Comparison of various bone cement ossiculoplasty techniques and functional results

Objective: In this study, functional results of different bone cement ossiculoplasty techniques are compared.

Methods: Retrospective case review at a tertiary referral center. Patients who underwent middle ear surgery and bone cement ossiculoplasty between 2006–2012 were included. A total of 52 patients, including 30 patients with ‘Incus to stapes’ (Group 1) and 13 patients with ‘malleus to stapes’ (Group 2), five patients with ‘incudoplasty?+?stapedotomy’ (Group 3), and four patients with ‘malleus to incus’ (Group 4) ossiculoplasty were enrolled in the study. Pre-operative and post-operative audiological findings of each group were evaluated.

Results: The mean hearing gain (the difference between pre-operative and post-operative air bone gap (ABG)) was 13?dB for Group 1, 30?dB for Group 2, 24?dB for Group 3, and 9?dB for Group 4. The pre-operative air pure tone averages (PTA) of groups 1, 2, and 3 improved significantly in the post-operative period (p?Conclusions: The results showed that glass ionomer cement is a simple and effective method for reconstruction of ossicular discontinuity in various ossicular chain pathologies and can be an alternative to conventional rebridging techniques such as sculpted incus interposition or partial ossicular replacement prosthesis (PORP).     

Utilization of incus with bone cement for total ossicular reconstruction

Abstract

Background: Total ossicular chain reconstructions are performed to connect mobile stapes footplate and tympanic membrane. Data on the use of incus for total ossicular reconstruction is quite limited in the literature.

Objective: The main objective of this study is to describe a novel surgical method that utilizes incus with bone cement to stabilize the ossicular chain for total ossicular reconstruction.

Materials and methods: 16 patients who underwent total ossicular reconstruction using our method were included in this study. We evaluated hearing by comparing preoperative and postoperative air-bone gap (ABG), air conduction (AC) and bone conduction (BC). The percentage of patients achieving ABG ≤20?dB was determined.

Results: The mean preoperative ABG was 35.3?±?8.2 and postoperative ABG decreased significantly to 23.7?±?7.6 (p?<?.001). The mean preoperative AC (57.5?±?10) decreased significantly postoperatively to (46.5?±?13.3)(p?=?.014). There was not any difference between pre- and post-operative BC. We achieved successful hearing results (ABG ≤ 20dB) in 44% of patients.

Conclusion: The use of incus with bone cement stabilization for total ossicular reconstruction seems a feasible option. Good hearing outcomes, and low cost, complication, and extrusion rate may be the main reasons to prefer this method.     

Malleus-to-footplate ossicular reconstruction prosthesis positioning: cochleovestibular pressure optimization.

AIMS: To determine 1) the best position for hydroxylapatite malleus-to-footplate (MFP), ossicular replacement prosthesis (ORP) in reconstructed ears, and 2) whether preserving the stapes superstructure (SS), when present, has acoustic advantages. BACKGROUND: Positioning of the MFP-ORP head beneath the neck of the malleus may produce maximal force, whereas positioning beneath the manubrium of the malleus may produce the greatest displacement. It is not clear which is the optimal placement position. In addition, we look at the effect of the SS on sound transmission to the inner ear in ossicular reconstruction. METHODS: The ear-canal air pressure and vestibular hydro-pressure were measured in human cadaver temporal bones with incus intact, removed, and replaced with the MFP-ORP; the ORP head was placed at three different positions on the malleus (head, mid-manubrium, and umbo) while keeping its base at the center of stapes footplate with intact or removed stapes SS. The vestibular pressure ratio between the ear with intact incus and MFP-ORP reconstructed ear is defined as Lmfp, the loss caused by the prosthesis in relation to the normal ossicular chain. RESULTS: The mean magnitude of Lmfp, averaged in the important speech frequency region of 0.5 to 3 kHz, is approximately 7.8 dB at the neck with stapes SS. In comparison, mean magnitude of Lmfp for mid-manubrium without stapes SS is 15 dB (p = 0.04), and with the stapes SS it is 16 dB (p = 0.05), whereas at the umbo without SS it is 15 dB (p = 0.03). In the 8 kHz region, the mean magnitude of Lmfp is approximately 1 dB with the stapes SS intact and approximately 8.5 dB when it was removed (p < 0.09). CONCLUSION: There are significant physiologic advantages to placing the hydroxylapatite MFP-ORP beneath the neck of the malleus and preserving the SS.     

Movements of the intact and reconstructed ossicular chain during changes in static pressure

Objective To investigate the motion of the normal and reconstructed ossicular chain during changes in static pressure.

