Extrusion rates and hearing results in ossicular reconstruction

Outcomes with Management of Cholesteatoma

This article provides an expert summary of the immense amount of outcomes research in cholesteatoma surgery. Specific topics discussed include canal wall-up versus canal wall-down surgery, ossicular chain reconstruction, endoscopic ear surgery, disease-specific quality-of-life outcomes, and congenital cholesteatoma.

Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results

PURPOSE

To describe the surgical procedure of exclusive endoscopic ossiculoplasty (EEO) with autologous grafts and evaluate audiological results, focusing on the advantages or drawbacks compared to the corresponding microscopic technique.

METHODS

A retrospective review of consecutive adult and pediatric patients affected by chronic otitis media (COM) with or without cholesteatoma who underwent EEO was conducted. Only autologous ossiculoplasty was included in the study. The procedure was performed by experienced surgeons of our institution between November 2014 and September 2019. Hearing outcomes were evaluated using postoperative air-bone gap (ABG) and success rates in different subgroups of patients and different types of ossiculoplasty (OPL) were analyzed. Our results were finally compared with the existing literature regarding both microscopic and endoscopic ossicular chain reconstruction.

RESULTS

In total, 74 endoscopic ossicular chain repair procedures performed within the study period met the inclusion criteria. Of these, 21 were pediatric patients (28%) and 53 were adults (72%). Surgical reconstruction procedures included 43 partial ossicular reconstructions (POR) and 31 total ossicular reconstructions (TOR). The postoperative ABG improved significantly compared to preoperative measurements, and the mean ABG closure was 7.85 dB HL (p = 0.00064). No statistically significant differences in audiological outcomes between TOR/POR techniques and pediatric/adult groups were found in our study cohort, with p values of 0.10 and 0.88, respectively.

CONCLUSIONS

At present, EEO can be considered a valid surgical option for re-establishing a functioning ossicular chain with acceptable hearing restoration in children and adults. Further reports in wider case series are required to confirm these results.

Long-Term Hearing Results of Endoskeletal Ossicular Reconstruction in Chronic Ears Using Titanium Prostheses Having a Helical Coil: Part 1-Kraus K-Helix Crown, Incus to Stapes

OBJECTIVES

1) To assess long-term hearing results after endoskeletal ossicular chain reconstruction (eOCR) using the titanium Kraus K-Helix Crown prosthesis, implanted incus to stapes, with glass-ionomer cement (GIC) in chronic ears and 2) to determine safety of the prosthesis and cement.

STUDY DESIGN

Prospective, nonrandomized, sequential, single center, single surgeon.

SETTING

Private practice, ambulatory surgical center.

PATIENTS

N = 15 males (42%) and 21 females (58%). Mean age was 40.4 years (range, 6-81 years); 38 ears (22 right ears [58%] and 16 left ears [42%]).

INTERVENTIONS

eOCR in chronic ears. Comprehensive preoperative and postoperative hearing measurements were performed for up to 9 years.

MAIN OUTCOME MEASURES

Postoperative hearing results at 1 year showed statistically significant improvement as compared with preoperative hearing. Long-term hearing results remained stable and showed no statistically significant change over 9 years.

RESULTS

Estimated mean pure-tone air conduction average improved by 14.5 dB (95% confidence interval = 10.3-18.7). Estimated mean speech reception thresholds improved by 15.5 dB (10.8-20.2). Word recognition scores improved by -2.2% (-5.3 to 1.0). The estimated mean postoperative air-bone gap was 10.5 dB (7.2-13.8). The estimated mean calculated air-bone gap was 11.3 dB (8.0-14.5). The estimated mean change in high-tone bone conduction (HTBC) average was +3.5 dB (0.9-6.0). Two prostheses extruded (5%). No patients experienced any unanticipated serious adverse effects or events.

CONCLUSION

eOCR using the K-Helix Crown prosthesis, incus to stapes, and GIC can significantly improve hearing at 1 year and maintain stable hearing over 9 years. Both prosthesis and cement are safe.

A Comparative Prospective Study to Evaluate Outcomes of Ossiculoplasty using Autograft Versus Synthetic Graft

Chronic Otitis Media is the most common cause of hearing impairment with ear discharge with which patients report to any otologist. The aim of management in such cases is to provide a safe ear and restore the hearing by Tympanoplasty. Many materials have been used for ossicular reconstruction, including both biological and synthetic materials. Minimally destroyed ossicle can be utilized for Ossiculoplasty while in case of complete destruction of ossicles, synthetic materials may be used such as teflon, titanium, hydroxyapatite etc. To evaluate the outcome of Ossiculoplasty using autograft versus synthetic graft. A prospective study done using non-probability convenience method of sampling involving a group of 50 patients were subjected to Tympanoplasty with Ossiculoplasty. Intra operative decision was taken on the type of graft to be used for Ossiculoplasty and the patients were divided into two equal groups, A (autograft) and B (synthetic graft) of 25 each. The patients were thereafter evaluated post surgery at periodic intervals of 3, 6 and 12 months. The improvement in hearing following surgery was significant (AB gap < 20 dB) in the range of 72% in Group A to 84% in Group B of patients 12 months after surgery. Also there was a 37% change in AC in Group A as compared to 40% in Group B, demonstrating marginally better improvement in hearing with synthetic graft as compared to autograft. The patients have significant improvement in hearing thresholds after ossiculoplasty with both autograft and synthetic graft. Teflon is an excellent alternative for ossiculoplasty when autologous incus is not available for use due to disease.

Audiometric Outcomes Comparing Endoscopic Versus Microscopic Ossiculoplasty

OBJECTIVE

To assess endoscopic and microscopic ossiculoplasty audiometric outcomes.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary academic center.

PATIENTS

Adult patients who underwent ossiculoplasty with either partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) from 2010 to 2019 with at least 1 year of audiometric follow-up were included.

INTERVENTIONS

Endoscopic or microscopic ossiculoplasty.

MAIN OUTCOME MEASURES

Postoperative air-bone gap (ABG) after at least 1 year.

RESULTS

A total of 198 patients, 53.5% female, and a median age of 47.5 years, met inclusion criteria. 64.1% of patients were reconstructed with a PORP, and 31.8% were reconstructed using an endoscopic approach. The median audiometric follow-up was 27 months. The median postoperative ABG was 16.9 dB overall, 15.6 dB for PORP reconstruction, and 19.4 dB for TORP reconstruction (PORP versus TORP, p = 0.002). For TORP reconstructions, the median ABG for both endoscopic and microscopic TORP was 19.4 dB (p = 0.92). For PORP reconstructions, the median ABG for endoscopic PORP was 12.3 dB compared with 16.3 dB for microscopic PORP (p = 0.02). Using multivariate linear regression to predict postoperative PORP ABG, and controlling for age, prior ossiculoplasty, middle ear mucosal disease (granulation, fibrosis, polyposis), middle ear atelectasis, myringitis, contralateral middle ear disease, and use of byte prostheses, endoscopic PORP reconstruction was associated with improvement in ABG over the microscopic approach by 4.4 dB (p = 0.04).

CONCLUSIONS

For PORP ossiculoplasty procedures, endoscopic ossiculoplasty is associated with improved postoperative ABG compared with microscopic ossiculoplasty.

