The Basic Research And Clinical Treatment Of The Recurrence Otorrhea After Open Mastoid Surgery

BackgroundWith the basic research and the continuous development of microsurgical techniques, the cholesteatoma surgery,a growing number of doctors in the ear lesions completely removed on the basis of tympanoplasty,and the tympanic membrane reconstruction ossicular with a view to restoring or improving after the hearing,but open mastoid operation with the same closed-mastoid surgery is still one of the most basic surgical methods.The open mastoid surgery after 10～20%of the patients relapsed otorrhea, many brought to life with the inconvenience.For this reason,many scholars of its causes,prevention and treatment have been studied.At present the open after surgery recurrent papillary otorrhea trip again surgery,has been a broad consensus.But once again before the surgery still several issues worth paying attention:①infected mastoid cavity how pathological changes,how to deal with infected tissue;②mastoidectomy cavity infection immune micro-environment and otorrhea recurrence;③old before the surgery again mastoidectomy cavity effective preoperative evaluation;④the therapeutic effect of reoperation.In this study,we will study the issue of theem,respectively,and reported as follows.PartⅠHistopathological study of the mastiodectomy cavity in patients following open mastoidectomy on middle earObjectiveTo investigate the histopathological changes in the discharging mastoidectomy cavities,and try to provide the pathological basis for the revision surgery of the discharging middle-mastoid cavities. MethodsHistopathological features of material removed from different sites of 147 discharging mastiodectomy cavities at revision operations were reviewed retrospectively.ResultsThere were 305 different specimen were obtained from 147 old mastoidectomy cavities(218 from recidivation otorrhea ear,87 from uninfective ear).The uninfective mastoid cavity were covered with applanation stratified pavement- epithelium.The cicatricial tissue were below to them,which were including the hyalinization fibrous tissue,blood vessel hyperplasia,and a few of infiltrating leukomonocyte.The remain auricular bone and implanted bone and cartilage were keeping their own form.While, in the recidivation otorrhea mastoid cavity,the granulation was the most common pathological finding,besides,including the infected mucous,epithelium,ossicles,and all of the specimen removed from the cavities showed inflammation.The remain auricular bone and implanted bone and cartilage were fibrous degeneration and deform.ConclusionAfter the opened mastoid operation,the open mastoid cavity were covered with applanation stratified pavement-epithelium.The cicatricial tissue were below to them. In the discharging cavities,the inflammatory is extensive,granulation is the most common pathological findings,and including all the specimen,it tended to come from previous infections or infection again.PartⅡDown-regulation of Toll-like receptor 4 induced endotoxin tolerance in the cutaneous covering of postoperative mastoid cavities with otorrheaObjective The postoperative mastoid cavity is exposed to a high density and diversity of bacteria,but very little is known about how the immune environment is maintained in these regions with otorrhea.In this study,we investigated the changes in the toll-like receptor(TLR)2 and 4 signaling pathways and inflammatory cytokine production in the cutaneous covering of mastoid cavities with otorrhea and in normal auditory canal skin.MethodWe investigated the expression of TLR2 and TLR4,as well as downstream signal pathway proteins,nuclear factor-kB(NF-kB)DNA binding,and secretion of tumor necrosis factor-a(TNF-a)in 28 samples of the cutaneous covering obtained from the postoperative mastoid cavity with otorrhea and 10 normal external auditory canal skin samples.ResultsWe found that the frequency of TLR2- and 4-positive cells was not increased in cutaneous covering relative to normal skin(p＞0.05),but the TLR4 mRNA and protein were down-regulated(p＜0.05).In this pathophysiological process,there was also a lack of downstream signal pathway protein activation and secretion of TNF-a(p＞0.05).ConclusionThe expression of TLR 4 and associated downstream events,such as the activation of signal pathway proteins and inflammatory cytokine production,were down-regulated in the cutaneous covering of postoperative mastoid cavity with otorrhea,possibly leading to endotoxin tolerance.PartⅢHigh resolution computer tomography and magnetic resonance in evaluation the operation middle earsObjectiveTo determine the reliability of high-resolution computer tomography for the diagnosing of problematic cavities following mastiodectomy for chronic otitis media.Patients and methodsA retrospective study was made of 65 patients who suffered from problematic mastoid cavities after tympanomastiodectomy operations.All of the patients were examined by high resolution Computer tomography of the temporal bone followed by surgical reexploration of the middle ear and mastoid.CT findings were analyzed and correlated with surgical findings.ResultsHRCT can detect the site and extent of the disease tissue in the temporal bone well, and also predict the integrity of the facial never canal and lateral semicircular canal wall;there has a good correlation with the operative findings.It is the same for the mallus and incus detected,but a lesser extent for stapes.ConclusionHRCT can provide informations regarding the nature and extent of recurrent or resident disease of the surgically altered mastoid cavities as well as possible anatomic variations,which may not be apparent on the basis of clinical findings alone.HRCT scanning should be performed on all patients who presenting with problematic cavities after tympanomastoid surgery for chronic otitis media.PartⅣThe Treatment of the Otorreah after the Open Mastoid Operation By Rebuilding the Posterior Canal Wall and TympanoplastyObjectiveTo present and assess a surgical technique,rebuilding the posterior canal wall and tympanoplasty,when necessary,repairing the ossicular chain,and to treat the infected mastoidectomy cavitys.Patients and Methods132 cases(148 ears)were treated by total middle ear reconstruction for problematic mastoid cavity following mastoiectomy,and followed up for 1-13 years.The infection during operation,anatomic figure,hearing results,complication and recurrence of cholesteatoma were recorded.ResultsThere was a high infection rate during operation.After operation,90.5%(134/148) of the ears were dry;68.2%(101/148)of the ears,has statistically significant hearing improvement(p＜0.05),with an average preoperative 4-frenquence pure tone average air-bone gap of 50.8±9.5dB improving to 27.6±8.3Db,contracting 18.9±10.1dB. Postoperatively,the posterior canal wall and tympanic cavity had almost normal appearance in 81%(120/148)of cases,Recurrence otorrhea occurred in 16.7% (25/148)of ears.Recurrence chlesteatoma occurred in 26.5%(9/34)of ears.ConclusionRebuilding the posterior canal wall and tympanoplasty can eliminate the discharging of opened cavity and reconstruct the hearing ossicular chain,Our results indicated that it is an useful procedure to treat the mastoid cavity discharging and can also improve hearing level.And it also had a good controlling of recurrence chlesteatoma.