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Mukhitdinov Ulugbek, Tashkent Pediatric Medical Institute, Uzbekistan E-mail: ulugbek30@mail.ru
ANALYSIS OF UNSATISFACTORY OUTCOMES AFTER TYMPANOPLASTY
Abstract: This article analyzes the unsatisfactory outcome after tympanoplasty for 12 months after the surgery of 204 patients (total 246 ears), aged from 10 to 50. Patients were divided into 3 groups, three different autografts in terms of their elasticity, thickness and springiness were used. The analysis of the research showed that 25 (10,2%) patients had an unfavorable outcome after the surgery period. Re-perforation was detected in patients of the group-I 3 months after surgery, whereas in patients group-III after 1 month. After studying this research, it was found that in order to obtain a stable effect in hearing improvement surgeries, it is necessary to take into account the age factor, the size of the perforation, the permeability of the Eustachian tube, the duration of the chronic process, the time elapsed from the last exacerbation, its correct treatment, micro-operation methods, the surgeon's experience and postoperative care, as well as preventative measures to combat acute diseases of the upper respiratory tract and violations of the function of the nasal cavity and nasopharynx play an important role in the postoperative period.
Keywords:
Relevance. Currently, chronic inflammatory diseases of the middle-ear are the leading causes of hearing loss in children [5; 10]. The problem of hearing restoration in children is of great social importance, since auditory dysfunction in early childhood leads to a delay in the formation of speech and psycho emotional development [13]. Surgical rehabilitation of hearing in children is most often performed with chronic otitis media (COM) and persistent perforations [3].
With the development of medical technology and surgeon's practical skill, the number of unsatisfactory results after hearing improvement surgeries is gradually decreasing. These long-term outcomes show that tympanoplasty is still inadequate in a number of patients, especially when extensive destructive processes require complex restoration interventions.
Over the past decades, significant advances have been made in the surgical treatment of patients with COM, however, despite this; the percentage of re-operations on the ear remains high enough and, according to different authors, is between 15% and 60% of all surgical interventions in otosur-gery[1; 2; 4; 5; 6; 8; 9; 11; 12].
Evaluation of the outcomes of tympanoplasty is important not only in specific cases, but also for all the progress of hearing improvement surgeries. According to remote outcomes of surgical interventions, it is possible to judge the correctness of indications for this type of surgery, the rational scheme of postoperative treatment and the tactics of outpatient observation
The aim of the research. Conduct analysis of unsatisfactory outcome after tympanoplasty.
Material and methods. There have been analyzed the unsatisfactory outcomes after tympanoplasty for 12 months after the surgery of204 patients (total 246 ears), aged from 10 to 50.
Timpanoplasty in the examined patients was performed in the absence of acute purulent process in the middle ear for the last 6-12 months. The study included only patients who underwent tympanoplasty of type I-III (according to Wullstein H, 1972) endaural approach, where auto materials were used as a plastic material (tragus perichondrium-cartilage, tragus perichondrium and temporal fascia muscles of the patient). The patients were divided into three equal groups. The efficacy of tympanoplasty in three groups was studied in the postoperative period for 12 months of observations by the morphological and functional results of the surgery. Evaluation of the outcomes of surgical treatment was carried out, both in the early postoperative period, and in the remote terms for the following indicators:
Dynamics of the otoscopic picture - by outcomes of a otomicroscopy examination (anatomical result);
Auditory function was assessed by outcomes of an audio-logical examination (functional outcomes);
Middle ear cavity morphology - by outcomes of CT or MSCT studies of temporal bones.
On the basis of studying the history of the disease, the nature of perforations, operative findings, in 25(10.2%) patients, in our opinion, the likely causes ofthe unsatisfactory anatomical and morphological outcomes were determined. When collecting anamnesis, the duration of COM in 107(52.5%) patients was more than 10 years, in 73(35.8%) patients from 5 to 10 years, the frequency of exacerbations of the chronic process in 142(69%) patients from 1 to 4 times in year.
In the study of all patients' eustachian tube prior to surgery, there was a violation ofventilation and drainage functions of II-III degree. Of the total group, patients with total perforation of the tympanic membrane prevailed - 147(59.8%).