Adverse Events Associated with Ossicular Prostheses: Utility of a Federal Database

OBJECTIVES

Ossicular prostheses have demonstrated utility in ossicular chain reconstruction, but their use also is associated with complications. This study aims to explore the utility of the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for the systematic analysis of complications associated with ossicular prostheses. It also summarizes adverse events to patients (AEPs) and device malfunctions (DMs) reported in the MAUDE database, and attempts to examine the consequences brought about by these events and to identify likely root causes.

STUDY DESIGN

Retrospective analysis of the MAUDE database.

METHODS

The MAUDE database was queried for reports from January 2010 to May 2020. Data were extracted from reports involving the use of ossicular prostheses.

RESULTS

Seventy-three medical device reports, reports submitted to the Food and Drug Administration detailing suspected device-associated malfunctions, injuries, and deaths, involved ossicular prostheses and were included for analysis, from which 126 adverse events were extracted. Of these, 50 (39.7%) were AEPs, while 76 (60.3%) were DMs. The most common AEPs were foreign body and hearing loss, while the DMs reported most commonly were broken prosthesis and displaced prosthesis. Of the 76 DMs, 19 (25%) were attributed to mishandling by the operator, while 6 (7.9%) were due to a defective device. Broken prosthesis was the DM most commonly attributed to mishandling by the operator in 16 (32.7%) cases.

CONCLUSION

Ossicular prostheses are used extensively for ossicular chain reconstruction, but also are associated with adverse events. The MAUDE database in its current form does not appear sufficient for the systematic review of adverse events associated with ossicular prostheses. A more standardized reporting format with clearly defined categories and inclusion of relevant variables might improve the quality of information provided by the MAUDE database.

Hearing Outcomes With a Novel Total Ossicular Replacement Prosthesis

INTRODUCTION

A total ossicular replacement prosthesis (TORP) is used to reconstruct the ossicular chain in the absence of the stapes suprastructure. The Wildcat prosthesis is a novel TORP that eliminates the need for a separate footplate shoe prosthesis and aims to improve ease-of-use and stability. This study evaluates hearing outcomes using the Wildcat prosthesis.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary neurotology referral center.

METHODS

Retrospective chart review of 64 patients undergoing ossicular chain reconstruction using the Wildcat TORP. Hearing outcomes after surgery were assessed with air conduction pure-tone average, bone conduction pure-tone average, air-bone gap (ABG), speech recognition threshold , and word recognition score as primary outcome measures. The stability of hearing outcomes was evaluated on subsequent long-term follow-up.

RESULTS

At mean short-term follow-up of 4.4 ± 2.7 months, ABG improved from 31.0 ± 13.0 dB preoperatively to 22.5 ± 10.0 dB (p < 0.001) with 51.6% achieving ABG less than 20 dB. No significant difference in any primary outcome measures was found when analyzing outcomes by initial versus revision surgery, use of cartilage graft, or type of mastoidectomy. The only exception was a smaller reduction in ABG of 4.2 dB for patients with canal wall down mastoidectomy compared with a 13.7 dB ABG closure in patients with canal wall up mastoidectomy (p = 0.039).

CONCLUSION

Total ossicular chain reconstruction using the Wildcat demonstrates versatility in challenging cases to provide hearing outcomes that are comparable to published data using TORPs.

Long-term histological results of ossicular chain reconstruction using bioceramic implants

Middle ear problems are addressed using tympanoplasty, which requires a mobile tympanic membrane and secure sound-conducting mechanism. The present is a long-term, retrospective, non-controlled study on the results of ossiculoplasty using bioceramic implants of autochthonous origin and which defined the statistical relevant factors that could influence the rate of implant rejection. In a cohort of 108 patients ossiculoplasties with bioceramic implants were performed and patients were followed up clinically for a period of minimum 7 years. Several factors were identified that could influence the results of the implantation and the statistical correlations were studied. The rejection rate after 9.12 years was 21% (23 patients). Histological integration rate was 79% (85 patients), similar to results reported in literature for both bioceramic and titanium implants. Hydroxyapatite has many of the ideal characteristics required to be a good prosthesis with a high degree of biocompatibility, very low extrusion rate, low risk of disease transmission and good functional results. Although perhaps considered of historical interest, bioceramic implants are cheaper and can be produced locally, which is a great advantage for struggling economies.

Effect of a boomerang-shaped Conchal cartilage graft for Type three Tympanoplasty on Hearing

Introduction  Chronic suppurative otitis media atticoantral disease (CSOM-AAD) is often associated with ossicular erosion resulting in significant hearing loss. Absence of the stapes suprastructure is a poor prognostic indicator of hearing outcome, which necessitates an effective reconstruction technique for ossicular continuity and restoration of middle ear volume. In the present study, we used a boomerang-shaped conchal cartilage graft.

Objective  To evaluate the improvement in hearing using a boomerang-shaped conchal cartilage graft for Type III tympanoplasty in cases of CSOM-AAD in which the stapes suprastructure was absent and to study the incidence of intraoperative/postoperative complications of this procedure.

Method  A total of 21 patients with CSOM-AAD who were found to have absent stapes suprastructure intraoperatively were included. A boomerang-shaped conchal cartilage graft was placed over the stapes footplate for reconstruction following canal wall down mastoidectomy. Pure tone audiogram (500, 1,000, 2,000 and 4,000 Hz) was done preoperatively and at 12 weeks postoperatively. Hearing outcome and incidence of complications were noted.

Results  There was a statistically significant reduction in the hearing loss for air conduction and air-bone gap (ABG) of 6.1 dB and 6.9 dB respectively ( p  < 0.05). Air-bone gap < 30 dB could be achieved in 71.4% of the patients as compared with 23.8% preoperatively. No significant difference was noted in the bone conduction threshold (p > 0.05). A better hearing outcome was observed at higher frequencies (2,000, 4,000 Hz). No major complications were encountered.

Conclusion  A boomerang-shaped conchal cartilage graft is effective when used for Type III tympanoplasty, especially at higher (2,000, 4,000 Hz) frequencies, and is comparable to newer materials such as titanium total ossicular reconstruction prosthesis (TORP). No major intraoperative/postoperative complications were noted.

Superiority of Second Stage Ossiculoplasty

OBJECTIVE

To compare hearing results of single stage ossiculoplasty with second stage ossiculoplasty, and to provide a proper indication of operation options (single stage or second stage ossiculoplasty) according to patients' clinical conditions.

STUDY DESIGN

Retrospective case review study.

SETTING

Tertiary referral center.

PATIENTS

A total of 175 patients with chronic otitis media.

INTERVENTIONS

Tympanoplasty or mastoidectomy with tympanoplasty (M&T) as well as ossiculoplasty of either single or second stage between January 2009 and March 2016 by one surgeon (S.N.P.).

MAIN OUTCOME MEASURES

Hearing outcomes evaluated by mean postoperative air-bone gap (ABG) and success rates in various subgroups of middle ear surgeries and different types of ossiculoplasty were analyzed.

RESULTS

Among 175 patients, 120 underwent single stage ossiculoplasty, and 55 underwent second stage ossiculoplasty. The benefit of second stage ossiculoplasty in hearing results both at 3 months visit (p < 0.001) and 2 years visit (p = 0.003) were observed. The superiority of second stage ossiculoplasty was found in 20 dBHL cut off value with a statistical significance. The subgroups of canal wall down mastoidectomy and the first, non-revision middle ear surgery showed statistically significant benefits with second stage ossiculoplasty.

