Stapes Superstructure Research Articles

術後性乳突腔障害症例の検討

The open method is useful as a surgical technique for aural cholesteatoma or adhesive otitis media, but there are problems that arise from the opened mastoid cavity.Eighty-five ears with mastoid cavity problems, which had been operated on at our clinic from 1982 to 1991, were examined in this study. Earlier, One operation had been conducted on 52 ears, 2 on 24 ears, 3 on 7 ears, and 4 and 5 on 1 ear each. The average number of operations per ear was thus 1.5. The time since the first operation was 3 years and 4 months to 58 years and 1 month (average, 28 years and 11 months). The initial disease was chronic suppurative otitis media in 24 ears, aural cholesteatoma in 19, acute mastoiditis in 9 and unknown in 33.The main complaint of 62 patients was otorrhea. Thirty-four were found to have vestibular vertigo when the mastoid cavity was being cleaned. Only 8 labyrinthine fistulae were recognized during operation. In 45 ears the malleus was missing, in 51 ears the incus, and in 37 ears the stapedial super-structure.The mastoid was obliterated in 69 ears, bone chips were used in 50 ears and hydroxyapatite granules in 19 ears. The canal wall was reconstructed in 10 ears and revision operation was conducted in 6 ears. After mastoid obliteration, otorrhea was found in 6 patients, drum retraction in 6, and drum perforation in 2. In 31 of the 34 patients with vertigo there was good improvement after the operation. Hearing was generally not improved, especially in types 3 and 4 with ossicular reconstruction.

Ossicular Reconstruction in Ears With Cholesteatoma

Ossicular reconstruction in ears with cholesteatoma is similar to ears without cholesteatoma involvement. The important difference is that all cholesteatoma must be meticulously and completely removed or the reconstruction will fail. Special prostheses of bone or hydroxyapatite are used to rebuild the conductive mechanism. If only the incus is absent, an incus replacement prosthesis is employed between the malleus and intact stapes. When the stapedial superstructure is also missing, the incus-stapes prosthesis is utilized. These prostheses are interlocking in that a notch created in the top of the body of the implant engages the malleus and a cup in the lower part slips over the stapedial head, or a shaft extends to the stapedial footplate when the stapedial crura are missing. In either case the patient hears by direct columellar pressure from the new tympanic membrane to the fluids of the inner ear. Care is taken to preserve the patient's tissues and anatomy for use in reconstruction. If the patient's malleus or posterior bony wall must be sacrificed to eradicate the disease, these structures are immediately rebuilt with homograft tissue so that an orderly rebuilding of the conductive components may proceed. If the cholesteatoma has been extensive or infected and the middle ear mucosa is of poor character, definitive reconstruction is delayed to a second stage.

Superstructure of stapes: an analysis by high-resolution computed tomography

High-resolution Computed Tomography (HRCT) of the temporal bone has now become a routine test for the diagnosis of various temporal bone lesions. Correct assessment of such minute structures as ossicles, especially stapes, is important in the pre-operative HRCT evaluation. On the other hand, analysis for the reliability of HRCT findings has not been done, including the superstructure of the stapes. A retrospectively study was done in order to assess the availability of HRCT findings in axial overlapping scans in 226 ears, with respect to the superstructures of stapes. The study was concerned with the analysis of HRCTs of 148 normal ears, 71 ears of chronic otitis media and 7 ears of ossicular abnormalities. HRCT findings were compared to those of surgeries in pathological cases. The present study revealed that the superstructures of stapes are noted in 70% when the stapes surrounded by air. The major limitations in the proper analysis of stapes by HRCT are partial volume averaging and effects of soft tissue silhouetting, this is especially so when the stapes is surrounded by soft tissue density.

