Histopathology of ossicular grafts and implants in chronic otitis media

Ossiculoplasty: A Prospective Study on 50 Patients Using Various Graft Materials

With large number of grafts available for ossiculoplasty, choice becomes difficult. An ideal graft should be safe, easily available, cost efficient, with good hearing results, uptake and low extrusion rates. The ear nose and throat surgeon is still facing the indecision over type of graft to be selected. A prospective study was conducted in Department of Otorhinolaryngology, Rajindra Hospital, Patiala (August 2012-2014) on 50 patients 15-60 years, of either sex with ABG > 40 dB. Operative procedure planned and type of graft decided intraoperatively. Autografts included remodelled malleus, remodelled incus and tragal cartilage grafts. Synthetic (Teflon) grafts were PORP and TORP. Graft uptake/failure was noted at 1 and 3 months. PTA done at 3 months postoperatively. Net hearing gain (change in ABG) was calculated for various grafts used and analysed. Mean age was 35.26 ± 13 yrs, male and female 1:1. Most common involved ossicle was incus (100%) followed by stapes (36%) and malleus (34%). Autografts, 23, uptake in 20 (86.95%), failure 3 (13.04%) cases. Synthetic grafts, 27, uptake 18 (66.66%) and failure 9 (33.33%). 'p'value 0.09 (non significant). Mean hearing gain, autografts 14.47 ± 6.54 dB and synthetic grafts 14.57 ± 13.12 dB. 'p' value 0.976 (non significant). No significant difference seen in mean hearing gain and uptake/failure of autografts and synthetic grafts. Autografts being cost effective are preferred choice.

Selective Contribution of Bioactive Glasses to Molecular and Cellular Pathways

Over the past few decades, biomedical scientists and surgeons have given substantial attention to bioactive glasses as promising, long-lasting biomaterials that can make chemical connections with the neighboring hard and soft tissues. Several studies have examined the cellular and molecular responses to bioactive glasses to determine if they are suitable biomaterials for tissue engineering and regenerative medicine. In this regard, different ions and additives have been used recently to induce specific characteristics for selective cellular and molecular responses. This Review briefly describes foreign-body response mechanisms and the role of adsorbed proteins as the key players in starting interactions between cells and biomaterials. It then explains the physicochemical properties of the most common bioactive glasses, which have a significant impact on their cellular and molecular responses. It is expected that, with the development of novel strategies, the physiochemical properties of bioactive glasses can be engineered to precisely control proteins' adsorption and cellular functions after implantation.

Evaluation of Type III Tympanoplasty Using Cartilage Ossiculoplasty in Cholesteatoma Ear Surgery

This prospective observational study evaluates the role of tympanoplasty type III in cholesteatoma ear disease during same sitting with mastoid surgery using cartilage ossiculoplasty. Forty patients of chronic suppurative otitis media-cholesteatoma disease were recruited in the study. All the patients had extensive cholesteatoma and underwent canal wall down mastoid surgery. Tympanoplasty type III, that is, stapes columella, minor columella, or major columella, was done in each case along with mastoid surgery depending upon the remnant ossicular status. Conchal cartilage graft was used for ossiculoplasty along with temporalis fascia graft. Hearing and graft uptake results were evaluated at the end of 6 months postoperatively. Of the 40 cases, 3 cases failed tympanoplasty. In the remaining 37 cases, a statistically significant hearing improvement (air-bone gap of 33 dB) was observed postoperatively. Seven cases underwent stapes columella, 13 cases underwent minor columella, and 17 cases underwent major columella tympanoplasty type III. Although a hearing improvement was recorded in all these subgroups, a statistically significant hearing gain was present only in tympanoplasty type III minor columella cases thereby underlying the importance of intact stapes. However, it is difficult to discern the type of tympanoplasty type III that the patient would undergo prior to the ear surgery.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

Bioactive Glasses: Where Are We and Where Are We Going?

