Malleus Handle Research Articles

Repair of a Malleus‐Handle Fracture Using Calcium Phosphate Bone Cement

We report a case of a 60-year-old woman who reported a popping sound in her left ear, induced by changes in pressure, since she pulled her index finger out of her ear canal after accidentally inserting it while washing her hair. Otoscopic examination revealed a wrinkled tympanic membrane and irregular malleus handle. An isolated malleus-handle fracture resulting from barotrauma was suspected. The fracture was repaired surgically using calcium phosphate bone cement. Postoperatively, the problem disappeared and her hearing recovered. This case is the first to demonstrate the efficacy of calcium phosphate bone cement for repairing a malleus-handle fracture.

Congenital cholesteatoma in the tympanic membrane

We report here the case of a 7-month-old boy with congenital cholesteatomas in the tympanic membrane. A large mass was found occluding most of the inferior half of the tympanic membrane, with a small mass just posterior to the malleus handle. The cholesteatomas were removed via an endaural approach without violating the integrity of the tympanic membrane. Our patient is probably the youngest reported with congenital cholesteatomas in the tympanic membrane. The importance of early diagnosis of congenital cholesteatoma of the tympanic membrane is suggested, and the treatment and etiology of congenital cholesteatoma of the tympanic membrane are discussed.

Prognostic Factors in Ossiculoplasty

To analyze predictive factors of outcome after ossiculoplasty using a standard ossicular prosthesis system. Retrospective review of 140 ossiculoplasties, performed by the same senior surgeon, with titanium prostheses. Academic hospital and tertiary referral center. All patients undergoing ossiculoplasty with Spiggle and Theis or Kurz titanium total and partial prostheses. Documented, postoperative follow-up had to be provided. A total of 129 patients (140 ears; 53 men and 76 women) were evaluated. These included ossiculoplasties using 75 Spiggle and Theis prostheses (30 partial and 45 total) and 65 Kurz prostheses (35 partial and 30 total). Mean preoperative and postoperative air-bone gaps and the changes in mean hearing loss were analyzed using a four-frequency (500, 1,000, 2,000, and 3,000 Hz) pure tone average. Success rate was defined as postoperative air-bone gap within 20 dB. A one-way analysis of variance was used to analyze group differences. A multivariate statistical analysis was then undertaken to define the significant factors. There were no statistical difference between the Spiggle and Theis and the Kurz prostheses. Multivariate statistical analysis has identified the predictive value of the presence or absence of the malleus handle and the mucosal status of the middle ear in the prognosis of ossiculoplasties. Anatomical and technical factors diversely affect the functional outcome of tympano-ossiculoplasties. A better knowledge of their predictive value will enable accurate, preoperative, individual assessment when counseling patients with regard to the success of any proposed intervention. The use of these factors will also permit precise matching of future series to allow accurate comparisons.

先天性アブミ骨底板固着症例に対する手術―ツチ骨とキヌタ骨へのワイヤー固定の比較検討―

We report the surgical results of stapes surgery using the Schukneht-type wire piston prosthesis performed on 30 ears with fixation of the stapes footplate and absence of the long process of the incus. The prosthesis was reformed to avoid dislocation and fixed to the handle of the malleus. The surgical results in another 49 ears, the comparator group, in which the prosthesis was fixed to the long process of the incus because the anomaly was restricted to fixation of the footplate without other associated anomalies, were also analyzed for comparison. The mean postoperative air conduction hearing levels were 28.6dB in the subjects and 21.6dB in the comparator group, and the mean hearing improvements were 35.7dB and 29.7dB, respectively. The success rate of the operation, based on the criteria established by the Japan Otological Society, was 90% in the subjects and 98% in the comparator group. The mean postoperative air-bone gap in the subjects was 15.8dB, which was 4.3dB higher than that in the comparator group. The difference between the two groups was considered to be due to the difference in the effectiveness of the conduction mechanism after the surgery. We therefore concluded that the surgical procedure using the Schukneht-type wire piston prosthesis to fix the malleus handle is a useful surgical method that yields satisfactory results.

