- 期刊
復發性耳前瘻管之手術
An Operation for Recurrent Preauricular Fistula
摘要
背景：耳前瘻管切除手術雖是小手術，但是文獻報告的手術失敗率高或是復發的機會高，這些都造成醫師與患者極大的困擾，因此有必要去探討手術高失敗率及延遲性復發的原因。 材料及方法：本研究以回朔性方式，經由病歷紀錄，從1987年6月至2006年6月，共有392人次的耳前瘻管切除手術，從其中挑選出是接受修正手術的患者作爲探討的對象。探討內容包括病人年紀、性別、接受手術的患側（左側或右側）、血液生化檢查、上次手術的時間、醫院科別及手術過的次數、麻醉方式、開刀前後所見、細菌培養及術後追蹤情形等。 結果：共有46名病患47耳（1名患者爲兩耳）共經歷64次的耳前瘻管再度手術，其中男性有13名，女性有33人，左邊爲21耳，右邊爲26耳。患者年紀從5歲到54歲，平均是25.8歲。患者再次接受修正手術時距上次手術時間，最短爲10天最長爲15年，大部分在1年內完成修正手術，共有28名29耳(62%)。患者接受手術的科別除了主要是耳鼻喉科，還包括一般外科、小兒外科、整形和皮膚科。修正手術前的主要症狀是舊傷口已形成肉芽組織併持續流膿有17耳，手術傷口雖癒合卻常會腫痛，但用抗生素可以控制的有14耳，術後傷口不癒合9耳，形成膿瘍需切開引流4耳，形成表皮樣囊腫2耳，有新的瘻管開口但仍常分泌物流出1耳。手術發現殘存的瘻管壁仍與耳軟骨相黏者最多占70%(33/47)，瘻管壁存在疤痕組織中有23%(11/47)，無殘存的瘻管壁僅傷口感染者有6%(3/47)。 結論：耳前瘻管的盲端多成多指狀突出，並有部份瘻管壁與耳輪腳的軟骨膜緊密相黏，管壁不易切除乾淨是造成手術失敗的主因。延遲性復發，本質上也是沒有把管璧切除乾淨，只是手術之後管璧與周圍組織產生不同類型的變化。出現的症狀有快慢和嚴重程度不一的的情形，因此再度接受手術的時間可以從一個月內到超過15年。了解瘻管的解剖構造，抱持慎重的態度和經驗，可以減少手術的失敗率。
並列摘要
BACKGROUND: Although excising preauricular fistula is a fairly minor surgery, the recurrence rate is high. This study attempts to determine the cause of the high operative failure rate. MATERIALS AND METHODS: A retrospective chart review was carried out of 47 revised preauricular fistula operations involving 46 patients who had visited the Mackay Memorial Hospital from July 1987 to July 2006. RESULTS: The patients ranged in age from 5 years to 54 years, with an average of 25.8 years. The time interval from the previous operation to the revised operation ranged from 10 days to 15 years. The physicians who performed the initial excision of the fistulas included otolaryngologists, plastic surgeons, general surgeons, pediatric surgeons and dermatologists. The presenting local findings before the revised operations were as follow: discharge from the granulation tissue (17 ears), persistent preauricular area swelling that was unresponsive to antibiotics (14 ears), delayed wound healing with a persistent purulent discharge (9 ears), abscess formation requiring incision and drainage (4 ears), epidermoid cyst formation (2 ears), and new aperture formation with discharge (1 ear). The residual sinus wall seemed to lead to the consequent operative failure. In our series, 62% (29/47) of the revised operation was carried out within the first year of initial extirpation. Over all 33 ears (70%) had residual fistula wall that remained on the spine of the helix and 11 (23%) ears had fistula within the scar tissue. Only three ears (6%) had wound infection without any fistula remnant being found. CONCLUSION: The presence of multiple protruding pouches associated with the fistula wall and their firm adhesion to the cartilage make complete removal of the fistula wall difficult and this is especially true during the inflammation stage. The residual sinus wall usually seems to cause the failure of the previous operation. In revision operations, it is necessary that the surgeon should first identify the residual fistula wall near the spine of helix.