Prognostic factors in ossiculoplasty.

OBJECTIVE: To analyze predictive factors of outcome after ossiculoplasty using a standard ossicular prosthesis system. STUDY DESIGN: Retrospective review of 140 ossiculoplasties, performed by the same senior surgeon, with titanium prostheses. SETTINGS: Academic hospital and tertiary referral center. PATIENTS: All patients undergoing ossiculoplasty with Spiggle and Theis or Kurz titanium total and partial prostheses. Documented, postoperative follow-up had to be provided. A total of 129 patients (140 ears; 53 men and 76 women) were evaluated. INTERVENTIONS: These included ossiculoplasties using 75 Spiggle and Theis prostheses (30 partial and 45 total) and 65 Kurz prostheses (35 partial and 30 total). MAIN OUTCOME MEASURES: Mean preoperative and postoperative air-bone gaps and the changes in mean hearing loss were analyzed using a four-frequency (500, 1,000, 2,000, and 3,000 Hz) pure tone average. Success rate was defined as postoperative air-bone gap within 20 dB. A one-way analysis of variance was used to analyze group differences. A multivariate statistical analysis was then undertaken to define the significant factors. RESULTS: There were no statistical difference between the Spiggle and Theis and the Kurz prostheses. Multivariate statistical analysis has identified the predictive value of the presence or absence of the malleus handle and the mucosal status of the middle ear in the prognosis of ossiculoplasties. CONCLUSION: Anatomical and technical factors diversely affect the functional outcome of tympano-ossiculoplasties. A better knowledge of their predictive value will enable accurate, preoperative, individual assessment when counseling patients with regard to the success of any proposed intervention. The use of these factors will also permit precise matching of future series to allow accurate comparisons.     

Autograft ossiculoplasty in cholesteatoma.

Although using autogenous ossicles in reconstruction offers stable hearing results with good tendency for healing and minimal extrusion, their use in cholesteatomatous ears has been criticized for the possibility of progressive osteitis, bone resorption and cholesteatoma recurrence. In the present study we have been investigating a way which affords safe re-implantation of such ossicles. Treatment by burring followed by autoclaving seems to offer an implant that is safe both bacteriologically and pathologically. We have found no evidence that cholesteatoma could develop from such treated ossicles.     

Hydroxyapatite versus titanium ossiculoplasty.

OBJECTIVE: To compare the results of ossicular chain reconstruction using hydroxyapatite (HA) and titanium (TI) prostheses. STUDY DESIGN: Retrospective study and case series. SETTING: Tertiary referral center. PATIENTS: One hundred sixty-eight patients presenting chronic otitis media with or without cholesteatoma. INTERVENTION: Ossiculoplasty using partial or total HA and TI ossicular replacement prostheses (TORP and PORP, respectively). MAIN OUTCOME MEASURES: Patients were assessed at 2 months postoperatively to establish short-term results. Results of treatment for conductive hearing loss were reported according to guidelines. Available audiometric data at 1, 2, 3, and 5 years were used to assess prosthesis stability. Average postoperative air-conduction gain, air-bone gap, and sensorineural hearing level were measured at four frequencies: 0.5, 1, 2, and 4 kHz. Statistical analyses compared outcomes for HA TORP versus TI TORP and HA PORP versus TI PORP. RESULTS: Postoperative air-bone gap of less than 20 dB was obtained in 50% of HA TORP versus 45.8% of TI TORP cases and in 63.2% of HA PORP versus 72% of TI PORP cases. Preoperative middle ear status and presence/absence of malleus significantly influenced postoperative audiometric results. All types of prosthesis demonstrated significant postoperative air-conduction gain decrease on follow-up. Prosthesis exclusion was observed in three cases (1.78%). CONCLUSION: Prostheses using both types of biomaterial gave good functional results and stability with low exclusion rates, with no statistically significant differences between the two. Trends could be observed for slightly better results for HA in total reconstruction and for TI in partial reconstruction. The degradation in postoperative functional gain seemed to be independent of prosthesis type.     