Rotational tomography of the normal and reconstructed middle ear in temporal bones: an experimental study

Imaging is an essential diagnostic tool in reconstructive middle ear surgery, especially in pre-operative planning. Due to ongoing improvement of imaging quality and development of new imaging techniques like e.g. rotational tomography (RT) post-operative follow-up and immediate evaluation of surgical results may become more important. The aim of this experimental study was to evaluate RT as a new tool for postoperative determination of middle ear anatomy and implant position in temporal bones. RT was performed in ten temporal bone specimen after insertion of different middle ear prostheses concerning material, shape and length (PORP; TORP; Stapes piston). An implantable hearing device (Symphonix Soundbridge) was also implanted and visualized. For comparison some specimen additionally underwent conventional computed tomography (CT), including the newest technology. Characterization of anatomical structures of the temporal bone using RT was of comparable quality to conventional CT-scans in all investigated specimen while requiring approximately 30% of the CT's irradiation exposure. Unlike CT the RT showed almost no problems due to metallic artefacts of the implanted prostheses. Furthermore RT enabled a 3-dimensional view of the temporal bone and angle determination of inserted prostheses towards the tympanic membrane and/or the malleus handle. Detailed imaging of the prostheses allowed determination of shape, material and localization within the specimen's reconstructed middle ear. The new imaging technique of RT allows precise presentation of anatomical structures and middle ear implants in temporal bones. Following these experimental results it will be our future work to evaluate this method in clinical practise.

Lateral Tympanoplasty for Total or Near‐Total Perforation: Prognostic Factors

To identify prognostic factors affecting outcome in lateral tympanoplasty for total or near-total tympanic membrane perforation. Retrospective case series. Patients were those presenting with total or near-total tympanic membrane perforation undergoing lateral tympanoplasty from 1999 to 2004. We systematically collected demographic, clinical, audiologic, and outcome information. Student t test was used to determine group differences. Logistic regression analysis was used to examine the relationship between success of grafting (dependent variable) and the independent variables. Multiple regression analysis was used to examine the relationship between postoperative air-bone gap (ABG) and independent variables. There were seventy-seven cases (58 primary and 19 revision cases) with average follow-up of 17 months. Successful tympanic membrane grafting occurred in 91% of cases. None of the independent variables studied was predictive of the success of graft incorporation (P > .05). The mean preoperative ABG was 29.8 +/- 10 dB and improved to a postoperative ABG of 16.5 +/- 11 dB (P < .001). Smaller preoperative ABG and normal malleus handle were associated with smaller postoperative ABG. In revision cases, mastoidectomy was associated with better functional results. Successful grafting of near-total and total tympanic membrane perforations occurred in 91% of the cases and was independent of demographic, disease, and technical variables. Disease variables (preoperative ABG and status of malleus handle) had a greater prognostic value on postoperative ABG than other variables. In revision tympanoplasty, mastoidectomy is associated with a better functional outcome.

Myringoplasty for anterior and subtotal perforations using KTP-532 laser

A retrospective study was performed on patients who underwent myringoplasty for either anterior or subtotal perforations over an 8-year period (from 1994 till 2004). We used the KTP-laser assisted anterior anchoring technique combining with anterior "pull-back" method. Patients' ages ranged from 6-62 years (median 36.5). The mean follow-up period was 2.8 years (minimum 6 months). The audiological results were analysed with the "Pytel software", which was developed in our department. As for the procedure, the drum remnant was freed from the malleus handle with the use of the laser and elevated out of it's sulcus anterior-superiorly. Large fascia graft was fashioned with a split of 4-5 mm in the middle of one edge. The graft was placed using the underlay technique medial to the handle of the malleus. A pull-back tunnel was created at the border of the anterior quadrants to further facilitate the survival of the graft. In this series the graft taking rate was 100%. Reperforation due to an undersized fascia was observed in one case. Post-operative audiological results indicated no bone conduction threshold elevation in any frequencies. Using the laser, cochlear trauma can be prevented, double fixation of the drum prevents lateralisation and blunting. Wide canalplasty makes both the approach and the follow-up very easy. Thorough soft tissue and bone work is advantageous from the fascia taking rate point of view.

Malleus–stapes assembly: experience with two prostheses

Tympanoplasty is often a necessary part of middle-ear surgery, the most common defect being that between an intact, mobile stapes and the malleus handle. The most readily available tissue is the patient's incus, reshaped to bridge the space between an intact stapes and the malleus. When the incus cannot be used, the hydroxyapatite Wehrs incus prosthesis can be used as an alternative.Twenty-six patients had an autograft incus ossiculoplasty and 20 patients underwent modified Wehrs incus prosthesis ossiculoplasty. The average post-operative air-bone gaps (ABGs) were 16.2 dB hearing loss (dBHL) and 17.2 dBHL, respectively. Air-bone gap closure to within 15 dBHL was achieved for 48 per cent of incus autografts and for 57 per cent of Wehrs prostheses, and to within 20 dBHL for 77 per cent and 62 per cent, respectively. Over four years follow up, the reconstruction was stable for each group, the ABGs being 17.7 dBHL and 17.1 dBHL, respectively.