CONCLUSION

Second stage ossiculoplasty has overall advantage in hearing results compared with single stage ossiculoplasty and could be more advantageous to the patient who needs canal wall down mastoidectomy or whose operation is the first middle ear surgery.

Manubrio-incudo-stapedioplasty for reconstruction of Austin-Kartush type B ossicular defects

OBJECTIVE

Manubrio-incudo-stapedioplasty functional outcomes were compared to those of other methods for reconstructing Austin-Kartush type B ossicular defects.

METHODS

Forty-two patients underwent Austin-Kartush type B ossicular defect reconstruction using: manubrio-incudo-stapedioplasty (13 patients), an autologous incus (19 patients) or a titanium ossicular replacement prosthesis (10 patients). For manubrio-incudo-stapedioplasty reconstruction, the malleus head was removed, the manubrium was relocated posteriorly and the incus short process was placed on the mobile footplate. The manubrium was placed on the incus body groove and bone cement was applied to stabilise the manubrium-incus junction. Pre- and post-operative hearing thresholds were assessed.

RESULTS

The air-bone gap decreased from 25.9 ± 6.0 dB to 12.3 ± 5.0 dB (p &lt; 0.05) in the manubrio-incudo-stapedioplasty group. The hearing gain was 13.6 ± 5.2 dB for manubrio-incudo-stapedioplasty, 3.4 ± 14.2 dB with the autologous incus, and 3.3 ± 11.07 dB with the titanium ossicular replacement prosthesis. Hearing improvement was greater for manubrio-incudo-stapedioplasty compared to the other reconstruction methods (p &lt; 0.05).

CONCLUSION

Manubrio-incudo-stapedioplasty resulted in satisfactory hearing outcomes in patients with Austin-Kartush type B ossicular defects. This technique can be considered a stable, inexpensive and effective method to reconstruct Austin-Kartush type B ossicular defects.

Audiological Results of Total Ossicular Replacement Prosthesis with Cartilage Shoe Technique

Objective

The aim of this study was to investigate functional results of total ossicular replacement prosthesis (TORP) shaft stabilization with a cartilage shoe in chronic otitis media patients with cholesteatoma who had undergone canal wall down tympanomastoidectomy (CWDT). In addition, it was determined whether the presence of granular and edematous mucosa in middle ear altered functional outcomes.

Methods

Sixty patients, who had undergone CWDT with the use of TORP for the reconstruction of ossicular chain, were divided into two groups. Patients with cartilage shoe were classified as Group 1 (n=30) and those without the shoe were classified as Group 2 (n=30). Patients in both groups were classified into "A" and "B" subgroups according to the middle ear risk index (MERI). Air conduction (AC) and bone conduction thresholds were evaluated preoperatively and postoperatively.

Results

There was no statistically significant change between preoperative AC thresholds of the groups and subgroups (p>0.05). There were statistically significant differences regarding AC thresholds and air-bone gap (ABG) values between Groups 1 and 2 at the postoperative 12th month (p<0.05). Postoperative AC thresholds and ABG values of Group 1B patients with a high MERI score were statistically significant at all frequencies than those of Group 2B patients (p<0.05). When ABG values were compared, it was observed that functional results were better in Group 1B, but a statistically significant difference was observed only at 2000 Hz (p<0.01).

Conclusion

The cartilage shoe method for titanium TORP stabilization that is used for ossicular reconstruction during CWDT has been found to have a beneficial effect on auditory outcomes. Cartilage shoe application increases positive effects on hearing outcomes, particularly if the middle ear mucosa is granular and edematous.

Comparison of Ossiculoplasty Using Autograft Ossicle Versus Allograft (Teflon)

Chronic suppurative otitis media in almost any form can disrupt the integrity of ossicular chain. Various materials have been used for ossicular substitution or reconstruction, including both biologic and alloplastic materials. Teflon piston is now the most widely used prosthesis for reconstruction of the ossicular chain in cases of otosclerosis. The oto-surgeons are still confronted with problems of ossicular reconstruction regarding the surgical procedure to be done, type of graft to be selected especially in low and poor socioeconomic population. Thus, there is a need felt to comprehensively and holistically evaluate the outcome of ossiculoplasty using Autograft ossicle versus Allograft ossicle (Teflon). Total 64 patients of chronic suppurative otitis media with no active ear infection and air-bone-gap of more than 15 dB were admitted for surgery and divided into two groups according to material used for ossiculoplasty as group A (Autograft) and group B (Allograft). Patients were evaluated at 3 and 6 months post-operatively using audiogram. In both Group A and B, the average pre-operative AC was 40.62 dB (SD 9.65) and 39.37 (SD 10.53) respectively. In 3 months there was a change of 8.83% from 40.62 dB to 37.03 dB in Group-A (p < 0.109, not statistically significant) and 13.10% change from 39.37 dB to 34.21 dB in Group-B (p < 0.049, statistically significant) whereas at 6 months, air conduction improved by 14.22% in Group-A (p < 0.01, statistically significant) and by 21.81% in Group-B (p < 0.001, highly statistically significant). Post-operatively at 3 months, improved AB gap was 62.5% in Group-A and 68.75% in Group-B patients. Post-operative AB gap at 6 months, improvement was seen in 78.12% in Group-A while it was 81.25% in Group-B patients. Alloplastic Teflon ossicle appears to be a good alternative for ossicular reconstruction where autologous incus is not available or disease precludes its use.

"Tumulus" stabilization of a total ossicular replacement prosthesis

Functional failure of total ossicular replacement prostheses (TORP) is often due to secondary displacement, ranging from simple subluxation to prosthesis extrusion following recurrence of severe tympanic membrane retraction. Several surgical techniques have been proposed to stabilize a TORP, mostly using superimposed non-organic or resorbable heterologous materials. We describe a simple so-called "tumulus" surgical technique that limits prosthesis displacement and extrusion, regardless of the type of TORP, by using a few fragments of autologous cartilage that are always available and perfectly tolerated at no cost. Review of 31 cases treated by this technique did not reveal any cases of prosthesis displacement and only one case (3.2%) of prosthesis extrusion with audiometric results comparable to the best results reported in the literature.

Otologic manifestations of Larsen syndrome

OBJECTIVE

To describe and discuss otologic manifestations of Larsen syndrome, based on a case report and a systematic review of the literature.

MATERIALS AND METHODS

We performed a PubMED database search, and we selected studies reporting otolaryngologic manifestations secondary to Larsen syndrome. The selected articles were read in full, and three researchers independently extracted data from the studies. In parallel, we report the case of a 14-year-old patient who had hearing loss secondary to Larsen syndrome.

RESULTS

Fifteen studies met our selection criteria. Seven studies reported hearing loss in patients with Larsen syndrome (4 had conductive hearing loss and 3 had mixed hearing loss). The conductive hearing loss may be secondary to ossicular malformations and/or middle ear effusions. Other causes for conductive hearing loss are mesenchymal remnants in the middle ear, Eustachian tube dysfunction, and cleft palate. Surgical management of the hearing loss is possible in selected cases, although the surgical and anesthetic risks should be considered. Hearing aids seem to be safe and effective treatment options for the hearing loss secondary to Larsen syndrome.