Material and Methods Experiments were carried out using seven fresh human temporal bones Using digital photography, movements of the malleus were measured during incremental pressure changes between +500 and -500 daPa with the incus in situ and following its removal. The pattern of movement of the ossicles was recorded in the form of digital video clips. This was carried out with the ossicular chain intact and also when it had been reconstructed with an incus graft and four different types of artificial prosthesis.

Results The lateral to medial movement of the malleus during changes in static pressure is converted into a predominantly superior to inferior movement of the incus. Conventional reconstructions using a graft or prosthesis transmit the malleus movement directly to the stapes so that it is pushed in and out of the oval window. Reconstructions with prostheses which restore the mammalian three-ossicle pattern, by contrast, move in a similar manner to the normal incus.

Conclusions Ears reconstructed using conventional techniques are more at risk from pressure changes than those in which a "physiological" method is used.     

The use of bone cement for ossicular chain defects

Bone cement is a good and cheap option for some ossicular chain problems such as incudostapedial re-bridging. The purpose of this retrospective study is to evaluate the audiologic results after reconstruction of three different types of ossicular chain defects, using bone cement. Group 1 consists of 42 patients who underwent an ossiculoplasty using bone cement between the damaged long process of the incus and an intact stapes superstructure. Group 2 consists of 46 patients in which incus interposition between malleus and stapes superstructure was performed, using bone cement to fix the interposed incus. For group 3, consisting of 32 patients who had a present malleus, a defective long process of the incus and a missing stapes superstructure, a re-shaped incus was placed between the stapes footplate and the malleus and bone cement was again used as a fixator. Preoperative and postoperative pure-tone audiometric findings were obtained and hearing differences were assessed. The mean preoperative and postoperative air-bone gaps were 34.8 and 15.6, 35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3, respectively. There was a significant improvement in hearing outcomes in all the groups when comparing preoperative and postoperative mean air-bone gaps (p < 0.001). The postoperative air-bone gap was ≤20 dB in 76 % of patients in group 1, 64 % of patients in group 2, and 46 % of patients in group 3. Bone cement is an effective and cheap option for some ossicular chain problems such as incudostapedial re-bridging. It may also be used to fix the interposed incus to the stapes superstructure and/or malleus to avert displacement.     

Surgical treatment of tympanosclerosis

During the 5-year period (1971-1976), 45 patients at the Shea Clinic underwent reconstructive surgery for tympanosclerosis. The most common ossicular chain problem was found to be malleus and incus fixation (33%); malleus, incus, and stapes fixation (22%); and stapes fixation (13%). The most successful reconstructive approaches included removal of tympanosclerosis from tympanic membrane or isolated plaque from ossicular chain, the use of the Partial Ossicular Replacement Prosthesis (PORP), and the Total Ossicular Replacement Prosthesis (TORP).     

Ossiculoplasty with a cartilage-connecting hydroxyapatite prosthesis for tympanosclerotic stapes fixation

Many cases of tympanosclerotic stapes fixation are accompanied by fixation or erosion of malleus and/or incus. This status of the ossicular chain is one of the reasons that ossiculoplasty for tympanosclerotic stapes fixation is more difficult than that for otosclerosis. We conducted a retrospective review of seven patients who were operated on for tympanosclerotic stapes fixation between 2002 and 2006. All of the patients had abnormal conditions of the malleus and/or incus and underwent stapedectomy and total ossiculoplasty with hydroxyapatite prosthesis (Apaceram T-7 type), which has a planar-like head portion that contacts a piece of cartilage. Postoperative hearing results were assessed in all seven patients after at least 1 year. The postoperative air-bone gap (ABG) was closed within 10 dB in two of seven patients, and was less than 20 dB in six of seven patients. The mean postoperative ABG was closed within 10 dB at 1 and 2 kHz and less than 20 dB at low frequencies (0.25 and 0.5 Hz). There was almost no hearing improvement at high frequencies (4 and 8 kHz). There were no patients with postoperative sensorineural hearing loss. The present study shows that stapedectomy and total ossiculoplasty with cartilage-connecting hydroxyapatite prosthesis is effective and safe for stapes fixation accompanied by fixation or erosion of the malleus and/or incus.     

