Partial Ossicular Prosthesis Research Articles

Atrophy of the long process of the incus with unknown origin – a rare cause of acquired conductive hearing loss: A clinical case report and mini-review of the literature

Introduction: Among the pediatric population, the most common cause of conductive hearing loss is exudative otitis media. If fluid is not present in the tympanic cavity, an assessment of the middle ear transmission system is recommended. Aim: To present a clinical case of atrophy of the long process of the incus in a 17-year-old patient with a 10-year history of conductive hearing loss, exhibiting an air-bone gap of 30 to 50 dB in the right ear qualified for exploratory tympanotomy. Literature review of internet databases to identify similar clinical cases. Material and methods: CARE guidelines were used to standardize the description of the clinical case. Surgical treatment included an exploratory tympanotomy using an endaural approach, visualizing atrophy of the long process of the incus and the connective tissue band connecting the stapes head to the lateral wall of the tympanic cavity. The eardrum was preserved. An ossiculoplasty was performed using autogenic materials – interposition of the incus. Internet databases PubMed and Scopus were searched using the search string „Incus atrophy” OR „Incus necrosis” AND NOT „Stapedectomy”. Results: On follow-up one month after surgery a hearing improvement was observed with a reduction in air-bone gap to 10–15 dB. No complications were observed. Discussion: Atrophy of the long process of unknown origin is a very rare cause of acquired conductive hearing loss. A review of literature revealed 8 manuscripts describing similar cases, which are presented and discussed in the manuscript. Ossiculoplasty in such cases might be performed using autogenic or artificial materials as partial ossicular prostheses or bone cement. Conclusions: Careful evaluation of imaging studies and hearing tests can often identify a defect in the conductive system; exploratory tympanotomy is often required. In cases such as the one presented, interposition of the incus might be a viable option.

Ossiculoplasty Outcome Parameter Staging Index as a Prognostic Factor in Ossiculoplasty

Aims: To evaluate the prognostic value of Ossiculoplasty Outcome Parameter Staging (OOPS) index with reference to the audiological outcome in the patients undergoing ossiculoplasty. Study Design: A prospective study. Setting: A tertiary referral hospital. Subjects: The study comprised 118 patients suffering from chronic otitis media with or without cholesteatoma. Materials and Methods: Ossiculoplasty was done by autologous incus interposition, partial ossicular prosthesis, and total ossicular prosthesis. Temporalis fascia graft was used for myringoplasty in all the patients. When partial ossicular replacement prosthesis or total ossicular replacement prosthesis was used a thin slice of cartilage was interposed between graft and prosthesis. The mastoidectomy was performed when needed, and whenever possible, a canal wall-up procedure was performed. Results: The short-term (measured after 3 and 6 months of surgery) and long-term (measured at 1 and 2 years after surgery) outcome of ossiculoplasty measured as a relationship between mean audiological gain and OOPS index score had a statically significant difference. Conclusion: The OOPS index is an appropriate prognostication index to predict accurately both the short- and long-term outcome of ossiculoplasty.

Ossiculoplasty in incudostapedial joint defects: audiologic outcomes of three type of partial ossicular prostheses in retrospective clinical study 1995‐2015

Ossiculoplasty in incudostapedial joint defects: audiologic outcomes of three type of partial ossicular prostheses in retrospective clinical study 1995‐2015

Postoperative hearing in tympanoplasty preserving the manubrium of malleus and tensor tympani muscle tendon

Objective:To study the effect of retaining the manubrium of malleus and tensor tympani muscle tendon （TT） on postoperative hearing reconstruction in tympanoplasty. Methods:Ninety-seven patients underwent tympanoplasty and ossiculoplasty in Peking University Third Hospital from January 2012 to December 2017, their postoperative results of audiometry were analyzed and compared with the preoperative results. The patients were divided into two groups according to retaining the manubrium of malleus and TT or not during the operation. Retention group include the cases with the manubrium of malleus and TT retained, resection group include the cases with TT resected with the manubrium retained or resected. T test was used to analyze and compare the differences of air conduction threshold air-bone gap （ABG） and the postoperative improvement between the two groups. Results:One year after operation, the air conduction thresholds and ABG were lower in retention group （n= 44） than those in resection group （n= 53） at each frequency, and there were differences with statistically significant at 0.25, 0.5 and 1.0 kHz （P<0.05）; the postoperative improvement of hearing thresholds and ABG at above frequencies in retention group was better than that in resection group. In cases with canal-wall-up operations or partial ossicular prostheses implanted, the above differences still existed between the two groups with statistical significance （P<0.05）; while in cases with canal-wall-down operations or total ossicular prostheses implanted, there were no significant differences between the two groups （P>0.05）. Conclusion:The preservation of the manubrium of malleus and TT is significant for postoperative hearing improvement in tympanoplasty, especially in the canal-wall-up operation with partial ossicular prostheses.

