Reporting results in ossiculoplasty

Hearing Outcomes After Ossiculoplasty With Bone or Titanium Prostheses-A Nationwide Register-Based Study

OBJECTIVES

This study compares hearing outcomes of two prosthesis materials, bone and titanium, used in ossiculoplasty.

DESIGN

This retrospective nationwide registry-based study uses data systematically collected by the Swedish Quality Registry for Ear Surgery (SwedEar).

SETTING

The data were obtained from clinics in Sweden that perform ossiculoplasty.

PARTICIPANTS

Patients who underwent ossiculoplasty using either bone or titanium prostheses were registered in SwedEar between 2013 and 2019.

MAIN OUTCOME MEASURES

Hearing outcome expressed as air-bone gap (ABG) gain.

RESULTS

The study found no differences between bone and titanium for ABG or air conduction (AC) for either partial ossicular replacement prostheses (PORP) or total ossicular replacement prostheses (TORP). In a comparison between PORP and TORP for ABG and AC outcomes, regardless of the material used, PORP showed a small advantage, with an additional improvement of 3.3 dB (95% CI [confidence interval], 0.1-4.4) in ABG and 2.2 dB (95% CI, 1.7-4.8) in AC. In secondary surgery using TORP, titanium produced slightly better results for high-frequency pure tone average. The success rate, a postoperative ABG ≤20 dB, was achieved in 62% of the operations for the whole group.

CONCLUSION

Both bone and titanium used to reconstruct the ossicular chain produce similar hearing outcomes for both PORP and TORP procedures. However, titanium may be a preferable option for secondary surgeries involving TORP. The success rate, a postoperative ABG ≤20 dB, is consistent with other studies, but there is room for improvement in patient selection criteria and surgical techniques.

Application of Machine Learning to Predict Hearing Outcomes of Tympanoplasty

OBJECTIVE

This retrospective study aimed to evaluate the performance of machine learning techniques in predicting air-bone gap after tympanoplasty compared with conventional scoring models and to identify the influential factors.

METHODS

We reviewed the charts of 105 patients (114 ears) with chronic otitis media who underwent tympanoplasty. Two numerical scoring systems (middle ear risk index [MERI] and ossiculoplasty outcome parameter staging [OOPS]) and three algorithms (random forest [RF], support vector machine [SVM], and k nearest neighbor [kNN]) were created. Experimental variables included age, preoperative air-bone gap, soft-tissue density lesion in the tympanic cavity in CT, otorrhea, surgical history, ossicular bone problems in CT, tympanic perforation location, perforation type (central or marginal), grafting material, smoking history, endoscopy use, and the operator whose experience was 20 years or longer, or shorter. Binary classification, postoperative air-bone gap ≤15 or >15 dB, and multiclass classification, classification into seven categories by 10 dB, were performed, and the percentages of correct prediction were calculated. The importance of features in the RF model was calculated to identify influential factors.

RESULTS

The percentages of correct prediction in binary classification were 62.3%, 72.8%, 81.5%, 81.5%, and 81.5% in MERI, OOPS, RF, SVM, and kNN, respectively, and those in multiclass classification were 29.8%, 21.9%, 63.1%, 44.7%, and 50% in the same order. The RF model suggested larger preoperative air-bone gap, and older age could make the postoperative air-bone gap larger.

CONCLUSION

The machine learning techniques, especially the RF model, are promising methods for precise postoperative air-bone gap prediction.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2371-2378, 2023.

Surgical Efficacy of Mastoidectomy in Chronic Otitis Media: Squamosal Type

Chronic Otitis Media-Squamosal type is an erosive process, which when confined to ossicular chain causes varying degrees of hearing impairment. As the disease progresses to involve surrounding vital structures, it causes various complications like facial palsy, vertigo, mastoid abscess, which are more common than the other intracranial complications, and require a definitive surgical intervention i.e., mastoidectomy at the earliest. A retrospective study on 60 patients who had been operated for squamosal type were analysed for the demographics, symptomatology, intraoperative extent of cholesteatoma, type of mastoidectomy done, various graft materials used for reconstruction, post operatively for graft uptake, hearing improvement and the results were analysed using ChOLE classification of cholesteatoma. Although Intact Canal Wall mastoidectomy had improved post op PTA values, there was no significant difference in the Air-Bone gap closure when Intact Canal Wall mastoidectomy was compared to Canal Wall Down Mastoidectomy.

