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.     

Experience with fibrin glue in type-III tympanoplasty with stapes elevation

In a retrospective study, type III tympanoplasties with stapes elevation on two groups of patients were compared. In group I (101 patients) the stapes elevations, the temporalis fascia grafts for tympanic membrane reconstruction, the grafts of periosteum and cartilage used for repair defects of the posterior bony meatal wall and the Stacke-II plasty replaced in its original position after tympanoplasty were also fixed with fibrin glue (Tissucol). Group II (control group of 102 patients) was operated with fibrin glue. In group I the fascial grafts of the tympanic membrane healed faster, more securely and without fewer complications. The external auditory canal however healed equally well in both groups. Early hearing results of type III tympanoplasty could be improved by fixing the stapes elevations with fibrin glue.     

Ossicular reconstruction with autograft in type III

OBJECTIVE: The prostheses known as biocompatible are usually proposed for columellar repair in absence of stapes but at which cost and which long-term tolerance? It appeared useful to study the possibilities of autograft ossicular reconstruction (incus and cortical bone) in absence of suprastructure of the stapes. MATERIAL AND METHODS: Retrospective study for 82 operated patients for cholesteatoma with lysis of the cruras of the stapes. Columellar repair was obtained by prosthesis, columella of cortical mastoid bone, and more often autograft of incus (54 cases). The technique of Autogreffe Tympanum-Cartilage-Os-Platinum (ATCOP) (Autograft Tympanum-Cartilage-Bone-Footplate is described: tympanic repair by fascia and cartilage from the concha is made at the first surgical step. Type III ossiculoplasty is performed at the second look. The distance tympanum-footplate is then lower than 6 mm and the body of the incus, preserved as a spare ossicle in the mastoid, has a sufficient length to be interposed in between new drum and footplate. RESULTS: 78% of the patients have final air bone gap less or equal than 30 decibels. The average post op air bone gap is 23 decibels with incus while it was 42 decibels before surgery. Average gain is 19 decibels. The cost of autograft is null and tolerance is excellent. CONCLUSION: Patient's incus is usable in type III ossiculoplasty thanks to a cartilage graft of the tympanic membrane. Patient's ossicle is a material of choice for columellar repair even in absence of the suprastructure of the stapes. Prostheses in biomaterial appear justified in case of absent or destroyed incus.     

Revision stapes surgery with and without laser: A comparison

In this study, the results of 76 revision stapes surgeries performed from 1974 to 1992 were reviewed. Either the KTP or the argon laser was used in 40 operations. Prosthesis problems were the most common cause for revision (63%) followed by eroded/ necrotic incus (29%) and adhesions (29%). Overall “success” in air-bone gap closure (air-bone gap ≤ 10 dB) was 46% for first revisions and 33% for second or greater revisions. The “improvement” rate (air-bone gap ≤ 20 dB) was 65% for first revisions and 53% for second or greater revisions. There was no statistically significant difference in hearing results between laser surgery and conventional technique. However, an absence of adhesions was noted when the laser had been used in the primary procedure.     

Three-dimensional surgical anatomy for stapes surgery computer-aided reconstruction and measurement.

To define anatomical relationships relevant to stapes surgery, computer-aided three-dimensional reconstruction and measurement were performed on nine normal temporal bones. The mean distance from the inferior portion of the long process of the incus to the center of the oval window was 3.80 mm. The shortest distance from the center of the oval window to the utricular macula, saccular membrane, and macula averaged 1.37, 1.60, and 2.13 mm. Surgery directed posteromedial-superior from the oval window was found to be most dangerous because it would come so close to the utricular macula; a posteromedial-inferior approach was found to be safest. The distance from the inferior margin of the oval window inferiorly to the cochlear duct in the hook portion ranged between 0.58 and 1.29 mm, suggesting that when a drill hole is made on the inferior margin of the oval window to lift up a depressed stapes footplate, the hole should not be greater than 0.5 mm in diameter.     

Success of cartilage grafting in revision tympanoplasty without mastoidectomy.

