OTOSCLEROSIS (otosclerosis; grech, us, ot[os] ear + sclerosis; synonym otospongiosis) — the focal defeat of a bone labyrinth of an inner ear which is characterized by the progressing decrease in hearing and feeling of a sonitus. The lake arises usually during puberty and proceeds chronically. Women are ill more often. The accruing decrease in hearing happens usually a consequence of so-called fixing by the otosklerotichesky center of the basis of a stirrup (fig. 1) in a window of a threshold. The center can be localized in the field of a window of a snail and in a snail that also leads to a hearing impairment.
Fixing of the basis of a stirrup was found for the first time by A. Valjsalyea in the first half of 18 century at a research of a temporal bone of the person. J. Toynbee noted that one of the most frequent reasons of relative deafness is the anchylosis of a stirrup in a window of a threshold. The term «sclerosis» in relation to a disease of an ear was introduced by A. F. Troeltsch for the first time. It designated this term a special form hron, a catarrh of a middle ear, at a cut the sclerous changes in a mucous membrane leading to restriction of mobility of a stirrup and membrane of a window of a snail are observed. These changes were considered as the main reason for fixing of a stirrup. Basic change in views of essence of otosklerotichesky process was made by A. Polittser in 1893. On the basis of comparison a wedge, and pathoanatomical data he came to a conclusion that fixing of a stirrup in a window of a threshold often is result not hron, catarral average otitis, and the investigation absolutely peculiar patol. process in the most bone labyrinth. He suggested to call this disease not of a sclerosis, and otosclerosis. Later A. Polittser's opinion was confirmed with histologic researches F. Betsolda, etc.
the AETIOLOGY AND the PATHOGENY
the Aetiology and a pathogeny are not found out. Nek-ry researchers consider O. a hereditary disease. Significance is attached to anomalies of the constitution. Many scientists consider that changes of a bone labyrinth at O. are expression of inferiority of a mesenchyma of an organism. Such opinion is confirmed a wedge, observations. Dighton (Ch. A. A. Dighton) in 1912 described O. in combination with blue scleras and an osteopsathyrosis (see. Bone formation imperfect ). E. Ruttin and F. R. Na-ger at a histologic research found out that the structure of the otosklerotichesky center differs from diffusion changes of a bone labyrinth at an osteopsathyrosis.
It is noted that neuroendocrine factors exert impact on emergence and O.'s current. Connection of the beginning of a disease and strengthening of its manifestations with the period of puberty, periods, pregnancy, childbirth etc. is established. According to F. R. Na-ger, almost at a half of women, sick O., at pregnancy, a thicket repeated, deterioration in hearing is observed. There are instructions that disbolism can be an origin
of O. Opisana separate cases of a combination of O. to a thyrotoxicosis, cretinism, an acromegalia etc. The great value of dysfunction of epithelial bodies is attached.
According to N. V. Belogolovov, the main reason for emergence and O.'s development — a sound injury of a bone labyrinth. In confirmation of it data of experiments of V. G. Yermolaev are provided, according to the Crimea the intensive high-pitched sound causes clear damages to a bone labyrinth in an ear of white mice. Z. Angelu-scheff, V. A. Simolin, etc. specify that impact on an ear of ultrasonic waves is the important factor leading to emergence and development of the Lake. These waves promote proliferation of a bone tissue in a bone labyrinth. According to Vittmak (To. Wittmaack) and A. Eckert-Mobius, an origin of O. consists in disturbance of blood circulation in a bone labyrinth. Perozz (L. Re-rozzi) paid attention to existence of the crack in a bone labyrinth which is located in close proximity to a first line of a window of a threshold. F. Siebenmann called this crack of «fissura ante fenestram». It was noted that it is executed connecting tkanyo, surrounded with the neogrowing stiff cartilage, and the remains of this cartilage quite often remain in this area and at adults. According to Perozzi, the otosklerotichesky center arises in that case when process of substitution of a bone cartilaginous tissue begins. It was later is proved gistol, Anson's researches in more detail (V. by Anson) and That will do (T. Bast). To. JI. Hilov suggests that O. represents defeat not only a bone labyrinth, but also all acoustic analyzer, including its representation in bark of a great brain.
The PATHOLOGICAL ANATOMY
Patol, process at O. has focal character and is limited by the bone labyrinth concluded in a pyramid of a temporal bone. In other bones of an organism of changes, similar to otosklerotichesky, it is not observed. In this sense of O. it is possible to call a disease of a bone tissue of a labyrinth conditionally. Exclusiveness of defeat of a bone labyrinth at O. is explained with uniqueness of formation of its bone wall, edges it is formed by three layers of the bone tissue differing as ossification: endosteal, enchondral and periosteal. By the time of the birth of the child the bone labyrinth is created in such degree that it corresponds to a bone labyrinth of the adult. At the same time formoobrazovatelny processes in periosteal and endosteal layers of a bone wall of a labyrinth are almost finished while in an inner enchondral layer the osteogenesis with substitution of the remains of an embryonal cartilage proceeds. Islands of an embryonal cartilage are found sometimes and in the basis of a stirrup.