[Ossiculoplasties: about 30 cases and literature review]

L'objectif était d'évaluer les résultats fonctionnels des ossiculoplasties. Il s'agissait d'une étude rétrospective, au sein du service d'otorhinolaryngologie (ORL) et de chirurgie cervico-faciale (CCF) au centre hospitalier universitaire (CHU) Mohammed VI d'Oujda, étalée sur une durée allant du mois d'octobre 2018 au mois de mars 2020, ayant pu regrouper 30 patients parmi 45 otites séquellaires qui ont été opérés pour ossiculoplastie par une voie transméatale endoscopique. La moyenne d'âge des patients était de 31,8 ans avec un sex-ratio F/H de 1,5. L'exploration de la caisse du tympan a montré, selon la classification d'Austin, 18 cas type A, 5 cas type B, 3 cas type C et 4 cas type D. Soixante-dix pourcent (70%) des oreilles opérées avaient un déficit audiométrique entre 30 et 40 dB et 30% des patients ont un déficit audiométrique ≥40 dB. L'ossiculoplastie type II a été la plus pratiquée dans 26 cas avec utilisation du cartilage tragal dans 18 cas, interposition d'enclume autologue et mise en place d'une PORP en titane dans 4 cas pour chacune alors que l'ossiculoplastie type III a été pratiquée dans 4 cas avec mise en place d'une opération de reconstruction totale des osselets (TORP) en titane. Le groupe d'ossiculoplastie type II avait un gain auditif ≥20 dB dans tous les cas alors que celui d'ossiculoplastie type III ne l'avait que dans un seul cas. Le taux de réussite était de 90%. L'analyse de ces résultats montre que globalement les résultats sont légèrement moins bons dans les ossiculoplasties type III que dans les ossiculoplasties type II. Cependant, les études comparatives entre différents montages, entre prothèses et autogreffes ou entre différents types de matériaux n'objectivent que des différences minimes pour un même auteur ou pour une même équipe. Il semble pour beaucoup d'auteurs que la préservation du manche du marteau permette de meilleurs résultats fonctionnels.

Do high-frequency air-bone gaps persist after ossiculoplasty?

OBJECTIVES

Conventional reporting of postoperative hearing outcomes utilizes a pure-tone averaged air-bone gap (ABG) that is biased toward low frequencies. Consequently, a high-frequency ABG after otologic surgery may go unnoticed. In this study, we evaluate changes in low- and high-frequency ABG following ossiculoplasty.

STUDY DESIGN

Retrospective review.

SUBJECTS AND SETTING

Consecutive series of patients who underwent ossiculoplasty at a single tertiary care center. Patients with pre- and postoperative audiograms were included.

METHODS

Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 kHz. Pre- and postoperative ABGs were compared.

RESULTS

Thirty-seven consecutive patients were included. Mean age at surgery was 38 years (range, 7-77 years). Reconstruction materials included: cartilage (N = 4), hydroxyapatite cement (N = 5), and partial or total ossicular replacement prostheses (N = 20 and N = 8, respectively). Postoperatively, the mean low-frequency ABG improved by 11.9 ± 15.1 dB (P < .0001) and the mean high-frequency ABG improved by 5.9 ± 16.0 dB (P = .030). Low-frequency ABG closure was significantly larger than high-frequency ABG closure (P = .007). Mean postoperative persistent high-frequency ABG was 22.0 ± 13.8 dB.

CONCLUSION

In this series, ossiculoplasty improved ABG across all frequencies, but greater improvements were observed at low frequencies when compared to high frequency. Current reporting standards may not identify persistent high-frequency ABG. Additional study of the mechanisms of high-frequency sound conduction in reconstructed middle ears is needed to improve high-frequency hearing outcomes in ossiculoplasty.

LEVEL OF EVIDENCE

Level 4.

Outcome parameters in speech audiometry: retrospective analysis of data and reporting quality in clinical studies

OBJECTIVES

The use of standardized outcome parameters is essential for the comparability of clinical studies. Pure-tone audiometry and speech audiometry are widely used, but there is no systematic evaluation of the outcome parameters in clinical application. Nevertheless, there is presumably a great heterogeneity especially in the field of speech audiometry. This study presents a snapshot of the current situation of documentation and usage of outcome parameters in otologic research.

STUDY DESIGN

Retrospective study of existing literature analyzing common speech audiometric test material and procedure MAIN OUTCOME MEASURES: Intervention Studies from 2012 to 2016 concerning hearing ability were eligible for evaluation. Studies were analyzed with regard to study design, pathology and intervention, speech audiometric parameters, pure-tone audiometry, implementation of reporting standards and journal related data.