Bioactive glasses caused a revolution in healthcare and paved the way for modern biomaterial-driven regenerative medicine. The first 45S5 glass composition, invented by Larry Hench fifty years ago, was able to bond to living bone and to stimulate osteogenesis through the release of biologically-active ions. 45S5-based glass products have been successfully implanted in millions of patients worldwide, mainly to repair bone and dental defects and, over the years, many other bioactive glass compositions have been proposed for innovative biomedical applications, such as soft tissue repair and drug delivery. The full potential of bioactive glasses seems still yet to be fulfilled, and many of today's achievements were unthinkable when research began. As a result, the research involving bioactive glasses is highly stimulating and requires a cross-disciplinary collaboration among glass chemists, bioengineers, and clinicians. The present article provides a picture of the current clinical applications of bioactive glasses, and depicts six relevant challenges deserving to be tackled in the near future. We hope that this work can be useful to both early-stage researchers, who are moving with their first steps in the world of bioactive glasses, and experienced scientists, to stimulate discussion about future research and discover new applications for glass in medicine.

Outcome of Incus Interposition after Preservation in Soft Tissue

INTRODUCTION

The lenticular process of the incus succumbs to necrosis in chronic otitis media. Few researchers have addressed the issue of autograft incus preservation in the soft tissue of the tragus or mastoid cavity. Nonetheless, preservation of the incus in this method during the second stage of ossiculoplasty is a subject that is still up for debate. This study was carried out to demonstrate the hearing outcome after a modification of the incus interposition technique, which involved preserving it in the periauricular soft tissue.

MATERIALS AND METHODS

In the primary operations, tympanoplasty was performed with a postauricular incision. At the end of the surgery, a small pocket was created to preserve the incus beneath the temporalis fascia. The second stage of ossiculoplasty was performed 6 to 18 months after the primary operation. Post-operative pure tone audiometry was analyzed after at least 12 months and was considered successful after achieving an air-bone gap (ABG) within 20 dB.

RESULTS

In this paper, we analyzed 199 ears. The mean duration of follow up was 2.5 years. We achieved post-operative ABG within 20 dB in 157 patients (78.9% of patients).

CONCLUSION

This study indicates the efficacy and safety of incus interposition when it is preserved in the postauricular soft tissue.

[The prevalence of tympanosclerosis and the effectiveness of its surgical treatment]

The objective of the present study was to characterize the epidemiological variants of tympanosclerosis and the effectiveness of the surgical treatment of the patients presenting with this condition. We have undertaken the analysis of the results of 1965 surgical interventions on the patients suffering from different forms of chronic otitis media (COM) performed during the period from 2009 till 2014 with a view to determining the frequency of tympanosclerosis (TSC). In 542 cases, it proved possible to evaluate the intraoperative findings, stages and methods of reconstructive surgery, the anatomical and functional outcomes and effectiveness of the intervention. At present, the signs of tympanosclerosis are identified in 27.6% of the patients presenting with chronic otitis media including 88.7% and 11.3% suffering from the perforating and non-perforating forms of this pathology, respectively. In 74% of the cases its manifestations are diagnosed in the patients having the tubotympanic form of COM. In 53.3% of the patients TSC foci are responsible for the fixation of the ossicular chain whereas in 46.7% of the cases the auditory ossicles retain mobility. As many as 88.6% of the patients underwent the one-step surgical intervention, 10.7% were managed using two-step surgery, and 0.7% of the patients were given the three-stage treatment. Type I tympanoplasty was performed in 62% of the patients, type III tympanoplasty in 30.4%, and various types of stapedoplasty in 4.6% of the cases. The favourable anatomical and functional outcomes at the first stage of the surgical intervention with the use of the autogenous tissues for tympano- and ossiculoplastic surgery were achieved in 87.9% of the patients on the average (by means of the closure of the tympanic defect in 92.2% and by re-fixation of the selected elements of the ossicular chain in 17.3%of the cases). The anatomical and functional effectiveness of the second-stage surgical intervention was estimated at 93.1%.

Ossicular replacement prostheses from banked bone with ergonomic and functional geometry

This study shows the fabrication of innovative ossicular replacement prostheses (ORPs) based on banked cortical bone using computer numerically controlled ultraprecision micromilling, as a substantial improvement of "second generation" ORPs. Our aim is to combine optimal middle ear compatibility and surgical manageability in a single device, by releasing off-the-shelf homograft ORPs provided with the appealing features of synthetic ORPs, such as lightness, safety, measurement accuracy, surface decoration, and geometric plasticity. The new total ORP prototype was 13.1 ± 0.1 mg, leading to 81% weight reduction with respect to the previous model. Surface motifs of the head plate were applied to prevent slipping and migration after surgery, as shown by finite element modeling analysis. In addition, bone ORPs were provided with holed head plates to facilitate their surgical positioning while reducing their mass. A comparative measurement of acoustic responses of bone against synthetic partial ORPs in the 250-8000 Hz frequency range demonstrated their superior behavior. This study showed that banked compact bone can be optimally manufactured, eventually enabling the fabrication of light, standardized, and highly performant ORPs. The new bone ORPs may represent the ideal combination of biocompatibility and technology which can ultimately accomplish unmet otosurgical needs. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2495-2506, 2017.