Osteogenesis Imperfecta of the Temporal Bone and its Relation to Otosclerosis

Osteogenesis imperfecta (OI) designates a heterogeneous group of heritable disorders of connective tissue that in addition to bone may affect tendons, ligaments, fascia, skin, sclerae, blood vessels, teeth, and hearing. The current classification identifies at least four major syndrome groups or types. It also recognizes a considerable number of additional syndromes that may represent supplementary types or subgroups. Loss of hearing is the least constant of the prominent features of OI. Its incidence varies between 26% and 60%. In OI, formation and remodelling of bone are variously affected. In the temporal bone the development of the inner ear capsule may be involved severely. In the stapes the disturbance in lamellar bone formation can lead to extreme thinness, dehiscence, and nonunion of the stapedial superstructure with the footplate. Osteogenesis imperfecta can be associated with otosclerosis, another bone dysplasia with a different morphology. Otosclerosis, in turn, may interfere with sound conduction and perception. Thus, the hearing loss encountered in OI may be the result of OI, otosclerosis, or a combination of both.

Hearing results after cholesteatoma surgery: the Iowa experience.

This study compared the hearing outcome of canal-up and canal-down mastoidectomies for removal of cholesteatoma in 455 ears. An intact canal wall procedure was performed in 92 patients while the remainder (N = 363) underwent a canal-down operation. The hearing results for both procedures are dependent on the presence of the stapes superstructure. When the stapes superstructure was intact, 52% of the patients with canal-up operations had an air-bone gap of less than 20 dB. The corresponding figure for canal-down cases was 37%. When there was no stapes superstructure, 54% of the canal-up cases and 19% of the canal-down cases obtained a similar ABG closure. Preserving the posterior external auditory canal wall results in slightly better hearing function. However, when the stapes superstructure is intact, the difference in hearing function is not remarkable, and must be weighed against the potential for residual disease or recurrence associated with canal-up procedures.

Reconstructing the absent lenticular process.

When a surgeon encounters an absent lenticular process of the incus, he must either reposition the incus or attempt to bridge the small gap between the remaining incus long process and the stapes capitulum. Our solution to this problem is to place a Lippy modified Robinson stapes prosthesis on the stapes footplate and attach it to the remaining long process, thus bypassing the stapes superstructure. This modified Robinson prosthesis has a portion of the well removed allowing the eroded long process to enter from the side. The hearing results of 63 cases at 6 months (two-thirds of which had a concurrent tympanoplasty) are 67% within 10 dB and 91% within 20 dB of the preoperative bone hearing level. The use of an existing and proven prosthesis provides both stability and, to date, the most successful hearing results for reconstructing the absent lenticular process.

The predictive value of high resolution computerized tomography in chronic suppurative ear disease.

High resolution computerized tomographic scanning was used in the preoperative evaluation of 50 patients with chronic suppurative ear disease. The radiological predictions were compared with the operative findings in each case. This form of imaging proved to be highly accurate in depicting the extent of soft tissue within the middle ear cleft and mastoid. With the exception of the long process of the incus and the stapes superstructure, the state of the ossicular chain was correctly predicted in over 90% of cases. Erosion of the labyrinth was clearly depicted in 4 of the 5 cases in which it occurred. A correct pathological diagnosis was made radiologically in 44 cases (88%). The selective use of this modality in the evaluation of patients with chronic suppurative otitis media is valuable.

Ceramic prostheses used as a columella.

Ceramic stems, their lateral end capped with a modelled ossicle, or ceramic prostheses manufactured with a cap-shaped head were used as a columella from the stapes footplate to the tympanic membrane or a fascia graft in 41 ears operated on during 1982-1985. Six ears had no membrane perforations and no severe disease of the tympanic mucosa. Twelve ears underwent primary operations for cholesteatoma and 23 ears had revision surgery. Good hearing improvement occurred in well-aerated ears while hearing in ears with extensive tympanic disease did not improve after surgery. No tissue reactions to the ceramic prosthesis were observed and no prosthesis was extruded. Ceramic can be regarded as an acceptable alternative to bone for columella grafts used in surgery for chronic middle ear disease when the stapes superstructure is missing.

Possible role of peptides derived from otosclerotic bone in the mechanism of sensorineural hearing loss.