RESULTS

279 studies were included. Over 50% of the analyzed studies lacked proper documentation. In the remaining studies, there was a broad variance concerning the documented speech audiometric parameters, most often with a fixed presentation level of 65 dB SPL.

CONCLUSION

The lack of generally used standards for reporting hearing outcomes makes it difficult to compare results of different clinical studies. An adequate description of the methods would be a first and important step in improving reports on audiological outcomes.

Canal wall down approach for tympano-mastoid cholesteatoma: long-term results and prognostic factors

The aim of this study is to analyse the long-term anatomical and functional outcomes and prognostic factors of the canal wall down (CWD) tympanoplasty for the treatment of tympano-mastoid cholesteatoma. A total of 895 patients treated for tympano-mastoid cholesteatoma with follow-up longer than 10 years were included. Recidivism (recurrent and residual) cholesteatoma rates and functional results were analysed. The rate of recidivism was 7.7% (6.7% persistence and 1% recurrent disease). Recidivism was higher in paediatric patients (10.1% versus 5.0% of adults). Pathological middle ear mucosa and pars tensa was associated with increased rates of recidivism. Postoperatively, air pure-tone-average (aPTA) ≤ 30 dB was achieved in 36.4% of patients. Of 895 patients, a revision CWD tympanoplasty for chronic otorrhoea was performed in 14 cases (1.5%) with complete recovery in all cases. Nine of those patients had a recurrence of cholesteatoma and five had cavity problems related to granulation, de-epithelisation or recurrent infection. Paediatric patients and absence of stapes superstructure were associated with the worst auditory outcomes. Six-month results were always better than long-term results. A CWD approach was demonstrated to be effective, achieving the goals of cholesteatoma treatment.

A new device for real-time peroperative monitoring of ossicular chain reconstruction during middle ear surgery

To limit functional surgical failure and reduce the rate of revision surgery in case of surgical ossicular chain reconstruction, a piezoelectric device was developed for assessment of ossicular chain vibrations during the middle ear surgery. The device resembled a pen and consisted of a reusable main body and a disposable sensitive head including piezoelectric polymer sensor. Almost all of components of the device were made of polymer for light weight and for acoustic impedance matching to the middle ear system. Several frequencies can be analyzed simultaneously and several measures can be taken by time. The results showed that the device can record normal and reconstructed ossicular chain vibration in response to an acoustic stimulation, with similar results to those achieved by laser Doppler vibrometer. This light, handheld and low-cost device allows fast, easy and safe assessments of normal ossicular chain mobility and ossicular chain reconstruction efficiency. Primary pre-clinical trial showed very promising performance of the device that could be used to qualitatively control ossiculoplasty during real-time surgical procedure. Clinical assessments will be done to further evaluate the real-life performance of the device.

Tympanoplasty - news and new perspectives

Techniques and biomaterials for reconstructive middle ear surgery are continuously and steadily developing. At the same time, clinical post-surgery results are evaluated to determine success or failure of the therapy. Routine quality assessment and assurance is of growing importance in the medical field, and therefore also in middle ear surgery. The exact definition and acquisition of outcome parameters is essential for both a comprehensive and detailed quality assurance. These parameters are not the audiological results alone, but also additional individual parameters, which influence the postoperative outcome after tympanoplasty. Selection of patients and the preoperative clinical situation, the extent of the ossicular chain destruction, the chosen reconstruction technique and material, the audiometric frequency selection and the observational interval are only some of them. If these parameters are not well documented, the value of comparative analyses between different studies is very limited. The present overview aims at describing, comparing, and evaluating some of the existing assessment and scoring systems for middle ear surgery. Additionally, new methods for an intraoperative quality assessment in ossiculoplasty and the postoperative evaluation of suboptimal hearing results with imaging techniques are available. In the area of implant development, functional elements were integrated in prostheses to enable not only good sound transmission but also compensation of occurring atmospheric pressure changes. In combination with other components for ossicular repair, they can be used in a modular manner, which so far show experimentally and clinically promising results.

Hearing Outcomes after Ossicular Reconstruction with Removal of the Malleus

Objectives

(1) Evaluate hearing outcomes of patients after planned malleus removal during ossicular chain reconstruction. (2) Analyze hearing results for titanium (Ti) and hydroxyapatite (HA) total ossicular prostheses (TOPs) and partial ossicular prostheses (POPs). (3) Compare Ti and HA partial prostheses.

