. Lowering the sound thresholds by 20 dB is considered a good result.

Auriculoplasty by implantation methods

In cases where the lower jaw is smaller on the side of the lesion (especially in the Goldenhar syndrome), the ear reconstruction should initially be performed. And then the lower jaw. Depending on the technique of reconstruction, the marginal cartilage, taken for the auricle skeleton, can be used for the reconstruction of the lower jaw. If the reconstruction of the lower jaw is not planned, then with auriculoplasty, the asymmetry of the skeleton of the facial part of the skull should be taken into account.

An important point in the management of such patients is the choice of the time of surgical intervention (for large deformations where rib cartilage is required, auriculoplasty should be started at the age of the patient after 7-9 years). In the case of mild deformities, non-surgical correction can be performed in infants by applying bandages.

Of the proposed methods of surgical correction of microtensions, multistage auriculoplasty with rib cartilage is most common. Lack of high probability of resorption of the graft. Of synthetic materials, silicone and porous polyethylene are used.

There are several ways of reconstruction using endoprostheses. Auriculoplasty should be performed first for two reasons. The first reason is that any attempt at reconstructing the hearing is accompanied by marked scarring, which significantly reduces the use of the skin of the parotid region (a larger intervention for auriculoplasty may be required, and not a very good cosmetic result). The second reason is that in the case of unilateral defeat, the external rudiment and pendants are perceived as a serious congenital pathology, while hearing impairment is regarded as something not worthy of attention, because the patient hears well due to a healthy ear and does not suffer from the development of speech.

Since surgical correction of microtia is performed in several stages, the patient or his parents should be warned about the potential risk, including an unsatisfactory aesthetic result.

Selection of patients. The patient must be of sufficient age, physique and height to be able to take the marginal cartilage for the auricle skeleton. In a lean patient, the rib-cartilage joint can be palpated and the size of the cartilage can be estimated. Insufficient amount of rib cartilage can interfere with the success of the operation. The rib cartilage can be taken from the side of the lesion, but it is preferable with the opposite. A severe local injury or a widespread burn of the temporal region is hampered by surgery due to widespread scarring and lack of hair. In the presence of chronic infections of the deformed or newly formed auditory canal, surgical intervention should be postponed.

Preoperative preparation consists in measuring the auricle of an abnormal and healthy ear. In lateral measurements, determine the vertical height, the distance from the outer corner of the eye to the leg of the curl, the distance from the outer corner of the eye to the front fold of the lobe. The axis of the auricle coincides with the axis of the nose. When measuring in the frontal plane, attention is drawn to the height of the upper point of the auricle as compared to the eyebrow, and the rudiment is compared with the lobe of the healthy ear.

A piece of X-ray film is applied to the healthy side, the contours of the healthy ear are applied. The resulting sample is further used to create a frame of the auricle from the rib cartilage. With a two-sided microtia, a sample is created by the ear of one of the relatives of the patient.

Auriculoplasty with cholesteatoma. In children with congenital stenosis of the external auditory canal, there is a high risk of developing cholesteatoma of the external and middle ear. When cholesteatoma is detected, the first operation should be performed on the middle ear. In these cases, a temporal fascia is used in the subsequent auriculoplasty (the donor site is well hidden under the hair, and a large area of tissues can be obtained for reconstruction on a long vascular pedicle, which allows to remove scars and improper tissues and close the rib transplant well). A split skin graft is superimposed on top of the rib cage and the temporal fascia.

Ossiculoplasty is carried out at the stage of retraction of the reconstructed auricle or after completion of all stages of auriculoplasty with BTE. Another type of rehabilitation of the auditory function is implantation of the bone hearing aid.

Auriculoplasty in microtia. The most widely used method of surgical treatment of microtia by the method of Tanzer-Brent is multistage reconstruction of the auricle using several autologous rib transplants.

The first stage consists in transplantation of a skeleton of an auricle, formed from rib cartilages. For the collection of the rib cartilages, a cut of the skin and soft tissues along the edge of the rib arc is made and the cartilages of the sixth, seventh and eighth ribs opposite to the development of the ear on the side of the chest are exposed. Of the twin cartilages of VI and VII, the ribs form the body of the auricle and antianuctures. The cartilage of the VIII rib is most convenient for forming a curl. The author prefers to create the most striking shape of the curl. The wound on the chest is sutured, making sure in the absence of pneumothorax.

The cutaneous pocket for the rib transplant is formed in the parotid region. In order not to disrupt vascularization of tissues, it should be formed, already having a prepared skeleton of the future auricle. The position and dimensions of the auricle are determined from the pattern of the X-ray film on the healthy side with a one-sided anomaly or from the auricles of the patient's relatives with a two-sided microtia. In the formed skin pocket a cartilaginous skeleton of an auricle is introduced. The rudiment of the auricle at this stage of the operation is left intact.

After 1.5-2 months, it is possible to conduct the second stage of the reconstruction of the auricle - the transfer of the earlobe to the physiological position.

In the third stage, the auricle and the BTE are separated from the skull. The incision is made around the periphery of the curl, retreating a few millimeters from the edge. The tissues in the tail area are contracted by cutaneous and fixing others, thereby slightly reducing the wound surface; a hair growth line is created that does not differ significantly from the healthy side. The wound surface is covered with a split skin graft taken from the hip in the "panty zone". If the patient is shown meatotimpanoplasty, then it is carried out at this stage of auriculoplasty.

