TYMPANOPLASTY (Greek tympanon a drum + plastike sculpture, plastics) — operational recovery of the sound carrying out system of a middle ear destroyed by pathological process for the purpose of improvement of acoustical function.
The first attempts of the operative measures which were a prototype of T., treat the second half 19 and the beginning is 20 century old (see Hearing-improving of operation). Further were engaged in development of these operations Moritts (W. Moritz, 1951), Vullstein (H. L. Wullstein, 1952), Tsellner (F. Zollner, 1952), Goto (S. Goto, 1953), etc. The term «tympanoplasty» is offered by Vull-shteynom. In the Soviet Union methods T. developed and improved D. M. Rutenburg (1956), I. M. Rosenfeld (1958), Yu. B. Preobrazhensky (1959), N. V. Zberovskaya (1963), etc.
Indication to T. is relative deafness (see), caused by hl. obr. hron. a purulent inflammation of a middle ear (see. Otitis ), is more rare — adhesive otitis (see. Tympanosclerosis ), injuries, anomalies of development of a middle ear (see), etc.
It is contraindicated T. at an aggravation hron. otitis and labyrinth, intracranial and other complications of otitis, and also at dysfunction of an Eustachian tube (see. Acoustical pipe ) and the sound perceiving device. Relative contraindications — dystrophic processes and allergic diseases of a nose and adnexal bosoms, drinks, etc.
According to Vullstein (1955) classification, distinguish five main types T. Operation of the first type is made at injury only of a tympanic membrane, (see), carrying out plastics it through outside acoustical pass (fig., a). Operation of the second type is shown at limited defects of a head or a neck of a hammer at the remained and mobile other acoustical stones. A tympanic membrane or the rag replacing it, napr, auto-or allotransplant, enter before contact with a nakovalnestremenny joint, reducing thereby the sizes of a drum cavity a little, but keeping all its departments (fig., b). Operation of the third type is carried out when the anvil or it is destroyed and the head of a hammer had to be removed in the course of operation, and only the mobile stirrup remained. At the same time the tympanic membrane of a pla the rag replacing it is entered before contact with a head of a mobile stirrup (miringostapedopeksiya), creating the design similar to a structure of the sound carrying out system at birds (a so-called columella effect according to the name of the only acoustical stone — the columella connecting a tympanic membrane to the basis of a stirrup at birds). As a result of this operation the neotimpanalny cavity forms (fig., c), do not enter it supratympanic space (supratympanic deepening, T.) and a mastoidal cave (see the Mastoid). Operation of the fourth type is applied in the absence of all acoustical stones, except for the basis of the stirrup which kept mobility. At the same time a plastic rag close a pneumatic cavity between the mouth of an Eustachian tube and a window of a threshold, protecting a window of a snail from sound pressure (shielding) and creating a neotimpanalny cavity, in to-ruyu the mouth of an Eustachian tube and a window of a snail opens (fig., d). Due to increase in a difference of sound pressure upon windows of a labyrinth hearing improves.
Resort to operation of the fifth type at an immovability of the basis of a stirrup. In this case make a staiyedektomiya and a stapedoplasty with use of prostheses, hags about otosclerosis (see); at an underdevelopment of a window of a threshold carry out windowing of a labyrinth (fig., e).
Before operation comprehensively investigate function of hearing (see. Audiometriya ), revealing sufficiency of a so-called cochlear reserve (see. Inner ear ), check function of an Eustachian tube, carry out treatment of inflammatory diseases. At hron. a purulent inflammation of a middle ear most of specialists carry out the sanifying operation providing running in the subsequent to T in the beginning. on a so-called dry ear. At bilateral relative deafness and equally functioning sound perceiving systems of both ears of T. carry out, as a rule, on worse the hearing ear.
At operation use an operative microscope (see) and special microtools, and also the equipment for an irrigation and suction. Operate more often under a local infiltration anesthesia (see. Anesthesia local ), giving chance to control a condition of hearing and function of a facial nerve during operation! The section of skin is made in outside acoustical pass or in zaushny area, along the line of an attachment of an auricle. Trepanation of a temporal bone is carried out, as at so-called radical operation of an ear (see. Otitis ) or using the technique developed especially for T. At the last create the control openings conducting in supratympanic space through a lateral wall of supratympanic deepening in a mastoidal cave or in a lower part of a drum cavity.