Study Design

Retrospective case series with chart review.

Setting

Tertiary health care organization.

Subjects and Methods

A chart review was conducted of 139 consecutive patients who presented with chronic otitis media with perforation (with or without cholesteatoma) and were treated with initial-stage tympanoplasty (with or without mastoidectomy) and managed with TOP (n = 22) or POP (n = 117) between July 2010 and July 2015. The malleus was completely removed in all cases. Hearing was assessed via bone and air conduction pretone averages (0.5, 1, 2 kHz) pre- and postoperatively. Air-bone gap (ABG) and change in ABG (ΔABG) were analyzed. Pre- and postoperative values were compared.

Results

The overall mean ABG decreased from 29.4 ± 12.3 dB to 18.2 ± 11.4 dB postoperatively ( P < .001) with a mean ΔABG of 14.5 dB (95% CI, 12.793-16.203). Overall success was achieved by 69.1%. The POP group achieved higher success (70.9%) than the TOP group (59.1%; P = .0001). Mean ABG decreased significantly within surgical groups (TOP and POP) and prosthesis material groups (Ti and HA; all P < .001). Ti had statistically higher success than HA in both techniques: POP ( P = .0478) and TOP ( P = .0251). There was a 98% graft take rate.

Conclusion

Planned malleus removal during ossicular chain reconstruction, regardless of disease extent, allows for simpler reconstruction and comparable favorable results to preservation of the malleus and should be considered during surgical planning.

Data and Reporting Quality in Tympanoplasty and Ossiculoplasty Studies

Objective

The objective of our study was to check the documentation of hearing outcome parameters and influencing factors (surgical, pathological, and methodological) in published literature evaluating hearing outcome after tympanoplasty. We aimed to assess how effectively the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) 1995 guidelines were applied.

Study Design

Retrospective noncontrolled study.

Setting

Ear research center.

Subjects and Methods

This study was based on a PubMed research, including peer-reviewed English-speaking original studies published from January 2005 to December 2015. In total, 169 studies were checked for correct description of study population, surgical methodology, study design, and documentation of the hearing outcome. In addition, the correct application of AAO-HNS 1995 criteria was checked.

Results

Pre- and postoperative air-bone gap were shown as mean ± standard deviation in half of all series (52% vs 56%). The recommended frequency spectrum (0.5-3 kHz) was used in 46%, while a documentation of frequency spectrum was available in 85%. Whereas a statement on presence of stapes suprastructure (81%) and initial pathology was usually available, mucosa status (17%) and aeration (8%) were only shown in few series. Revision cases, staged cases, and myringoplasty graft material were documented in 46% to 57%. Type and material of prosthesis were represented in 74% to 82%. None of the publications analyzed fulfilled all 10 AAO-HNS criteria. In 10%, 7 to 9 criteria were used correctly.

Conclusion

A heterogeneous description of surgical and pathological findings and the application of minimal reporting standards are essential preconditions to enable comparisons between different studies and to generate meta-analysis.

Autologous incus versus titanium partial ossicular replacement prosthesis in reconstruction of Austin type A ossicular defects: a prospective randomised clinical trial

OBJECTIVE

This study aimed to compare the functional and anatomical outcomes of ossiculoplasty using an autograft incus or a titanium partial ossicular replacement prosthesis for reconstructing Austin type A ossicular defects.

METHODS

Patients with Austin A ossicular defects were randomly divided into two groups: one group underwent ossiculoplasty with an autologous incus (the autologous incus group) and the other underwent ossiculoplasty with a titanium partial ossicular replacement prosthesis (the titanium prosthesis group). Otoscopic examination and audiological assessment was done pre-operatively and at 3, 6 and 12 months post-operatively.

RESULTS

A post-operative average air-bone gap closure of less than 20 dB was seen in 13 patients (65 per cent) in the autologous incus group and 7 (35 per cent) in the titanium prosthesis group. There were fewer post-operative complications in the autologous incus group (20 per cent) than in the titanium prosthesis group (45 per cent).

CONCLUSION

Hearing outcomes and graft take up after ossiculoplasty were significantly better when an autologous incus rather than a titanium partial ossicular replacement prosthesis was used to reconstruct Austin type A ossicular defects. The major disadvantages of the titanium prosthesis were unpredictable results and more post-operative complications.