Otosclerotic stapes footplates, superstructures and temporal cortical bones were extracted with 0.25 M guanidine X HCl 0.5 M EDTA (pH 7.4) solution. The extracted non-collagenous peptides/proteins were separated chromatographically on a Sephadex G-25 microcolumn. The peptide composition of the bone samples were compared by capillary analytical isotachophoresis (ITP) in the molecular mass range 0.3-5 kD. The otosclerotic stapes footplate contained 13 ITP subfractions, while the stapes superstructures and cortical bone contained only 9 and 10, respectively. An otosclerosis-specific ITP subfraction was also detected in the stapes footplate, but not in the stapes superstructure or cortical bone. This subfraction was previously demonstrated in the otosclerotic perilymph as well. Four ITP subfractions occurred common in the otosclerotic stapes footplate, the superstructure and the cortical bone. Two of these common subfractions were not found in the cortical bone peptide extract, but all of them revealed higher than normal levels in the otosclerotic perilymph.

Non-collagen proteins of stapedial bone matrix in perilymph of otosclerotic patients.

Non-collagen proteins extracted from the otosclerotic stapes footplate, superstructure and temporal cortical bone were compared with the protein patterns of normal and otosclerotic perilymph by analytical isotachophoresis (ITP). Normal and otosclerotic perilymph yielded basically identical isotachophoretic subfractions. Thirteen subfractions were detected moving as anions at pH 9.6 in the normal perilymph, versus 16 subfractions of similar character in the otosclerotic perilymph. Of these 16 protein subfractions, one (which was not detected in the normal perilymph) could be found in the ITP-gram of the stapes footplate non-collagen proteins, but not of the stapes superstructure or temporal cortical bone. Our results support the concept that protein can enter the inner ear fluid spaces from the otosclerotic bone. The biological significance of these proteins has not yet been clarified.

Cathepsin-B activity in otosclerosis.

Cathepsin-B activity was determined fluorimetrically in the otosclerotic stapes footplate, the stapes superstructure, normal temporal cortical bone, and os frontale osteoma. Measurements with a synthetic substrate made determinations in individual samples possible. The cathepsin-B activity in the otosclerotic stapes footplate was one order of magnitude higher than that of the superstructure, which was not affected by the disease. The cortical bone and the superstructure displayed similar activities, as did os frontale osteoma and otosclerosis. The high lysosomal proteinase activity appears to be closely connected to the otosclerotic bone resorption process.

アブミ骨上部構造消失例の臨床像

Preoperative hearing loss, microorganisms isolated from ear discharge, duration of ear complaints, the ages of patients, surgical treatment and postoperative restoration of hearing were studied in chronic suppurative and cholesteatomatous otitis media with destroyed stapedial superstructure. Pre- and postoperative hearing loss were determined by averaging air-bone gaps of 0.5, 1, and 2kHz.The following results were obtained.1) Dehiscence of the stapedial superstructure is more frequently found in cholesteatoma than in chronic suppurative otitis media. The stapedial superstructure was more rapidly destroyed in cholesteatoma.2) Pseudomonas aeruginosa was isolated with a significantly higher incidence from ear discharge of chronic purulent otitis media.3) Infection of plural micro-organisms was found to have no significant effects on stapedial destruction.4) Preoperative audiograms showed air-bone gags of 30dB or more at all frequencies in 42.9% of the patients, and 26.6% of them showed air-bone gaps of 30dB or more at all frequencies except one.5) Postoperative air-bone gaps were around 30dB in 7 of the 13 radical mastoidectomy ears.6) Postoperative air-bone gaps were 33.9dB for radical mastoidectomy, 29.0dB for type IV tympanoplasty and 25.8dB for modified type IV tympanoplasty.

Edge enhancement computed tomography scanning in inflammatory lesions of the middle ear.

The high resolution modification of an EMI 5005 scanner was utilized with an edge enhancement technique to study inflammatory lesions of the temporal bone. Bone erosions caused by cholesteatomas can be accurately delineated because of the circumscribed nature of expansion. The soft tissue masses cannot be appreciated by present CT techniques. Erosions of the horizontal semicircular canal and involvement of the sinus tympani are readily visualized by CT scanning. Computed tomography is limited in demonstrating the stapes superstructure and horizontal portion of the facial canal due to the inability to obtain good coronal scans. The remaining ossicles can be demonstrated with equal clarity with pluridirectional tomography.