The final stage of auriculoplasty involves the formation of a tragus and an imitation of the external auditory canal. On the healthy side of the shell area, a full-layer skin-cartilage flap is cut with a J-shaped incision. From the area of the shell on the side of the lesion, a part of the soft tissues is additionally removed to form a deepening of the auricle. The tragus is formed in a physiological position.

The disadvantage of the method is the use of cartilage ribs of the child for the curl, while there is a high probability of melting cartilage frame in the postoperative period (according to different authors, up to 13% of cases). The great thickness and low elasticity of the formed auricle are also considered a disadvantage.

The method of Tanzar-Brent was modified by S. Nagata. The skin incisions of the parotid region proposed by him and the transfer of the ear lobe to the horizontal position are already performed at the first stage of the reconstruction of the auricle. The tragus in the cartilaginous elements of the skeleton of the future ear canal is included immediately. Here, cartilages of the patient's VI-VIII ribs are also used, however, the probability of melting cartilage autografts in comparison with allografts is less (up to 7-14%).

Such a complication as melting of the cartilage negates all attempts to restore the patient's auricle, leaving scarring and tissue deformation in the area of interference, so there is still a constant search for biologically inert materials that can be kept well and permanently, given shape to the patient for life .

The method of T. Romo suggests the use as a skeleton of auricle porous polyethylene; The advantage of the method is the stability of the created shapes and contours of the auricle, as well as the absence of melting cartilage. Separate standard fragments of a skeleton of an auricle are developed.

At the first stage of reconstruction, a polyethylene auricular skeleton is implanted under the skin and the superficial temporal fascia; in the second stage, the auricle is removed from the skull and the tail fold is formed. Of the possible complications, the authors note nonspecific inflammatory reactions, loss of temporomandibular fascial or free cutaneous flaps and extraction of polyethylene scaffold.

It is known that silicone implants keep shape well, are biologically inert, in connection with what they are widely used in maxillofacial surgery. HA Mileshina and co-authors use a silicone skeleton in the reconstruction of the auricle. Implants, made of soft, elastic, biologically inert, non-toxic silicone rubber, withstand any type of sterilization, retain elasticity, strength, do not dissolve in tissues and do not change the shape. Implants can be treated with cutting tools, which allows you to adjust their shape and size during the operation. To avoid disturbance of blood supply to tissues, to improve fixation and reduce the weight of the implant, it is perforated over the entire surface at a rate of 7-10 holes per cm.

Stages of auriculoplasty with a silicone skeleton coincide with the reconstruction stages proposed by S. Nagata.

The use of a ready silicone implant excludes additional traumatic operations on the chest in cases of reconstruction of the auricle using a cartilaginous autograft, and also shortens the duration of the operation. The silicone skeleton of the auricle makes it possible to obtain an auricle, which is close to normal by contours and elasticity, while the use of a cartilaginous allograft as a skeleton of auricle has a low aesthetic result. However, when using silicone implants, you should remember the possibility of their rejection.

The most common complications of the plasty of the auricle with the costal cartilage are pneumothorax and lung collapse with the separation of the marginal cartilage and use them as the framework of the future auricle. Other complications are associated with compression on transplanted tissues with improper application of bandages in the postoperative period, infection of the wound through a previously formed external auditory canal or during surgery. Follow up also postoperative hematomas, facial nerve paralysis, NST, necrosis of transplanted grafts, development of keloid scars.

A W-shaped incision of the skin of the parotid region to form a pocket for a silicone or cartilaginous implant prevents extrusion of the auricle framework. To prevent disruption of transplanted transplant nutrition, a separate formation of the anterior and posterior surfaces of the auricle is used.

Further management

To improve the nutrition of transplanted tissues, parenteral administration of drugs improving microcirculation (rheopolyglucin, pentoxifylline, vinpocetine, ascorbic acid solution, nicotinic acid solution) is recommended, as well as hyperbaric oxygenation.

To close the donor surfaces, special sterile medicinal wipes are used. In the field of auriculoplasty, on the chest and on the donor sites of the buttocks, the formation of hypertrophic scars is possible. In this case, prescribed prolonged glucocorticoids, which are introduced into the base of the rumen, as well as phonophoresis with enzymes (collagenase, hyaluronidase).

Perhaps the development of postoperative stenosis of the external auditory canal (40% of cases). In these cases, apply soft protectors in combination with ointments containing glucocorticoids. When there is a tendency to decrease the size of the external auditory canal, a course of endaural electrophoresis with hyaluronidase (8-10 procedures) and injections of hyaluronidase solutions at a dose of 32-64 UE (10-12 injections) is recommended depending on the age of the patient.

Postoperative management of patients with atresia of the external auditory meatus consists in the appointment of resorption therapy (electrophoresis with hyaluronidase on the postoperative stenosis zone and administration of hyaluronidase solution at 32-64 UE intramuscularly). In total, 2-3 courses of resolving therapy are recommended with an interval of 3-6 months.

Forecast

As a rule, the improvement of the auditory function is 20 dB, which requires a hearing aid in case of a bilateral anomaly. Aesthetic correction in some cases does not satisfy the patient.

[1], [2], [3], [4], [5]