Tympanosclerosis involving the ossicular chain: mobility of the stapes in association with hearing results

Conclusion. The preoperative bone conduction level provides not only prognostic information but also information on the mobility of the stapes in tympanosclerosis. The surgical results depend upon the stapes mobility.

Objectives. We aimed to evaluate operative findings and hearing results of tympanosclerosis involving the ossicular chain, in order to understand the pathophysiology and to establish better surgical treatment of tympanosclerosis.

Patients and methods. Between January 1998 and March 2004, 29 patients (29 ears) with tympanosclerosis involving the ossicular chain underwent tympanoplasty at our hospital. Patients with myringosclerosis only, or with an associated cholesteatoma, were excluded from this study. The clinical and operational records and pre- and postoperative pure tone audiograms were reviewed retrospectively.

Results. Intact canal wall tympanoplasty was applied to all 29 patients. A non-staged operation was performed on 21 patients, and a staged operation was performed on the remaining 8 patients. In 25 patients (86.2%), the sclerotic lesion of the ossicles was located in the epitympanum. In the remaining four, the sclerotic lamella coated only the ossicular chain. On average, the preoperative air conduction hearing level of 57.9 dB was significantly improved to 46.3 dB after tympanoplasty. The success rate of middle ear surgery was 65.5% (19 of 29 patients), according to the criteria of the Otological Society of Japan. In 16 patients (55.2%), the mobility of the stapes was preserved (group A), while in the remaining 13 patients (44.8%), the stapes was fixed (group B). The mean preoperative bone conduction of 25.5 dB in group A was significantly better than that of 37.2 dB in group B. The hearing result significantly improved in group A but not in group B. The success rates were 75% (12 of 16 patients) in group A and 53.8% (7 of 13 patients) in group B.     

鼓室硬化症鼓室成型术25例临床分析

目的：总结手术治疗鼓室硬化症的临床经验。方法：回顾性总结2001年11月至2005年2月我科经治的25例鼓室硬化症临床资料。手术均在全麻显微镜下采用剥除硬化灶,修补鼓膜或加听骨链重建行Ⅰ期鼓室成型术。采用颞肌筋膜修补鼓膜，以自体乳突骨皮质或陶瓷人工听骨重建听骨链。结果：病灶侵及鼓膜、鼓岬、砧锤骨、镫骨及周围，均呈板障型乳突，无并发胆脂瘤。听力提高15?dB以上24例（96%），术后4例有眩晕。结论：尽量清除硬化灶，形成宽大的鼓室，并重建鼓膜和听骨链，手术疗效与病灶影响听骨链程度有关，精确、熟练的耳显微外科技术是成功的关键。     

鼓室硬化病变程度与影像学及听力学相关性分析

目的探讨高分辨cT影像、术前听力在鼓室硬化的诊断、术前评估听骨链完整性及镫骨活动度中的价值。方法回顾性分析经手术证实的81例鼓室硬化患者术前颞骨高分辨CT影像资料、术前听力平均气骨导差、术中硬化灶分布及听骨链完整性、镫骨活动度等数据,进行Spearson秩相关分析及Logistic回归分析。结果高分辨CT影像与术中所见符合率87.7％,平均气骨导差与听骨链完整性相关系数r=-0．407,P〈0．01：镫骨病灶与镫骨活动度r=-0．287,P〈0．01;镫骨显影与镫骨活动度r=0．480,P〈0．01：平均气骨导差与镫骨活动度r=-0．265,P〈0．05;Logistic回归分析提示在调整混杂因素后,平均气骨导差在镫骨周围病灶、听骨链完整性、镫骨活动度、硬化灶与听骨粘连中仍有明显差异,有统计学意义（P〈0．05）。结论颞骨高分辨CT影像可以清晰显示鼓膜和鼓室内的硬化斑块,平均气骨导差可以大致判断听骨链完整性、镫骨活动度情况,为术前评估病变程度、制定手术方案具有指导意义。     

持续灌流模式耳内镜下Ⅲ、Ⅳ型鼓室硬化症手术疗效分析

目的 探讨采用持续灌流耳内镜手术模式(CIM-EES)一期鼓室成形术治疗Ⅲ、Ⅳ型鼓室硬化症的临床疗效.方法 2019.3-2020.9对17例(21耳)Ⅲ、Ⅳ型鼓室硬化症患者,在持续灌流模式耳内镜下采用外嵌法,一期行Ⅱ型鼓室成形术,观察分析手术时间,鼓膜愈合成功率,并比较术前及术后6个月平均气、骨导听阈(PTA)及气骨...     