The Otosklerotichesky centers arise in an enchondral layer of a bone labyrinth on border with a periosteal bone. Favourite localization of the centers — area near labyrinth windows (medial edge of a window of a threshold and the cape), a bone labyrinth of a snail, bone semicircular channels, especially in the general bone leg of front and back semicircular channels, a wall of internal acoustical pass. Defeat of pyramids of both temporal bones is observed, and the sizes and prevalence of the centers are identical. O.'s centers in a bone labyrinth make a so-called histologic otosclerosis since usually clinically are not shown. Distribution of the otosklerotichesky center on a niche of a window of a threshold with transition to the basis of a stirrup leads to an anchylosis drum stremennogo a syndesmosis, followed by disturbance of air sound transmission and development of conductive relative deafness — the clinical Lake. If histologic O. is always bilateral defeat, then clinical O. can be shown a long time as unilateral process.
Involvement in otosklerotichesky process of the basis of a stirrup originally was considered only as result of distribution from - the sclerous center from a bone labyrinth (fig. 2). Operational treatment of O. expanded opportunities gistol, researches from - the sclerous center in a remote stirrup. Detection of the otoskleroti-chesky center in the basis of a remote stirrup at preservation of a ring linking of a stirrup and integrity of a cartilaginous surface of a plate indicates a possibility of independent development of otosklerotiche-sky process in the basis of a stirrup. Emergence of the otoskle-rotichesky center in the basis of a stirrup finds an explanation in patterns of an embryogenesis of a stirrup, the basis to-rogo forms together with a bone labyrinth. Legs of a stirrup and a head, apparently, can be involved in otosklerotichesky process at its distribution from the basis. In a hammer and an anvil otosklerotichesky process does not develop. There are separate observations patol, changes of a hammer and anvil at a clinical otosclerosis, but the interpretation of these changes as from - the sclerous centers raises doubts.
On gistol, to a structure O.'s center differs from the compact bone of periosteal and enchondral layers of the capsule of a labyrinth surrounding it or from a bone of the basis of a stirrup markedly. It represents the limited site of chaotic stratification of the bone structures of various degree of a maturity which are fancifully differentiated by lines of pasting. Large bone little bodies in these structures are distributed by uneven groups in a small amount of basphilic main substance. Quite often bone cavities look empty. Along with sites of a compact structure in the otoskleroti-chesky center zones of a spongization of a bone tissue — a characteristic sign of otoskleroti-chesky reorganization of a bone are found. Zones of a spongization of a bone tissue are sites of the rassasyvaniye of an otosklerotichesky bone proceeding as a smooth resorption, is more rare as an alar rassasyvaniye with participation of osteoclasts. Marrowy spaces of spongy sites of a bone contain the wide thin-walled vessels overflowed with blood. It reflects the general pattern of the strengthened blood supply of a bone at resorptive and kosteobrazovatelny processes. Gistol, division of the otosklerotichesky centers into spongy and sclerous (compact) is considerably conditional since it reflects dominance in the center of sites of this or that structure. However this division matters at morfol, assessment of activity of the otosklerotichesky center. The active otosklerotichesky center is a site of an unripe bone with active osteoplastic and resorptive processes, the expressed krovenapolneniye of vessels of marrowy spaces, as a rule, of a spongy structure. At gistokhy. a research in active from - the sclerous center a large number of acid glyu-kozaminglikan is found (hyaluronic and chondroitinsulphuric to - t), and also high activity of an alkaline phosphatase is defined. The quiet otosklerotichesky center represents the site reconstructed, but more mature bone with formation of laminated bone structures and reduction of blood supply at the expense of a zapustevaniye of vessels by the approaching bone, as a rule, of a compact, sclerous structure. Development of the otosklerotichesky center tends to gradual subsiding of process of bone reorganization. There are observations testimonial of resuming of activity of the quiet centers after a long dormant period.
The CLINICAL PICTURE
varies Klin, O.'s current at different patients and during various periods of life at the same patient. To predict character of a current of O. and degree relative deafness (see) can be difficult. More often the disease develops slowly; in nek-ry cases very bystry progressing of process (a fulminating form) is observed. The indirect signs giving the chance to assume a severe form of a disease are: the beginning of a disease at early age, the progressing deterioration in perception of high-pitch tones through air and a bone at young age, existence of diseases of O. in a family.
A constant objective sign of an otosclerosis — decrease in hearing as dysfunction of the sound carrying out device.
In most cases both ears are surprised, however at the beginning of a disease hearing is usually reduced on one ear, and another can be involved in process only in several months or even years. Progressing of relative deafness can temporarily stop, and then under the influence of these or those adverse external and internal factors to renew. Does not cause full deafness of O. In large part cases the paradoxical symptom which is that patients hear the speech in a noisy situation better — on the street, in the subway, the tram, the train etc. is expressed. This phenomenon carries the name paracusis Willisii (see).
Frequent, quite often very burdensome subjective symptom of O. — feeling of a sonitus. Intensity and the nature of noise are very various. Sometimes it disturbs patients only in a silent situation, in other cases is so sharply expressed that becomes the main symptom. Noise can be low or high-pitch tone. For the characteristic his patients often resort to figurative comparisons (noise reminds chirring of a grasshopper, noise of the engine, the boiling samovar, a sea surf, the flying arrow etc.). Nek-ry researchers assume that noise is a consequence of disturbance of blood circulation in an ear or toxic action of the otosklerotichesky center on the terminations of an eighth cranial nerve. Sometimes sick O. complain of dizziness, a cut has passing character more often, is frequent — on feeling of pressure in an ear.