In vitro evaluation of a malleus head to stapes head 'incus replica' prosthesis

An ossicular prosthesis produced by making a mould from a cadaveric incus and injecting ionomeric cement into it (incus replica prosthesis, IRP) has been cemented to the malleus head and stapes head and evaluated in fresh human temporal bones using a laser vibrometer. Stapes velocity was recorded under acoustic stimulation and foot plate displacements were derived. Fourteen frequencies between 125 Hz and 8000 Hz have been used. Measurements were made with the ossicular chain intact, following removal of the incus, with the prosthesis cemented to the malleus, but not the stapes, and with the incudo-stapedial joint cemented. In a second series of experiments the performance of the IRP was compared with that of a Causse partial ossicular replacement prosthesis, using the same experimental set-up. The results indicate that the prosthesis performs almost as well as the intact ossicular chain and that cementing the incudo-stapedial joint gives better sound transmission than leaving it uncemented. In addition the IRP outperforms the conventional partial ossicular replacement prosthesis.     

Surgery for congenital anomalies of the middle ear with mobile stapes

Summary In a series of 104 patients with congenital middle ear anomalies operated on from 1964 to 1986, 27 cases were found in which the stapes footplate was mobile and the conductive deafness was due to an anomaly in the remaining part of the ossicular chain. In 8 cases the middle ear anomaly was caused by discontinuity of the ossicular chain owing to congenital malformation. In the other 19 ears, epitympanic fixation of the ossicular chain was observed, whether or not in combination with malformation of the stapes, incus or malleus. Ossicular chain reconstruction produced an improvement of at least 15 dB in 6 of the first 8 cases with discontinuity of the ossicular chain. The mean gain was 31 dB. Epitympanotomy with exposure of the fixed ossicle and if necessary ossicular chain reconstruction led to an improvement of at least 15 dB in 12 of the 19 ears, with a mean gain of 28 dB. Correspondence to: E. Teunissen     

Surgery for tympanosclerotic stapes fixation accompanied by malleus fixation at the anterior malleus: report of 2 cases

Most tympanosclerotic stapes fixation involves fixation or erosion of the malleus and/or incus. This status of the ossicular chain is one reason that ossiculoplasty for tympanosclerotic stapes fixation is more difficult than that for otosclerosis. In some cases, the malleus is fixed only at the anterior, while the incus is intact. In such cases, anterior spinotomy can recover mobilization of the malleus, then a prosthesis can be used for the long process of the incus during ossiculoplasty. We conducted stapedectomy with anterior spinotomy on 3 ears in 2 patients. Over 15 dB of hearing was regained in all 3 ears 6 months after surgery. No significant sensorineural hearing loss was seen in any ear. To adapt this surgical procedure, it is necessary to evaluate preoperative CT findings and the status of the ossicular chain during surgery.     

锤骨-前庭桥接术在镫骨外科中的应用(附6例报告)

目的:探讨锤骨-前庭桥接技术在治疗并发锤砧传声功能障碍的以耳硬化为主体的镫骨病变患者中的可行性、安全性及有效性。方法:对2005年3月~2007年3月78例镫骨手术中采用锤骨-前庭桥接技术的锤镫手术6例进行回顾性分析,就手术步骤、术中发现及术后眩晕加以讨论,并比较手术前后的纯音测听结果。结果:6例均存在镫骨底板固定,其中2例并发可能炎症参与的锤砧、砧镫关节变形、僵硬、固定,1例并发锤砧关节周围局灶性鼓室硬化,另2例并发锤骨前上韧带固定,最后1例为手术操作意外导致锤砧关节脱位。6例术后均无明显眩晕,0.5、1.0、2.0及4.0 kHz频率范围的平均气骨导差均<10 dB,未发现4.0 kHz切迹。随访3个月~2年。结论:以锤骨-前庭桥接技术为基础的锤镫手术对于不同原因所致的并发锤砧传声功能障碍的耳硬化是一种安全、有效的治疗方法。     

Tympanoplasty in Korea (ossiculoplasty)

Three hundred and ninety three cases of ossicular reconstruction are presented. In the most favourable cases with both malleus handle and stapes present, this presents a closure of the air-bone gap to within 20 dB better than 80%. With connective tissue, underlay and fixation technique and staging are all important aspects of ossicular chain repair. Preservation of the function of the sound conduction mechanism in most favourable cases (malleus handle and stapes arch present) were improved by the employment of a sculptured, fitted incus prosthesis between the handle of the malleus and the head of the stapes.     