The Collagen Structure of the Tympanic Membrane

To analyze the distribution of 3 collagen types in healthy tympanic membranes, during healing of a perforation, and during infection. Immunohistochemical study of collagen types I, II, and III in the tympanic membranes of healthy rats as well as during healing of a perforation and in the presence of infection with Streptococcus pneumoniae at various time points. Laboratory research center at a university hospital. Type II collagen was a main constituent of the lamina propria of the pars tensa, whereas type I collagen was found mainly in the pars flaccida. Collagen types I and III were found at the insertion to the malleus handle and in the loose connective tissue surrounding the main collagen layer of the pars tensa. After myringotomy, collagen types I and III were found at the perforation border and around dilated blood vessels early in the healing phase. During infection, the collagen layer was thickened and stained strongly for type II collagen. Collagen types I and III were found in the edematous connective tissue around the main collagen layer and around dilated blood vessels. Three months after perforation or infection, all 3 collagens were present in the lamina propria of the tympanic membrane. Extensive amounts of all 3 collagen types were present in the scar tissue in the tympanic membranes of rats that had undergone myringotomy during the presence of acute otitis media. The lamina propria of the pars tensa is mainly made up of type II collagen, whereas type I collagen is found in the pars flaccida. Thus the fibrous structure of the pars tensa and flaccida is composed of diverse collagen types, which reflects the different physiological properties of these tissues. Collagen types I and III are present in the acute healing phase after myringotomy and infection, and the collagen content of the tympanic membrane is modified during the inflammatory and healing process.

Isolierte Hammergriff-Fraktur

Eine isolierte Fraktur des Hammergriffs kann eine seltene Differenzialdiagnose bei akut einsetzender Schwerhorigkeit sein. Haufig sind diese Frakturen durch Kopftraumata bedingt. Anzeichen einer isolierten Fraktur des Hammergriffes sind neben der Schallleitungsschwerhorigkeit eine abnorme Beweglichkeit des Hammergriffs beim Vasalva-Manover mit uberhohter Compliance im Typ-A-Tympanogramm. Wir berichten uber eine Patientin mit den typischen Symptomen und Untersuchungsbefunden bei einer isolierten Fraktur des Hammergriffes. Als Frakturmechanismus wird die rasche Unterdruckentstehung nach Herausschnappen des Fingers aus dem Gehorgang diskutiert. Zusatzlich kam es mit dem Eintritt der Horminderung zu einem Tinnitus auf der betroffenen Seite. Zur Schienung der Fraktur wurde das Trommelfell mit Knorpel unterfuttert.

Ossiculoplasty with Intact Stapes and Absent Malleus: The Silastic Banding Technique

To report an original method of ossicular reconstruction with intact stapes and absent malleus. Ossiculoplasty is performed with a total ossicular replacement prosthesis positioned from the stapes footplate to the under-surface of the tympanic membrane, using a Silastic banding technique to stabilize the prosthesis. A prospective study of ossicular reconstruction using the Silastic banding technique. A consecutive series of cases with intact stapes superstructure and missing malleus handle (Austin-Kartush Group C) is presented. One tertiary referral center. Ninety-nine patients who underwent total ossicular reconstruction with Silastic banding technique were enrolled in the study from January 2000 to December 2002. Ossiculoplasty with total ossicular replacement prostheses with Silastic Rubber Band for chronic otitis media and non-inflammatory disease. Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap, bone-conduction threshold, and air-conduction threshold were assessed. Postoperative audiometry was performed at the 6th, 9th, 12th, 18th, 24th, and 36th months. Overall, a postoperative air-bone gap closed to within 10 dB was achieved in 61.5% of cases. An air-bone gap smaller than 20 dB was obtained in 77% of cases. Postoperative improvement of air-conduction thresholds by at least 20 dB was found in 51% of cases. There was no case of postoperative sensorineural hearing loss. One case of extrusion of the prosthesis was seen (1%). Stabilizing the total ossicular replacement prosthesis with the Silastic banding technique when performing ossicular reconstruction is a safe, effective method when the stapes supra-structure is present and the malleus absent.

