Hydroxyapatite granules used in the obliteration of mastoid cavities in rats

Prospective Experimental study in which we created a bony defect in the mastoids of rats and filled it up with hydroxyapatite to evaluate bone regeneration, to solve the problems of open cavities after mastoidectomies that frequently present with otorrhea, infection, granulation tissue and hearing loss.ObjectiveThe aim was to evaluate bone regeneration in defects created in the mastoids of rats, using hydroxyapatite, to see how much of the cavity we could reduce.Material and methodsTwelve rats Wistar-Furth were used. A 0.5 × 0.5 cm bone defect was created in both temporal bones of the rats, and filled with 15 micrograms of hydroxyapatite. The left side was used as control. The animals were slaughtered 40 days afterwards and histology analyses were carried out.ResultsIn the hydroxyapatite group, the new bone growth involved an area of 68.53% of the total; and in the control group it was only of 15.97%.Discussion and ConclusionIt was observed a very good hydroxyapatite integration to the temporal bone in this experimental model. The microscopic results were superior with the use of hydroxyapatite when compared to the control group. It is a safe method and easy to apply to solve the problems of open cavities with chronic discharge and difficult to clean.     

Reconstruction of the outer attic wall by cortical bone and bone cement

ObjectiveTo asses using cortical bone and bone pate with and without glass ionomer bone cement (GIBC) for reconstructing the outer attic wall (OAW) defect during cholesteatoma surgery without mastoid cavity obliteration.MethodThis is a prospective case series of 25 patients who underwent primary surgery for cholesteatoma with presence of OAW defect that was reconstructed by cortical bone graft and bone pate, further fixation of the cortical bone graft in place was done by GIBC in 18 patients.ResultsThere was significant improvement of persistent otorrhea and hearing loss after surgery (P < 0.001). Recurrence of cholesteatoma was found in 2 patients (8%), residual TM perforation was found in one patient (4%).ConclusionReconstruction of OAW by cortical bone and bone pate is an effective surgical option to decrease the incidence of recurrence in cholesteatoma surgery. Glass ionomer bone cement can be added safely to fix the cortical bone graft in the OAW defect.     

Benchmarks for the Dichotic Sentence Identification test in Brazilian Portuguese for ear and age

IntroductionDichotic listening tests should be used in local languages and adapted for the population.ObjectiveStandardize the Brazilian Portuguese version of the Dichotic Sentence Identification test in normal listeners, comparing the performance for age and ear.MethodsThis prospective study included 200 normal listeners divided into four groups according to age: 13–19 years (GI), 20–29 years (GII), 30–39 years (GIII), and 40–49 years (GIV). The Dichotic Sentence Identification was applied in four stages: training, binaural integration and directed sound from right and left.ResultsBetter results for the right ear were observed in the stages of binaural integration in all assessed groups. There was a negative correlation between age and percentage of correct responses in both ears for free report and training. The worst performance in all stages of the test was observed for the age group 40–49 years old.ConclusionsReference values for the Brazilian Portuguese version of the Dichotic Sentence Identification test in normal listeners aged 13–49 years were established according to age, ear, and test stage; they should be used as benchmarks when evaluating individuals with these characteristics.     

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.     

Materialien zur Rekonstruktion des Schalleitungsapparats

To rehabilitate most cases of conductive hearing loss closure of ear drum perforations and rebuilding of the ossicular chain can be performed. Due to the great number of biocompatible bone substitute materials available it is occasionally difficult for the surgeon to choose the most favorable substitute. Autogenous structures (ossicles, cortical bone, cartilage) and allogenous tissues (ossicles, cortical bone, cartilage, dentin) are possible bone replacement materials. Xenogenic tissue is currently not used in middle ear surgery. Ionomer cement is a hybrid material for replacement of bone but does not fit direct classification of the various classes of alloplastic materials in current use: that is, metals (gold, steel wire, platinum, titanium), plastics (polyethylene, polytetrafluorethylene) and ceramics (ceramic oxide, carbon, calcium-phosphate ceramic, vitreous ceramic). For restoration of the sound conductive apparatus preference is given to autogenous ossicles because cortical bone is resorbed and cartilage weakens over time. Most surgeons do not use allogenous tissue, because of the possible transmission of such infectious disease as immunodeficiency syndrome or Creutzfeldt-Jakob disease. Only dentin deserves special attention as a possible bone substitute in the middle ear because its form can be preserved during sterilization. Based on the observations available to date, it becomes apparent that titanium implants hold greater promise than gold. Form-stable synthetic materials are not generally recommended due to foreign body reactions which have been confirmed by many investigators. Ceramic materials (e.g. ceramic oxide, carbon, calcium-phosphate ceramic, glass ceramic) are well tolerated in the middle ear and have also proved to be useful over time. Hybrid bone substitute ionomer cement is easily workable and well integrated, showing a good functional outcome. For many years good results in otosclerosis surgery have been achieved with a prosthesis made of platinum-wire and Teflon. Short-term follow-up periods hold great promise with pistons made of gold. Autogenous ossicles, ionomer cement and recently titanium protheses--as far as usable--are employed by the author for reconstructing the middle ear. For the time being platinum-Teflon prostheses and gold are used in otosclerosis surgery.     

