Total Ossicular Prosthesis Research Articles

Повышение устойчивости полного протеза слуховых косточек

When performing tympanoplasty, one of the key stages is ossiculoplasty – reconstruction of the chain of auditory ossicles through prosthetics. When the chain of auditory ossicles, including the superstructure of the stapes, is destroyed, complete ossicular prostheses are used. The main task of the surgeon when performing ossiculoplasty is to achieve a balance of reliable functional position of the prosthesis ensured by lateral stability, on the one hand, and the exclusion of its contact with surrounding immobile anatomical elements, on the other. According to the literature, the frequency of dislocation of a total prosthesis reaches 13%. The study included 159 patients divided into a study group (72 patients) and a comparison group (87 patients) who underwent ossiculoplasty using a total ossicular prosthesis between 2017 and 2021. In the comparison group, the stability of the prosthesis was ensured by fragments of highly purified gelatin sponge. In the study group, an oval plate of autologous cartilage graft measuring 2,5 and 3,5 mm was additionally used, attached to the prosthetic socket. The results of postoperative observation showed a statistically significant (p < 0,05) reduction in the incidence of prosthesis dislocation to 4,2% compared to the comparison group (10,8%). Functional results were also statistically better when comparing subgroups of patients who underwent tympanoplasty with a first stage using a closed technique.

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.

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.

Gray-Scale Inversion on High Resolution Computed Tomography of the Temporal Bone: An Observational Study

This is a qualitative study to explore the utility of gray-scale inversion or the "invert" function of high-resolution computed tomography (HRCT) scans in the diagnosis of temporal bone anatomy and pathology. This is a case series describing an innovative application of an existing image processing tool to visualize temporal bone anatomy and pathology. Illustrative patients at a tertiary referral center with otologic symptoms and findings leading to HRCT scans of the temporal bone were included. Diagnostic HRCT scans were evaluated utilizing the gray-scale inversion function (invert function). Nine illustrative cases which demonstrate conditions such as persistent stapedial artery, membranous stapes footplate, total ossicular prosthesis migration into the vestibule, third window syndrome such as superior semicircular canal dehiscence (SSCD) and cochlea-facial nerve dehiscence, otosclerosis, and ossicular chain discontinuity are included. The enhanced visualization was confirmed surgically in 3 cases, and 1 had physiological confirmation using cervical vestibular evoked myogenic potentials (cVEMP). Gray-scale inversion can be used to improve visualization of temporal bone anatomy and pathologic changes when diagnoses are in doubt. The invert function is a useful adjunct in the armamentarium of both radiologists and otologists when evaluating HRCT of the temporal bone.

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.

Hearing Outcomes after Revision Stapedectomy Managed with Total Ossicular Prostheses.

(1) To describe the use of total ossicular prostheses (TOPs) in the setting of stapedectomy requiring an incus bypass procedure. (2) To analyze the short- and long-term audiometric results of TOP utilization in the setting of stapedectomy for an incus bypass procedure. Case series with chart review. Tertiary neurotologic referral center. Seventeen cases of TOP reconstruction after stapedectomy were performed due to advanced incus erosion. The cases were assessed for pre- and postoperative bone conduction and air conduction pure-tone averages (PTAs; 0.5, 1, 2, 3 kHz), including high-tone bone conduction (1, 2, 4 kHz), air-bone gap, and speech discrimination scores. Hearing outcomes were measured: short-term (3 weeks) and long-term (average, 22 months). Among 17 ears undergoing revision stapedectomy managed with TOP reconstruction, the average number of previous revision attempts was 1.0 (SD, 1; range, 1-5). The preoperative bone conduction PTA was 30.7 dB preoperatively, while the preoperative air conduction PTA was 64.3 dB. The mean postoperative air-bone gap significantly decreased to 18.9 dB (SD, 12.7; range, 5-46.25; P < .003) with a mean follow-up of 22.2 months (SD, 25.0; range, 0.75-78). No significant decrement in high-tone bone conduction PTA was observed (mean, 0 dB; SD, 12.8; range, -36.7 to 20; P = .427); however, 1 ear revealed a severe decrease in PTA and speech discrimination score postoperatively. No further revisions were noted in follow-up. TOP reconstruction in the setting of previous revision stapedectomy with limited incudovestibular reconstructive options may lead to favorable hearing outcomes, but it carries an increased risk of sensorineural hearing loss.

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.

The use of cartilage in revision stapedectomy.