Monograph on Tympanosclerosis-Clinico-Pathological Corelation and Surgical Outcome: A Retrospective Study.

A retrospective study was conducted at a tertiary ENT care hospital with following aims, methodology and results: (1) To know the incidence of tympanosclerosis. (2) To classify tympanosclerosis surgically as well as histologically. (3) To know the long term hearing outcome of Tympanosclerosis surgery. It is a retrospective study at an ENT Hospital Centre in eastern India. Hospital ethical board clearance was duly obtained. All cases of tympanosclerosis were documented with special reference to surgical procedure, areas of involvement and postoperative hearing outcome. In this study, 90 cases of tympanosclerosis was found in 1880 cases of tympanomastoidectomies in 8years and had been divided into (1) Myringosclerosis (60 cases, 66.6%), (2) Ossicular Tympanosclerosis without involvement of footplate (23 cases, 25.6%), (3) Ossicular Tympanosclerosis with involvement of footplate (7 cases, 7.8%). Treatment options included osssicular mobilization keeping ossicular integrity and mobility, Total or partial ossicular prosthesis after removal of incus & stapes suprastructure, stapedectomy with Long malleus-footplate piston. Overall good hearing outcome (i.e., postoperative air-bone gap less than 20dB) was noticed in 85.5% of cases of Tympanosclerosis. Removal of tympanosclerosis with keeping the osssicular chain intact is the key to success; results are not favourable if footplate is totally fixed with disease.

Anatomical and functional results of ossiculoplasty with adjustable length titanium prostheses with and without hydroxyapatite

To compare the anatomical and functional results of the ossicular chain reconstruction with classic titanium adjustable prostheses and titanium adjustable prostheses with hydroxyapatite cap. The 300 patients (360 cases) with chronic suppurative otitis media were examined and operated. The patients are divided into 2 groups. Group A included patients who received an ossicular prosthesis with a hydroxyapatite cap (90 cases with a partial prosthesis and 90 with a full one). Group B included patients who received prostheses without hydroxyapatitis (90 cases with a partial prosthesis and 90 with a complete one). The patients who received a prosthesis with a hydroxyapatite cap were divided into two subgroups, depending on the autotissue, which was placed between the prosthesis cap and the nontympanic membrane: this is an autocartilage plate or perichondrium/fascial graft. The follow-up period after surgery was 38.5±14.4 months (from 12 to 48 months). In the long-term postoperative period, the subjects were assessed the values of the bone-air gap (BAG), the consistency of the nontympanic membrane, and the presence of signs of extrusion of the prosthesis cap. Comparison of anatomical and functional results between patients with full and partial ossicular prostheses was performed separately. A good result in the form of a 20 dB or more dB BAG reduction was achieved in 82.2% of patients who received a partial prosthesis (85 patients in group A and 63 in group B), and in 57.8% of patients who received a complete prosthesis (45 patients in group A and 59 in group B). The BAG values in the long-term period after surgery did not statistically significantly differ between patients who received a prosthesis with a hydroxyapatite cap or a fully titanium one (p=0.939 for patients with full prostheses and p=0.745 for patients with partial prostheses). The placement of cartilage or perichondrium/fascial graft between the hydroxyapatite prosthesis cap and the nontympanic membrane also did not affect the functional outcome (with full prostheses - p=0.651, with partial prostheses - p=0.142). It is possible to use ossicular prostheses with a hydroxyapatite cap without placing an autocartilaginous plate between the nontympanic membrane and the cap of the prosthesis. In the long term period, functional and anatomical results with hydroxyapatite cap prostheses do not differ statistically significantly from those with all-titanium prostheses.