鼓室成形术治疗不同类型鼓室硬化患者的近期疗效分析

目的探讨鼓室成形术治疗不同类型鼓室硬化患者的近期疗效。方法回顾性分析2008年2月至2011年2月间有完整资料且随访半年以上、经鼓室成形术治疗的33例鼓室硬化患者(I型8例,II型9例,III型2例,IV型14例)的临床资料,其中8例行鼓室探查+鼓膜成形术,25例行开放式乳突根治+鼓室成形术,以言语频率气导平均听力改善15dB以上或达应用听力水平为手术成功标准,评估其疗效。结果 33例患者术前言语频率气导平均听阈为54.09±9.76dB HL;术后半年随访时平均听阈为38.85±8.42dB HL,总手术成功率为63.64%(21/33),其中鼓室探查+鼓膜成形术8例中4例(50%)手术成功,开放式乳突根治+鼓室成形术25例中17例(68%)手术成功。结论鼓室成形术是治疗鼓室硬化的有效手术方法,开放式乳突根治+鼓室成形术能有效清除听骨链周围不同范围的硬化灶。     

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.     

An analysis of the single-stage tympanoplasty with over-underlay grafting in tympanosclerosis.

OBJECTIVES: Our objective was to analyze the results of tympanosclerosis surgery using over-underlay tympanoplasty and to find out the effect of single-stage surgery on hearing results. MATERIALS AND METHODS: Forty-two patients who were operated on for tympanosclerosis between July 1998 and February 2002 were included in the study. These were one-stage tympanoplasties, because second-stage operations and revisions were not included. Operative records and audiograms of the patients were obtained. Of the patients, 48% had bilateral tympanosclerosis. In three (7.1%) of the patients, tympanosclerosis and cholesteatoma occurred concomitantly. The cog was present in eight (20%) of 40 mastoidectomies. K?rner's septum was present in nine (22.5%) patients. The graft take rate was 95.2%. RESULTS: The pre- and postoperative air-bone gap values of the patients were not significantly different (p > 0.05). Thirty-three percent of the patients met the successful hearing criteria (air-bone gap <20 dB). However, 47% had an air-bone gap closure between 20 dB and 30 dB, whereas 20% had a gap of more than 30 dB. CONCLUSION: Single-stage surgery does not result in a satisfactory hearing improvement in most of the patients with tympanosclerosis. Only one third of the patients, most of whom had a mobile stapes, had satisfactory hearing results. Mobilization of a fixed stapes is not an effective option for hearing restoration in tympanosclerosis. Second-stage surgery for stapedectomy and placement of a prosthesis-like piston or total ossicular replacement prosthesis should be considered to obtain better hearing results in tympanosclerosis.     

手术治疗鼓室硬化症67耳

为了进一步讨论鼓室硬化症的手术效果，报告对鼓室硬化症６７耳行鼓室成型临床手术成功率为７２．９％，其中Ⅰ型与Ⅱ，Ⅲ型术后听力的改善率无显著差别。     

Surgical treatment of tympanosclerosis

OBJECTIVE: To report the hearing results of the surgical treatment of tympanosclerosis. STUDY DESIGN: A retrospective review of surgically treated cases of tympanosclerosis. SETTING: A tertiary referral center. PATIENTS: One hundred fifteen patients with middle ear tympanosclerosis operated on between 1987 and 1996, with an average age of 36 years (range 18-59 years). Cases were classified into four groups according to Wielinga and Kerr. Those with an associated cholesteatoma were excluded. INTERVENTION: Depending on the ossicular status, either mobilization of the major ossicles or epitympanic bypass procedure, mobilization of the stapes or stapedectomy. MAIN OUTCOME MEASURES: The postoperative pure-tone average was compared with the preoperative levels by use of conventional audiometry. The air-bone gap was measured. RESULTS: The average postoperative air-bone gap was 18.0+/-10.21 dB in the type II group (attic fixation of the malleus-incus complex with a mobile stapes). 21.8+/-9.5 dB in the type III group (mobile malleus-incus complex, if present, with stapes footplate fixation), and 22.92+/-10.03 dB in the type IV group (fixation of both the stapes footplate and the malleus-incus complex). Patients with a fixed malleus and mobile stapes had significantly better hearing results than those with stapes fixation (p = 0.042, Mann-Whitney U test). CONCLUSION: In ossicular attic fixation, atticotomy and mobilization of ossicles yielded better results than did the epitympanic bypass procedure. The difference, however, did not reach statistical significance. Patients with fixed stapes treated with stapedectomy displayed good hearing results immediately after surgery, but the air-bone gap deteriorated after some time.     