The Otoskopichesky picture, as a rule, happens normal. In nek-ry cases symptoms are expressed to Shvarttsa — raying through a tympanic membrane of a bright pink wall and Lempert's symptom — thinning of the interlayer of a tympanic membrane. Various researchers described also other indirect signs of O. — a blue shade of scleras, broad outside acoustical passes (Verkhovsky's symptom — Tiyo), hyposecretion of sulfur (Toynbee's symptom), a xeroderma owing to hyposecretion of sweat glands (a symptom of Hammershlaga), decrease in sensitivity of skin of outside acoustical pass (Freshels's symptom), exostoses in outside acoustical passes (Maier's symptom).
For diagnosis essential value has the anamnesis. At O. the so-called triad of Betsold — disturbance of perception of low tones, negative experience of Rinne comes to light (see. Rinne experience ) and the extended Shvabakh's experience (see. Shvabakh experience ). The mixed type of relative deafness, i.e. dysfunction not only the sound carrying out, but also sound perceiving system is quite often observed. It can be connected with localization of the otosklerotichesky center in a snail or with toxic action of the active center on a receptor of the sound analyzer. Negative experience of Zhelle (see. Zhelle experience ) confirms an anchylosis of a stirrup (the condensation of air in outside acoustical pass does not worsen perception of sounds neither during the carrying out through a bone, nor during the carrying out through air). Valuable diagnostic value logical tests — ultrasonic irritation of the minimum intensity, a kamertonalny research have as well other audio (see. Deafness ).
Acoustical pipes at O. are usually well passable. Blowing off of ears of hearing does not improve. At rentgenol. a research of temporal bones their expressed pnevmatization quite often is defined.
Differential diagnosis carry out with adhesive otitis (see. Otitis ), tympanosclerosis (see), anomalies of a chain of acoustical stones (see. Middle ear ), cochlear neuritis, Menyer's disease (see. Menyera disease ).
Pathogenetic treatment of O. does not exist. Conservative treatment is directed to improvement of hearing and reduction of feeling of a sonitus.
Conservative methods of treatment is offered much, but most of them was ineffective, and they did not find broad application. On a wedge, to observations of nek-ry researchers, use of sodium fluoride promotes at a part of patients of an inactivation, to consolidation of the otosklerotichesky center due to change of chemical structure of a bone that leads to the termination or delay of growth of the center and stabilization of level of hearing. According to Shambo (G. E. Shambaugh), L. G. Svatko, V. I. Galochkin, B. I. Chernyshov, prolonged use of this drug (within 1 — 3 years) in the dosage which is not exceeding 60 mg a day promotes reduction of a sonitus, at an endauralny ionophoresis — at nek-ry patients — to improvement of hearing.
For sick O.' treatment along with pharmaceuticals use the physical factors promoting delay of osteodystrophic process by improvement of blood supply, reduction of developments of stagnation and improvement of conductivity of the nervous device. The physical therapy is carried out on local (immediate effect on area of an ear) and to reflex and segmented techniques (on cervical and collar, orbital and occipital areas) or by alternation of these techniques.
At O.'s combination to cochlear neuritis apply to improvement of nerve conduction an electrophoresis of 2,5% of solution of Thiamini bromidum, 0,1% of solution of a prozerin or 0,5 — 0,25% of solution of Galantaminum and darsonvalization. At the subsequent treatment use reflex and segmented techniques of influence. In any course of treatment the physical therapy is combined with vibration or manual massage of area of an ear and a cervical and collar zone. Besides, apply acupuncture to O.'s treatment.
In most cases for sick O.' treatment perform surgery. Make two types of operation: an operative measure on a stirrup (mobilization of a stirrup, a stapedoplasty, a stapedectomy) and windowing of a labyrinth.
Operations on a stirrup
began to do Mobilization of a stirrup at relative deafness long ago. In 1876 Mr. J. Kessel made perforation of a tympanic membrane, entered the probe into a drum cavity and tried to shake them nakovalnestremenny a joint. Operation was not widely adopted since intervention was in essence made blindly. In 1888 Mr. E. Boucheron offered broader approach to a stirrup. He cut out a back half of a tympanic membrane, in most cases separated an anvil from a stirrup and a special hook tried to mobilize a stirrup, applying the movements on the direction of the course of action of sinews of a stapedial muscle.
The technique described by Mio (S. of Miot) in 1890 is closest to modern operation of mobilization of a stirrup. He made a myringotomy (a section of a tympanic membrane) and tried to mobilize the basis of a stirrup, influencing on nakovalnestremenny a joint, and also directly legs of a stirrup. At indications repeated operation was made.
In 1892 Blake and Jack (S. of Blake, F. Jack) at an anchylosis of the basis of a stirrup applied a stapedectomy (removal of a stirrup) with the subsequent closing of educated defect with a rag to improvement of hearing.