Audiological results of endoscopic surgical repair of the long process of incus

ObjectiveThe purpose of this study is to evaluate our experience with endoscopic repair of ossicular discontinuity at the incudostapedial joint, with or without an intact stapes suprastructure, and present our hearing results. We classify results based on the causative pathology, the type of ossiculoplasty, and type of lesion. We demonstrate the ability to endoscopically place a total ossicular replacement prosthesis (TORP), measuring 4.25 mm, between the stapes footplate and the incus remnant to reestablish ossicular continuity.MethodsThis was a retrospective case series conducted in tertiary referral center (Hopital de la Timone) Marseille, France. 25 patients underwent incudostapedial rebridging ossiculoplasty between 2009 and 2013. Fifteen cases of chronic otitis media and 10 otosclerosis revisions were included in the study. Three different materials were used in ossiculoplasty, hydroxyapatite cement, incus remnant, and partial/total ossicular replacement prostheses. Audiometric results were evaluated before and after ossiculoplasty. Twelve month follow-up data is provided.ResultsThe mean postoperative air-bone gap was 15 dB (5–25 dB). Hearing results were better inotosclerosis revisions. Hydroxyapatite cement produced an air-bone gap of 5 dB, TORP placed under the incus produced a 12 dB gap, and TORP placed under the malleus resulted in a 12 dB gap and one deaf ear. In cases of chronic otitis media, the residual air-bone gap was 17 dB with PORP, 12 dB with TORP, and 20 dB with incus transposition.ConclusionThe hydroxyapatite cement is effective in the reconstruction of ossicular discontinuity but the high price limits its utilization. TORP placed under the incus is a reliable and stable method of ossicular reconstruction that is cost effective and offers satisfactory hearing results in selected patients.     

Combination of ionomer cement and bone graft for ossicular reconstruction

The aim of this study was to investigate the efficacy of the reconstruction of large ossicular chain defects with a combination of ionomer cement and an autogenous cortical bone graft. Different individual solutions are described if at least the handle of the malleus is present: restoration of a large defect of the long process of the incus, formation of the incus body and the long process, and replacement of the missing superstructure of the stapes with a short bone graft standing on the footplate. In a unique case, total reconstruction of the malleus handle was carried out. In further cases where the malleus and the incus were absent, the missing superstucture of the stapes was replaced by a bone graft fixed to the remnant of the anterior crus, supplemented with a cortical bone PORP. Between 1993 and 2005, 84 patients underwent middle ear operations with the use of ionomer cement. In 16 ears (9 males, 7 females), a combination of ionomer cement and autogenous cortical bone graft was used for ossicular reconstruction, with a documented follow-up of at least 6 months to 7 years. All operations were performed under general anesthesia. The components of the cement were mixed by hand and transferred to the bare bone surface with a curved needle. Complex structures were built up step by step. In seven cases, the tympanic membrane was simultaneously reconstructed. The postoperative air–bone gap was < 20 dB in 11/16, 68% of the cases. No columella rejection occurred. The reconstructed malleus handle is still intact, though the hearing has deteriorated. The audiological results are encouraging and a further prospective study is under design in order to analyze the efficacy of the combination of ionomer cement and an autogenous cortical bone graft for ossicular reconstruction. The simultaneous reconstruction of the superstructure of the stapes and the long process of the incus or the whole incus makes PORPs or TORPs superfluous, if at least the handle of the malleus is present.     

Experimental ossicular fixations and the middle ear's response to sound: evidence for a flexible ossicular chain

A human temporal-bone preparation was used to determine the effects of various degrees of artificial ossicular fixation on the sound-induced velocity at the input-side (the umbo of the malleus) and the output-side (the stapes) of the ossicular chain. Construction of various degrees of attachment between an ossicle and the surrounding temporal bone provided a range of reduction in ossicular mobility or "fixations". The results demonstrate different effects of the fixations on the umbo and stapes velocity: fixations of the stapes or incus produce larger reductions in sound-induced stapes velocity (as much as 40-50 dB with extensive stapes fixation), than reductions in umbo velocity (typically less than 10 dB). Fixations of the malleus produce similar-sized changes in both umbo and stapes velocity. These differential effects are consistent with significant flexibility in the ossicular joints (the incudo-malleolar joint and the incudo-stapedial joint) that permits relative motion between the coupled ossicles. The existence of flexibility in the ossicular joints indicates that joints in the ossicular chain can effect a loss of sound-induced mechanical energy between the umbo and the stapes, with a concomitant reduction in the sound-induced motion of the stapes. The introduction of such losses in sound transmission by the joints raises questions concerning the utility of three ossicles in the mammalian ear. The consequences of ossicular flexibility to ossicular-chain reconstruction is discussed. Also, as examined in a more clinically directed paper [Laryngoscope 115 (2005) 147], the different effects of the various ossicular fixations on the motion of the umbo and malleus may be useful in the diagnosis of the site of fixations in humans with conductive hearing losses caused by such pathologies.     