钛质人工听骨在开放式乳突根治鼓室成形术中的应用

目的探讨钛质人工听骨在开放式乳突根治鼓室成形术中的应用方法以及对听力的改善作用。方法51例53耳胆脂瘤中耳炎和慢性化脓性中耳炎患者行开放式乳突根治术加I期鼓室成形术,分为两组:人工听骨组28耳,术中使用Spiggle&Theis钛质人工听骨进行听骨链重建(partial ossicular replacement prosthesis,PORP21耳,total ossicular replacement prosthesis,TORP 7耳);非人工听骨组25耳,未使用人工听骨单纯行鼓室成形IIIa型术式。随访1～3年,纯音测听检测两组患者术前、术后的气导听阈及气骨导差(air-bone-gap,ABG),进行统计学分析。结果钛质人工听骨组术前ABG(36.9±11.6)dB,术后(22.4±11.8)dB,平均缩小(13.44±8.8)d B,术前术后相比差异有显著性(t=4.6 1 9 3,P<0.01),无1例出现听骨脱出;非人工听骨组术前ABG(38.5±12.3)dB,术后(31.3±14.4)dB,平均缩小(7.28±8.7)dB,术前术后相比差异无显著性(P>0.05)。钛质人工听骨组听力提高水平明显优于非人工听骨组,差异有显著性(t=2.3015,P<0.05)。结论开放式乳突根治鼓室成形术中使用人工听骨进行听骨链重建,能够提高患者听力,钛质人工听骨组织相容性好,无排斥脱出发生,是较为理想的听力重建材料。     

乳突切开术并一期听骨链重建的临床疗效分析

目的：评估乳突切开术并一期行听骨链重建的临床疗效。方法：对2008-01～2011-06期间在我科住院行乳突切开术并一期钛人工听骨植入手术并且有完整随访资料的患者139例进行回顾分析,其中置入部分听骨赝复物（PORP）者91例,置入全听骨赝复物（TORP）者48例,随访时间为2～5年,纯音测听法（PTA）检测患者术前及术后听力,比较手术前后的气导听阈（0．5、1．0、2．0、4．0kHz四个频率气导之平均值）及气骨导差（ABG）,分析钛人工听骨在同期听骨链重建术的听力重建效果。术后ABG≤20dB为听力提高有效。结果：PORP植入患者术前气导平均听阈为（53．97±11．32）dB,术后为（36．80土11．68）dB,平均降低（17．17±5．79）dB;术前ABG平均为（31．84±6．17）dB,术后为（15．13±7．22）dB,平均缩小（16．71±5．50）dB;TORP组患者术前气导平均听阈为（58．05±11．35）dB,术后为（44．53±13．15）dB,平均降低（13．52±7．81）dB;术前ABG平均为（35．67±5．73）dB,术后为（21．48±7．01）dB,平均缩小（14．18±7．53）dB;各组术前术后的差异均有统计学意义（P〈O．01）。PORP组术后ABG≤20dB者（术后听力提高有效）共68例,有效率为74．73％;TORP组术后ABG≤20dB者共26例,有效率为54．13％;总有效率为68．63％,两组之间的差异有统计学意义（P＜0．05）。结论：乳突切开术并同期钛人工听骨植入取得了良好的听力效果,PORP比TORP的听力改善效果好。     

CO2激光在听骨链畸形手术中的应用

目的　分享CO2激光在先天性听骨链畸形手术中应用的临床经验。方法　回顾性分析本院2010年5月～2016年3月治疗的9例听骨链畸形患者。术中均应用CO2激光辅助镫骨底板打孔进行听骨链重建,通过比较患者术前与术后听力恢复情况及并发症的出现评价手术效果。结果  术中发现患者听骨链畸形以砧骨、镫骨联合发病为主,砧骨长脚及镫骨发育异常8例,单纯镫骨畸形1例。9例患者术后气导平均值（26.53±12.28）dB,气骨导差平均（9.44±9.62）dB,术后与术前比较听力提高明显,差异具有统计学意义（t =7.338,P＜0.01;t =7.176,P＜0.01）。结论　CO2激光有效改善患者术后听力,并未增加患者出现手术并发症的风险。     

Importance of atticotomy in chronic otitis media with fixation of ossicles.