Paranasal sinus reconstruction with bioactive bone cement--a 5-year animal experiment study

The newly developed bioactivated bone cement Palavital is composed of polymethylmethacrylate, glass fibers and bioactive glass ceramic. The superficially located glass ceramic particles offer the possibility of true bonding of the bone cement to the bony implantation bed. Reconstruction of the frontal sinuses and the skull was performed on 9 dogs. The follow up was 14 days to 5 years. The implants were checked by tomography and histology. All implants were tolerated without any inflammatory reaction. The bond between bone and implant was demonstrated. Palavital seems to be an improvement on bone cement on a polymethylmethacrylate base.     

Composite tragal perichondrial/cartilage autografts vs cartilage or bone paste grafts in tympanoplasty*

Extrusion of plastic or ceramic implants is a significant cause of failure in ossiculoplasty for chronic ear disease. This paper reports the use of a composite tragal cartilage and perichondrial autograft compared to cartilage or bone paste between the graft and tympanic membrane. At 2 years, there were no extrusions in the group with the composite graft (n= 18) and 5 extrusions in the cartilage/bone paste group (n= 18) (P= 0.02). The mean average air-bone gap was significantly better for the composite grafts at 2 years (15 dB vs 24 dB) (P < 0.05). Extrusions were eliminated and hearing results better at 2 years using the composite graft.     

Hydroxyapatite bone cement for suboccipital retrosigmoid cranioplasty: A single institution case series

Objective

To report rates of cerebrospinal fluid leak, wound infection, and other complications after repair of retrosigmoid craniotomy with hydroxyapatite bone cement.

Case report of a child with otoacoustic emissions and profound hearing loss in whom otoacoustic emissions were preserved after cochlear implantation

Abstract

Objective and importance

To highlight the complications of using hydroxyapatite (HA) bone cement when implanting a cochlear implant (CI) device.

Clinical presentation

A case series of three patients who had undergone cochlear implantation are presented. A bony defect was seen in the external auditory meatal wall posteriorly in all three cases. This was intimately related to the site of HA bone cement, which had been used to anchor the electrode array at the time of the original implantation. Persistent otorrhoea was usually a feature at clinical presentation.

Intervention (and technique)

Removal of the HA bone cement and repair of the bony defect has resulted in resolution of the otorrhoea and a functioning CI is present in all cases without further complications.

Conclusion

The use of HA bone cement in cochlear implantation may cause dehiscence of the external auditory meatal wall. Our experience has shown that the electrode array does not need to be secured with cement. It is therefore recommended by this centre that HA cement should not be used to secure the electrode array in cochlear implantation surgery.     

Cranial, iliac, and demineralized freeze-dried bone grafts of the mandible in dogs

Both autogenous bone grafts and demineralized freeze-dried allogeneic bone implants were evaluated for mandibular reconstruction. Four-centimeter segmental defects of the midbody of the edentulous mandible were reconstructed in 36 dogs, with specimens recovered at 3 and 6 months and quantitatively compared for total and new bone by histomorphometric analysis. Autogenous grafts consisted of corticocancellous cranial block (CB), corticocancellous iliac block (IB), and particulate cancellous iliac marrow (PM). The allogeneic bone was demineralized and freeze-dried, and consisted of particulate cortical endochondral bone (FP), cranial cortical block (FCB), and iliac cortical block (FIB). Clinically and histomorphometrically, results appeared to indicate that (1) CB compared favorably with IB at 3 and 6 months for total bone, but IB showed a trend for more new bone formation at 6 months, a trend that may be due to the thicker cortical component of CB, which requires longer time periods to remodel than the cancellous rich IB; (2) FP failed to achieve bony union at 3 months, with inadequate rates of new bone formation; and (3) FCB and FIB compared favorably for total bone with CB and IB at 6 months, although new bone for autogenous CB and IB was 26.9% and 45.4%, while new bone for allogeneic FCB and FIB represented only 7.9% and 17.4%.     

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).     

