Hüttenbrink K B
Universitäts-HNO-Klinik Dresden.
HNO. 1994 Sep;42(9):582-93.
The two classic types of chronic otitis media--chronic suppurative disease and cholesteatoma--not only differ in their clinical course and prognosis, but they also require different therapeutic strategies. Benign chronic suppurative disease with its chronic irritating otorrhea can often be managed conservatively. Surgery is recommended if improvement of hearing is the goal, but also to heal the chronic inflammatory disease. Diagnosis of a cholesteatoma, however, is a clear indication for surgical treatment; conservative and wait-and-see strategies are the exception. Even in cases of precholesteatoma, there is an increasing tendency for surgery to be performed to halt the progress of the retraction pocket. Preparations for ear surgery comprise an extensive investigation with tympanic microscopy, audio- and vestibulometry and radiography. The information given to the patient must be comprehensive, and should include details of operative strategies and the risks involved, thus allowing the surgeons to adapt their operative techniques to intraoperative findings. Several surgical techniques are recommended for the removal of cholesteatomas. There is no "best" method, however, as shown by fluctuations in the different more or less dogmatically propagated techniques performed in the last few decades. Nowadays, the operative procedure, i.e. whether open or closed technique, retroauricular or endaural approach, is individualized, which means the appropriate technique is chosen according to the requirements of a given case. Each technique has its own specific advantages (and disadvantages) and can be employed taking into account the individual factors of the chronic ear disease to be treated in order to reduce the intolerably high recurrence rates. The acoustic results of tympanoplasty, the pathophysics of which are briefly described, are also unsatisfactory. Closure of a drum perforation alone is connected with a high success rate regardless of the material used. Hearing results of ossicular chain reconstruction depend only partially on the prosthesis material in spite of the strong propagation of modern materials. Rather, mechanical factors and unresolved problems such as continuing tubal dysfunction and chronic inflammation are crucial as regards the successful restoration of normal hearing. Postoperative complications such as inner ear trauma, facial nerve injury etc. are rare; early diagnosis and treatment of complications improve the prognosis. The careful, sometimes extensive postoperative management is necessary and must continue lifelong in cases of cholesteatoma because of the high recurrence rate.
慢性中耳炎的两种经典类型——慢性化脓性疾病和胆脂瘤——不仅在临床病程和预后方面存在差异，而且需要不同的治疗策略。良性慢性化脓性疾病伴有慢性刺激性耳漏，通常可采用保守治疗。如果以改善听力为目标，或者为了治愈慢性炎症性疾病，建议进行手术。然而，胆脂瘤的诊断明确提示需要进行手术治疗；保守和观望策略为例外情况。即使在胆脂瘤前期病例中，为阻止回缩袋进展而进行手术的趋势也在增加。耳部手术的准备工作包括通过鼓膜显微镜检查、听力和前庭功能测定以及放射学进行广泛检查。向患者提供的信息必须全面，应包括手术策略细节和所涉及的风险，从而使外科医生能够根据术中发现调整手术技术。对于胆脂瘤的切除，推荐多种手术技术。然而，正如过去几十年中或多或少教条式推广的不同技术的波动情况所示，不存在“最佳”方法。如今，手术方式，即开放或闭合技术、耳后或耳道内入路，是个体化的，这意味着根据特定病例的要求选择合适的技术。每种技术都有其自身的特定优势（和劣势），可以考虑待治疗的慢性耳部疾病的个体因素来采用，以降低高得令人无法忍受的复发率。鼓膜成形术的声学效果，其病理物理学将简要描述，同样不尽人意。无论使用何种材料，单纯封闭鼓膜穿孔的成功率都很高。尽管现代材料大力推广，但听骨链重建的听力结果仅部分取决于假体材料。相反，机械因素以及诸如持续的咽鼓管功能障碍和慢性炎症等未解决的问题对于成功恢复正常听力至关重要。内耳创伤、面神经损伤等术后并发症很少见；并发症的早期诊断和治疗可改善预后。谨慎的、有时是广泛的术后管理是必要的，并且由于复发率高，胆脂瘤病例必须终身持续进行。