In 1899 G. Faraci published results of 30 operations of mobilization of a stirrup. In addition to a section of a tympanic membrane it made removal of the site of a back wall of outside acoustical pass. Attempts to mobilize the basis of a stirrup were made, influencing an anvil, a head of a stirrup and the basis, i.e. all modern techniques of mobilization of a stirrup were applied. Apparently, because of insufficiently perfect equipment, lack of necessary optics and lighting, inability to struggle with bleedings and, the main thing, because of danger of postoperative complications all operational methods of treatment at O. were recognized not only useless, but even as harmful.
In 1952 S. Rosen, defining fixing of a stirrup by its direct sounding, accidentally made mobilization of its basis then at once on the operating table at the patient normal hearing was recovered. It gave to it the grounds to develop a technique of intervention for mobilization of a stirrup for the purpose of improvement of hearing. Accumulation of big own material allowed a number of scientists to make changes to a technique and technology of operation, to improve tools, optics etc. There are various modifications of operation.
Operation of mobilization of a stirrup is shown to patients with the progressing relative deafness, at to-rykh the so-called cochlear reserve (an indicator funkts, conditions of the sound carrying out device) caused by an anchylosis of the basis of a stirrup comes to light. The cochlear reserve opredelya-lyatsya by the size of a bone and air interval. Rosen finds it possible to make mobilization of a stirrup at a bone and air interval 20 dB, V. Good-hill — 30 dB. At the same time the research of function of an inner ear since operation can be effective only at good or at least its satisfactory condition is of great importance. Therefore especially carefully investigate bone conductivity. Specification of indications to operation is helped by studying of ability of the patient to sort the speech and a research of a phenomenon of alignment at it or increase of loudness. This phenomenon is based on identification inadequately hypersensitivity (to the sound increasing on intensity) receptors of a snail at cochlear neuritis, to-ry is a contraindication for operation.
The age of patients has no essential value though nek-ry otokhirurg avoid without emergency to operate patients at young age since the operational injury of the center promotes progressing of process. Besides, at patients postoperative kokhleovestibu-lyarny complications are more often observed (labyrinthites, gidrops and a fistula of a labyrinth, a postoperative granuloma, partial or full dystrophy a neyroegshte-liya of a snail, a threshold and semicircular channels). Besides the neuroepithelium of a snail of young people is more sensitive to an operational injury. Therefore at detection of the «soft» center of O. during operation use a bypass technique, trying to injure less the centers, not too widely to open a threshold of a labyrinth. After operation by such patient appoint drugs of fluorine.
The majority of otokhirurg consider that in the beginning it is reasonable to make operation on an ear, a cut hears worse. Single-step bilateral intervention is not recommended. At indications previously sanify upper respiratory tracts.
Operations most often make under local anesthesia. Nek-ry otokhirurg apply hypnotic drugs and sedatives, drugs of morphine to premedication, quite often combining them with Pipolphenum and aminazine. However it is not necessary to aim at a condition of an excessive oglushennost of the patient since it can complicate a research of hearing during operation.
To remove stress of the patient on the operating table, sometimes use broadcasting via the earphone brought to other ear, the special program which is written down on a magnetic tape. After the small musical introduction the announcer tells the patient about the course of operation, possible feelings, explains how the patient shall behave during operation, etc. Then, at the request of the patient, broadcast music. All this renders the expressed calming effect.
Rosen offered three options of operation of mobilization of a stirrup: shaking of a stirrup through his neck (an indirect method); immediate effect on edge of the basis of a stirrup (a direct method); creation of an artificial opening in the basis of a stirrup (windowing of the basis of a stirrup). These operations apply consistently: in the beginning try to loosen a stirrup; if it does not work well, apply the second option of operation and if it does not lead to improvement of hearing — the third.
Indirect method. Operation is made under local anesthesia through the usual or automatic ear speculum entered into outside acoustical pass. The automatic funnel is fixed to a table that gives the chance to the surgeon to manipulate two hands.
Operation is performed under a microscope at 16-fold increase. Skin of outside acoustical pass is wiped with alcohol. Apply 1 — 2 ml of 2% of solution of novocaine with several drops of 0,1% of solution of adrenaline to anesthesia. Solution is entered subcutaneously into a back wall of outside acoustical pass on border of cartilaginous and bone departments.
