Malleus Relocation in Ossicular Reconstruction: Managing the Anteriorly Positioned Malleus: Results in a Series of 268 Cases

Linear transmission between malleus and stapes in cases with incus necrosis

OBJECTIVE

The outcome of cartilage interposition ossiculoplasty was assessed in cases of incus necrosis after posterior malleus repositioning in the plane of the stapes, in terms of hearing gain after ossicular reconstruction.

METHODS

A retrospective observational study was conducted of 30 patients admitted to an Ain Shams University hospital from March 2021 to September 2021. All patients with ossicular disruption due to chronic suppurative otitis media and hearing loss of more than 40 dB were included in the study. Pure tone audiometry was conducted for each patient after three months, six months and one year post operation.

RESULTS

The audiogram showed a post-operative air-bone gap of 20 dB or less in 83.33 per cent of patients (n = 25) at three months post-operatively and in 80 per cent of patients after six months; after one year, the results remained the same.

CONCLUSION

The use of cartilage interposition after malleus posterior mobilisation represents an excellent partial ossicular replacement technique.

TORP ossiculoplasty in the presence of an intact stapes superstructure

INTRODUCTION

In this series, we describe ossicular reconstruction using routine TORP in the presence of the stapes superstructure using a tympanic-membrane-to-footplate configuration.

MATERIALS AND METHODS

This is a case series of 12 patients who underwent TORP ossiculoplasties from 1st January 2010 to 31st October 2017. Data collected included demographics, indication for surgery, status of the middle ear and pre-operative and post-operative audiometric data (including pure tone average (PTA) and air-bone gap (ABG)).

RESULTS

The mean pre-operative PTA was 56.5 dB and ABG was 39.8 dB. Surgical success (ABG ≤ 20 dB) was achieved in 83.3%, with an average improvement in PTA of 24.3 dB and closure of ABG of 27.1 dB. The mean post-operative ABG was 12.7 dB.

CONCLUSION

TORP ossiculoplasty with tympanic-membrane-to-footplate configuration is a feasible means of ossicular reconstruction, independent of the status or spatial arrangement of the remnant ossicles. Using this technique, it is possible to achieve a consistently good outcome for improvement in hearing and closure of ABG.

Endoscopic ossiculoplasty: Is there any edge over the microscopic technique?

OBJECTIVES/HYPOTHESIS

To compare endoscopic ossiculoplasty with conventional microscopic technique in terms of postoperative hearing outcomes and complications.

STUDY DESIGN

Randomized controlled trial.

METHODS

One hundred eighteen patients diagnosed with ossicular chain discontinuity were randomly assigned into two groups, one undergoing endoscopic ossiculoplasty and the other undergoing ossiculoplasty by the microscopic technique, with the operating surgeon being same for both groups. The two groups were compared in terms of operative time, postoperative air-bone gap, mean air-bone gap closure, and incidence of complications. Teflon prostheses (partial ossicular chain replacement prosthesis [PORP] and total ossicular chain replacement prosthesis [TORP]) were used for reconstruction in all cases.

RESULTS

Endoscopic ossiculoplasty with PORP rendered a statistically significant mean postoperative air-bone gap and air-bone gap closure at 1 month when compared to that of microscopic PORP ossiculoplasty. However, there was no significant difference between the two techniques in terms of mean postoperative air-bone gap and air-bone gap closure at 3 and 6 months. In the TORP ossiculoplasty cases, there was no significant difference in mean postoperative air-bone gap and air-bone gap closure at 1, 3, and 6 months. In terms of operative time and incidence of complications, no statistical significance was found between the two groups.

CONCLUSIONS

Endoscopic ossiculoplasty appears to provide superior visualization and better early audiological outcome (in PORP ossiculoplasty cases) when compared to microscopic technique. However, long-term audiological outcomes and incidence of complications remain comparable.

LEVEL OF EVIDENCE

1 Laryngoscope, 130:797-802, 2020.

Long-term Outcomes of Ossiculoplasty With and Without an Intact Malleus

OBJECTIVE

To compare long-term hearing outcomes following ossiculoplasty with cartilage tympanoplasty with (M) and without (M) the malleus present.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

One twenty-six patients (18-88 yr of age) undergoing ossiculoplasty with tympanoplasty or tympanomastoidectomy using cartilage tympanic membrane grafts from 1998 to 2012 with at least 5 years of documented postoperative follow-up.