Ossiculoplasty in chronic otitis media: Surgical results and prognostic factors of surgical success

BACKGROUND AND OBJECTIVES

The goal of ossiculoplasty is to improve hearing. Successful ossiculoplasty depends on several factors. This retrospective study was carried out to analyze hearing results of ossiculoplasty in ears with chronic otitis media (COM) and evaluate clinical outcomes and factors predictive of hearing improvement.

SUBJECTS AND METHODS

We reviewed the results of 153 patients with COM (with cholesteatoma (COMC) and without cholesteatoma (COMWC)) who underwent ossiculoplasty between January of 2002 to December of 2011. Several potential prognostic factors were evaluated: cholesteatoma present vs absent; type of surgical procedure, state of the middle ear mucosa, state of the ossicular chain, type of prosthesis.

RESULTS

We analyzed 153 ossiculoplasties: 96 patients presented COMWC and 57 patients presented COMC. The ossiculoplasties were performed using autologous ossicles for the most part. All ossiculoplasties were carried out in one-stage surgery. In 38% of cases ossiculoplasty was combined with mastoidectomy; in the remaining 62% of cases, ossiculoplasty was performed without mastoidectomy. Ossiculoplasty was successfully achieved in 113 patients (74%). The presence of the stapes superstructure and normal mucosa were significant predictive factors of surgical success.

CONCLUSION

The majority of the ossiculoplasties improved hearing status satisfactorily. Multivariate analysis should be performed to investigate prognostic factors of favorable short-term hearing outcomes after ossiculoplasty. Better knowledge of these predictive factors may contribute to the surgeon's judgment and the information given to patients.

TORP Ossiculoplasty Outcomes with and without a Stapes Footplate Prosthesis

Objective

The titanium stapes footplate prosthesis (FPP) was designed to ensure a stable connection of a total ossicular replacement prosthesis (TORP) to the stapes footplate and maximize acoustic coupling by centering the footplate on the oval window. Our goal was to assess the impact of the FPP on TORP ossiculoplasty outcomes.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects

Adult patients undergoing TORP ossiculoplasty with (n = 53) or without (n = 108) a stapes FPP.

Methods

Rate of prosthesis displacement and audiologic outcomes were tabulated for statistical analysis.

Results

A lower rate of prosthesis displacement and statistically better audiologic outcomes were seen in FPP patients. The pure-tone average air-bone gap (PTA-ABG) was closed to <20 dB in 69.8% (37/53) of patients in the study arm and 44.4% (48/108) of patients in the control arm ( P = .003). The PTA-ABG was decreased by a mean ± SD of 19.3 ± 11.7 dB and 12.6 ± 11.0 dB in the study and control groups, respectively ( P = .0012).

Conclusions

Use of the titanium stapes FPP during TORP ossiculoplasty provides a statistically significant advantage in short-term PTA-ABG closure and a higher rate of successful rehabilitation of conductive hearing loss. Further studies are necessary to assess any long-term advantages a FPP may offer.

Audiometric Outcome Comparison between Titanium Prosthesis and Molded Autologous Material

Objective

To evaluate and compare the audiometric outcomes of ossicular reconstruction with titanium prosthesis and autologous material.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

Audiometric results of consecutive patients who performed ossiculoplasty with titanium prosthesis (n = 43) or autologous material (n = 48), from October 2008 to December 2011, were reviewed retrospectively and compared. The association between air-bone gain and age, ossiculoplasty material (autologous or titanium), preoperative diagnosis (chronic otitis media without cholesteatoma, cholesteatoma, or conductive hearing loss with intact tympanic membrane), and type of surgery (tympanoplasty, canal wall-down mastoidectomy, or canal wall-up mastoidectomy) was explored using regression analysis.

Results

Preoperative audiometric evaluation did not show differences between titanium and autologous groups in air-bone gap and pure-tone average. A postoperative decrease of 11.0 dB in air-bone gap and 12.4 dB in pure-tone average was observed in titanium ossiculoplasty compared with a reduction of 4.0 dB in air-bone gap and 5.1 dB in pure-tone average when autologous reconstruction was used. Mann-Whitney test revealed superior results in the titanium group compared with autologous reconstruction patients in air-bone gap ( P = .02) and pure-tone average ( P = .02). However, no statistically significant associations were observed after multivariate linear regression analysis of air-bone gap gain when adjusted for age, ossiculoplasty material, type of surgery, and preoperative diagnosis. One titanium prosthesis extrusion occurred during follow-up (2%).

Conclusion

Audiometric results achieved by titanium prosthesis are promising, but significant differences compared with autologous ossiculoplasty were not present.