Revision ossiculoplasty

Although ossiculoplasty, also known as ossicular chain reconstruction (OCR), was attempted initially in the early 1900s, it was not until the 1950s that it became commonplace and relatively well understood. Since then, there have been numerous technologic advances and a gain in the understanding of ossiculoplasty. However, successful OCR with resulting long-term stability can be a daunting task. Typically, the most common condition requiring revision OCR is chronic suppurative otitis media (COM) with or without cholesteatoma. Primary and revision OCR are performed also for blunt and penetrating trauma-induced conductive hearing loss, congenital defects (eg, atresia), and benign and malignant tumors. Typically, reconstruction in ears with COM is more difficult than in ears without infection. This article discusses the key factors involved in successful revision OCR.     

Realities in ossiculoplasty

The results of ossiculoplasty are frequently reported in terms of closure of the air-bone gap. This parameter is a reliable indicator of the degree of technical success, and is useful in comparing different materials and types of reconstructions. However, assessment of the operated ear alone does not evaluate the effect of surgery on binaural hearing ability, leading to the situation where sub-optimal advice may be given to patients pre-operatively. This article advocates a more patient orientated method of assessing the results of ossiculoplasty. Previous studies have indicated that the operated ear must reach an air conduction level of 30 dB for the speech frequencies, or be within 15 dB of the other ear, to ensure that the patient will gain significant benefit. A graphical method for the prediction of patient benefit is presented, and compared to the rule of thumb quoted above. The implications for surgeons and patients considering ossiculoplasty are obvious. Many statements routinely made to patients prior to surgery for conductive hearing loss are unduly optimistic and unrelated to the realities of reported results. There is a need to determine what types of such hearing losses can be helped surgically, and more importantly to what extent the patients hearing disability can be relieved.     

自体听骨在听骨链重建中的应用及疗效观察

目的探讨自体听骨用于听骨链重建术的临床疗效。方法回顾性分析58例(60耳)应用自体听骨行听骨链重建术患者的临床资料,术后随访时间3-18个月,平均11.6个月,分析言语频率的纯音听阈及气骨导差。结果术后无一例自体听骨脱出,3例移位,无鼓膜再穿孔、内陷,所有患者术后均干耳。平均纯音听力气导由术前54.7±6.4 d B提高到术后39.0±9.1d B,骨导由术前28.3±4.6 d B提高到22.2±4.2d B,PTA-ABG由术前26.4±7.9 d B缩小到16.8±8.2 d B,手术成功率(术后PTA-ABG≤20d B)为71.7%(43/60)。结论自体听骨取材方便、费用低、组织相容性好,塑形后用于听骨链重建可取得良好的听力效果,是听骨链重建术的理想材料。     

Artificial tympanic membrane and ossiculoplasty.

We report an unusual case of a subjective hearing improvement, confirmed by audiometry, in a patient using a paper towel prosthesis.     

Double cartilage block ossiculoplasty in chronic ear surgery.

OBJECTIVES/HYPOTHESIS: Multiple techniques of ossicular reconstruction have been advocated for hearing rehabilitation in the setting of chronic otitis media No single method can adequately address the clinical spectrum of disease severity. In the situation of a severely diseased ear requiring a canal wall down (CWD) mastoidectomy in the presence of an intact stapes superstructure, the authors have employed a double cartilage block (DCB) ossiculoplasty. The technique and short-term results are reviewed. STUDY DESIGN: Retrospective chart review in a tertiary referral otologic practice. METHODS: Twenty-three patients underwent a CWD tympanomastoidectomy with DCB ossiculoplasty. Ages ranged from 6 to 85 years (mean, 36.1 y). The majority of ears were actively draining at the time of surgery (83%) and most procedures were revisions of prior mastoidectomies (74%). Audiometric data (mean postoperative follow-up, 19.5 mo) were calculated according to 1995 American Academy of Otolaryngology-Head and Neck Surgery guidelines. RESULTS: Audiometric results were available in 20 patients. The mean air-bone gap (ABG) was 23.8 dB after surgery. Closure of the ABG to within 20 dB was achieved in 10 of 20 patients (50%). No cases of DCB extrusion have occurred to date. CONCLUSIONS: The DCB represents an excellent alternative to biocompatible prostheses for ossicular reconstruction in the setting of severe chronic ear disease. As with all methods of ossiculoplasty, long-term follow-up will be necessary to determine if this technique remains stable in the hostile environment in which it has been employed.     