CONCLUSION

Although rare, patients with Larsen syndrome may have hearing loss. The most frequent type of deficit is conductive, either secondary to malformation of the ossicles or middle ear effusion. Possible surgical correction of these abnormalities should be weighed against the anesthetic risks of these patients.

Surgical reconstruction of the ossicular chain with custom 3D printed ossicular prosthesis

Background

Conductive hearing loss due to ossicular abnormalities occurs from many causes, including trauma, infection, cholesteatoma, surgery and congenital anomalies. Surgical reconstruction of the ossicular chain is a well-established procedure for repair of ossicular defects, but is still plagued by high failure rates. Underlying disease and proper sizing of prostheses are two challenges that lead to component failure. Three-dimensional (3D) printing has been used successfully to solve a number of medical prosthesis problems. Custom 3D printing an individualized ossicular prosthesis would be a potential solution for the wide range of anatomic variation encountered in the pathological middle ear, and could decrease the rate of post-operative prosthesis displacement by increasing the likelihood of a proper fit, in addition to decreasing surgical time.

In this study, the incus was removed from three formalin-fixed cadaveric human temporal bones with no macro- or microscopic evidence of pathology. Imaging of the cadaveric bone was obtained using a standard temporal bone CT protocol. A custom prosthesis for each cadaveric human temporal bone was designed using the Mimics Innovation Suite software (Materialise, Belgium) and fabricated on a Form2 3D printer (FormLabs, Somerville, Massachusetts). Four surgeons then performed insertion of each prosthesis into each middle ear, blinded to the bone from and for which each was designed. The surgeons were asked to match each prosthesis to its correct parent bone.

Results

Each prosthesis had unique measurements. Each of the four surgeons was able to correctly match the prosthesis model to its intended temporal bone. The chances of this occurring randomly are 1:1296.

Conclusions

A custom 3D printed ossicular prosthesis is a viable solution for conductive hearing loss due to ossicular chain defects. Commercially available CT scanners can detect significant anatomic differences in normal human middle ear ossicles. These differences can be accurately represented with current 3D printing technology and, more significantly, surgeons can detect these differences.

Titanium incus interposition ossiculoplasty: audiological outcomes and extrusion rates

This study aimed to evaluate the benefit but also the extrusions, dislocations, and failures of a titanium incus prosthesis along with the long-term audiological outcomes. We prospectively collected data from 139 patients undergoing ossiculoplasty using the Fisch titanium incus prosthesis between 2001 and 2016. Overall, 126 patients with at least 6 months of follow-up (mean 4.5 years, range 6-155 months) were analyzed. Patients were grouped as "extrusion" (n = 9, 7%) if the prosthesis extruded, "failure" (n = 22, 18%) if a reoperation was needed concerning the prosthesis, and "stable" (n = 95, 75%) if the prosthesis remained functional in the middle ear. Mean postoperative air bone gaps (ABG) for 0.5-3 kHz for the overall group and the stable group were 19.8 (±11.9) and 15.3 (±7.5), respectively. Long-term results of stable group revealed an ABG (0.5-3 kHz) below 10 dB in 25% and below 20 dB in 81% of the patients. Atelectasis was the most frequent cause of extrusion, which occurred after a mean time of 28.7 months (range 15-48 months). Mean timing for reoperation was 30.7 months (range 5-131 months) in the failure group. There was no significant difference in mean postoperative ABG among patients with or without cholesteatoma, primary or staged ossiculoplasty in cholesteatoma, presence or absence of malleus head at the time of ossiculoplasty, open or closed cavity surgeries, or the degree of pneumatization of the temporal bone. The Fisch titanium incus prosthesis is a reliable alternative to using autologous incus for interposition ossiculoplasty, with similar hearing outcomes. Using this prosthesis, a 15 dB ABG should be expected.

Titanium Ossicular Chain Reconstruction Revision Success and Preoperative Factors Predicting Success

Objective Determine rates of success after revision titanium ossicular chain reconstruction with either partial or total ossicular replacement prosthesis and assess preoperative factors predicting positive outcomes. Study Design Case series with planned data collection. Setting Tertiary hospital. Subjects and Methods The charts of 76 surgical patients who underwent revision titanium ossicular chain reconstruction from 2003 to 2014 were abstracted from a prospectively maintained database at the Medical University of South Carolina. Postoperative air-bone gap (ABG) after revision surgery at short-term (<6 months) and intermediate to long-term (>1 year) follow-up and preoperative factors associated with postoperative ABG ≤20 dB were recorded. A paired t test or Wilcoxon signed-rank sum test was utilized to compare preoperative, short-term, or intermediate to long-term results. Results Seventy-six patients underwent revision ossiculoplasty and met inclusion criteria. Mean postoperative ABG was 22.5 at short-term follow-up ( P < .0001) and 24.4 at intermediate to long-term follow-up ( P = .003). Postoperative ABG ≤20 dB was achieved in 51.5% of patients. The only preoperative factor associated with postoperative ABG ≤20 dB was location of original primary ossiculoplasty ( P = .01). Conclusions This is one of the larger studies involving revision titanium ossiculoplasty. Revision surgery showed a significant improvement in postoperative ABG. The location of the original ossiculoplasty correlated with success of revision surgery (defined as postoperative ABG ≤20 dB). Patients who had the primary ossiculoplasty at an outside hospital may have better audiometric outcomes than patients who had it at a tertiary hospital.

Cartilage ‘shoe’: a new technique for stabilisation of titanium total ossicular replacement prosthesis at centre of stapes footplate

Objectives:

After tympanoplasty using a total ossicular replacement prosthesis, many unsatisfactory hearing results are due to dislocation of the prosthesis.

Material and methods:

We developed a cartilage guide for stabilising the total ossicular replacement prosthesis in the oval window niche. An oval-shaped piece of cartilage measuring 2.5 × 3.5 mm with a central hole was precisely punched out of a thin cartilage plate. The cartilage was placed in the oval niche, and its hole centred the prosthesis on the stapes footplate.

Results:

Hearing results in 52 patients confirmed acoustically the effectiveness of this method of total ossicular replacement prosthesis stabilisation on the stapes footplate. Subsequent ‘second-look’ surgery revealed stable ingrowth of the cartilage ‘shoe’ into the oval niche.

Conclusion:

Such a cartilage shoe might address one of the causes of unsatisfactory hearing following ossicular chain reconstruction with a total ossicular replacement prosthesis.

Preliminary application of intra-operative hearing monitoring by tone pip ABR via loudspeakers

CONCLUSION

This method might be an effective intra-operative way to access hearing threshold under general anesthesia in the operating room.

OBJECTIVE

To develop an intra-operative hearing monitoring method for surgeons to access hearing threshold under general anesthesia in the operating room.

METHOD

System establishment and calibration was done firstly. Normal hearing (NH) and conductive hearing loss (CHL) participants were recruited. This study applied pure tone audiometry (PTA) to all subjects and tone pip ABR (tp-ABR) via loudspeakers in sound booth and operating room for NH and CHL subjects, respectively. For NH subjects, Bland Altman was conducted to compare 1k Hz PTA and tp-ABR threshold. For CHL participants, Paired t-test, Satterth waite t'-test, and linear correlation analysis were used to compare the two methods. p < .05 was considered statistically different.