After opening of tympanic cavities and careful audit of all its departments delete patholologically the changed fabrics — granulations (see. Granulyatsionnaya fabric ), cholesteatoma (see), hems and synechias, sclerous mass, carious sites of a bone. The low-changed mucous membrane of a medial wall of a drum cavity is whenever possible kept for formation of a neotimpanalny cavity, and strongly changed — replaced with an autograft from a mucous membrane of a lip, a cheek or from a wall of a vein. Mobility of the basis of a stirrup and secondary tympanic membrane is checked, entering a drop of isotonic solution of sodium chloride into a pole of a window of a snail and carefully pressing the tool on the basis of a stirrup. Fluctuation of a light patch of light in this liquid testifies to mobility of these educations.
For myringoplasties (see), i.e. substitutions of the destroyed tympanic membrane or closing of the defect which is available in it, use rags of skin of outside acoustical pass both various others au-to-and allotransplants (a fascia of a temporal muscle, a wall of a vein, a periosteum, a firm meninx). Free skin transplants apply seldom. The transplant is stacked more often on an outer, deepitelizirovanny surface of the remains of a tympanic membrane and adjacent departments of outside acoustical pass. Sometimes it is stacked on the medial surface of a tympanic membrane; at the same time as the main rag apply connective tissue, covering it outside skin (split or prepared across Tirsh). Many specialists before it fill a neotimpanalny cavity with the resolving gelatinous sponge with antibiotics, edges is a support for a transplant, and also a peculiar depot of nutrients and antibiotics.
For recovery of partially destroyed chain of acoustical stones the remained its elements move so that to recover a continuity of the sound carrying out system. The separated elements connect a wire from tantalum or stainless steel, sinews, biol. glue, etc. In the absence of acoustical stones, but the kept and mobile basis of a stirrup use various options of prostheses from a bone, a cartilage or plastic. More and more change of tinned allotransplants of acoustical stones, sometimes in the uniform block with a tympanic membrane is widely adopted.
At a bone or full cicatricial obliteration of an Eustachian tube create artificial ways of aeration of a neotimpanalny cavity. So, M. R. Bogomilsky (1970) suggested to enter through the transplant replacing a tympanic membrane, a special tubule — a so-called perforation columella; To. 3. Borisov (1979) considers necessary in such cases to produce partial T., stacking a transplant so that under it there was a channel for intake of air.
At education as a result of T. big slowly epitet pziruyu-shcheysya cavities in a mastoid (sometimes from it pus separates for a long time) T. combine with mastoidoplastiky, edges it is admissible only in the absence of a cholesteatoma, carious process in a bone and other complications. M. I. Ovsyannikov (1958) suggested to enter for this purpose into such cavity a rag on a leg from the soft tissues covering a mastoid; nek-ry specialists fill a cavity in a mastoid cartilaginous or bone auto-or allotransplants, various plastic. To avoid formation of a big cavity, sometimes at T. keep a back bone wall of outside acoustical pass.
In the postoperative period the patient appoint a bed rest and antibiotics taking into account sensitivity of microflora to them. The bandage and tampons from outside acoustical pass are deleted usually for the 7th day. If fixing of a rag was made by the resolving sponges, their remains delete by means of a suction machine. As a rule, in 2 — 14 days after operation make ear inflations across Valsalva (see. Valsalva experience ) or to Polittser, and at their inefficiency — catheterization.
To complications, to-rye can arise during T., belong paresis of a facial nerve (see), emergence to-rogo is promoted destruction of walls of its channel carious process or a cholesteatoma, by inadvertent removal of a stirrup, the labyrinth phenomena (see. Vestibular reactions ). In the postoperative period paresis of a facial nerve as a result of hypostasis and influence of microorganisms and their toxins, the phenomena can develop labyrinthitis (see), etc. Partial sequestration of a labyrinth belongs to rare complications.
Positive functional effect in the remote terms after T. it is noted at most of patients.
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Yu. B. Preobrazhensky.