The experience of Kraków ORL clinic with ear operations in children

To determine the results of various types of tympano-ossiculoplasties and the degree of functional restoration following surgery.This prospective study comprises 51 consecutive patients with chronic suppurative otitis media (CSOM) – tubotympanic disease (TTD) and atticoantral disease (AAD), who presented to the academic department of Otorhinolaryngology – Head & Neck Surgery, in a tertiary care hospital in South India. All patients underwent a thorough examination and appropriate investigations. Eustachian tube function (ETF) was assessed preoperatively by methylene blue dye test and saccharin test. The size of the mastoids was measured by using a graph paper, on which the X-ray film of the mastoid taken in the lateral oblique view (Law’s view) was superimposed. Patients with CSOM (TTD) with less than 3 months of dry ear and small size mastoids on X-ray were subjected to cortical mastoidectomy and type I tympanoplasty; whereas patients with dry ear more than 3 months underwent type I tympanoplasty alone. Type III tympanoplasty was carried out in those with erosion of incus/malleus by placing temporalis fascia over the stapes superstructure. Patients with AAD underwent modified radical mastoidectomy (MRM) and ossicular reconstruction was carried out depending on the remnant of the ossicles. Partial Ossicular Replacement Prosthesis (PORP) made of plastipore was used for Austin’s type b ossiculoplasty; while Plastipore/Gold was used as Total Ossicular Replacement Prosthesis (TORP) in type d ossiculoplasty. Patients were reviewed after 15 days, 1 and 3 months post-operatively for a clinico-audiological assessment of the operated ear to evaluate the graft status and hearing improvement. The postoperative audiograms were recorded on the 2nd and 3rd visit.Of the 51 patients with CSOM; 37 had TTD and 14 had AAD. Of the 37 patients with TTD, 35 patients had normal ETF and 2 of them had partial dysfunction. With normal ETF, the graft uptake rate was 80% compared to partial ETF which had only 50%. Patients with large and medium size mastoids had 89% of graft uptake. Patients with small and medium size perforations had 100% graft uptake; whereas large and subtotal perforations had 75% and 71.43% respectively. A total number of 34 tympanoplasties and 17 ossiculoplasties were done. Of these; 29 were type I and 5 were of type III. Out of 17 ossiculoplasties, 3 were type b and 14 cases were of type d. We used 7 Gold and 7 Plastipore TORP for the type d ossiculoplasty and PORP in 3 of the cases. Using temporal fascia as graft material 34 patients underwent tympanoplasty in whom the graft uptake was 79.41%, while 17 patients underwent ossiculoplasty using temporalis fascia as graft, the graft uptake was 88.23%. Tympanoplasty done for small and medium size perforations had 100% hearing improvement with A–B gap <20 dB but patients who had large or subtotal perforations had 80% and 67% respectively. Hearing improvement to an A–B gap <20 dB was noted in 91% and 60% following type I and type III tympanoplasty respectively. Hearing improvement to an A–B gap <20 dB was noted in all the cases of type b ossiculoplasty and with type d ossiculoplasty (42%).Patients with normal Eustachian tube function, large and medium size mastoids, small and medium size perforations of the tympanic membrane would have a good rate of graft uptake with tympano-ossiculoplasties thereby returning to normal hearing postoperatively.

Experience With a Polyethylene Total Ossicular Replacement Prosthesis

Surgical reconstruction of ossicular defects in chronic middle ear disease is a difficult problem. We have reviewed our results with the use of the Plastipore total ossicular replacement prosthesis (TORP). Of 29 procedures that were analyzed, nine were considered successful. None of our patients had a stapes superstructure, and 13 had no malleus. Placement of the TORP under the malleus handle and use of extra tissue between the prosthesis and the tympanic membrane provided better hearing results, but extrusion of the prothesis still occurred. Positioning of the prosthesis and contraction of the middle ear space, which causes extrusion of the prosthesis, remain problems in this type of reconstruction.

Quantitation of digital clubbing by shadowgram technique.

Finger clubbing was quantified from the magnified silhouette of the right index finger in controls and patients with clubbing, using a simple shadowgram technique. There was good correlation between clinical assessment and measurement of both the profile angle and the hyponychial angle. The hyponychial angle appeared to be a more accurate indicator of clubbing than the profile angle.