Preferred technique in ossiculoplasty

Conductive hearing loss of up to 60 dB SL can result from ossicular discontinuity in the presence of an intact tympanic membrane. Reconstruction of the ossicular chain can be curative with preference being given to autologous products. For those cases where reconstruction with autologous products is not possible, synthetic prosthesis is necessary. Ossicular prostheses vary in regards to the construction material. The three most commonly used ossicular prostheses are derived from high density polyethylene sponge, hydroxyapatite, and titanium. This article reviews our techniques in ossicular reconstruction utilizing prosthetic products and reviews the literature regarding postoperative outcomes.     

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.     

'Tripod' ossiculoplasty in incudal lesions

A method of ossiculoplasty, in cases where the long process of the incus is eroded, is described. The defect created by the erosion of the incus is bridged by an autogenic or allogenic bone graft that leans on the stapes, the remaining part of the incus, and the side of the malleus. These three contact points allow for stability of the bony graft and account for the name tripod. The method was applied in 30 ears and was successful in all but three cases. All the rest (ie, 27 ears) achieved an average gain of 24.8 dB, leaving an average air-bone gap of 11.1 dB. The postoperative air-bone gap was 20 dB or less in all 27 ears that were successfully operated on; and in 21 of them (77.8%), it was no more than 10 dB. The average period of follow-up was 23.8 months. Operative success depended on both the technique chosen and the favorable selection of cases.     

Long-term hearing outcomes after ossiculoplasty in comparison to short-term outcomes.

OBJECTIVES: To investigate long-term hearing outcomes after ossiculoplasty. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: One hundred ninety-nine patients who underwent ossiculoplasty between 1989 and 2001 by the same surgeon and were followed for more than 5 years. METHODS: Postoperative hearing outcomes were considered successful if the postoperative air-bone gap was within 20 dB. The outcomes after 6 months and 5 years were analyzed. RESULTS: The overall rate of successful outcomes was 61.3% after 6 months and 54.3% after 5 years. There was a significant difference between 6 months and 5 years (p < 0.05). The significant deterioration of long-term hearing outcomes was found in malleus-present ears, ears with cholesteatoma/atelectasis, adults, and ears treated by one-stage operation. The reasons for long-term unsuccessful outcomes were adhesion or retraction of the ear drum in 13 ears (54.2%). CONCLUSION: The hearing outcomes after ossiculoplasty showed significant deterioration on long-term follow-up. Innovative approaches to the management of cholesteatoma/atelectasis are necessary to improve and stabilize long-term hearing outcomes.     

Some physical considerations in the choice of techniques for ossiculoplasty.

A comparative study between the monobloc tympano-ossicular implant and the classical columellar technique is made. Although both give satisfactory audiometric results, the follow-up of the columellar restoration showed some post-operative disadvantages, namely: invagination and perforation of the tympanic membrane, slipping of the columella, and fixation of the columella to the tympanic ring (bony annulus) or to the promontory. In view of the normal tympano-malleal fixation, the normal static pressure accomodation in the incudo-malleal joint and the normal topological situation, monobloc implant obviates the disadvantages inherent in the columellar technique. Two aspects of the monobloc implant need further examination; these are the restoration of the correct rotation axes and the incudo-stapedial connection.     