MAIN OUTCOME MEASURES

Short-term hearing results (pure-tone average air-bone gap [PTA-ABG] measured between 60 d and 1 yr after surgery), long-term hearing results (PTA-ABG measured ≥5 yr after surgery), Ossiculoplasty Outcome Parameter Staging (OOPS) index, and complications.

RESULTS

There were 46 patients in the M group and 80 in the M group. Preoperative PTA-ABG was 23.8 dB for M and 34.5 dB for M (p = 0.00001). Short-term postoperative PTA-ABG was 19.3 dB for M and 18.5 dB for M (p = 0.727). Long-term postoperative PTA-ABG was 18.2 dB for M and 19.6 dB for M (p = 0.500). The OOPS index was 4.11 and 6.41 for M and M, respectively, (p = 0.00001). Thirteen patients (10.3%) experienced complications.

CONCLUSION

Our data suggest that the malleus is not statistically significant with regard to its impact on final audiometric outcome following ossiculoplasty. This has implications in our clinic, particularly in our use of the OOPS index as a prognostic tool, and will likely lead to its revision. These data may further support the coupling theory of acoustic gain and weaken the catenary lever theory.

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 < 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 < 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.

Malleus to Stapes Bone Cement Rebridging Ossiculoplasty: Why Don't We Perform Frequently?

OBJECTIVE

To evaluate the effectiveness of malleus to stapes bone cement rebridging (MS-BCR) for Austin Kartush group A ossicular defects and compare the audiological results with incus interposition (IP) and incus to stapes bone cement rebridging (IS-BCR).

METHODS

Patients for whom type 2 tympanoplasty had been performed in a tertiary referral center were examined. Revision cases and those with graft failure were excluded. Three treatment groups were IS-BCR, IP, and MS-BCR. Preoperative and postoperative audiological results were compared.

RESULTS

A total of 92 patients were enrolled. The IS-BCR was performed in 42 (45.65%), IP in 18 (19.56%), and MS-BCR in 32 (34.78%) patients. Postoperative mean air bone gap was 20.1 ± 9.8 dB HL and did not differ significantly between the groups (P = .271). Postoperative mean air bone gap less than 20 dB HL was achieved in 23 (54.7%) patients in IS-BCR, 10 (55.5%) patients in IP group, and 24 (75%) patients in MS-BCR group (P = .06). Mean closure in air bone gap was 14.0 ± 11.6 dB HL. The changes in mean and frequency-specific air bone gap were not significantly different between treatment groups (P > .05).

CONCLUSION

Malleus to stapes bone cement rebridging may provide hearing results comparable to IS-BCR and IP.

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.

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.

Outcome of malleo-stapedotomy using the malleus relocation technique during revision stapes surgery

OBJECTIVE

This study aimed to use a new otological technique, malleus relocation, to solve the problems of ossicular reconstruction undertaken during revision stapes surgery for incus necrosis.

STUDY DESIGN

Prospective study of 12 patients undergoing revision stapedectomy for incus necrosis, in the otolaryngology department of Mansoura University, Egypt.

PATIENTS AND METHODS

Twelve patients underwent ossiculoplasty between June 2004 and June 2007, as part of revision surgery for otosclerosis with incus necrosis. All patients underwent ossiculoplasty using the malleus relocation technique. Ossiculoplasty used the patient's own, necrosed incus between the relocated malleus and the footplate.

RESULTS

Post-operative air-bone gap closure to within 10 dB was achieved in seven patients (58.3 per cent). An air-bone gap of less than 20 dB was obtained in 10 patients (83.3 per cent). Deterioration of bone conduction by 10 dB occurred in one case. No patients were left with a 'dead ear'. Patients' hearing was stable throughout the follow-up period (range six to 40 months; mean ± standard deviation 23.5 ± 12.8 months).

CONCLUSION

These findings indicate that malleus relocation, performed during revision stapes surgery, is a safe and efficient technique for the treatment of incus necrosis.

Tympanoplasty in chronic otitis media patients with an intact, but severely retracted malleus: a treatment challenge

OBJECTIVE

To analyze the outcome of patients with chronic otitis media (COM) with an intact, but markedly medialized ossicular chain, treated by removing the malleus head and interposing an autologous incus and then an underlay myringoplasty.

STUDY DESIGN

Retrospective clinical study.

SETTING

Tertiary referral center.