The drum cavity is opened with the section offered in 1946 by J. Lempert. It is made a special scalpel on 6 — 7 mm of a knaruzha from a tympanic membrane, begun from above and conducted along back, then lower and partially front walls (fig. 3, a). For removal of blood use a suction. Tips for it are prepared from stupidly cut off syringe needles of various caliber bent at an obtuse angle. Such tips it is necessary to have 3 — 4 not to waste time for their cleaning during operation. Beginning skin from the upper edge of a section gradually otseparovyvat from a bone to edge of a tympanic membrane (fig. 3, b). For this purpose use special raspatories. The tympanic membrane is gradually allocated from a bone trench and an otseparovanny part is lifted the raspatory up (fig. 3, c). According to Rosen, in 85% of cases at the same time the most part of a nakovalnestremenny joint is visible. However the stirrup most often is visible insufficiently well. Therefore usually it is necessary to delete with a spoon, a chisel or a mill 2 — 3 mm of a bone of a verkhnezadny wall of outside acoustical pass to areas of a voloknistokhryashchevy ring of a tympanic membrane. After that there are well distinguishable a long leg of an anvil, nakovalnestremenny a joint, a head and a so-called neck of a stirrup, its basis, the channel of a facial nerve, all extent of a sinew of a stapedial muscle, a drum string, a part of a nakovalnemolo-tochkovy joint and an inner surface of the handle of a hammer (fig. 3, d). In nek-ry cases the drum string disturbs a review of a stirrup, and this nerve should be removed, sometimes even to cut. Mobility of a stirrup is checked carefully perfected probe, to-ry put on a long leg of an anvil directly at a joint with a stirrup and make carefully (within 0,5 mm) traction of a kzada. If the basis of a stirrup is freely mobile in a window of a threshold, then this manipulation causes the movement of an anvil, a nakovalnestremenny joint, a head, a neck, legs of a stirrup and a sinew of a stapedial muscle. At freely mobile stirrup all these elements move synchronously as a single whole. If the stirrup is fixed not strongly, then more vigorous pressing by the same tool on a long leg of an anvil sometimes can sdelag its mobile. Mobility of a stirrup is defined not only an eye, but also by touch.
A false impression of the successful mobilization can be made at a fracture of one or both legs and at stretching or dislocation of a nakovalnestremenny joint. Therefore obligatory criterion of the successful mobilization, in addition to visual and tactile feelings, is definition of a condition of hearing. Clearly the expressed improvement of hearing after impact on a stirrup usually does not raise doubts that mobilization is reached. At strong fixing of a stirrup make shaking in its way of pressing on a front surface of a neck (only necks since it is the thickest and strong part of a stirrup; legs of a stirrup are less strong, and at O. their durability is even less). Apply a curved narrow mobilizer to impact on a neck (fig. 4, a). The end of a mobilizer put on nakovalnestremenny a joint in the beginning, and then remove inside before contact with a front leg of a stirrup. For registration of mobility of the basis of a stirrup it is possible to enter a drop of physiological solution into a niche of a window of a snail: at mobility of a stirrup pressing on it causes the shift of a drop of solution in a niche of a window of a snail that can be easily recorded on movement of a light patch of light. In a drum cavity use the thin needle probe to an adhesiotomy or granulations. After achievement of mobilization of a stirrup the tympanic membrane with adjacent skin of outside acoustical pass is stacked on the former place and slightly covered with a wadded ball. In the postoperative period change of balls is made as required (in sterile conditions depending on treatment by their blood or serous separated), and on 4 — the 5th day is usually deleted. If a postoperative current smooth, in 2 weeks after operation the tympanic membrane and skin of outside acoustical pass take a usual form.
Apply to the prevention of a reankylosis (repeated fixing) of a stirrup transossikulyarny (through a chain of acoustical stones) a method of mobilization of a stirrup by means of vibration massage. This method in 1884 applied to Lyutsa (And. J. Page of Lucae). Then it was altered in 1914 Mr. of J. Molinie, but was not widely adopted because anesthesia at interventions on an ear at that time was imperfect. In 1956 Mr. Mayerson (M. of Myerson), using modern methods of anesthesia, developed a new technique of transossikulyarny massage. This technique in 1959 was experimentally proved by N. A. Preobrazhensky and A. P. Svetlayev. Transossikulyarny massage is made on an outpatient basis. The patient shall be in a dorsal decubitus, skin of outside acoustical pass is wiped with alcohol, for anesthesia enter 0,5 ml of 2% of solution of novocaine with adrenaline into the area of a verkhnezadny wall of acoustical pass on border of bone and cartilaginous parts it. Use the electrovibrator. The probe of the vibrator processed by alcohol is put to a side shoot of a hammer then the vibrator is put in action. Duration of massage is from 30 sec. up to 1 — 2 min. At insufficient efficiency massage is repeated by 2 — 3 times at an interval of 7 days.
Direct method. If attempts to mobilize a stirrup impact on a neck do not achieve the goal, apply immediate effect on the basis (the term «direct method» from here). This operation on a being is continuation previous. The mobilizer is entered between edge of the basis and edge of a window of a threshold. For this purpose the tool is put over an anvil to a front leg of a stirrup (fig. 4, b), on a cut advance inside to the basis it. In this place the tip of the tool is entered between a bone rim of a window of a threshold and edge of the basis of a stirrup. The tip of the tool is entered on depth smaller, than thickness of the basis of a stirrup, and make them the easy movements towards edge of the basis of a stirrup and outside, as if trying to raise it. In such way quite often it is possible to mobilize it, and hearing is recovered as soon as delete the tool. If after removal of a mobilizer hearing is not recovered, the tool is entered between edge of a window of a threshold and bottom edge of the basis. Influencing the specified places, sometimes it is possible to achieve mobilization of a stirrup.
Operation is finished as well as at an indirect method. After manipulation on the basis of a stirrup in the postoperative period dizziness, than after manipulations on a neck of a stirrup is more often observed.