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.

Functional results after cholesteatoma surgery in an adult population using the retrograde mastoidectomy technique

In this retrospective study, we analyzed the functional results after using the retrograde mastoidectomy technique for cholesteatoma removal in an adult patient population. The described technique was used at a tertiary referral center for cholesteatoma removal in 218 adult patients, representing 242 operated ears, with an average follow-up time of 20.3 months. With the retrograde mastoidectomy technique, the cholesteatoma is removed posteriorly through the canal wall, from the epitympanic region toward the mastoid, with the option to reconstruct the posterior bony canal wall or create an open mastoid cavity, depending on the size of the defect. Primary surgery was carried out in 58.7 % ears, with the remaining 41.3 % representing revision surgery. In 151 cases, the posterior canal wall was reconstructed, and in 91 cases a classical CWD with an open mastoid cavity was created. In the majority of the cases (n = 213, 88.0 %), a primary hearing restoration was performed. There were 18 recurrences (12.7 %) in primary cases and 22 recurrences (22 %) in revision surgeries. Ninety percent of the recurrences (36 of 40 cases) occurred within 5 years. A postoperative air-bone gap of less than 20 dB was achieved in 61.6 % of the operated ears. Ears with a reconstructed posterior canal wall had significantly better hearing results than those cases in which a CWD procedure was used (air-bone gap of 17.6 versus 22.5 dB, p < 0.05). The retrograde mastoidectomy technique for cholesteatoma removal resulted in satisfying hearing results in the majority of the cases, with a recurrence rate comparable to the current literature.

Ossiculoplasty: revisited

Conductive hearing loss from ossicular chain abnormalities may result from either discontinuity or fixation of the ossicular chain. The ideal prosthesis for ossicular reconstruction should be biocompatible, stable, safe, readily available, and capable of yielding optimal sound transmission. At present ossiculoplasty techniques using alloplast materials are becoming popular but the fate of these synthetic materials in human middle ear requires further study. Autologous ossicle or cortical bone grafts maintain their morphologic contour, size, shape, and physical integrity for long periods of time, over 25 years making them still the choice at present. The choice of technique will still depend on the causative pathology, availability of graft, surgical experience.

Acquired cholesteatoma: classification and outcomes

OBJECTIVE

Reclassification of acquired cholesteatoma into the commonly observed presentations of this condition to provide a simple and clear grouping that indicates the pathology, management, and outcomes of the group cases.

PATIENTS

Virgin acquired cholesteatoma cases from a single center managed from 1986 to 2008 (515 cases).

INTERVENTIONS

Cases were managed by transcanal (20%) or intact canal wall techniques. Wall repairs successively used autograft cartilage (transcanal and early intact canal wall mastoidectomy cases), hydroxylapatite plates (1989-2007), or titanium sheeting (2007). Drum repairs used cartilage-perichondrial composite grafts. Assembly techniques were the preferred ossiculoplasty method.

RESULTS

Distribution: attic, 41%; pars tensa, 45%; and combined attic-pars tensa, 14%. Unclassifiable cases (n = 14) were excluded. Contralateral disease was present in 15% and effusions in 34% during or after surgery. Cell formation was most extensive in attic disease, least in combined patterns. Ossicular pathology was worse in the collapsed drum cases. Attic cases had the best hearing outcomes but risked recurrent disease, which required precise countermeasures. Overall, the combined pattern group carried the worst prognosis.

CONCLUSION

Compared with previous methods, the clinical classification proved simple, descriptive, and comprehensive. It provides a readily discerned practical basis for clinical management and research purposes.

Hearing and ossicular chain preservation in cholesteatoma surgery

OBJECTIVE

To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery.

METHODS

We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females).

RESULTS

At the first post-operative assessment, a median air-bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air-bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome.

CONCLUSIONS

In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

Malleus handle: determinant of success in ossiculoplasty

OBJECTIVE

The purpose of this study is to identify prognostic factors affecting outcome in ossicular chain reconstruction (OCR).

STUDY DESIGN AND SETTING

This study is a retrospective case series of electronic database at an academic institution.

MATERIALS AND METHODS

We reviewed 209 cases of chronic supportive otitis media performed from January 2000 through December 2007 and collected demographic, clinical, audiologic, and outcome information. Univariate analyses of group differences in terms of postoperative air-bone gap (ABG) changes were evaluated by analysis of variance. Multiple regression analyses were used to examine the relationship between postoperative ABG and the independent variables.