State of the Art: Reconstruction with Synthetic PORP and TORP

The purpose of this review article is to present salient pearls of successful ossiculoplasty, with particular attention paid to reconstructive strategies with synthetic partial ossicular prostheses and total ossicular prostheses. A refined level of dexterity and an appropriate attention to detail are needed to optimize audiometric outcomes in ossiculoplasty, as is a fundamental understanding of middle ear mechanics and the consistent anatomical relationships that exist in the middle ear, but perhaps the most important determinant of long-term hearing outcomes in ossiculoplasty is the middle ear environment. Successful ossiculoplasty requires a prudent and thoughtful approach to all phases of the patient’s care, and the final audiometric result is a synergistic product requiring both careful preoperative assessment, thoughtful prosthesis selection, and proficient technical execution.

Endoscopic exclusive transcanal approach to the tympanic cavity cholesteatoma in pediatric patients: Our experience

ObjectivesThe aim of the present study is to describe our experience in the management of tympanic cavity cholesteatoma in pediatric patients, treated with endoscopic exclusive transcanal approach. MethodsA chart review of clinical data and videos from the operations of 54 pediatric patients, undergoing surgery between January 2007 and December 2013, was made. Patients presenting with cholesteatoma involving the tympanic cavity (mesotympanum, epitympanum, protympanum and/or hypotympanum), with no mastoid involvement, were included in the first group and underwent an exclusive transcanalar endoscopic approach (TEA). In case of mastoid extension of the pathology, patients were included in the control group and underwent a canal wall up microscopic technique (CWU). ResultsIn this study, 34 males and 20 females, including 5 bilateral cases, giving a total of 59 ears, were reviewed. Median age was 9.6 years (range 4–16 years). 31 cholesteatomas underwent a TEA approach, while 28 underwent a CWU approach, based on inclusion criteria. No differences from congenital vs acquired form was made, due to the difficult to correctly distinguish always the two forms. The ossicular chain was preserved in 26.6% of patients (16 ears): 42% of patients (13 ears) undergoing a transcanal endoscopic approach and 10% of patients undergoing a canal wall up microscopic approach (3 ears) (P=0.006). Second look surgery was executed in 41.6% of patients (25 ears). In partial ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 29.4dB, while the mean postoperative pure-tone average was 27.1dB, with a mean increase of 2.3dB. In total ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 47.8dB, while the mean postoperative pure-tone average was 26.5dB, with a mean increase of 21.3dB. Recurrence rate was 12.9% (4 ears) for the transcanal endoscopic approach group and 17.2% (5 ears) for the canal wall up microscopic approach. Residual disease was present in 26.6%: 19.3% (6 ears) for the transcanal endoscopic approach group and 34.4% (10 ears) for the canal wall up microscopic approach. The mean follow up was 36 months (range 8–88). Kaplan–Meier analysis at 36 months showed a lower recurrence risk for the transcanal endoscopic approach compared with the canal wall up microscopic approach, but this data was not statistically significant (P=0.58). ConclusionThe transcanal endoscopic approach represents a feasible, minimally invasive and conservative technique for the management of pediatric middle ear cholesteatoma.

Comparisons of the mechanics of partial and total ossicular replacement prostheses with cartilage in a cadaveric temporal bone preparation

Conclusions: Reconstruction of the ossicular chain differentially affects the motion of the tympanic membrane (TM) and the stapes. Objectives: To determine the effect of different ossicular replacement procedures on the sound-induced motion of the TM and stapes. Methods: A combination of digital stroboscopic holography and laser Doppler vibrometry was used to determine the sound-induced motion of the TM and stapes in cadaveric temporal bones in which the ossicular chain was reconstructed using 12 varied standard techniques. The variations included the use of total or partial ossicular prosthesis, size of cartilage interposed between the TM and the prosthesis, and the length or fit of the prosthesis between the TM and stapes. The measurements were carried out in repeated measures format, so that each manipulation was performed in each temporal bone. Results: The volume displacement of the TM was in general reduced by reconstruction, with the largest reductions occurring with high-frequency stimulation in the reconstructions with a ‘large’ cartilage oval interposed between the TM and the prosthesis. Larger stapes motions in response to low-frequency sound were observed with either ‘loose’ or ‘best’ fit TORP with a ‘small’ cartilage plate between the TM and the prosthesis.