Letter regarding two recent publications on interaural attenuation in the International Journal of Audiology

Abstract

Objective: The purpose of this study was to evaluate the effectiveness of a distance training program in infant hearing health to community health workers (CHWs). Design: Pre- and post- tests were administered to two groups of subjects following the use of an interactive CD-ROM for tele-educational training. Study sample: Two groups of subjects were used: Group I (GI) consisted of 43 CHWs who had previously participated in at least one training activity involving hearing health, and Group II (GII) were 47 CHWs who had received no prior training in hearing health. Results: CHWs retained a significant amount of training content. There was not significant correlation between the global post-training questionnaire score and performance on the simulation activity (GI: r = 0.11, p = 0.698 and GII: r = 0.29, p = 0.074), and the simulation activity performance was significantly better among GI CHWs (p = 0.05). Conclusion: The CHWs’ training in infant hearing health using an interactive tele-educational tool was effective, as the CHW demonstrated significant short-term information retention and applied such data in hypothetical situations representative of their daily activities.     

Effects of glass ionomer cement on facial nerve: a clinical and histopathologic evaluation

Objective: The aim of this study was to investigate the clinical and histopathologic effects of glass ionomer cement (GIC) on facial nerve.

Methods: Eight Wistar albino rats were included in the study. Under general anesthesia, bilateral facial nerves of rats were dissected. Saline was injected into right facial nerves, while GIC was dropped on left facial nerves. Facial nerve functions of the rats were evaluated using mustache and bling reflex scores everyday along 14 days. On the 14th day, rats were sacrificed, and facial nerves examined in terms of inflammation, granulation tissue, and foreign body reaction. The clinical and histopathologic changes on facial nerves were compared for both groups.

Results: In clinical evaluation, facial nerve functions did not significantly differ between two groups (p?=?.301). On histopathologic examination, bone cement group had significantly more foreign body reaction, granulation tissue, and inflammation compared with the control group (p?=?.001; p?=?.002; p?=?.003, respectively).

Conclusions: Bone cement directly applied on the nerve causes foreign body reaction increased inflammation and granulation tissue. Nonetheless it does not lead to a permanent facial nerve dysfunction.     

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.     

Reconstruction of old radical cavities.

Various techniques and materials have been proposed to deal with problems connected with radical cavities including recurrence of inflammatory processes, requirement of regular medication, social inconvenience (i.e., inability to practice any water sport, work in adverse environment, etc.). The present paper details the results of revalidation of old radical cavities using as filling a mixture of tricalcium phosphate and hydroxyapatite granules. Three techniques were used in reconstruction of the posterior canal wall. In the first procedure, the material was incorporated with fibrin adhesive to fill the cavity. In the other two methods the ceramic granules were covered respectively with a sheet of bone pate-fibrin sealant or with septal cartilage homografts. Twenty-four patients with chronic discharging old radical cavities were operated with anatomic results of 91.7 percent successful graft taken. The functional results showed an air-bone gap less than 30 dB in 72.7 percent of the cases after 6 months. After 2 years hearing gain was satisfactory in 63.6 percent of the patients. The different methods of reconstruction of posterior canal wall did not influence these findings.     

The use of hydroxyapatite cement and a pericranial/deep temporal fascia graft for cranioplastic reconstruction of translabyrinthine craniectomy defects

Most translabyrinthine temporal bone defects are reconstructed with free abdominal fat grafts, with or without the use of hydroxyapatite cement. However, these procedures are associated with considerable morbidity at the graft donor site, with a 6 to 15% incidence of cerebrospinal fluid (CSF) leaks, and with postoperative headaches. We have developed a new technique for reconstructive cranioplasty that involves the use of hydroxyapatite cement and a pericranial/deep temporal fascia graft. This technique obviates the need for an abdominal fat graft and therefore circumvents the morbidity associated with it; it may also significantly reduce the incidence of CSF leaks and postoperative headaches. We describe the results of our use of this technique in a series of 10 patients. Based on our early findings, we believe that this technique holds great promise for reconstructive cranioplasty following translabyrinthine craniectomy.     

Comparison of early hearing outcomes of type 2 ossiculoplasty using hydroxyapatite bone cement versus other materials

ObjectivesTo compare the hearing outcomes of type 2 ossiculoplasties for erosion of the long process of the incus according to the reconstruction material used: cartilage, ossicles, hydroxyapatite (HAP) partial ossiculoplasty reconstruction prostheses (PORP), titanium PORP, and HAP cement. Complications related to cement reconstruction were systematically investigated and reported.Material and methodsSeventy patients operated between 2007 and 2011 for non-cholesteatomatous chronic otitis media were included in this study. Mean air-bone gap (500, 1000, 2000 and 4000 Hz) was compared preoperatively and 3 months postoperatively according to the reconstruction material used. Postoperative results were classified as good (air-bone gap < 10 dB), acceptable (air-bone gap 10–20 dB) or insufficient (air-bone gap > 20 dB) and were compared according to the reconstruction material used.ResultsGroups were comparable in terms of preoperative air-bone gap (P > 0.05, Anova). The mean postoperative air-bone gap was 14.82 ± 11.52 dB in the cartilage group, 13.31 ± 9.03 dB in the ossicles group, 22.12 ± 11.95 dB in the HAP PORP group, 13.75 ± 11.20 dB in the titanium PORP group, and 7.26 ± 8.99 dB in the HAP cement group. Statistical analysis showed a significant air-bone gap difference only between HAP PORP and HAP cement groups (P = 0.021, Tukey's test). No significant difference was observed between groups when classified by air-bone gap class (P = 0.29, Fisher's test). No major complication was reported with HAP cement with a minimum follow-up of 10 months.ConclusionHAP cement provides similar hearing outcomes to autologous material and titanium PORP, and better outcomes than HAP PORP in our patients. These results must be confirmed in a larger series with a longer follow-up.     