RESULTS

(1) Bland Altman showed all plots were inside the 95% confidence interval, indicating that there was no difference between the two methods for NH subjects. (2) The two methods had a high correlation (Pearson's coefficient =0.872 > 0.6, p < .05) in assessing hearing threshold in the operating room. (3) Satterth waite t'-test showed the ossicular chain malfunction enlarged the deviation of threshold by the two methods (.01 < p < .025).

Long-Term Results of TORP-Vibroplasty

OBJECTIVE

Assessing long-term results of patients treated with total ossicular replacement prosthesis (TORP)-vibroplasty.

DESIGN

Retrospective analysis.

SETTING

Tertiary referral center.

PATIENTS

A total of five patients (two women, three men; mean age, 66 yr) were eligible for evaluation after an average follow-up period of 5.1 years after TORP-vibroplasty.

INTERVENTIONS

Implantation of an active middle ear device in conjunction with a titanium coupler for oval window placement in patients with chronic middle ear disease with missing stapes suprastructure.

MAIN OUTCOME MEASURES

Audiometric outcomes and satisfaction of the patients.

RESULTS

The functional gain was 45.2 and 45.6 dB HL at 6 months and 5.1 years after implantation, respectively. The speech recognition using the Freiburg monosyllabic word test and speech intelligibility showed postoperatively a distinct improvement and revealed no statistically significant change across time for the entire follow-up period. According to the International Outcome Inventory for Hearing Aids questionnaire, the patients stated considerable subjective benefits and satisfaction with the device.

CONCLUSION

The good outcomes of TORP-vibroplasty in chronic disabled ears are stable. They provide long-term and long-lasting satisfying audiologic results combined with a high satisfaction of the patient. Prerequisite is the stable attachment to the cochlear windows.

Titanium versus Hydroxyapatite Prostheses: Comparison of Hearing and Anatomical Outcomes after Ossicular Chain Reconstruction

Objective

This study aimed to compare hearing and anatomical outcomes after ossicular chain reconstruction with titanium or hydroxyapatite prostheses.

Methods

In this study, patients who underwent tympanoplasty and ossicular chain reconstruction with titanium or hydroxyapatite prostheses at a university hospital from January 2007 to February 2013 were retrospectively reviewed; they had a minimum follow-up period of 6 months. Patients were divided into 4 groups according to the type of prostheses. The surgical procedure, follow-up examinations, preoperative, and postoperative audiometry results were noted and evaluated for partial and total prostheses. The results were compared both for titanium and hydroxyapatite prostheses.

Results

The study subjects included 51 patients. Titanium had better hearing results in partial prostheses (p<0.05), while the anatomical outcomes were similar. Nevertheless, both types had similar results in total prostheses (p>0.05). The extrusion rate was 5.8% for all patients.

Conclusion

Both types of prostheses had satisfactory functional and anatomical results and no preponderance could be stated, except for the hearing results of partial titanium prostheses.

Biocompatibility of silver containing silica films on Bioverit® II middle ear prostheses in rabbits

For several centuries silver is known for its antibacterial effects. The middle ear is an interesting new scope for silver application since chronic inflammations combined with bacterial infection cause complete destruction of the fragile ossicle chain and tympanic membrane. The resulting conductive deafness requires tympanoplasty for reconstruction. Strategies to prevent bacterial growth on middle ear prostheses are highly recommended. In this study, rabbits were implanted with Bioverit® II middle ear prostheses functionalized with silver containing dense and nanoporous silica films which were compared with pure silica coatings as well as silver sulfadiazine cream applied on nanoporous silica coating. The health status of animals was continuously monitored; blood was examined before and after implantation. After 21 days, the middle ears were inspected; implants and mucosal samples were processed for electron microscopy. Autopsies were performed and systemic spreading of silver was chemically analyzed exemplarily in liver and kidneys. For verification of direct cytotoxicity, NIH 3T3 cells were cultured on similar silver containing silica coatings on glass up to 3 days. In vitro a reduced viability of fibroblasts adhering directly on the samples was detected compared to cells growing on the surrounding plastic of the same culture dish. In transmission electron microscopy, phagocytosed silver silica fragments, silver sulfadiazine cream as well as silver nanoparticles were noticed inside endosomes. In vivo, clinical and post mortem examinations were inconspicuous. Chemical analyses showed no increased silver content compared to controls. Mucosal coverages on almost all prostheses were found. But reduction of granulation tissue was only obvious around silver-coated implants. Single necroses and apoptosis in the mucosa were correlated by intracellular accumulation of metallic silver. For confirming supportive healing effects of middle ear implants, silver ion aggregates need to be tested in the future to optimize biocompatibility while assuring bactericidal effects in the middle ear.

Long-term outcome of ossiculoplasty using autogenous mastoid cortical bone

OBJECTIVE

To observe the long-term outcome of ossiculoplasty using autogenous mastoid cortical bone in chronic otitis media in-patients.

METHODS

Sixty-one ears of 57 in-patients with chronic otitis media, with or without cholesteatoma, underwent type III tympanoplasty using autogenous mastoid cortical bone as the prosthetic material. Twenty-one ears were treated by canal wall down mastoidectomy and 40 ears by canal wall up mastoidectomy. The follow-up period was 3 to 6 years (average 4.2 years). Pure tone averages for thresholds at 0.5, 1, 2 and 3 kHz were calculated using standard conventional audiometry.

RESULTS

The pre-operative mean air-bone gap of 31.6 dB, for all ears, was reduced to 20.3 dB post-operatively. For the 40 canal wall up ears, this value decreased from 30.8 dB to 19.9 dB, and for the 21 canal wall down ears it decreased from 33.0 dB to 21.0 dB. The differences between the pre- and post-operative mean air-bone gap values were significant.

CONCLUSION

No cases of extrusion, necrosis or resorption were exhibited for the autogenous mastoid cortical bone prosthesis. A significant hearing improvement was obtained in the majority of cases and this remained stable over time.

Titanium prosthesis or autologous incus for total ossicular reconstruction in the absence of the stapes suprastructure and presence of mobile footplate

The purpose of this study was to compare the hearing results after total ossicular replacement with a titanium prosthesis or autologous incus in the absence of stapes suprastructure and presence of mobile footplate as a retrospective medical record review in a tertiary referral center setting. There were 49 patients who had total ossicular reconstruction (titanium prosthesis, 40 patients; autologous incus, 9 patients). Medical records were reviewed after total ossicular replacement. Air-bone gap at 1 and 2 years after surgery were determined with the 4-frequency average (0.5, 1, 2, and 4 kHz) and the American Academy of Otolaryngology-Head and Neck Surgery 4-frequency average (0.5, 1, 2, and 3 kHz). The number of patients who had air-bone gap <20 dB was determined. For comparisons that were based on American Academy of Otolaryngology-Head and Neck Surgery 4-frequency average, mean air-bone gap at 2 years after surgery was significantly smaller for the titanium prosthesis (21 dB) than autologous incus group (31 dB; P ≤ 0.03); the frequency of patients who had air-bone gap <20 dB at 1 or 2 years after surgery was significantly greater for the titanium prosthesis (1 year, 40%; 2 years, 56%) than autologous incus group [1 year, 0% (P ≤ 0.03); 2 years, 0% (P ≤ 0.04)]. Titanium prosthesis ossiculoplasty gave better results than autologous incus in the absence of the stapes suprastructure and presence of a mobile footplate.