OBJECTIVE: Candidates for revision tympanoplasty have experienced at least one failed attempt at repair of the tympanic membrane and are, therefore, at higher risk for subsequent repair failure. The adjunctive use of mastoidectomy with tympanoplasty in those patients with noncholesteatomatous chronic otitis media is often used to decrease the risk for subsequent failure. However, at this institution, where we use cartilage tympanoplasty, mastoidectomy is rarely performed in the absence of cholesteatoma. Our objective was to assess outcomes in patients undergoing revision tympanoplasty without mastoidectomy using cartilage grafting. STUDY DESIGN: We conducted a retrospective case review. SETTING: Tertiary referral center. PATIENTS: A total of 95 patients (42 female, 53 male; 5-81 yr of age) with a recurrent perforation who were treated surgically with cartilage tympanoplasty without mastoidectomy were included in the chart review. Patients must have undergone at least one previous tympanoplasty without mastoidectomy and had to have complete audiologic and chart follow up. INTERVENTIONS: An underlay tympanoplasty technique using either a tragal cartilage-perichondrium island graft or palisaded concha cymba cartilage was used. Ossiculoplasty was performed as needed. MAIN OUTCOME MEASURE: Main outcome measures were incidence of reperforation of the grafted tympanic membrane, hearing result, and prevalence of other complications. RESULTS: Successful closure without reperforation was obtained in 90 of 95 patients (94.7%). Average postoperative pure-tone average air-bone gap was 12.2 +/-7.3 dB compared with 24.6+/-13.8 dB preoperatively (p <0.001). CONCLUSIONS: Revision tympanoplasty with cartilage provided equivalent results to tympanoplasty with mastoidectomy. Thus, mastoidectomy may not be necessary in revision tympanoplasty in the absence of cholesteatoma if the repair is made with cartilage.     

Annular ligament reconstruction - a better technique in the surgical treatment of stapes fixation

Reconstruction of the annular ligament using vein graft at the stapedotomy site gives a very good gain at low, frequencies as compared to Stapedotomy without a tissue seal It also protects against perilymph leak 1 0 8mm stapedotomy with a 0 4mm piston with 0 2 mm vein graft interposition is a better technique in the surgical treatment of stapes fixation The purpose of the present study is to determine the effectiveness of vein graft in sealing the oval window in small fenestra stapedotomy for stapedial otoselerosis We performed a prospective randomi ed trial in 80 cases of stapedial otoselerosis, 40 with and 40 without having a tissue seal at a tertiary referal center Ihere was a good air bone gap closure in both the groups There was a better gain in the lower frequencies in subjects where the vein graft was used     

The effect of stapes mobility on hearing outcome and which procedure to choose in fixed stapes in children tympanosclerosis

OBJECTIVES: Our objective was to evaluate the features of tympanosclerosis in children and to determine the effect of stapes mobility and the type of one-stage operation on hearing outcomes. MATERIALS AND METHODS: Fifty-one children who were performed different types of single-stage otologic surgery for tympanosclerosis between January 1997 and December 2006 were retrospectively chart reviewed. The children were divided into two groups according to the mobility of ossicular chain, especially the stapes. Stapes fixed group was also evaluated in detail according to the type of surgery that was performed. Patients who had previous ventilation tube insertion, tympanic membrane parasynthesis or any other otologic surgery were excluded from the study. Improvement of the hearing by at least 10 dB and air-bone gap less than 20 dB were accepted as success criteria after 24 months of follow-up period. RESULTS: The air conduction levels, and the air-bone gap values of both groups were improved significantly after the single-stage operations. Pure tone averages pre- and postoperatively for stapes mobile group were 45.55+/-15.96 and 34.50+/-16.64 dB (p=0.002); and in stapes fixed group these were respectively 43.97+/-13.45 and 33.16+/-12.14 dB (p<0.001). When pre- and postoperative air-bone gap levels were evaluated it was seen that in both groups they were improved more than 10 dB, from 34.10+/-11.37 to 23.05+/-12.32 dB (p=0.002) in stapes mobile group and from 35.29+/-11.65 to 24.48+/-12.50 dB (p<0.001) in stapes fixed group. In stapes fixed group air-bone gap was less than 20 dB in 11 of 23 (47.8%) patients who had mobilization and 3 of 8 (37.5%) patients who had small fenestra stapedotomy operations. Although it was not statistically significant, gain was more than 10 dB only in 2 of 8 (25.0%) patients in the stapedotomy group but 14 of 23 (60.9%) patients in mobilization group (p=0.698 for ABG and p=0.220 for gain). The change in the bone conduction levels were improved 0.75 dB in group 1 and got worse 0.52 dB in group 2 and this was not statistically significant (p=0.239). CONCLUSIONS: In this study about children, the status of stapes and the place of tympanosclerotic mass had no significant negative effect on hearing improvement. You can perform mobilization in one-stage if you are experienced and have to prefer second-stage surgery if stapes is fixed and stapedectomy is needed.     