Windowing of the basis of a stirrup (creation of an artificial opening in the basis of a stirrup). When the direct method of intervention does not yield results, apply the third, even more difficult — creation of an artificial opening in the basis of a stirrup. The artificial opening is created or in bottom edge of the basis, or in its center. Apply the so-called fenestrator in the form reminding sharply ground crochet hook to this manipulation (fig. 4, c). To them make a puncture of the basis of a stirrup on depth no more than 1 mm. At careful rotation of the tool the opening created by a puncture increases since the hook of the tool breaks off small sites of a bone of the basis of a stirrup. After the tool is removed, it is possible to see the opening conducting in a threshold. In many cases in this opening the perilympha is visible. Sometimes it is possible to notice also the movement of a perilympha if to place a blob of wet cotton wool in a niche of a window of a snail and rhythmically slightly to pressure him. If the basis of a stirrup thick and a bone its dense that does not give the chance easy pressing on a fenestrator to make a puncture, recommend to use previously the probe for the purpose of simplification of passing of a fenestrator. For this purpose the probe is held between a big and index finger and rotary motions on the course and against the course of an hour hand enter it into the basis, as if drilling a window in a threshold. The opening made thus is expanded with a fenestrator. Nek-ry otokhirurg perforate the basis of a stirrup an electromill.
Other options of operation on a stirrup. A large number of various modifications of operations on a stirrup is offered, at to-rykh as the mechanism transmitting a sound use its separate elements. One of such modifications is operation of a front krurektomiya. The principle of such operations consists in excision of a front leg, a section of the basis of the stirrup (platino-tomiya) and mobilization of its back segment keeping communication about flax-tikulyarnym a shoot of an anvil by means of a back leg of a stirrup by Fowler's method (fig. 4, d).
Shift of a back segment of the basis together with a back leg of a stirrup of a kpereda after removal of the front segment changed by process is called a monokruralny transposition or method of movement of a back leg of a stirrup. Various options of such technique are developed by Pryuvo (M. Pruvot), etc. Also Dzhuers's method consisting in a transposition of a back leg of a stirrup on the fragmented site of the mobilized basis of a stirrup is close to them. At the same time the sinew of a stapedial muscle is cut, and the joint capsule is not present. All these conservative surgeries received the general name of methods of a partial stapedectomy. They are applicable at copular fixing of a stirrup, at the small centers of O. and rather wide niche of a window of a threshold.
All other types of operations on a stirrup received the name of a stapedoplasty. They consist in a considerable exposure of perilymphangeal space and replacement of the basis of a stirrup with a transplant. Options of a stapedoplasty are distinguished depending on a technique of closing of a window of a threshold and a form of a prosthesis of a stirrup.
The stage preceding a stapedoplasty is the platinekto-miya — removal of everything (or almost everything) the bases of a stirrup. After that the threshold is closed any plastic material (a rag of a vein, a fatty tissue, an autofibrinny film or a gelatinous sponge), and between it and a long leg of an anvil place a prosthesis of a stirrup (fig. 4, e). The stapedoplasty
was widely used since 1958 when J. Shea published the first results of this operation. He entirely deleted the changed stirrup, closed a window of a threshold a rag of the vein (taken from a brush), and put on a polyethylene tube a lenticular shoot of an anvil, the end established a cut in a window of a threshold on a rag of a vein. Since then various options of a stapedoplasty are offered, to-rye essentially do not differ from each other. Generally they differ by options of prostheses of a stirrup. Portmann (M. of Port-mann) suggests to use as a prosthesis separate elements of a stirrup, H. F. Schuk-necht — a wire and fatty prosthesis, N. A. Preobrazhensky and O. K. Patyakina, V. F. Nikitina — autokhryashch an auricle. Also prostheses from teflon, the combined prostheses from teflon and a tantalic wire are offered. The operation accompanied with removal of all stirrup is rather traumatic. Therefore otokhirurg aimed at more sparing options of operation bypassing the otosklerotichesky center. It is necessary to carry the so-called piston stapedoplasty offered Shi in 1959 to number of such operations. At this operation delete only legs of a stirrup and in the basis form a small window. Through it enter a prosthesis into an open threshold, to-rogo strengthen top end on a long leg of an anvil. As a prosthesis use teflon, steel or a teflonoprovolochny prosthesis (fig. 4, e). The threshold is pressurized the strip found from a wall of a vein or lumps of fat.
There is some other modifications of a piston stapedoplasty.
In all cases it is necessary to aim at preservation of function of a stapedial muscle. At the same time blood circulation in distal departments of an anvil is least of all broken and at the same time the protective acoustic role of a stapedial muscle so important at well mobile piston is used. This option of operation gains ground.
For check of efficiency of operation on a stirrup check hearing the speech and conduct an audiometric research directly on the course of an operative measure.
Complications after operations on a stirrup it is possible to divide into three basic groups. Refer damage of the device of sound carrying out to the first group, a cut can occur both during the performance of operation, and in various terms after it.
Enter into this group traumatic perforation of a tympanic membrane; perforation, resulting from its aseptic necrosis (usually at reoperation); perforation owing to the postponed inflammation of a middle ear. By data A. I. Kolomiychenko, Antoli - Kan - dely (E. Antoli-Candela), this complication meets in 3 — 7% of cases.