Hearing Benefit in Allograft Tympanoplasty Using Tutoplast Processed Malleus

Objectives. Tutoplast processed human cadaveric ossicular allografts are a safe alternative for ossicular reconstruction where there is insufficient material suitable for autograft ossiculoplasty. We present a series of 7 consecutive cases showing excellent air-bone gap closure following canal-wall-down mastoidectomy for cholesteatoma and reconstruction of the middle ear using Tutoplast processed malleus. Patients and Methods. Tympanoplasty with Tutoplast processed malleus was performed in seven patients to reconstruct the middle ear following canal-wall-down mastoidectomy in a tertiary ENT centre. Main Outcome Measures. Hearing improvement and recurrence-free period were assessed. Pre-and postoperative audiograms were performed. Results. The average pre operative hearing loss was 50 ± 13 dB, with an air-bone gap of 33 ± 7 dB. Post operative audiograms at 25 months demonstrated hearing thresholds of 29 ± 10 dB, with an air-bone gap of 14 ± 6 dB. No prosthesis extrusion was observed, which compares favourably to other commercially available prostheses. Conclusions. Tutoplast processed allografts restore conductive hearing loss in patients undergoing mastoidectomy and provide an excellent alternative when there is insufficient material suitable for autograft ossiculoplasty.

Evaluation of functional results of CWD surgery with ossicular replacement prosthesis due to cholesteatoma using computed tomography

With the use of high-resolution computed tomography, this retrospective clinical study evaluated the factors affecting hearing in patients who were operated on due to chronic otitis media with cholesteatoma and underwent ossiculoplasty with titanium total ossicular replacement prosthesis (TORP). Fifteen patients with postoperative hearing results of 20 dB or less air-bone gap, and thirteen patients with postoperative hearing results of 21 dB or more air-bone gap were the subjects of this study. All patients were operated on due to chronic otitis media and underwent ossiculoplasty with titanium TORP. High-Resolution Computed Tomography (HRCT) and pure-tone audiometry were performed on each patient after an average of 17 months, postoperatively. Three-dimensional oblique CT cross-sections were analyzed with Vitrea 2(®) software. The presence of soft tissue in the middle ear and contact between the prosthesis head plate and the bone had an adverse effect on hearing (p < 0.05). The angle between the TORP and the oval window did not seem to affect the hearing results (p > 0.05). The study results indicate that an examination of the patients with poor postoperative hearing with HRCT may help find the possible cause and allow for the determination of the prosthesis location.

Round window vibroplasty: long-term results

CONCLUSIONS

The round window (RW) approach in the use of the Vibrant Soundbridge(®) (VSB) is a safe and effective treatment of conductive and mixed hearing losses for a period of more than 3 years of device use.

OBJECTIVE

To investigate the long-term safety and efficacy as well as user satisfaction of patients with conductive and mixed hearing losses implanted with the VSB using RW vibroplasty.

METHODS

Twelve patients with conductive and mixed hearing losses were evaluated after 40 months of daily VSB use. Safety was assessed by evaluating reports of postoperative medical and surgical complications as well as by changes in bone conduction hearing thresholds. Efficacy outcome measures included aided and unaided hearing thresholds, speech recognition in quiet and in noise and subjective benefit questionnaires.

RESULTS

The safety results revealed no significant medical complications. One subject experienced sudden hearing loss after 18-24 months of device use, but still continues to wear the device to her satisfaction. With regard to efficacy, there were no significant changes from short- to long-term results in aided word understanding, functional gain or speech recognition threshold, suggesting that the outcomes are stable over time. Subjective questionnaires revealed either the same or better results compared with the short-term data.

Incus replacement malleostapedotomy in quiescent chronic otitis media with a mobile stapes footplate: an alternative to TORP in select cases

OBJECTIVE

To review the results of malleostapedotomy for incus replacement in the setting of quiescent chronic otitis media and a mobile stapes footplate and to discuss the potential application for this technique in select cases.

PATIENTS

Seven individuals having undergone malleostapedotomy in the setting of quiescent chronic otitis media and a mobile stapes footplate between 2004 and 2009.

INTERVENTION

Review of surgical results and hearing outcomes as measured by preoperative and postoperative pure-tone audiometry.

MAIN OUTCOME MEASURES

Closure of preoperative air-bone gap and change in preoperative versus postoperative pure-tone bone conduction thresholds.

RESULTS

Improvement in air-bone gap was noted in 6 of 7 subjects with an average closure of 17 dB. In 5 of 7 subjects, the air-bone gap was closed to 20 dB or less, and in 3 of 7 subjects, the air-bone gap was closed to 10 dB or less. No significant changes in postoperative bone conduction pure-tone average thresholds were noted. No immediate or delayed complications were encountered over an average follow-up time of 23.6 months (range, 5-42 mo).

CONCLUSION

Although the data are limited by the small sample size, malleostapedotomy seems to be a potentially safe and effective alternative to placement of a total ossicular replacement prosthesis in properly selected specialized instances of quiescent chronic otitis media. Further study is recommended to more definitively establish the safety and efficacy of this technique.

The floating mass transducer on the round window versus attachment to an ossicular replacement prosthesis

HYPOTHESIS

The Vibrant Soundbridge floating mass transducer (FMT) is part of a commercially available implantable hearing device in which the FMT can be placed in the round window (RW) niche or attached to a partial (V-PORP) or total ossicular replacement prosthesis (V-TORP) contacting the stapes head or footplate. The goal is to provide efficient transfer of sound vibration into the cochlea. The hypothesis is that the FMT location on the prosthesis is superior to the RW location.

BACKGROUND

No direct comparisons of the 3 FMT sites have been performed using the same measurement location.

METHODS

A new measurement method called the third window method was used in eleven fresh human temporal bones to compare the sites. A small hole was made into the scala tympani of the temporal bones preserving the endosteum. A reflective target was placed on the third window endosteum and displacement of the cochlear fluid was measured using a Polytec HLV-1000 laser Doppler vibrometer. The input to the FMT at all locations was a constant 316 millivolts (mV); the frequency range was 0.5 to 8.0 kHz.

RESULTS

The V-PORP and V-TORP FMT locations both provided statistically significant better performance above 1.0 kHz than the RW site but not below that frequency. The V-PORP and V-TORP responses were similar at all test frequencies.

CONCLUSION

In this temporal bone model, the FMT provided better higher frequency performance when attached to a PORP or TORP than in the RW niche.

Ossicular chain reconstruction: Titanium versus plastipore

OBJECTIVE

To compare the complication rate and hearing results of a new, lightweight, titanium ossicular replacement prosthesis with Plastipore prostheses (Xomed, Jacksonville, FL).

STUDY DESIGN

Retrospective.

METHODS

Charts were reviewed for type of operation, type of prosthesis used, extrusion rate, prostheses failure rate, and hearing thresholds at multiple frequencies and at multiple follow-up points. The dependant variable for hearing results was the four-frequency average air-bone gap.