RESULTS

There were 105 cases of OCR the met the inclusion criteria (44 primary and 61 revision tympanoplasties), with an average follow-up of 19 months. The diagnoses were chronic suppurative otitis media without cholesteatoma in 36 cases and cholesteatoma in 69 cases. The mean preoperative ABG was 34 +/- 15 dB, and the mean postoperative ABG was 20 +/- 14 dB (P < 0.001). Of the independent variables analyzed, the type of procedure (ie, OCR performed during second-look tympanoplasty vs canal wall up vs canal wall down), preoperative ABG, and status of malleus handle were predictive of the success of OCR.

CONCLUSIONS

Favorable prognostic factors in OCR include smaller preoperative ABG and the presence of an intact malleus handle.

Titanium versus autograft ossiculoplasty

CONCLUSION

In this comparative series, hearing results were superior with titanium compared with autograft ossiculoplasty in the absence of a stapes superstructure. However, in the presence of a stapes superstructure, titanium ossiculoplasties gave superior results to autografts only when comparing an air-bone gap of < 10 dB.

OBJECTIVE

To compare the hearing outcomes of autograft versus titanium ossiculoplasty at 1 year.

METHODS

Two consecutive groups of patients with chronic suppurative otitis media with and without cholesteatoma suitable for ossiculoplasty, either primarily or as a staged procedure, were recruited for the study. A total of 52 consecutive patients who underwent an autograft ossiculoplasty were compared with 51 consecutive patients who underwent a titanium ossiculoplasty. Hearing results were statistically compared at 1 year between the two groups using the four frequency average (FFA) of 0.5/1/2/4 kHz and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) four frequency average of 0.5/1/2/3 kHz. The results were analysed statistically.

RESULTS

A statistically significant number of titanium TORP ossiculoplasties achieved an air-bone gap closure to within < 20 dB compared with the autograft equivalent group (p = 0.039 FFA; p = 0.016 AAO-HNS). The number of titanium PORP ossiculoplasties achieving an air-bone gap closure to within < 10 dB compared with the autograft equivalent group was also statistically significant (p = 0.006 FFA; p = 0.002 AAO-HNS).

Bilateral hearing results of 751 unilateral stapedotomies evaluated with the Glasgow benefit plot

Aims:

We aimed to evaluate bilateral hearing function in patients undergoing primary unilateral stapedotomy, according to the 1995 American Academy of Otolaryngology, Head and Neck Surgery guidelines and the Glasgow benefit plot. We also aimed to analyse the effect of pre-operative hearing impairment type on post-stapedotomy hearing.

Study design:

Retrospective chart review.

Methods:

Medical records relating to 1369 stapedotomies performed by the senior author (JJH) from 1991 to 2006 were reviewed. Seven hundred and fifty-one patients undergoing primary unilateral stapedotomy were included. Hearing results for these patients were evaluated according to the criteria of the 1995 American Academy of Otolaryngology, Head and Neck Surgery Committee on Hearing and Equilibrium guidelines, and the Glasgow benefit plot. Subgroups of patients with pre-operative unilateral, bilateral symmetrical and bilateral asymmetrical hearing loss were separately analysed.

Results:

The most successful results, as regards the achievement of bilateral, socially serviceable hearing, were demonstrated in patients with unilateral hearing loss; 78 per cent of these patients had normal hearing post-operatively. Overall, patients' achievement of bilateral, socially serviceable hearing correlated highly with their type of pre-operative hearing impairment (r = 0.74). Normal post-operative hearing levels also correlated with pre-operative bone conduction (r = 0.61).

Conclusion:

This study represents the largest reported series of primary stapedotomy cases evaluated with the Glasgow benefit plot. Patients' bilateral post-operative hearing function depended on their type of pre-operative hearing impairment. Pre-operative bone conduction thresholds, corrected for Carhart's effect, were useful in predicting achievable post-operative air conduction.

The functional and anatomical results of the canal wall down tympanoplasty in extensive cholesteatoma

CONCLUSION

Although we have shown that malleus handle and mucosal factors were important prognostic factors for hearing, we were unable to show the positive effect of the stapes superstructure on hearing results. The positive effect of the presence of the stapes superstructure on hearing results is closely related to the quality of the mucosa.

OBJECTIVE

The aim of this study was to investigate the impact of ossicular and mucosal factors on hearing in primary canal wall down (CWD) surgery with ossicular chain reconstruction (OCR) performed for extensive acquired cholesteatoma.