Traumatic dislocations of an anvil, and in later period — an aseptic necrosis of her long leg are described. Report about cases of a rassasyvaniye of a leg of a stirrup at its interposition, shifts of a leg of a stirrup. There are messages on shift and a false ankylosis of the prostheses replacing a stirrup, their rejection, fibrous or bone fusion of a window of a threshold in cases of acute outside and average otitis (1% of operations, according to N. A. Preobrazhensky and O.K. Patyakina).
Effects of these complications which are localized on average to fish soup in most cases can be liquidated at repeated audit of a drum cavity.
Carry labyrinth complications to complications of the second group. Dysfunction of the sound perceiving device (a snail of a labyrinth) or vestibular function of a labyrinth, or the combined disturbance of their functions is possible. Cochlear complications can be temporary and constant. Many otokhirurg carry all cases of deterioration in hearing on bone conductivity to defeat of a snail of a labyrinth and decrease in legibility of the speech, separately allocating cases of full «cochlear deafness». Cochlear complications after a stapedoplasty make from 1 to 9%, and «cochlear deafness» — from 0,5 to 4%. The number of these complications varies depending on a technique of operation, and also from extent of otosklerotichesky defeat of the basis of a stirrup. One of the reasons of cochlear complications is the mechanical injury of a webby labyrinth the tool or a bone fragment.
Vestibular disturbances (dizziness, nausea, disturbance of balance) usually are caused by the same reasons. The disturbance of vestibular function of a labyrinth which dragged on after operation is observed at injury of manipulations in the field of a threshold more often. There is a certain dependence between the frequency of vestibular complications and a technique of operation. Most often they arise after more traumatic stapedectomy, is more rare at a piston stapa to plastics. Postoperative subjective dysfunctions of a vestibular labyrinth divide on early, dragged on for a long time (up to 2 — 6 months and more), and late — incidentally repeating.
Refer the disturbances of taste and slyunovy-division which are observed at an injury of a drum string to complications of the third group. The liquorrhea arising during the performance of slukhouluchshayushchy operations on a stirrup is a rare, but heavy complication. It can complicate a successful completion of operation. However and the executed operation usually either does not improve hearing, or leads to full loss of acoustical function.
Paresis and paralyzes of a facial nerve are a consequence of a direct injury of a nerve or can arise on 8 — the 9th day after operation, probably, owing to inflammatory (aseptic) hypostasis of a cover of a trunk of a nerve. From among rare complications note plentiful bleeding from a stapedialny artery or a bulb of an internal jugular vein. More than 100 cases of meningitis after operation on a stirrup are described.
Results of operation on a stirrup. It is known that mobilization of a stirrup as ineffective operation is made seldom. At a stapedoplasty results vary depending on a method of operation: at installation of a leg of a stirrup on a rag of a vein the positive take is observed in 70% of cases; at installation of a polyethylene prosthesis on a rag of a vein — in 65,6%; a wire prosthesis on a rag of a vein — in 75%; during the use of a wire prosthesis with a lump of fat — in 65 — 83%; with a sponge — in 72 — 80,5%; at a piston technique — in 88 — 96,5% (term of observation of 6 years).
Not always the result of operation happens resistant. Quite often through various terms after an operative measure hearing is returned to preoperative level. It results from a reankylosis of a stirrup more often (at its mobilization), a reankylosis of a kolyumella, a rassasyvaniye of a leg of a stirrup, fusion of a window of a threshold and other reasons. In such cases it is necessary to resort to audit of a drum cavity and a reoperation.
Windowing of a labyrinth
At a full obliteration of a niche of a window of a threshold an otosklerotichesky bone when there are technical obstacles for production of a stapedoplasty, otokhirurg resort to so-called windowing of a labyrinth. This operation provides creation of an artificial bypass way for carrying out sounds in a snail. The stirrup remains fixed, the natural window of a threshold does not function, but instead of it in one of departments of a lateral wall of a labyrinth (most often in the horizontal semicircular channel) the new artificial window is created.
The technique developed by J. Lempert and improved by a row Soviet from - surgeons — Ya. D. Missionzhik, A. R. Hanamirov, A. A. Atkarska, K. L. Hilovym is taken as a basis of an operative measure.
Windowing of a labyrinth is rather heavy for the patient with an operative measure. In most cases after operation during nek-ry time symptoms of a serous labyrinthitis are observed that is expressed in decrease in hearing below preoperative level, emergence of an ataxy, spontaneous nystagmus not aside - the operated ear, dizziness, nausea, sometimes vomitings. These phenomena, gradually decreasing, usually in 2 — 3 weeks disappear. The irritation of a labyrinth can be explained with hemorrhage in perilymphangeal space, toxic influence of the injured trabeculas and a periosteal surface of a rag. The improvement of hearing reached by operation not always happens constant. Hearing can partially worsen or return to preoperative level. Usually it occurs on 5 — 8th month after operation and depends on partial or full fusion of a window in the semicircular channel. Sometimes after operation passing paresis of a facial nerve is observed. Meningitis, thrombosis of a bulb of an internal jugular vein, abscess of a temporal share of a brain belong to rare complications.
