Histologic changes in the anterior mallear ligament and the head of the malleus in otosclerosis

Comparison of Tympanic Membrane Perforation With and Without Calcification of Anterior Mallear Ligament Under Transcanal Endoscopic Type I Tympanoplasty

OBJECTIVES

Chronic suppurative otitis media (CSOM) induced tympanic membrane perforation (TMP) can be accompanied by anterior mallear ligament (AML) calcification. So far, comparative evaluations of TMP with and without AML calcification have rarely been reported. The aim of the current study is to compare the hearing outcomes of TMP with and without calcification of AML under transcanal endoscopic type I tympanoplasty.

METHODS

Records of 67 patients diagnosed with CSOM and receiving transcanal endoscopic type I tympanoplasty were divided into the AML calcification group (Cal group, n = 31) and the non-AML calcification group (non-Cal group, n = 36). The 31 patients in the Cal group were divided into subgroup A and B according to the severity of calcification. The operation time, closure rate, and pre- and postoperative audiometric results were retrospectively collected and analyzed.

RESULTS

Preoperatively, the Cal group had higher mean air-bone gap (ABG; P = .022), and ABGs at 250 Hz (P = .017) and 500 Hz (P = .008) compared with the non-Cal groups. The Cal group showed higher improvements of ABGs at 250 Hz (P = .039) and 500 Hz (P = .021) compared with the non-Cal groups postoperatively.

CONCLUSIONS

The TMP with AML calcification leads to higher ABGs at low frequencies. The hearing outcomes are similar for TMP both with and without AML calcification after surgery. Our results suggest that transcanal endoscopic type I tympanoplasty is an appropriate surgical method for TMP with AML calcification, if the lesion can be detected and completely eliminated.

Endoscopic Management of Malleus Head Fixation in Revision Stapes Surgery

OBJECTIVE

Malleus ankylosis is an uncommon finding during stapes surgery, which can result in functional failure if undetected during primary surgery. Its management can be difficult and different approaches and solutions have been described to date, most of which require interruption of the ossicular chain. We report the management of such condition through a transcanal endoscopic technique, with preservation of ossicular chain integrity.

PATIENTS

The procedure was carried out in a patient affected by otosclerosis with persistent hearing loss after primary stapes surgery.

INTERVENTION

Surgical treatment of malleus head fixation through a totally endoscopic transcanal approach during revision stapes surgery.

MAIN OUTCOME MEASURE

Pure tone audiometry, speech audiometry.

RESULTS

The patient experienced a complete closure of the air-bone gap. No postoperative vertigo or sensorineural hearing loss were observed.

CONCLUSIONS

The present report describes the transcanal endoscopic management of malleus ankylosis during revision stapes surgery, which has not been previously reported in the literature. Pearls related to this approach and advantages in comparison to previously described approaches of the literature are discussed as well.

The discomallear ligament: anatomical, microscopical, and radiologic analysis

BACKGROUND

Several anatomic relationships between the ear and the temporo-mandibular joint have been proposed to account for the presence of tinnitus during temporo-mandibular disorders. Among the otomandibular structures, the discomallear ligament (DML) is interposed between the malleus and the retrodiscal capsular complex. The aim of present paper was to study through dissection the frequency and morphology of DML, to characterize its type of collagen, and to evaluate the DML on routine computed tomography (CT).

METHODS AND RESULTS

The study has been conducted on five un-embalmed adult cadavers, and in all cases, the DML was present (100%). It was constituted mainly by fibers of collagen I, with abundant elastic fibers. On CT exams of 40 patients with no reported pathology of the ear, on axial images, a dense structure, going from the upper end of the petrotympanic fissure to the neck of the malleus, was present in all the cases. In 90%, it showed a triangular shape, in 5% a rectangular shape, and in 5% a curved course. The mean length of the antero-medial side was 2 ± 0.6 mm and that of the antero-lateral side was 1.63 ± 0.5, and the mean area was 1.29 ± 0.83 mm².

CONCLUSION

The DML could represent an anatomical structure that joining the temporo-mandibular joint and the malleus may play a role in the otologic symptoms during temporo-mandibular disorders.

Isolated malleus fixation: A pediatric case series

OBJECTIVES

The goal of this review was to review our series of isolated malleus fixation in pediatric patients, a rare entity causing conductive hearing loss. Malleolar fixation is poorly described in this patient population.

METHODS

A retrospective review of pediatric tympanoplasties by the senior author over a four-year period was performed. Only cases with isolated fixation of the malleus were reviewed. Primary outcome of interest was post-operative hearing. Paired t-tests were used to calculate pre- and post-operative hearing outcomes.

RESULTS

Five cases were analyzed. Mean age at time of surgery was 9.1 years (range 4.4-16.0 years). Average follow-up after surgery was 13.9 months (range 4.4-31.2 months). Patients were otherwise healthy and typically presented after a failed school hearing test despite previously good hearing. Three out of five cases showed radiographic evidence of bony fixation (60%) on computerized tomography (CT). Otoscopy was unremarkable in all cases. Average procedure time was 41.2 min and consisted of transcanal tympanoplasty with excision of fixed bony segment. A significant improvement in both pre- and post-operative air bone gaps was observed (p = 0.005)., with average ABG of 14.75 dB.

CONCLUSIONS

Isolated pediatric malleolar fixation is an uncommon cause of pediatric conductive hearing loss. CT scan is useful for identifying this abnormality, and surgical correction results in improved post-operative hearing outcomes, potentially obviating the need for hearing amplification.

Revision surgery for otosclerosis: An overview

Stapes surgery for otosclerosis has been proved to be a very satisfying procedure. However, the condition is difficult for the patients with no or little hearing gain after surgery and for those who had sudden or gradual hearing loss after a successful air-bone gap closure in the follow-up period. The issue of re-exploring the middle ear is challenging. A general review of this subject from several points of view remains lacking. In this study, articles related with the revision surgery for otosclerosis have been reviewed after a PubMed research and common and/or contradictory points were documented. The aim of this study is to give an insight to diagnostic and therapeutic approaches for the clinicians in patients who need a revision surgery. In conclusion, prosthesis problems, loose prosthesis in stapedotomy and migrated prosthesis in stapedectomy are the most common causes for revision surgery. Most important indicators which effect better hearing outcome following revision surgery are those ears with the presence of incus, with no obliteration of oval window, with small fenestra stapedotomy and the experience of surgeon. The risk of neurosensorial hearing loss in revision cases is not high but the hearing gain is limited as compared to primary cases. The rate of 10 dB air-bone gap closure is around 60%-70% at most and even less promising results have been reported. Patient’s demands and expectations have to be clarified in a realistic way.