Bony ankylosis of hydroxyapatite prostheses in the middle ear

BACKGROUND

Ossiculoplasty is a commonly performed middle ear procedure. Ossicular chain reconstruction (OCR) prostheses should be made of a biocompatible material; one such common material is hydroxyapatite (HA).

METHODS

2 patients were identified who had HA OCR prostheses which had fused to the middle ear bony structures. One HA OCR had fused to the fallopian canal in the tympanic segment and represented a management dilemma. The other fused to the scutum.

CONCLUSION

Bony ankylosis of a HA containing OCR prosthesis should be considered in the differential diagnosis of a failed ossiculoplasty. Depending on the location of the fusion, special measures may be needed to free the prosthesis from the underlying middle ear structures.

Stabilization of total ossicular replacement prosthesis using cartilage "shoe" graft

PURPOSE

We aimed to determine the effect of a cartilage shoe graft placed between the foot of the TORP and the stapes footplate on hearing improvement and long-term displacement rates.

MATERIALS AND METHODS

Patients who underwent TORP ossiculoplasty were divided into two groups. The TORP-alone group consisted of 32 patients who underwent TORP placement without cartilage shoe graft and served as the control group. The study group consisted of 56 patients who underwent placement of cartilage shoe graft together with TORP. Pure-tone audiometry was administered to all patients before and 3, 6 and 12 months after surgery. Indications for surgery, surgical technique used, postoperative complications, and air and bone conduction thresholds at 500, 1000, 2000 and 4000 Hz were recorded for all patients.

RESULTS

No significant difference in postoperative air-bone gaps was observed between the groups. The number of patients with air-bone gaps less than 20 dB was 14 (25%) in the study group and 8 (25%) in the control group. There was no significant difference in changes in air-bone gaps between the groups. Dislocation of the prosthesis was observed in 3 patients in the study group (5.3%) and 4 in the control group (12.5%). There was less dislocation of the prosthesis in the study group, but the difference was not statistically significant.

CONCLUSION

Placement of a cartilage graft between the footplate of the stapes and the foot of the prosthesis may have positive effects on long-term hearing improvement and rates of prosthesis displacement. Further research with larger patient numbers is needed to identify the advantages of shoe graft.

Cartilage palisades in type 3 tympanoplasty: functional and hearing results

To evaluate the functional and hearing outcomes using full thickness broad cartilage palisades for tympanic membrane reconstruction in type 3 tympanoplasty with titanium prostheses. The retrospective study performed at a tertiary referral institute included 30 patients with posterior mesotympanic retraction pockets or tympanic membrane perforations requiring tympanic membrane and type 3 ossicular reconstruction. Patients with disease extending beyond the aditus requiring canal wall down mastoidectomy were excluded. Disease removal from posterior mesotympanic and epitympanic recesses was confirmed using angled endoscopy and ossicular reconstruction was performed using titanium partial or total ossicular replacement prostheses. Tympanic membrane reconstruction was done, with or without attic reconstruction, using full thickness broad cartilage palisades harvested from the tragus with perichondrium attached laterally. Patients were assessed at 24 and 48 weeks for graft status and any evidence of implant extrusion. Hearing evaluation was done using subjective assessment and pure tone audiometry. In total, 27 out of 30 patients had intact and completely healed grafts at 48 weeks postoperatively (a success rate of 90 %) showing full union and epithelialization of palisades, and with three patients displaying small defects. The mean pure tone air bone gap pre- and postoperatively was 32.4 and 8.8 dB, respectively, with most patients reporting satisfactory postoperative hearing. No evidence of implant extrusion was found in the 48-week period. Tympanic membrane reconstruction using full thickness palisades of tragal cartilage provides good functional and hearing outcomes in type 3 tympanoplasty with titanium prostheses.