Improvement of hearing to the level of 30 dB and above directly after operation is observed approximately in 90% of cases. According to Shambo (G. E. Shambaugh), in two years after operation hearing at the level of not lower than 30 dB kept at 75% of patients.
At relative indications to operation at patients with dysfunction not only results of operation are worse than the sound carrying out, but also sound perceiving device.
The number of unsuccessful operations and postoperative complications at all types of operations at O. can be reduced by the correct selection of patients for operation. It is necessary to specify carefully all indications and contraindications to an operative measure.
It is necessary to refrain from operation at an inflammation of skin of outside acoustical pass, at acute inflammatory respiratory diseases, in the presence hron, the centers of an infection (carious teeth, a furunculosis, etc.).
The stapedoplasty is not shown at acute mental disorders or heavy somatopathies, malignant tumors, collagenoses, etc. At the expressed hypertension operation can be made only after appropriate therapeutic preparation, against the background of antihypertensives and premedication.
The most essential measures of the prevention of postoperative complications can be taken in the course of the operative measure. The choice of the most sparing option of a stapedoplasty matters; the carrying out operation with the minimum injury of a chain of acoustical stones sparing the relation to a sinew of a stapedial muscle; careful selection of a prosthesis, careful manipulations in the field of a window of a threshold and its careful sealing after installation of a prosthesis.
Postoperative regime of patients in essential degree is dictated by character and injury of the carried-out operative measure, and also specific features of reactivity of an organism of the patient.
After operation observance of a high bed rest is necessary; e.g., after any kind of a stapedoplasty it usually does not exceed 2 days, but at the vestibular phenomena (dizziness, nausea, disturbance of balance) can be prolonged up to 4 — 5 days and more.
Bandaging is usually made in a bed next day after operation: delete tampons and dry skin of outside acoustical pass, powdering it powder from sulfanamide drugs. The wadded filter in acoustical pass then is changed daily while there is a wound discharge.
On the eve of operation preventively appoint antibiotics of a broad spectrum of activity and give them for a week. If by this time inflammatory changes of a tympanic membrane disappear, cancel them. At the prolonged vestibular phenomena appoint Pipolphenum or aminazine, drugs of a belladonna (Belloidum, bellaspon), diuretics (furosemide), intravenous injections of glucose.
In the postoperative period, from the first days, for elimination of the reactive inflammatory phenomena and bystry healing appoint microwave therapy in a weak and thermal dosage. For the prevention of development of rough hems and removal of the reactive inflammatory phenomena diadynamic currents are shown. At hypertensia apply an electrophoresis of antipyrine to reduction of a sonitus (1 — 5% solution of salicylate antipyrine), at hypotension — an electrophoresis of ephedrine (0,1 — 0,5% solution of muriatic ephedrine) on a collar zone.
Stay of patients in a hospital after mobilization of a stirrup — usually 7 — 8 days, and after a stapedoplasty — 10 — 12 days.
After an extract issue to the patient the sick-list on 2 — 3 weeks, being guided by its general state. Sometimes at vestibular frustration longer release from work is required. In exceptional cases there can be a need for transfer of the patient into temporary disability.
After an extract patients within the first month are recommended to avoid a noisy situation (radio - telecasts, etc.). Within 2 — 3 months after operation it is necessary to observe the mode of hypoactivity, to avoid an excessive exercise stress. The work connected with a sharp inclination of a trunk or turns of the head, work about the fast-rotating objects at height, etc. is contraindicated. Patients are warned about danger of flights in the airplane.
Employment of the patients who underwent an operation on a stirrup shall be defined not only by a profession of the patient and conditions of his work, but also degree of relative deafness, existence of the vestibular phenomena. Quite often, if kind of work of the patient (loader, kessonshchik, spiderman, etc.) can promote emergence of complications, change of a profession is reasonable. However the modern sparing methods of operations on a stirrup at O. allow most of patients not only to keep their profession, but also to continue study or to gain the new, not demanding normal hearing specialty.
After operation on a stirrup dynamic observation and control of a condition of hearing is shown to patients in the conditions of policlinic. Gradual decrease in hearing due to disturbance of air conductivity to preoperative level can indicate a false ankylosis of the prostheses replacing a stirrup or repeated fusion of a window of a threshold. In the majority of such cases audit of a middle ear and a reoperation is shown, to-ruyu usually make later half a year after the first operative measure. The sudden hearing loss on the sound perceiving type which is followed by dizziness and noise in an ear allows to assume disturbance of blood circulation in an inner ear, gidrops or a fistula of a labyrinth. In such cases urgent hospitalization of the patient is shown.
At consultation it is reasonable to warn women, sick O., about a possibility of deterioration in hearing after pregnancy. At the same time, as showed observations, childbirth not always has significant effect on hearing in the operated ear.
In most cases to expect character and speed of development of process, and also extent of final decrease in hearing happens very difficult.
As the etiology and O.'s pathogeny are not found out, its prevention is ineffective. It is noted that alcohol, smoking, overfatigue, physical (noise, vibration etc.) and mental injuries cause deterioration in a course of process.
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H. A. Preobrazhensky; M. I. Antropova (fizioter.), V. P. Bykova (stalemate. An.).