PATIENTS AND METHODS

A total of 134 adults who had CWD surgery with OCR for extensive acquired cholesteatoma between January 1996 and May 2007 were retrospectively analyzed.

RESULTS

The graft insufficiency was 13%, chronic infection without cholesteatoma was 6% and cholesteatoma recurrence was 8% after the first operations. The rate of anatomic failure was 10% after a follow-up period of 46.3 months. In this study, we present the anatomic results for 136 ears and functional results for 135 ears. The hearing gain was significantly higher in the cholesteatoma-only group when compared with the mucosal-cholesteatoma disease group. Forty-three ears (54%) in the cholesteatoma-only group and 23 ears (42%) in the mucosal-cholesteatoma disease group had postoperative ABG within 20 dB. The best hearing results were obtained in Austin group B, while the worst hearing results were evident in Austin group C (p=0.017). Postoperative ABG was within 20 dB in 44% (n=31) of the patients with an intact stapes superstructure, while this ratio was 54% (n=35) when the stapes superstructure was absent.

Results of primary ossiculoplasty in ears with an intact stapes superstructure and malleus handle: inflammation in the middle ear at the time of surgery does not affect hearing outcomes

OBJECTIVE

To determine whether any factors are predictive of success or failure in primary ossiculoplasty employing autologous bone in Austin-Kartush Group A (stapes and malleus handle present) ears.

STUDY DESIGN

Retrospective review of a single-surgeon case series.

SETTING

Two District General Hospitals in the United Kingdom.

PATIENTS

Of 135 patients undergoing primary repair, 116 had sufficient data for analysis (mean follow-up 33 months).

MAIN OUTCOMES MEASURED

Postoperative air-bone gaps (pABG) in patients with differing qualities of middle-ear mucosa (active versus inactive), differing pathologies (mucosal versus squamous) and differing surgical procedures [canal-wall up (CWU) versus canal-wall down (CWD)].

SECONDARY OUTCOME MEASURE

'Belfast Rule of Thumb' (operated ear hearing brought to 30 dB or better or to within 15 dB of contralateral ear).

RESULTS

Postoperative ABGs were closed within 10 dB in 37%, 20 dB in 74% at latest follow-up. The only significant factors predicting hearing outcomes were the status of the canal wall (CWU = 14.1 dB, CWD = 24.7 dB: significant, P = 0.00) and whether surgery was primary or revision. Mean ABG was 14.7 for inactive middle ear mucosa, 17.2 for active middle ear mucosa (not significant, P = 0.25). Excluding CWD procedures from the analysis improved outcomes to 80% (within 20 dB) and 41% (within 10 dB) overall, and the mean for active and inactive ears to 14.2 and 14.0 dB respectively. Postoperatively, 82% of patients fulfilled the 'Belfast Rule of Thumb'.

CONCLUSION

The most significant prognostic factor affecting hearing outcomes - status of the canal wall - is independent of staging. The factor most associated with staging - the status of the middle ear mucosa - is only weakly associated with a successful functional outcome.

Myringostapediopexy and myringolenticulopexy in mastoid surgery

Objective:

To compare hearing results in patients undergoing myringostapediopexy or myringolenticulopexy in canal wall down mastoidectomy.

Study design:

Case series of one surgeon. A retrospective review of 83 consecutive mastoid cavity operations for primary cholesteatoma. Only those patients who had undergone either myringostapediopexy or myringolenticulopexy were included.

Setting:

District general hospital.

Patients:

Forty-two procedures were performed in 40 patients. The mean age was 42 years old. The average follow up was 5.9 years.

Intervention:

Seventeen patients underwent myringolenticulopexy (the incus head was excised, leaving the lenticular process attached to the stapes prior to graft placement) and 25 underwent myringostapediopexy (type III tympanoplasty).

Main outcome measures:

Audiometry three to six months after surgery, and status of mastoid cavity after a minimum follow up of one year.

Results:

Comparison of post-operative hearing results for the two groups showed a statistically significant hearing advantage for myringolenticulopexy (p = 0.029). In the myringolenticulopexy group, 92 per cent achieved a post-operative air–bone gap of less than 30 dB, compared with 62 per cent in the myringostapediopexy group. The mean post-operative air–bone gaps in the two groups were 17.5 and 24.7 dB, respectively.

Conclusion:

When surgically feasible, the technique of myringolenticulopexy is a useful method of preserving serviceable hearing in single-stage mastoid cavity surgery.

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.

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.

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.