The use of bone cement for ossicular chain defects

Bone cement is a good and cheap option for some ossicular chain problems such as incudostapedial re-bridging. The purpose of this retrospective study is to evaluate the audiologic results after reconstruction of three different types of ossicular chain defects, using bone cement. Group 1 consists of 42 patients who underwent an ossiculoplasty using bone cement between the damaged long process of the incus and an intact stapes superstructure. Group 2 consists of 46 patients in which incus interposition between malleus and stapes superstructure was performed, using bone cement to fix the interposed incus. For group 3, consisting of 32 patients who had a present malleus, a defective long process of the incus and a missing stapes superstructure, a re-shaped incus was placed between the stapes footplate and the malleus and bone cement was again used as a fixator. Preoperative and postoperative pure-tone audiometric findings were obtained and hearing differences were assessed. The mean preoperative and postoperative air-bone gaps were 34.8 and 15.6, 35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3, respectively. There was a significant improvement in hearing outcomes in all the groups when comparing preoperative and postoperative mean air-bone gaps (p < 0.001). The postoperative air-bone gap was ≤20 dB in 76 % of patients in group 1, 64 % of patients in group 2, and 46 % of patients in group 3. Bone cement is an effective and cheap option for some ossicular chain problems such as incudostapedial re-bridging. It may also be used to fix the interposed incus to the stapes superstructure and/or malleus to avert displacement.

Passive and active middle ear implants

Besides eradication of chronic middle ear disease, the reconstruction of the sound conduction apparatus is a major goal of modern ear microsurgery. The material of choice in cases of partial ossicular replacement prosthesis is the autogenous ossicle. In the event of more extensive destruction of the ossicular chain diverse alloplastic materials, e.g. metals, ceramics, plastics or composits are used for total reconstruction. Their specialised role in conducting sound energy within a half-open implant bed sets high demands on the biocompatibility as well as the acoustic-mechanic properties of the prosthesis. Recently, sophisticated titanium middle ear implants allowing individual adaptation to anatomical variations are widely used for this procedure. However, despite modern developments, hearing restoration with passive implants often faces its limitations due to tubal-middle-ear dysfunction. Here, implantable hearing aids, successfully used in cases of sensorineural hearing loss, offer a promising alternative. This article reviews the actual state of affairs of passive and active middle ear implants.

Good Manufacturing Practices—Grade Preformed Ossicular Prostheses from Banked Bone via Computer Numerically Controlled Micromilling

Objectives:

The aim of this study was the fabrication of ossicular replacement prostheses (ORPs) from decellularized banked cortical bone via computer numerically controlled (CNC) ultraprecision micromilling, in order to obtain preformed clinical-grade tissue products, reproducing shape, size, and details perfectly comparable to those of synthetic devices.

Methods:

Banked femoral compact bone was used to fabricate partial and total ORPs via CNC micromilling according to Good Manufacturing Practices procedures. Drawings of ORPs with different shapes and sizes were uploaded to the computer interface, and different surface-finish parameters were tested. The obtained products underwent dimensional, weight, and surface characterizations. A histologic analysis was pursued to compare the bone matrix compactness of the produced ORPs to that of the ear ossicles.

Results:

Banked-bone ORPs were produced with high dimensional accuracy. Partial ORP weights averaged (±SD) 31.2 ± 0.6 mg, and total ORP weights averaged 69.3 ± 0.7 mg. The best-finish mode allowed microscale or nanoscale roughness free from machinery textures to be obtained. Finally, the histologic analysis confirmed that the extracellular matrix compactness of the produced ORPs was suitable for ossicular chain replacement.

Conclusions:

This study assesses the fabrication feasibility of novel banked-bone ORPs of extremely high dimensional accuracy. Such devices are aimed at combining the most favorable aspects of both synthetic (reproducibility, convenience, and biosafety) and biological replacements (total biocompatibility).

From natural bone grafts to tissue engineering therapeutics: Brainstorming on pharmaceutical formulative requirements and challenges

Tissue engineering is an emerging multidisciplinary field of investigation focused on the regeneration of diseased or injured tissues through the delivery of appropriate molecular and mechanical signals. Therefore, bone tissue engineering covers all the attempts to reestablish a normal physiology or to speed up healing of bone in all musculoskeletal disorders and injuries that are lashing modern societies. This article attempts to give a pharmaceutical perspective on the production of engineered man-made bone grafts that are described as implantable tissue engineering therapeutics, and to highlight the importance of understanding bone composition and structure, as well as osteogenesis and bone healing processes, to improve the design and development of such implants. In addition, special emphasis is given to pharmaceutical aspects that are frequently minimized, but that, instead, may be useful for formulation developments and in vitro/in vivo correlations.