人工听骨在鼓室成形术中的应用

目的评价人工听骨在鼓室成形手术中的应用效果。方法对解放军总医院耳鼻咽喉头颈外科2004年9月至2006年4月施行的中耳炎手术中，接受人工听骨部分赝复物——多孔聚乙烯听骨赝复物（Partialossicularreplacementprostheses，PORP，美国美敦力公司）植入进行听骨链重建的患者42例进行随访。对随访半年以上、资料完整的38例（38耳）进行回顾性总结，应用SPSS统计软件进行疗效分析。计算语言频率（0．5，1，2kHz）气导平均听力及气骨导差，比较不同手术方式和PORP植入方式对疗效的影响。结果38耳鼓膜修补后1个月复查均愈合良好，但术后3个月时发现2例听骨脱出（均为术中人工听骨表面未置软骨片者）。38耳术前气导听力33．75～68．5dBHL，平均为（56．82±13．64）dB；骨导听力0～47．5dB，平均为（20．217±12．099）dB；术后气导听力平均为（34．23±15．04）dB，与术前相比t=3．682，P〈0．01。术前气骨导差（ABG）16．25～62．5dB，平均（36．625＋12．189）dB，其中21-30dB的9耳，〉30dB的24耳。术后ABG平均为（21．064±12．243）dB，与术前相比较，t=5．552，P〈0．01。其中术后ABG差≤20dB的19耳，20～30dB的9耳，〉30dB的8耳。术后ABG≤20dB者及ABG较术前缩小15dB者（术后听力提高有效）共28耳，总有效率为76-3％。结论PORP是一种可在听骨链重建中推广的人工听骨材料，术后取得良好的听力效果，但应注意避免术后听骨脱出。     

Ossicular chain reconstruction: the TORP and PORP in chronic ear disease

The traditional objectives of tympanoplasty are infection control, closure of the ear by grafting techniques, and hearing rehabilitation via ossicular reconstruction. The multiplicity of contemporary prostheses and surgical options available would seem to underscore the magnitude of the ossicular reconstruction problem in the difficult chronic ear relative to all else. The success of stapedectomy has led to great expectations for all problems of ossicular reconstruction. The circumstances of the chronic ear is a milieu hostile in comparison and precludes any such comparison. Multiple sites of ossicular pathology, variations in mucosa health, inconsistent middle ear aeration and the overall complexity of the chronic ear present the otologist with a physiodynamic problem the solution of which is far from simplistic. The TORP and PORP have been enthusiastically endorsed in this regard, as a very suitable answer. Such enthusiasm, however, has been largely derived from data accumulated in the short term, often in less than a year's follow-up. This report reviews the authors' results in 141 patients in whom 86 TORPs and 55 PORPs were employed. For comparison, hearing data in 276 ears in which the fitted incus prosthesis, the authors' preferred reconstruction format, was used. Success for TORP reconstruction was assessed as air-bone gap closure to within 30 dB and for PORP, to within 20 dB. This was accomplished in 85% and 49% respectively. Extrusion rate, overall, was 10%. Relative advantages and disadvantages of the TORP and PORP are discussed and serve as a basis for the decision to continue to use this method of ossicular reconstruction. This data is put into perspective in acknowledging that the TORP and PORP are not the ultimate solution to this problem. When employed in combination with newer techniques in cartilage tympanoplasty, further improvement is expectant.     

Comparative study of hearing improvement in type 1 tympanoplasty with and without canalplasty

Introduction  Widening of the external auditory canal is canalplasty. It is an intergral part of tympanoplasty, especially in anterior perforations and gives wide surgical access for proper repair. Materials and methods  After elevating tympanomeatal flaps the canal is widened using conical cutting and diamond burrs following which entire tympanic annulus is visible and corresponds to an inverted truncated cone. Results  Canalplasty gives 9 db gain in hearing compared to without canalplasty. Conclusion  Canalplasty gives better visualization, better graft placement and better post-operative care.