PATIENTS

The search criteria within the prospective surgical database was COM with a central perforation (without cholesteatoma) with a markedly medialized malleus handle (the umbo adherent to the promontory) with an intact ossicular chain (study, n = 15) or an incus necrosis at the lenticular process (incus, n = 23). Only primary surgeries performed at our otorhinolaryngology department were included.

INTERVENTION

All patients underwent the same surgical procedure consisting of an autologous incus interposition and underlay myringoplasty with temporalis fascia.

MAIN OUTCOME MEASURE

The patients' audiological and follow-up data were retrieved from the database. The postoperative audiogram (0.5-3 kHz) with the longest follow-up was used.

RESULTS

The preoperative air-conduction thresholds were less impaired in the study group than in the incus group. After their surgery, all, except 3 patients, improved their hearing, and 97% had an intact tympanic membrane at a mean follow-up of 2 years. The air-bone gap was closed within 20 dB in 80% (study) and in 87% (incus), in one third of all patients even within 10 dB. Although the largest improvement was seen in the lower frequencies, closure of the air-bone gap at 4 kHz was difficult to achieve.

CONCLUSION

Patients presenting with COM, a (central) perforation, a medially rotated malleus and intact ossicular chain are a treatment challenge. Lateralizing the malleus handle may require disconnection of the ossicular chain and an autologous incus interposition to bring back the reconstructed tympanic membrane in its original position and improve the hearing.

Surgical Findings and Long-Term Hearing Results in 3,050 Stapedotomies for Primary Otosclerosis

OBJECTIVE

To evaluate with a new otologic database the results of primary stapes surgery for otosclerosis with up to 14 years of follow-up in a consecutive series of 2,525 patients operated on by the same surgeon with the same technique (stapedotomy and vein graft interposition) and to provide online access to the complete data of this study for the reviewers. To study the effect of specific operative findings (obliterative otosclerosis and simultaneous malleus ankylosis) and age at the time of surgery on the long-term outcome.

STUDY DESIGN

Prospective clinical study using a new computerized otologic database.

SETTING

: Tertiary referral center.

PATIENTS

Two thousand five hundred twenty-five patients who underwent 3,050 stapedotomies for otosclerotic stapes fixation were enrolled in this study from January 1991 to December 2004. Separate analyses were made for two unique pathologies (92 cases of obliterative otosclerosis and 19 cases of simultaneous malleus ankylosis) diagnosed during surgery and for patients in two age brackets (<or=18 yr [28 patients] and >or=65 yr [302 patients]).

INTERVENTION

Stapedotomy with vein graft interposition and reconstruction with either a Teflon piston, a bucket handle prosthesis, or a total prosthesis.

MAIN OUTCOME MEASURES

Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were all assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 14 years.

RESULTS

Overall, the postoperative ABG was closed to 10 dB in 94.2% of cases. The mean four-frequency postoperative ABG was 1.7 dB compared with 25.6 dB preoperatively. The mean four-frequency bone-conduction thresholds were unchanged postoperatively. A significant postoperative sensorineural hearing loss (SNHL; >15 dB) was seen in 0.5% of cases in this series. Postoperative ABG was achieved to within 10 dB in 95% of cases of obliterative otosclerosis and in 64.7% of cases of simultaneous malleus ankylosis. A significant postoperative SNHL (>15 dB) was seen in 4.8% of cases of obliterative otosclerosis and was not observed in any cases of simultaneous malleus ankylosis. Postoperative ABG was achieved to within 10 dB in 93.5% of cases in the pediatric series and in 94.5% of cases in the senior series. A significant postoperative SNHL (>15 dB) was seen in 0.7% of cases in the senior group but was not observed in the children.

CONCLUSION

Using a new otologic database, our series confirms that stapedotomy with vein graft interposition for otosclerotic stapes fixation is a safe and successful treatment for long-term hearing improvement. The deterioration in hearing with time after stapedotomy did not exceed the rate of hearing loss because of presbyacusis. Therefore, argon laser stapedotomy with vein graft interposition is our preferred surgical technique in the treatment of otosclerosis. Obliterative otosclerosis and simultaneous malleus ankylosis may be encountered during stapedotomy. Our study shows that reasonable success rates can still be expected in these situations. Stapedotomy results in the elderly and in children are comparable to those obtained in patients of other groups of age undergoing surgery for otosclerosis without an increased risk for complications.