Seventy-seven patients with chronic otitis media were reviewed. Of the 77 patients, 42 underwent tympanoplasty with a columella, and 35 underwent myringoplasty and atticotomy. Twenty-five of the latter 35 patients showed less than 10 dB of hearing improvement with a patch test before operation. The ossicular chain was not disconnected in any of the 25 patients, but the mobility was severely restricted. It was interesting that fixation of the malleus was found at surgery in 80% (20/25) of the patients, whereas the stapes was immobilized in only 16% (4/25). Myringoplasty and atticotomy instead of tympanoplasty with a columella was sufficient to achieve hearing improvement in most of such cases. However, conventional atticotomy was not able to achieve improvement in the mobility of the ossicles because the mobility is usually severely restricted at the malleus. Removal of the anterior tympanic spine is the key to recovery of the mobility of the malleus, resulting in hearing improvement. Rate of success was obtained in 24 of 25 ears (96%).     

经典Wullstein Ⅲ型鼓室成形术在慢性化脓性中耳炎手术中的应用分析

目的：探讨经典Wullstein Ⅲ型鼓室成形术在慢性化脓性中耳炎手术中的适应证及其术后听力效果。方法回顾性分析行开放式Ⅲ型鼓室成形术的患者34例（34耳）,患者均有听骨链破坏而镫骨结构完整,鼓膜内陷与镫骨头或砧骨豆状突直接连接,根据术中是否植入钛合金部分人工听骨（partial ossicular replacement prosthesis,PORP）分为两组, Wullstein Ⅲ型鼓室成形术（Ⅲ型组）11例和植入钛合金部分人工听骨（PORP组）23例。分别比较两组术后0.5、1、2和4 kHz的平均气导听阈、平均气骨导差的变化情况。结果Ⅲ型组患者术前平均气导听阈为46.59±16.60 dB HL,术后为34.89±10.34 dB HL,气导听阈提高11.70±19.30 dB HL;PORP组术前平均气导听阈为44.23±12.31 dB HL,术后为37.08±14.36 dB HL,提高7.14±14.39 dB HL;Ⅲ型组术前平均气骨导差（air-bone gap,ABG）为23.98±13.08 dB HL,术后为16.25±6.98 dB HL,缩小7.73±14.93 dB HL;PORP型组术前平均ABG为26.58±10.27 dB HL,术后为19.40±13.28 dB HL,缩小7.17±13.63 dB HL。两组患者在气导听阈提高值及ABG缩小的差异均无显著统计学意义（P＆gt;0.05）。结论开放式鼓室成形术中,如果鼓膜内陷与镫骨头或砧骨豆状突形成连接,可以予以保留,短期随访术后听力水平与植入PORP重建听骨链的效果相当,长期效果还需随访观察。     

Incus reposition: Goblet prosthesis

A stainless steel goblet shaped prosthesis is used to attach the repositioned incus to the stapes. A two year follow-up was made of the first 116 patients in which the prosthesis was used for ossicular reconstruction. The incidence of extrusion and ankylosis is diminished, and 75% of all cases had closure within 10 db. An additonal 20% had closure within 20 db of bone conduction thresholds. Revisions have been less with this technique than with others: 40% of 116 patients had an uncomplicated tympanoplasty; 60% had a tympanoplasty with mastoidectomy. The results are, of course, more favorable in the group without mastoidectomy. Of these, 86% had closure to within 10 db of bone conduction level. These findings suggest that the use of the goblet prosthesis results in improved hearing. These findings conclude that the use of the goblet prosthesis results in better hearing than that obtained with other methods of ossicular chain reconstruction.     

虚拟耳镜对鼓室成形术前后鼓室结构的观察

目的 探讨虚拟耳镜在鼓室成形术中的临床评估作用.方法 应用虚拟耳镜观察耳病患者102例(204耳),72例(75耳)完成鼓室成形术和外耳道鼓室成形术,其中慢性中耳炎53例(55耳),先天性外耳道闭锁1 9例(20耳).结果 23耳慢性化脓性中耳炎胆脂瘤型,虚拟耳镜观察19耳听骨链破坏,手术证实23耳均有听骨腐蚀;32慢性化脓性中耳炎骨疡型,虚拟耳镜观察29耳听骨链不同程度破坏,手术证实23耳锤骨和砧骨侵蚀,11耳镫骨头或镫上结构缺失;20耳先天性外耳道闭锁,中耳畸形,术前提示18耳听骨畸形,2耳小鼓室无听骨链,手术证实17耳外耳道闭锁,听骨严重畸形,2耳镫骨缺失,1耳前庭窗闭锁.2耳术后突然听力下降,复查虚拟耳镜发现移植听骨与鼓膜脱离.虚拟耳镜与手术探查符合率,中耳炎为92%,先天性外耳道闭锁、中耳畸形为100%.结论 虚拟耳镜为鼓室成形术术前病变程度及术后疗效评估提供可靠的影像学依据.     