Results of ossicular chain reconstruction with glass ionomer cement in pediatric patients

ObjectiveThe aim of our study was to analyze the hearing results of ossicular chain reconstruction in incus long process defects in pediatric patients.MethodsThis retrospective study included 15 pediatric patients that had incus long process defect due to chronic otitis media or adhesive otitis, and repaired with glass ionomer cement between 2009 and 2015. The audiological tests (air conduction thresholds, bone conduction thresholds, air bone gap) obtained preoperatively and one year after surgery were compared. In addition, preoperative and postoperative air bone gap differences were estimated to determine hearing gain.ResultsMean air conduction and air bone gaps decreased significantly one year after surgery when compared to the preoperative values (p< 0.001 for both). Mean hearing gain was 20.33 ± 6.36 dB one year after surgery.ConclusionUse of glass ionomer cement to repair incus long process defects is a suitable method that improves hearing in pediatric patients. Further large studies that compare glass ionomer cement ossiculoplasty with other ossicular reconstruction methods are needed.     

Biphasic ceramics and fibrin sealant for bone reconstruction in ear surgery

Bone reconstruction is still a matter of concern in middle ear surgery despite the large number of surgical techniques proposed. A composite made of biphasic calcium phosphate ceramic granules mixed with human fibrin sealant, forming a moldable material that is easy to set for bone reconstruction, has been used with success over a 16-year period for reconstruction of the posterior canal wall or for mastoid obliteration. In a retrospective series of 72 ears with long-term follow-up (average follow-up of 46 months), regular microscopic examination, and computed tomographic controls, we have evaluated this bone reconstruction technique for radical mastoidectomy cavities or the closed technique. The bone reconstruction material provided an immediate anatomic reconstruction that remains stable and is well tolerated over the long term. A slight leakage of granules in the meatus was initially observed in several patients with transient aseptic otorrhea. Fifty-seven ears were followed up for 1 year or more. Satisfactory clinical results with complete regression of the mucous membrane disease were found in 82.4% of the patients, with perfect stability of the material in 65%. We did not observe any cases of recurrent cholesteatoma in or behind the filling material. Eighteen biopsies were performed between 8 and 84 months after surgery during a second surgical step performed for functional purposes or for recurrent cholesteatoma; 17 of the 18 cases showed osteointegration of the filling material. After a 16-year experiment, we consider this technique to be a highly satisfactory procedure that could be extended to other situations of bone reconstruction.     

Physiologic reestablishment of ossicular continuity during excision of retraction pockets: use of hydroxyapatite bone cement for rebridging the incus

OBJECTIVE: To analyze the results obtained from hydroxyapatite bone cement repair of ossicular discontinuity between the incus and stapes during surgery of retraction pockets. DESIGN: Clinical study of a case series. SETTING: Otolaryngology Department, Tanta University Hospitals, Tanta, Egypt. PATIENTS: A total of 62 previously untreated patients (82 ears) with retraction pockets. INTERVENTIONS: Hydroxyapatite bone cement was used to repair defects at the incudostapedial connection in 82 ears with retraction pockets. The ears were divided into 2 groups: group 1 included 48 ears with a small defect in the long process of the incus; group 2 included 34 ears with a large defect in the long process of the incus. In addition, 20 control patients underwent surgery using plastipore partial ossicular replacement prostheses. Hearing results were reported in 4 frequencies (0.5, 1, 2, and 3 kHz). Analysis of the results was performed using the paired t test with significance level at .05. MAIN OUTCOME MEASURES: Anatomic and audiologic results. RESULTS: Significant postoperative improvement of pure-tone air conduction threshold averages and air-bone gap averages were reported in the 3 studied groups. The postoperative air-bone gap averages showed significantly better outcome in groups 1 and 2 compared with controls (P<.001), while there was no statistically significant difference between groups 1 and 2 (P>.05). CONCLUSIONS: Bone cement ossiculoplasty offers cost-effective and significant improvement in conductive hearing loss. It provides an excellent alternative to ossiculoplasty with preformed prostheses. We believe the indications for bone cement were validated by these results.