Piezosurgery for Posterior Wall Mobilization in Chronic Suppurative Otitis Media

Modern trends in surgery of chronic suppurative otitis media are the performance of sanitizing and reconstructive surgery with the maximum possible restoration of the anatomical relationship of the middle ear structures and replenishment of lost functional elements, the so-called “closed” type surgery. We have proposed and demonstrated on a clinical example a method for surgical treatment of chronic suppurative otitis media by resection and reconstruction of the posterior wall of the auditory canal, which is carried out as follows: according to the data of computed tomography of the temporal bones with three-dimensional modeling, the linear dimensions and volume of the supposed resected part of the posterior bone wall of the external auditory canal are measured, four lines are marked oriented along the length of the auditory canal to form a cut with the formation of a V-shaped in cross-section edge of the bone resection from the attic side and an L-shaped in cross-section edge of the bone resection from the facial nerve side, while the long arm of the L-shaped in cross-section edge is located above the facial nerve. The surgical stage is performed under general anesthesia, with the patient in the supine position. Under the control of an operating microscope, retroauricular access to the tympanic cavity is performed, the state of the sound-conducting system is determined, the vestibular window and the cochlear window are revised, their functional mobility is restored, and the tympanic orifice of the auditory tube and tympanic sinus are revised. Granulations, scars, altered mucous membrane, and cholesteatoma are removed. Identification points and lines of the proposed cut on the posterior wall of the auditory canal, which were previously marked on computed tomography, are established. During the operation, after performing a retroauricular incision and separating soft tissues, access to the antrum is performed through the mastoid cells using a burr. This stage of the operation corresponds to the surgical volume of the operation — separate atticoantrotomy. The pathological contents of the antrum are partially removed until the proposed incision lines in the area of the posterior wall of the auditory canal are visualized from the antrum side. Using a piezoelectric saw (piezoelectric ultrasonic vibrations with a frequency of 28–36 kHz, a range of 60/200 Hz, the thickness of the working part of the saw is 0.25–0.50 mm, a constant supply of sterile 0.9% NaCl), mobilization of the bone wall of the posterior external auditory canal is performed along previously marked lines by four oblique cuts to form a V-shaped bone edge in cross-section on the attic side and an L-shaped bone edge in cross-section on the facial nerve side, with the long arm of the L-shaped edge in cross-section located above the facial nerve. The resected wall is placed in a sterile isotonic solution (0.9% NaCl). After removing the posterior bone wall of the external auditory canal, sanitization of the cavities of the middle ear and mastoid process is performed. Reconstruction of the posterior wall of the external auditory canal is performed by repositioning the previously extracted fragment of the posterior wall of the external auditory canal into the existing grooves, the cut line is additionally reinforced with bone chips. In this way, normal anatomy is restored in the reconstruction area. Temporal fascia, perichondrium or cartilage of the auricle are used to replace the eardrum. Reconstruction of the auditory ossicular chain is performed using artificial prostheses. The meatotympanic flap is returned to its original position, the wound in the retroauricular region is sutured layer by layer, the external auditory canal is tamponed with a hemostatic sponge.
Conclusion: The proposed method of surgical treatment of chronic otitis media by resection and reconstruction of the posterior wall of the auditory canal allows for a good overview at the stage of sanitation of the middle ear cavities, and at the stage of reconstruction, for maximal restoration of the anatomy of the middle and outer ear, which is the main technical and economic improvement that allows for increasing the effectiveness of surgical treatment of patients with chronic otitis media.
Key words: chronic suppurative otitis media. piezo-surgical technics, piezosurgery, ultrasonic bone surgery, otosurgery, piezootosurgery
Conflict of interest. The authors declare no conflict of interest.
Financing. The work was completed without sponsorship.