Medical science
Subtotal perforation was detected in 77(31.3%) patients and small perforation in 22(8.9%) patients.
In general, patients with unsatisfactory outcomes were identified with total and subtotal defects of the tympanic membrane, with otomicroscopy before the surgery was determined in more than 90% of patients. The examined patients under the indications were tomographic examination. Tomography examination was performed according to the indications of the patients. Based on the conclusion of the MSCT of the temporal bones, the tactics of surgical treatment were conducted.
Results of the research. The examined patients were made up of three groups. In group-I, surgical treatment was performed in 69(33.8%) patients (87 ears) with dry meso-tympanitis, where tragus perichondrium-cartilage was used. However, patients have experienced repeated otorrhoea with secondary perforation, which required repeated surgical intervention. In the postoperative period within 3 months, l(l.15%)(0.00-3.39) patient had peripheral tympanic membrane perforation, after 6 months in l(l.15%)(0.00-3.39) patient, due to dysfunction of the eustachian tube and after 12 months in 3(3.45%)(0.00-7.28) patients, due to exacerbation of chronic diseases of the paranasal sinuses.
In Group-II, surgical treatment was performed in 67(32.8%) patients (78 ears) with dry mesotympanitis, where the tragus perichondrium was used. In patients of Group-II 3 months after the surgery, the autograft edge detachment occurred in 1 patient (l.28%)(0.00-3.78), which was the development of adhesion processes in the tympanum, after 6 months relapse of the disease followed by detachment in 3(3.85%)(0.00-8.11) patients,, 1 of these patients underwent re-surgery. In a follow-up in 12 months, in 4(5.13%)(0.23--10.02) patients after acute upper respiratory tract infection, a relapse of the underlying disease was detected.
There are 68 (33.4%) patients (81 ears) in group III, whom we used the fascia of the temporal muscle, after 1 month of observation, 4(4.94%)(0.22-9.66) patients had a relapse of the disease followed by the autograft detachment; there was an observation of another 4(4.94%)(0.22-9.66) patients in 3
months and another 3(3.70%)(0.00-7.82) in 6 months. All (11) patients underwent reoperation with perforation closure. In a follow-up in 12 months, l(l.23%)(0.00-3.64) of the patient had a relapse of the disease followed by perforation which was due to acute upper respiratory tract infection.
Summarizing this observation from 246 surgeries, unsatisfactory outcomes were detected in only 25 (10.2%) patients. In the first group only 5(5.75%)(0.86-10.64) out of 87 operated patients, in 4 of them (4.60%)(0.20-9.00), the hearing remained at the level of the preoperative period. In the second group 8(10.26%)(3.52-16.99) out of 78, in 7 of them (8.97%)(2.63-15.32), the hearing remained at the level of the preoperative period, in connection with the ossification of the auditory ossicles and the development of adhesive processes in the tympanum with an autograft detachment. In the third group in 12(14.81%)(7.08-22.55) patients out of 81.11 of them (13.58%)(6.12-21.04) were re-operated, improving of the auditory function failed in 5(6.2%) patients.
In patients with unsatisfactory outcomes, the average air conduction threshold in the speech frequency (500-4000 Hz) was on average 47.6 ± 10.3 Db, bone density - 11.8 ± 6.4 Db, and the level of bone-air fracture - 35.8 ± 9.7 Db.
Thus, studying the results of research, it can be said that two-layered autografts (cartilage with perichondrium) was the most durable and more "elastic" material replacing the tympanic membrane
The conclusion. Studying this research, we can assume that the main causes of reperforations were; extensive defect of the tympanic membrane, dysfunction of the eustachian tube, the process of mucous membranes, duration of chronic process, the time since the last exacerbation, its correct treatment, the age factor, the method of microoperations, experience of surgeon and postoperative care, a narrow auditory canal leading to technical difficulties during the surgery, as well as preventive measures to combat acute upper respiratory tract infection, disorders of the function of the nasal cavity and nasopharynx play an important role in the postoperative period.
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