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     

Titanium versus nontitanium prostheses in ossiculoplasty

Objectives/Hypothesis: To compare the hearing outcomes and complications observed using either titanium or nontitanium prostheses in a 7-year consecutive series of ossiculoplasties performed by a single surgeon. Study Design: Retrospective. Methods: A database of ossicular reconstruction surgeries was reviewed for preoperative and postoperative audiometric data including air and bone conduction thresholds at four frequencies and speech reception thresholds. Outcomes were evaluated at time points less than and greater than 6 months postoperatively. Baseline demographic and surgical characteristics and postoperative complications were also noted. Results: A total of 105 cases had sufficient audiometric data available for analysis, including 80 performed with titanium and 25 with nontitanium implants. Follow-up ranged from 1.2 to 74.2 months, with a mean of 14.9 months. Mean air-bone gap at initial follow-up was 21.7 dB in the nontitanium group and 15.4 dB in the titanium group; this difference was significant (P = .01). Postoperative air-bone gap of less than 20 dB at initial follow-up was achieved in 50.0% of nontitanium cases and 77.1% of titanium cases (P = .012). This difference in “success” rates persisted at longer follow-up but did not achieve statistical significance. Mean speech reception thresholds at <6 months was 29.7 dB in the nontitanium group and 22.6 dB in the titanium group (P = .049). Extrusion was observed with two nontitanium prostheses (8.0%) and three titanium prostheses (3.8%) (P > .05). Conclusions: Titanium ossicular prostheses provide hearing outcomes superior to those of nontitanium prostheses when evaluated within 6 months after ossiculoplasty.     

Use of autotransplants and implants in ossiculoplasty

The paper presents a comparative analysis of efficacy of ossiculoplasty (OP) using different transplants. A total of 202 operations were performed. Prostheses made of the fragments of the auditory ossicles, or a cortical layer of the temporal bone (n=81), of nail plate (n=56), titanium implants (n=65) were applied. A satisfactory result was achieved in 72-87% ossiculoplasties. Functional outcomes of OP did not vary significantly with type and material of the prosthesis. Main causes of poor OP results were fixation or displacement of the prosthesis with fibrous tissue; in case of titanium prostheses -- perforation of the tympanic membrane with prosthesis extrusion.     

A new double-cartilage block ossiculoplasty: long-term results.

OBJECTIVES: To determinate whether ossicular chain reconstruction performed with modified double-cartilage block (DCB) ossiculoplasty used by authors, leaving the intact perichondrium layer on the cartilage surface in contact with tympanic membrane, results in significant hearing results and prevents DCB displacement and DCB loss of stiffness when compared with the original DCB technique described by Luetje and Denninghoff. MATERIALS AND METHODS: Sixty-five ossicular reconstructions using DCB ossiculoplasty were performed from 1996 to 2001 in the whole study group. Eight patients had an inadequate follow-up and were excluded from the study. In the first 25 cases, the original DCB ossiculoplasty technique described by Luetje and Denninghoff was performed (Group 1). In the second group, 32 modified DCB ossiculoplasties were performed. The same author performed all cases. The main follow-up for the whole study group was 7 years. Audiometric data were calculated according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery guidelines. MAIN OUTCOME MEASURES: Mean postoperative air-bone gap closure to less than 20 dB, incidence of DCB displacement from tympanic membrane, and incidence of loss of DCB stiffness. RESULTS: Comparison data of hearing results, incidence of DCB slippage, and incidence of DCB loss of stiffness in the group performed with original technique and in the group with modified technique showed statistical significance. Successful rehabilitation (pure-tone average air-bone gap <20 dB) of conductive hearing loss was obtained in 48% of cases in Group 1 (original DCB) and in 81.2% of cases in Group 2 (modified technique). In the group with original DCB ossiculoplasty, the displacement of implant and its loss of stiffness occurred more often than in the second group. CONCLUSION: The modified DCB represents an excellent partial ossicular replacement prosthesis. The perichondrium layer left attached on the cartilage surface in contact with tympanic membrane increases the stability of DCB and prevents the displacement and the loss of stiffness of the cartilage. The modified DCB ossiculoplasty is easy to perform. Hearing results are satisfactory and lasting. The cost is null, and the tolerance is excellent.