RESULTS

There were 84 patients undergoing tympanoplasty with the Plastipore prosthesis and 53 with the titanium. There was one extrusion in the titanium group. There was an additional single incidence of prosthesis failure in the titanium group. Overall hearing results were comparable with an air-bone gap average of 19.3 dB in the Plastipore group compared with the titanium group with an air-bone gap of 22.0 dB (P =.08). Sixty percent of patients had a postoperative air-bone gap of 20 dB or less in the Plastipore group. In the titanium group, 45.3% achieved a 20 dB or less postoperative air-bone gap. Plastipore had a lower air-bone gap than the titanium when a canal wall up operation was performed (17.8 vs. 23.9 dB) and tended toward a lower air-bone gap when a total ossicular prosthesis was needed (22 vs. 27 dB) (P <.07).

CONCLUSION

The titanium prosthesis is a new ossicular replacement prosthesis that provides excellent visualization during insertion and provides hearing results that are comparable with Plastipore. The Plastipore prosthesis performed better in canal wall up mastoidectomy situations and tended toward better performance when a total ossicular replacement prosthesis was needed.

Biofilm formation by Pseudomonas aeruginosa on ossicular reconstruction prostheses

PURPOSE

Ossicular chain reconstruction may be complicated by prosthesis extrusion. As prostheses are commonly placed in middle ears contaminated with biofilm-forming bacteria, such as Pseudomonas aeruginosa (PA), extrusion may be caused by development of a biofilm on the prosthesis and the host response to this biofilm. The purpose of this experiment was to determine if PA forms biofilm on different ossicular chain reconstruction prostheses to a different degree.

METHODS

Prostheses made of titanium, hydroxylapatite (HA), and plastic (23 each) were cultured with PA in broth for 96 hours. Biofilm formation was assessed by electron microscopy and quantitative microbiology.

RESULTS

Titanium prostheses formed less biofilm than plastic (P = .0003) and HA (P = .003), but there was no difference between HA and plastic. Correction for surface area did not alter these significant differences.

CONCLUSIONS

Pseudomonas aeruginosa forms biofilm on ossicular prostheses, particularly those made of plastic and HA. These differences could, in part, explain the extrusion propensity of certain biomaterials.

Ossicular chain reconstruction with a titanium prosthesis

Objective:

Ossicular chain damage from chronic ear disease is a significant problem in the Australian population. The ideal ossicular chain reconstruction prosthesis has yet to be defined. This paper examines, for the first time, the use of a titanium prosthesis for ossicular chain reconstruction in Australian patients.

Study design:

Retrospective chart review.

Subjects and methods:

All patients undergoing ossicular chain reconstruction with a titanium prosthesis between 1 February 2002 and 31 March 2007.

Results:

Results showed a low complication rate, with only one extrusion out of 55 cases (1.8 per cent). Successful rehabilitation of conductive hearing loss (i.e. to ≤20 dB air–bone gap) was obtained in 85 per cent of the partial ossicular chain reconstruction group and 77 per cent of the total ossicular chain reconstruction group. Pure tone thresholds improved by an average 18 dB in the partial reconstruction group and 25 dB in the total reconstruction group.

Conclusion:

Titanium is an ideal material for ossicular chain reconstruction due to its ease of insertion, low rate of extrusion and good functional results.

Cartilage ossiculoplasty by lever method

CONCLUSION

We invented a new ossicular chain reconstruction by lever methods (OCRLM) in tympanoplasty type III with the canal wall down technique and investigated the postoperative hearing results of the 24 patients who had undergone this surgery. Postoperative air-bone gaps (ABGs) followed up for 2.1-3.2 years gave satisfactory improvement audiometrically compared with former reports.

OBJECTIVE

To present newly devised methods applied from the viewpoint of mechanical dynamics for ossicular chain reconstruction in tympanoplasty.

MATERIALS AND METHODS

A total of 24 cholesteatoma patients who underwent tympanoplasty with mastoidectomy using the canal wall down technique and ossicular chain reconstruction with OCRLM between May 2003 and April 2004 were investigated. The postoperative ABG of a four-frequency (0.5, 1, 2, and 4 kHz) average of OCRLM followed up for 2 years or more was assessed.

RESULTS

Patients who underwent OCRLM showed good postoperative hearing results. Average postoperative ABGs of less than 10, 15, 20, 25, and 30 dB were 4.2, 37.5, 70.8, 91.6, and 100%, respectively. A gap of >30 dB was absent and the mean postoperative ABG was 17.2dB. The OCRLM method was satisfactory to improve hearing and effectively reduce the ABG postoperatively over the period of observation.

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.

Ossiculoplasty

Contemporary surgical techniques for treating various pathologies affecting the middle ear address not only eradication of the underlying disease process but also restoration of normal auditory function. Trauma, neoplasms, inflammatory processes, and cholesteatomas can erode and alter normal middle ear components and relationships vital for the transmission of auditory energy to the inner ear. Over the last five decades, various ossiculoplasty techniques and prostheses have been studied and reported in the literature. Unfortunately, the multitude of reconstructive techniques attests to the fact that none of the currently available methods are ideal.

Long-Term Results of Ossiculoplasty: Reasons for Surgical Failure

OBJECTIVES

To present the value of a dedicated ear audit clinic, the overall long-term results of ossiculoplasty, and the reasons for surgical failure.

STUDY DESIGN

Retrospective analysis was performed on ossiculoplasty cases in a county hospital. The information was extracted from a computer database. Individual patient case records were reviewed in all cases of surgical failure.

METHODS

All patients who had ossiculoplasty were routinely followed-up in a dedicated ear audit clinic on a yearly basis. Between 1988 and 1999, the author performed 242 ossiculoplasties and their outcomes were monitored in the ear audit clinic. The 5-year results are presented.

RESULTS

Even with the benefit of a dedicated audit clinic and a stable population, only 74.4% of ears had a known outcome at 5 years after ossiculoplasty. In the present series, 61.1% of partial and 37.6% of total ossicular reconstructions have an air-bone gap of 20 dB or better at 5 years. Of 83 identifiable late failures, 47 were caused by persistent or recurrent abnormalities within the middle ear and only 36 were thought to be caused by prosthesis-related or surgeon-related problems.

CONCLUSION

The overall long-term results of ossiculoplasty have not dramatically improved in recent years, in spite of all the great advances in biomedical technologies. Unless there is a breakthrough in the understanding and management of the underlying otitis media, the long-term outcome of ossiculoplasty is unlikely to improve dramatically.

Should Ossicular Reconstruction Be Staged Following Tympanomastoidectomy

OBJECTIVES

To determine whether ossicular reconstruction (OCR) performed concurrent with tympanomastoidectomy for cholesteatoma results in significantly different hearing results when compared to OCR performed in a separate, staged procedure.

STUDY DESIGN

Retrospective.

MATERIALS AND METHODS

Study subjects were patients undergoing OCR within a 2-year period. Intervention was OCR concurrent with tympanomastoidectomy for cholesteatoma (group 1) or staged following tympanomastoidectomy for cholesteatoma (group 2). Main outcome measures were mean postoperative air-bone gap (ABG), proportion achieving ABG closure to <20 dB and <30 dB for group 1 and group 2 overall and when controlling for type of mastoid cavity created (open or closed) and the status of the stapes suprastructure (TORP vs. PORP OCR).