Evaluation of a cement incus replacement prosthesis in a temporal bone model.

In reconstruction of the ossicular chain for a damaged incus, it is important that the incus replacement prosthesis (IRP) length is ideal in order to provide optimal tension between the tympanic membrane or malleus and stapes head to achieve the best post-operative hearing result. Even though the length of commercially available IRPs can be adjusted, it still may be difficult to achieve clinically. We describe experiments in a human temporal bone model using dental cement as an IRP after removal of the incus. This cement IRP (CIRP) hardens in situ and becomes the length of the gap to be spanned so that tension should be ideal. Two different CIRPs were studied; one was a conventional rod-type CIRP connecting either the umbo or mid-malleus handle to the stapes head. The second was a Y-shaped CIRP (Y-CIRP), connecting two sites on the malleus to the stapes head. The wide Y-CIRP connected the malleus head and umbo to the stapes head, while the narrow Y-CIRP connected the malleus neck and mid-handle to the stapes head. The acoustic performance of these experimental CIRPs was studied using a laser Doppler vibrometer system in 12 fresh human temporal bones. The CIRP demonstrated better acoustic performance than conventional IRPs studied previously in the same model. While all the CIRPs showed similar function below 2.0 kHz, the narrow Y-CIRP appeared best above 3.0 kHz. A prosthesis of this type may have an acoustic advantage over conventional IRPs.     

Diagnosis of ossicular chain in the middle ear by high-resolution CT]

This study was conducted to assess the usefulness and limitation of high-resolution CT for evaluating the condition of ossicular chain in the middle ear. Preoperative CT findings of the ossicular chain were compared with the operative findings of ossicles in 26 patients with chronic otitis media or congenital ossicular anomaly who underwent tympanoplasty. Total defect of head of the malleus, body of the incus and long process of the incus were completely detected by high-resolution CT. But the reliability in detecting the defect of handle of the malleus and superstructure of the stapes were 33.3% and 60%, respectively. Defect of the I-S joint (1 case) and partial defect of stapes crus (2 cases) could not be diagnosed correctly in the preoperative estimation. Although these findings demonstrate the limitations of high-resolution CT in the diagnosis of ossicular chain, it will be diminished by the advanced space resolution of CT in the future.     

Clues for facial canal dehiscence in chronic otitis media

Introduction and objectivesThe goal of this study was to determine the impact of external and middle ear findings in the incidence of facial canal dehiscence (FCD) during mastoidectomy for chronic otitis media.Material and methodsWe examined the operative details of 186 patients who underwent primary tympanomastoidectomy for chronic otitis media between January 2015 and January 2020 retrospectively.In this study we only evaluated the second portion of the facial nerve canal.ResultsThe global prevalence of FCD was 22.6% (42/186 patients) with a higher incidence, of 38.7% (36/93), in patients with chronic otitis media with cholesteatoma (C-COM).Associations were found between facial canal dehiscence, labyrinthine fistula (p? .001) and facial nerve paralysis (p? .001).Ossicular erosions were observed at a significant level in patients with facial canal dehiscence, the incidence of FCD was significantly higher (p = .005, Odds ratio 5.489) when malleus and incus were eroded, incus plus stapes were eroded (p = .014; OR 4.059) and malleus, incus, and stapes together were eroded (p = .002; OR 4.929).ConclusionsThis study revealed an incidence of facial canal dehiscence of 22.6%. It also revealed that the presence of lateral semicircular canal fistula is associated with a higher prevalence of facial canal dehiscence.The same was noted in the case of some ossicular erosions, especially the combinations of eroded malleus and incus, incus and stapes, and all 3 ossicles.These findings raise awareness about the usefulness of middle ear findings in predicting FCD, thus providing valuable information for the otological surgeon to avoid iatrogenic injuries.     

Tympanoplasty in Korea (ossiculoplasty)

Summary Three hundred and ninety three cases of ossicular reconstruction are presented. In the most favourable cases with both malleus handle and stapes present, this presents a closure of the air-bone gap to within 20 dB better than 80%. With connective tissue, underlay and fixation technique and staging are all important aspects of ossicular chain repair. Preservation of the function of the sound conduction mechanism in most favourable cases (malleus handle and stapes arch present) were improved by the employment of a sculptured, fitted incus prosthesis between the handle of the malleus and the head of the stapes.A part of this paper was presented at the 3rd Asia-Oceania Congress of Otolaryngology, held in Bali on July, 1975