Surgery for congenital stapes ankylosis with an associated congenital ossicular chain anomaly

The surgical findings and results are presented on 32 ears with congenital stapes ankylosis with an associated congenital anomaly of the ossicular chain. One third of the patients had a syndromal diagnosis. In 26 ears, stapedectomy could be performed. In 2 other ears, stapes ankylosis to the bony facial canal was mobilized successfully. In the 4 remaining ears, surgical intervention had to be limited to an exploratory tympanotomy for various reasons. The average hearing gain was 23 dB for the 28 ears on which stapes surgery had been performed. A substantial hearing gain of at least 15 dB was achieved in 19 of these 28 ears (68%). The end result was limited to a small extent by an average preoperative sensorineural component of 16 dB in the hearing loss. A review of the findings and results from other larger series in the literature are presented.     

Stapedectomy in the Pediatric Patient

The purpose of this study was to evaluate and compare the results of stapedectomy in pediatric patients with otosclerosis and tympanosclerosis. A retrospective review of 14 patients (15 ears) who underwent stapedectomy from 1993 to 1995 was conducted. In 5 ears stapedectomy for tympanosclerosis was performed; 9 patients had otosclerosis and 1 had Treacher Collins syndrome. Patients were evaluated for preoperative and postoperative air-bone gaps, preoperative and postoperative speech reception thresholds, postoperative air conduction hearing improvement, and preoperative and postoperative speech discrimination. Children with otosclerosis who underwent stapedectomies had an average postoperative airbone gap of 16 dB with an average air conduction hearing improvement of 17.6 dB. Children with tympanosclerosis who underwent stapedectomies had an average air-bone gap of 14 dB with an average air conduction hearing improvement of 28 dB. Stapedectomy is a safe and effective treatment for otosclerosis and tympanosclerosis in pediatric patients.     

Reconstruction of the entire ossicular conduction mechanism

OBJECTIVES/HYPOTHESIS: Stapes fixation combined with fixation, absence, or malformation of the malleus-incus complex requires an uncommon surgical reconstruction and offers a unique combination of challenges and hazards. This situation may occur in the presence of severe tympanosclerosis, otosclerosis, congenital ossicular malformations, and revision surgery for either stapedectomy or chronic ear disease. In previous reports, this procedure has been grouped with total ossicular reconstruction without much distinction. However, the challenges unique to this problem deserve special consideration. The present report offers a treatment plan for a group of patients requiring reconstruction of the entire ossicular conduction mechanism including removal of the stapes footplate. STUDY DESIGN: Retrospective review. METHODS: Three thousand three hundred fifty (3350) charts of patients requiring total ossicular replacement prostheses (TORPs) were reviewed. Of this group of patients, only 21 of 3350 patients from 1977 to 1999 required TORP placement and removal of the stapes footplate. The patients were followed for an average period of 50 months. RESULTS: Hearing results indicated an overall improvement in the air-bone gap of 10 dB, with 52% achieving an air-bone gap of less than 20 dB. Of the 21 cases, 5 revision surgeries were performed. Three were performed because of a displaced TORP (14.2%). and 2 were performed because of extruded TORPs (9.5%). CONCLUSIONS: Reconstruction of the entire ossicular conduction mechanism including removal of the stapes footplate can be successfully achieved with improvement of the air-bone gap of less than 20 dB. Hearing results and extrusion rates are comparable to reported results of TORP placement on a mobile footplate. Successful stapedectomy and simultaneous ossicular chain reconstruction can be performed as a single or staged procedure. Special attention is paid to avoid intrusion of the prosthesis into the vestibule.     

Postoperative result for tympanic membrane perforation

Ears with tympanic membrane perforation show a wide range of pathophysiology from simple perforation to mobility impairment of the ossicular chain complicated by sclerotic and/or inflammatory lesions of the middle ear. In surgery on such ears, we determine checkpoints and proceed based on the order of procedure. We studied postoperative results for 37 ears of patients undergoing tympanoplasty in the 3 years from June, 1996 to May, 1999. Lesions accountable for mobility impairment of the ossicular chain were confirmed and removed in the order of calcified tympanic membrane, tip of malleus handle, around the anterior tympanic spur, and epitympanum. Success in improving in hearing was 89.2% overall. Conductive impairment (air conduction-bone conduction gap) left on the patch test was found to differ with the site and range of tympanic and middle ear lesions. This can serve as a guide in preoperatively predicting the type of operation required.