RESULTS

Eighty-three patients were identified. Forty underwent OCR concurrent with tympanomastoidectomy and 43 underwent a staged OCR after tympanomastoidectomy. Overall, similar hearing results were seen in the two groups. When considering the status of the stapes and mastoid cavity, concurrent OCR resulted in improved mean postoperative ABG in a closed mastoid cavity with an intact stapes suprastructure (P = .024). Furthermore, a greater proportion of patients who had concurrent OCR within this group achieved ABG <20 dB and ABG <30 dB, although this difference did not reach statistical significance (P = .092 and P = .078, respectively). By contrast, staged OCR resulted in improved mean postoperative ABG and ABG <30 dB in open mastoid cavities with an absent stapes suprastructure (P = .040, and P = .019, respectively). Similarly, a greater proportion achieved ABG <20 dB, approaching statistical significance (P = .055).

CONCLUSIONS

Staged OCR is advantageous in those with most severe disease, whereas those with least severe disease may benefit from a concurrent OCR.

Hearing results with the titanium ossicular replacement prostheses

The purpose was to study the hearing results in patients receiving a Kurz titanium Bell partial ossicular replacement prosthesis (PORP) or an Aerial total ossicular replacement prosthesis (TORP). The study was a retrospective chart review in a tertiary otologic referral center. A computerized otologic database was used to identify 111 patients implanted with either a PORP or TORP prosthesis. Audiograms were reviewed and air-bone gaps were calculated for each patient. The improvement of the average air-bone gap (ABG) was 10.2 and 12.7 dB at 3 and 20 months after ossiculoplasty, respectively. Sixty-six percent of patients (73/111) had a postoperative air-bone gap of 20 dB or less. The ABG for the titanium PORP prosthesis was 14.3+/-9.7 dB, compared with 25.2+/-13.7 dB for the TORP prosthesis (P <0.05). The ABG to within 20 dB or less was obtained in the PORP group in 77% of the cases, versus 52% of the cases in the TORP group (P <0.05). Two extrusions of the prostheses were observed at 17 and 20 months after surgery (1.8%). Revision procedures for functional failure were carried out in 20 patients (18%). The rate of sensorineural hearing loss was 3.6%. The major factors influencing good audiometric results were the surgical procedure preserving the external auditory canal and the presence of the stapes. The best hearing results were achieved when a PORP was used in an intact canal wall (ICW) procedure, and the worst hearing results were achieved when a TORP was used in a canal wall down (CWD) procedure. The titanium Kurz prosthesis has been an effective implant at our institution for ossicular reconstruction.

Titanium Clip Prosthesis

OBJECTIVE

Prostheses for the reconstruction of a defective ossicular chain should be stable and firmly anchored to the ossicular remnants. This will prevent a defective connection from causing diminished sound transmission efficiency and will keep the prosthesis from tilting or even losing contact, which would result in a sound transmission block. Through temporal bone experimentation, we have consequently developed a very lightweight titanium prosthesis, which is fastened onto the stapes head with a clip mechanism.

METHODS

When temporal bone experiments using laser Doppler vibrometry confirmed that the prosthesis functioned well acoustically and when luxation experiments proved that it could be safely used without the risk of stapes dislocation, the prosthesis was used in a clinical application within an observational study. The University of Dresden Otorhinolaryngological Hospital as well as seven surgeons from five other hospitals participated in the study.

RESULTS

The results of 133 operations showed that, in over 90% of the cases, the prosthesis could be implemented without problems and with good mechanical stability. The first acoustical results obtained during the first year from 49 patients showed a sound transmission improvement range from 12 dB to 14 dB.

CONCLUSION

With the clip prosthesis, it seems possible to further improve defective middle ear function, which would allow the patient to regain social hearing after middle ear reconstruction. The reliability of the fastening is an innovation. Revision operations showed a stable prosthesis-stapes complex in the middle of a recurring cholesteatoma and the prosthesis could always be easily pulled from the stapedial suprastructure.

Ossiculoplasty with total hydroxylapatite prostheses anatomical and functional outcomes

OBJECTIVE

To evaluate the results of partial and total ossicular reconstruction prostheses entirely made of hydroxylapatite.

STUDY DESIGN

A retrospective review of cases followed-up between 1997 and 2000.

SETTING

Tertiary referral center.

PATIENTS

One hundred adult patients (60 men and 40 women) were studied. The mean age was 55 years (range, 25 to 65 years). Fifty patients had a previous tympanoplasty. The series included 45 cholesteatomas (45%), 37 chronic otitis media without cholesteatoma (37%), 13 retraction pockets (13%), and 5 posttraumatic ossicular displacements (5%).

INTERVENTION

A one-stage ossiculoplasty with a partial ossicular reconstruction prosthesis (n = 65) or a total ossicular reconstruction prosthesis (n = 35) was performed. This was associated with a simple mastoidectomy in 70 cases and a radical mastoidectomy in 10 cases.

MAIN OUTCOME MEASURES

All patients were followed-up at 1 year, and 50 were reexamined 2 years after surgery. Clinical and audiometric data were collected in a database at each visit.

RESULTS

A prosthetic extrusion was noted in two cases (2%). A prosthetic displacement occurred in 10 cases (10%). A revision surgery was carried out in 10 cases because of an ossiculoplasty failure or a disease recurrence. At 1 year, the residual air-bone gap was lower in cases with a partial ossicular reconstruction prosthesis than those with a total ossicular reconstruction prosthesis (16 +/- 9.3 versus 23 +/- 13.7 dB, p < 0.05). The gain in mean air conduction threshold was 21 +/- 12.8 dB in cases of partial ossicular reconstruction prosthesis and 19 +/- 11.3 dB in cases of total ossicular reconstruction prosthesis (not significant). Revision surgery, canal wall-down mastoidectomy, or cholesteatoma yielded poorer functional results.

CONCLUSION

Partial ossicular reconstruction prosthesis and total ossicular reconstruction prosthesis entirely made of dense hydroxylapatite yielded high rates of air-bone gap reduction and high anatomic stability.

Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results

OBJECTIVES

The educational objectives were to discuss a new technique to manage acquired cholesteatomas and to compare this with standard approaches used for cholesteatoma removal. The study objective was to determine the feasibility of using a new approach, the reversible canal wall down approach, in conjunction with bone cement to remove acquired cholesteatomas and, potentially, preserve the ossicular chain.

STUDY DESIGN

Retrospective review of five patients who underwent resection of their acquired cholesteatomas using a technique that maximizes exposure, yet preserves the posterior canal wall and, potentially, the ossicular chain.

METHODS

In the setting of a tertiary otological referral center, five consecutive patients with acquired cholesteatomas underwent reversible canal wall down surgery. Four patients were male (ages, 41, 53, 26, and 10 y), and one patient was a woman [age, 51 y]). A reversible canal wall down mastoidectomy approach was used in the patients. Main outcome measures were intraoperative findings with respect to cholesteatoma removal and postoperative clinical examination, including postoperative audiograms.

RESULTS

Five patients had dry ears postoperatively. One patient initially had granulation tissue forming on the posterior ear canal. This eventually resolved. The patients who had a postoperative audiogram after cholesteatoma resection with ossicular chain preservation noted an improvement or stabilization in their hearing.

CONCLUSIONS

Using the reversible canal wall down approach in conjunction with bone cement, one is able to obtain excellent exposure of the cholesteatoma and, potentially, preserve the ossicular chain. This approach may be particularly useful in revision cholesteatoma surgery or in cases of acquired cholesteatoma in which the surgeon may be able to preserve the ossicular chain.

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.