To evaluate the incidence of stapedectomy patients who developed significant chronic ear disease resulting in reconstruction of the tympanic membrane with cartilage and concomitant revision stapedectomy. Audiometric results of this subgroup within revision stapedectomy are analyzed, and the salient features of the reconstruction method are discussed. Retrospective study of revision stapedectomy patients during the years 2003-2012. Tertiary referral center. Cartilage tympanoplasty and revision stapedectomy. Seventeen patients (18 ears) of 144 revision stapes patients were studied who required cartilage tympanoplasty and revision stapedectomy. One-half underwent revision stapedectomy with a modified Lippy prosthesis (MLP), and one-half required a total ossicular prosthesis (TOP). The mean postoperative air-bone gap (ABG) was 11.1 dB with mean pure tone average (PTA) hearing improvement of 15.6 dB.The rate of ABG closure was 55.6% <10 dB and 38.8 % >10 dB and <20 dB. The number of patients requiring revision stapedectomy due to significant chronic ear disease is small. This paper discusses the management and successful outcome of these more difficult revisions.

Ossiculoplasty in Missing Malleus and Stapes Patients

To present the preliminary results of new malleus replacement prosthesis combined with a total ossicular prosthesis in middle ear reconstruction in patients missing the malleus and stapes. Prospective experimental and nonrandomized clinical study. Tertiary referral center. An original titanium malleus replacement prosthesis (MRP) was designed to be inserted into the external auditory canal and to replace a missing malleus for various middle ear pathologies. The MRP was tested experimentally and clinically. The vibratory properties of the new prosthesis were measured using laser Doppler vibrometry. Ninety patients with missing malleus and stapes, undergoing 92 ossicular reconstructions were enrolled in this study from September 1994 to March 2012. Comparative analyses were made between a group of 34 cases of ossicular reconstructions with total prosthesis (TORP) positioned from the tympanic membrane to the stapes footplate (TM-to-footplate assembly) and a group of 58 cases of ossicular reconstructions with TORP positioned from a newly designed malleus replacement prosthesis (MRP) to the stapes footplate (MRP-to-footplate assembly). Preoperative and postoperative audiometric evaluation using conventional audiometry, that is, air-bone gap (ABG), bone-conduction thresholds (BC), and air-conduction thresholds (AC) were assessed. Experimentally, the vibratory properties of the MRP are promising and remain very good even when the MRP is cemented into the bony canal wall mimicking its complete osseous-integration, if this were to occur. This finding supports the short-term clinical results as in the TM-to-footplate group; the 3-month postoperative mean ABG was 23.3 dB compared with 12.5 dB in the MRP-to-footplate group (difference, 10.8; 95% confidence interval, 4.0-17.6); 37.0% of patients from the TM-to-footplate group had a postoperative ABG of 10 dB or less, and 48.1% of patients had a postoperative ABG of 20 dB or less, as compared with 58.1% and 79.1%, respectively, in the MRP-to-footplate group. The average gain in AC was 11.0 dB in the TM-to-footplate group as compared with 21.3 dB in the MRP-to-footplate group (difference, -10.3; 95% confidence interval, -18.2 to -2.4). The results of this study indicate that superior postoperative hearing thresholds could be achieved using a MRP-to-footplate assembly, compared with a TM-to-footplate assembly in patients with an absent malleus undergoing ossiculoplasty. The postoperative AC thresholds, after 3 months and 1 year, are significantly lower in patients treated with the MRP-to-footplate assembly.

Total Ossiculoplasty: Advantages of Two-Point Stabilization Technique

Objective. Evaluate a porous polyethylene prosthesis with two-point stabilization in total ossiculoplasty. This approach utilizes a lateral as well as a medial graft to stabilize a total ossicular prosthesis (TOP). Study Design. Retrospective cohort review of total ossiculoplasty. Methods. All patients who underwent total ossiculoplasty during the years 2004–2007 were included in the study group. Only five patients (10%) had primary surgery whereas 45 (90%) underwent revision surgery. Cartilage grafts covering the prosthesis (Sheehy, Xomed) laterally were used in all patients with areolar tissue being used for medial stabilization at the stapes footplate. Follow-up examination and audiometrics were performed a mean of 8.1 months following surgery. Results. The percentage of patients closing their ABG to within 10 dB was 44% with 66% closing their ABG to within 20 dB. The mean four-frequency hearing gain was 15.7 dB. The mean postoperative ABG was 15.7 dB. Conclusion. Audiometric results following total ossiculoplasty surgery using two-point stabilization exceeded results from the otologic literature. Proper two-point fixation with areolar tissue and stabilization utilizing cartilage were the keys to achieving a relatively high percentage of success in chronic ear disease in this sample.