Malleus osteotomy: improving access to the anterior tympanum

Access to the anterior tympanic cavity is often restricted by the handle of the malleus. The aim of this paper is to describe a surgical malleus osteotomy that allows the malleus handle to swing superiorly. The authors have found few problems related to this technique, especially with regard to restoration of normal post-operative hearing.

耳小骨病変の画像診断

It has been widely pointed out that multislice CT (MSCT) is useful in middle ear disease. The evaluation of the pathological state of the middle ear using 3D CT imaging has been reported on up to now. It is well known that 3D CT imaging is susceptible to post-processing artifacts, whereas multiplanar reconstruction (MPR) is less susceptible to these artifacts. The usefulness of 2D CT imaging using MPR in the evaluation of ossicular lesions in middle ear diseases is discussed.MSCT imaging was performed by Aquilion® (Toshiba Medical Systems, Tokyo, Japan). The axial spiral scans were obtained. Dosimetric measurements using a head calibration phantom were performed for evaluating the radiation exposure of the lenses. The acquired high-resolution data were transferred to a workstation (ALATO VIEW, Toshiba).In approximately 90% of ears, MPR image findings of the malleus handle, the incus long process, incudostapedial joint and the superstructure of the stapes were compatible with their operative findings. Ninety-five to 100% of ears without soft tissue shadows around the ossicles showed agreement between the findings of MPR imaging and the operation. The footplate of the stapes in 7 of 48 ears showed a “sclerotic” finding. Five ears had an “erosive” finding. There was no correlation between MPR image findings and the mobility of the stapedial footplate. The results suggest that MPR imaging is valuable for providing information on the ossicles except the stapes footplate.MPR images showed abnormal findings in 29 of 32 ears (91%) with clinical otosclerosis, which showed demineralization located at the region anterior to the oval window corresponding to the fissula antefenestram, whereas the conventional axial images showed abnormal findings in 22 of 32 ears (69%). The results suggest that MPR imaging can detect small lesions in otosclerosis.

Isolated Malleus Handle Fracture: Case Report

A 16-year-old boy with post-traumatic hearing loss of the right ear is presented with the focus on clinical and operative observations including pre- and post-operative hearing thresholds. Pre-operative audiometry revealed a conductive hearing loss in the presence of normal otoscopy. Middle ear inspection revealed a fracture of the malleus handle with fixation of the umbo to the promontory. Hearing improved after ossiculoplasty by an incus interposition.

A New L-Shaped Titanium Prosthesis for Total Reconstruction of the Ossicular Chain

To describe the technique used for total ossiculoplasty with the Fisch titanium total prosthesis and evaluate the 1-year postoperative functional results in patients presenting with the stapes (or footplate) without the malleus handle. Prospective trial with preoperative and postoperative comparison. Academic and private practice tertiary care center for otologic surgery. Forty-nine consecutive patients operated on from September 1996 to December 2000. : Staged ossicular reconstruction with a Fisch titanium total prosthesis placed between the footplate and the tympanic membrane without regard to the presence or absence of the stapes arch. Coupling of the prosthesis to the footplate was achieved by various techniques, including perforation, foot and spike on the footplate without perforation, and shaft alone (without foot) with tragal cartilage fixation (disc or small wedges). There was no interposition of cartilage between the prosthesis head and the tympanic membrane. Pre- and postoperative air and bone-conduction thresholds and air-bone gaps for pure-tone averages of three and four frequencies and for single frequencies. Postoperative air-bone gap closures within 20 dB distributed equally (50%) between 0.5, 1, and 4 kHz and reached the highest rate (89%) at 2 kHz (p < 0.05). The postoperative air-bone gaps for pure-tone averages reached 0 to 20 dB in 57% and 0 to 30 dB in 87% of the cases. There were no dead ears and no partial or total extrusions of prostheses. The best functional results were achieved through perforation coupling of the spiked foot to the footplate in large oval windows and after fixation of the shaft (without foot) with tragal cartilage disc in narrow oval windows. The functional results of the L-shaped Fisch titanium total prosthesis implanted in ears with the stapes but no malleus handle are best at 2 kHz and better than those of comparable columellar titanium prostheses over the remaining tested frequencies.