Homograft Tympanoplasty Techniques and Results for Restoration of Hearing

The use of a homograft tympanic membrane with and without attached ossicles, staging the operation, and the use of sculptured homograft or autograft ossicles have improved the results in tympanoplasty. The indications and techniques of homograft tympanoplasty are described, and the results in 99 primary cases and 11 cases with repair of a mastoid cavity are given. The overall graft success rate was 86 per cent. In patients with an intact ossicular chain, the conductive loss was reduced to less than 20 dB. in 88 per cent. A hearing loss less than 20 dB. was obtained in 68 per cent with an intact stapes, in 77 per cent when the stapes superstructure was absent, and in 79 per cent in stapedectomy done at a second stage. The use of homograft material has provided the means for significantly improving the results in our patients who require tympanoplasty.

Symposium: contraindications to tympanoplasty.

AbstractA panel on contraindications to tympanoplasty connotes the need for self‐evaluation by the otologic surgeon. A polarity of opinion is developing among tympanoplastic surgeons. There are some who recognize few contraindications in these procedures in contrast to those who are very conservative. The panel has designated absolute and relative contraindications which must be determined according to the surgeon's dexterity and experience. A careful selection of patients in light of the relative contraindications is advocated.The contributors to this panel jointly enumerated the following contraindications, absolute and relative, to tympanoplasty:1. Extensive mucosal deficit (particularly with good hearing in opposite ear).2. Absence of middle ear bony framework (postoperative radical mastoidectomy).3. Non‐existence of stapedial superstructure (poor prognosis).4. Fixation of footplate (poor prognosis).5. Total eustachian tube obstruction.6. Extensive tympanosclerosis.7. Surgery on better hearing ear (except for compelling reason).8. Surgery on only serviceable ear (except for compelling reason).9. Minimum of discrimination is necessary (70–80 is borderline between good and bad prognosis).10. Patients with small air‐bone gap are usually non‐candidates (surgery could make them worse).11. Systemic diseases — i.e., tuberculosis, malignancy, diabetes, circulatory problems (obtain clearance from internist).12. Post irradiation base of skull (interferes with healing).13. Severe allergic disorders.14. Chronic sinusitis.15. Cleft palate.16. Extensive cholesteatoma (particularly with inexperienced aural surgeon).17. Avoid ear preferred by patient for hearing aid (a surgical accident might render ear useless).18. Ear in which previous surgery has been associated with serious complications (i.e., facial nerve paralysis, cerebrospinal fluid leak, lateral sinus rupture).19. Persistent wet ear after adequate local treatment (indicates eustachian tube problems and nasal pathology).20. Tympanoplasty in children not too successful. Eustachian tube does not achieve sufficient growth (until age 10–14 years) to prevent recurrent middle ear infection. There is a high probability of spontaneous healing.21. Age (under three or over 70).22. Fibrosis of middle ear and extensive tympanosclerosis (insufficient blood supply for good healing).23. Obliterative fibrosis of middle ear requiring space creating and adhesion preventing materials.24. Mumps exposure.25. Acute illness.26. Acute traumatic perforation.27. Perfect contralateral ear.28. Real benefit unlikely.29. Inability to remove epithelium at time of surgery.30. Acute or chronic external otitis.31. Unilateral congenital atresia.32. Bilateral congenital bony atresia before age six.

The homograft notched incus in tympanoplasty.

The homograft notched incus has evolved as a reliable, effective, and permanent prosthesis to reconstruct the middle ear conductive mechanism when the incus and stapedial superstructure are absent or destroyed. It has been found to be useful in a wide range of patients, and indications for its use are constantly expanding. The initial hearing results have been good, and follow-up audiograms indicate that the hearing gain will survive the test of time.

Total middle ear reconstruction.

Surgical technique and postoperative results are reported in 56 cases of total middle ear reconstruction in classical radical cavities. In 93% of the cases a normal or nearly normal anatomy of the drum and the ear canal was achieved, permitting the patient to swim. 83% reached the 30 dB level post-operatively or closed the air-bone gap to within 10 dB. The results were better in cases with remanent mobile stapes than in cases without stapes superstructure.