The ostrich middle ear for developing an ideal ossicular replacement prosthesis

The aim of the study was to investigate the validity of the avian middle ear model for researching the tympanoplasty mechanics. We studied the morphological details, acoustic transmission and quasi-static behavior of the ostrich tympano-ossicular system. The stained specimens of the ostrich middle ear were examined under a light microscope. The sound transfer function and quasi-static performance of the ostrich middle ear were evaluated using laser Doppler vibrometry. The application of pressure to the tip of the extracolumella causes a buckling movement of the ossicle between the cartilaginous and bony parts. Histologically, the intracolumellar connection can be identified as a junction zone between bone and hyaline cartilage. Sound conduction through the human middle ear is less effective than it is through the ostrich middle ear. The greatest difference (35 dB) was observed in the low-frequency region. Because the extracolumella bends, the medial displacements of the eardrum were not fully transmitted to the footplate. The amplitude of the ostrich columella footplate quasi-static medial displacements significantly exceeded that of the human footplate in both intact and reconstructed middle ears. The ostrich middle ear is a suitable model for designing total ossicular replacement implants. The main protective mechanism in the ostrich middle ear under quasi-static stress is a buckling movement of the extracolumella. The total ossicular prostheses of the new generation should contain an elastic element that allows an adaptation to greater quasi-static eardrum movements.

New Total Ossicular Replacement Prostheses With a Resilient Joint

New flexible total ossicular prostheses with an integrated microjoint can compensate for large static displacements in the reconstructed ossicular chain. When properly designed, they can mimic the function of the joints of the intact chain and ensure good vibration transfer in both straight and bent conditions. Prosthesis dislocations and extrusions are frequently observed after middle ear surgery. They are mainly related to the altered distance between the coupling points because of large static eardrum displacements. The new prostheses consist of 2 titanium shafts, which are incorporated into a silicone body. The sound transfer function and stapes footplate displacement at static loads were evaluated in human temporal bones after ossicular reconstruction using prostheses with 2 different silicones with different hardness values. The stiffness and bending characteristics of the prostheses were investigated with a quasi-static load. The sound transfer properties of the middle ears with the prostheses inserted under uncompressed conditions were comparable with those of ears with intact ossicular chains. The implant with the soft silicone had improved acoustic transfer characteristics over the implant with the hard silicone in a compressed state. In the quasi-static experiments, the minimum medial footplate displacement was found with the same implant. The bending characteristics depended on the silicone stiffness and correlated closely with the point and angle of the load incidence. The titanium prostheses with a resilient joint that were investigated in this study had good sound transfer characteristics under optimal conditions as well as in a compressed state. As a result of joint bending, the implants compensate for the small changes in length of the ossicular chain that occur under varying middle ear pressure. The implants require a stable support at the stapes footplate to function properly.

Cartilage-wire-fascia compact total ossicular replacement prosthesis in one-stage cholesteatoma surgery

Purpose Retraction pocket and extrusion of the ossicular prosthesis remain significant problems after tympanoplasty in cholesteatoma surgery. This study presents an alternative surgical technique with a total compact ossicular prosthesis including cartilage, wire, and temporalis fascia. Materials and methods A total of 42 patients (27 adults, 15 children) underwent an ear operation for cholesteatoma requiring total ossicular chain replacement during a 10-year period. Surgery included canal wall down mastoidectomy and reconstruction of the middle ear in one stage. The total ossicular replacement prosthesis was made by a stainless steel wire passed and secured through a piece of conchal cartilage and temporalis fascia positioned on the free end of the wire. The analysis of our data included hearing results pre-surgery and post-surgery, complications recorded in the case notes, and postoperative otoscopic findings. Results The mean air-bone gap decreased from 39.2 to 22.4 dB in the early postoperative period (mean follow-up, 12.8 months). Eight patients with a long-term follow-up (mean, 7.1 years) presented a small deterioration of their postoperative hearing improvement. The bone conduction did not present significant changes. Three patients developed postoperative infection and treated successfully with medical therapy. No significant complications as displacement or extrusion of the prosthesis and retraction pocket were detected postoperatively. Conclusion This is an alternative tympanoplasty technique with a stable cartilage-wire-fascia total ossicular prosthesis. This technique has a low complication rate; good hearing results and offers another surgical option to the surgeon especially for cases where the cost is a concern.

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.