7 cases of congenital aural atresia and stenosis

We have experienced 7 cases of congenital aural atresia or stenosis in the past 10 years. They include 3 males and 4 females, and all of them are under 10 years old except for one case (47-year-old man). We performed both a canalplasty and a tympanoplasty at the same time in all cases. We have treated 3 cases as tympanoplasty type I, 2 cases as tympanoplasty type II -c, 1 case as tympanoplasty typeIV-c, and 1 case without reconstruction of ossicle, The major cause of hearing loss after the operation was lateralization of the tympanic membrane and fixation of a collumela. We performed re-operations in 2 cases by establishing a bony annulus or replacing the collumela with an artificial ossicle. If the handle of malleus is there, the interdigited method is effective to prevent lateralization of the tympanic membrane.

Direct Application of Keratinocyte Growth Factor, Basic Fibroblast Growth Factor and Transforming Growth Factor-α During Healing of Tympanic Membrane Perforation in Glucocorticoid-treated Rats

Peptide growth factors and cytokines modulate both normal and impaired wound healing. Topical application of growth factors in the form of ear drops may counteract impairment of wound healing in the tympanic membrane (TM). We applied keratinocyte growth factor (KGF), transforming growth factor (TGF)- f or basic fibroblast growth factor (bFGF) to the perforated TMs of rats in which healing impairment had been caused by systemic administration of a glucocorticoid. Histologic studies of the injured TM, including anti-5-bromo-2'-deoxyuridine immunohistochemistry, were performed on the third day after wounding. In the control ear, epidermal migration was markedly inhibited by glucocorticoid treatment and no hyperplasia was observed in any layer at the perforation edge. TMs treated with KGF showed marked hyperplasia in the epithelial layer at the perforation edge. In the bFGF- and TGF- f -treated groups, hyperplasia was observed in the epithelial and intermediate layers of the TM near the malleus handle and annulus, while no hyperplasia was seen in any layer at the perforation edge. Only KGF, therefore, improved epidermal migration in the TM, while all the growth factors tested induced hyperplasia in the TM.

Postoperative Result for Tympanic Membrane Perforation

Ears with tympanic membrane perforation show a wide range of pathophysiology from simple perforation to mobility impairment of the ossicular chain complicated by sclerotic and/or inflammatory lesions of the middle ear. In surgery on such ears, we determine checkpoints and proceed based on the order of procedure. We studied postoperative results for 37 ears of patients undergoing tympanoplasty in the 3 years from June, 1996 to May, 1999. Lesions accountable for mobility impairment of the ossicular chain were confirmed and removed in the order of calcified tympanic membrane, tip of malleus handle, around the anterior tympanic spur, and epitympanum. Success in improving in hearing was 89.2% overall. Conductive impairment (air conduction-bone conduction gap) left on the patch test was found to differ with the site and range of tympanic and middle ear lesions. This can serve as a guide in preoperatively predicting the type of operation required.

Contemporary ossiculoplastic options

Chronic suppurative otitis media frequently results in disruption of the ossicular chain. Once disease has been eradicated, the next goal of surgery is reconstitution of an intact sound conduction mechanism from the tympanic membrane to the inner ear. Many surgical techniques and prostheses have been developed to accomplish this result. Advances in biomaterials have increased their use and acceptance rather than autograft and homograft reconstruction. Use of the residual malleus handle for reconstruction is driving changes in ossicular prosthetic design. Ossiculoplasty often occurs concurrently with tympanic membrane grafting. Thus, tympanoplasty technique must be considered when ossiculoplasty is performed. Stratification of ossicular defects and middle ear status is essential to standardize reporting and allow valid comparisons between studies. The Middle Ear Risk Index is recommended as a uniform reporting protocol.

Use of the Malleus Handle as a Landmark for Localizing the round Window Membrane

Localization of the round window membrane is desirable in order to allow a more direct application of medication to the inner ear. A new procedure has been developed to deliver direct, near-continuous inner ear perfusion to the round window with the Silverstein MicroWick. In this office procedure, the wick is inserted through a tympanostomy tube into the round window niche. Accurate localization of the round window is a necessary component of this procedure. In an effort to ascertain the precise location of the round window, we examined 25 cadaveric human temporal bones and measured the distance from the umbo to the round window in each sample. We found that the round window was an average of 3.44 mm (+/- 0.68) from the umbo and was situated at an average angle of 113.2 degrees (+/- 9.8) from the long process of the malleus. Our simple and reliable determination of the relationship between the malleus handle and the round window niche allows for the accurate placement of the Silverstein MicroWick and other devices.