Hearing Outcomes in Functional Surgery for Middle Ear Malformations

To standardize the information for families of children having functional surgery for middle ear malformations, we describe the audiometric results of the subgroup of patients with the most favorable anatomic conditions: viable auditory canal, intact tympanic membrane, mobile stapes, and corresponding to a Jahrsdoerfer score of 8 or higher. Case series, tertiary referral center. Charts of patients undergoing functional surgery for congenital middle ear malformations were reviewed for demographic data, preoperative Jahrsdoerfer score, ossicular chain status, type of ossiculoplasty, and audiometric data before and 6 months postsurgery. Eighteen consecutive interventions were performed on 13 patients (average age of 9 years, 8 girls and 5 boys) between 2004 and 2011. The ossiculoplasties performed were as follows: incus repositioning (4), double-layer tragal cartilage (5), intact native chain reconstruction (3), and partial ossicular prosthesis (6). Mean air bone gap (ABG) was 40.8 ± 12.4 dB preoperatively and 20.9 ± 12.9 dB postoperatively (p < 0.0001). Preoperative and postoperatively mean air conduction PTA thresholds were 49.9 ± 9.5 and 30.0 ± 14.1 dB, respectively (p < 0.0001). All ears operated on except one had air conduction improvement. There were no complications. Functional surgery for congenital middle ear malformations gives variable hearing outcomes. In this study, with the most favorable anatomic conditions, 12 ears (67%) of 18 had air conduction improvement below 30 dB.

A new approach for malleus/incus fixation: no prosthesis necessary.

To describe a novel approach to manage malleus/incus fixation. Retrospective review of 363 patients with conductive hearing loss operated on since 1996. Academic tertiary referral center. Three hundred sixty-three patients with conductive hearing loss, an intact tympanic membrane, and without history for chronic infection underwent middle ear exploration. Three hundred forty-three had otosclerosis and underwent laser stapedotomy; the remaining 20 patients had laser release of their malleus/incus fixation. Twenty patients are presented in this paper. Nineteen patients were diagnosed with malleus fixation before surgery. One patient had a total perforation and mobility of the ossicular chain was not verified preoperatively. This patient was, intraoperatively, noted to have complete ossicular fixation. Conductive hearing loss was identified using audiometry and tuning forks. Nineteen of the 20 patients had the diagnosis confirmed using micropneumotoscopy and noting immobility of the malleus. A transcanal approach was used, and the malleus/incus fixation was released using a laser. This space was expanded upon using a drill. A 1.5-2.0 mm space was created where the ossicular fixation existed, thereby reducing the likelihood of refixation. Audiometric studies before and after intervention were compared. One to seven years of follow up are provided. Preoperative air-bone gaps ranged from 18 dB to 51 dB and averaged 33 dB. Postoperative air-bone gaps ranged from 1-36 dB and averaged 13 dB. No patients have experienced refixation. There were two complications: one perforation requiring a tympanoplasty and one patient sustaining a 20 dB high-frequency sensorineural loss, most likely secondary to inadvertent drill contact to the ossicular chain. When fixation of the malleus and/or incus is found, treatment options exist. A common technique involves removal of the incus and head of the malleus and reconstruction with an incus interposition or a partial ossicular prosthesis. Another technique proposed by the senior author (M.D.S.) is maintenance of the normal anatomy and use of the potassium-titanyl-phosphate laser and drill to free the ossicles and widen the epitympanum. This series shows successful closure of the air-bone gap with this technique.

Universal middle ear prosthesis

A middle ear prosthesis 10 is provided having a first portion 12 including a head 16 for engaging the tympanic membrane and a cannulated shaft 20 extending from head 16. The first portion of 12 is operable alone as a partial ossicular prosthesis. A second portion 14 is provided including a shaft having a distal portion 26 insertable in the cannulated shaft 20 of first portion 12. Second portion 14 when in combination with first portion 12 provides a total ossicular prosthesis.