Primary malleus fixation: diagnosis and treatment

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Histopathology of the Incudomalleolar Joint in Cases of "Indeterminate" Presbycusis

LEVEL OF EVIDENCE

Retrospective study.

Isolated malleus fixation: A pediatric case series

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Congenital Familial Fixation of the Malleus

We present a familial association of radiographically and surgically demonstrated mallear fixation with concurrent stapedial abnormality and dehiscence of the facial nerve in a father and son, including history, physical findings, surgical findings, radiologic analyses, and a literature review. A 12-year-old boy presented with long-term left-sided conductive hearing loss, and was found to have mallear fixation and a dehiscent facial nerve on a computed tomographic (CT) scan of the temporal bone. Release of the malleus was performed at surgery, revealing hypermobility of the remaining ossicular chain. A repeat CT scan of the temporal bone showed successful release of the mallear head. The patient's father later presented with bilateral hearing loss, and a CT scan of the temporal bones showed bilateral osseous fixation of the mallear head to the tegmen and bilateral facial nerve dehiscences. He underwent right middle ear exploration, but release of the malleus was not performed because of the risk to the dehiscent facial nerve. The stapes crurae were found to be filiform at surgery. This is the first reported familial association of mallear fixation. Mallear fixation with facial nerve dehiscence and an abnormal stapes occurring in a parent and his child is interesting embryologically, and suggests that these anomalies may be genetically linked.

Surgery of idiopathic malleus fixation

OBJECTIVE

To describe and compare 2 different surgical techniques used in treatment of malleus fixation syndrome.

STUDY DESIGN

A retrospective study including 24 patients (25 ears). In 11 of them, the attical fixation was removed via a transmastoid approach without disruption of the ossicular chain. In 14 patients, an ossiculoplasty was performed via a transcanal approach; the malleus head was removed with the incus, and the ossicular chain was reconstructed either by incus interposition (9 cases) or by using a partial ossicular replacement prosthesis (5 cases). The hearing results were analyzed according to the Committee on Hearing and Equilibrium Guidelines of the American Academy of Otolaryngology.

RESULTS

In the group of attical fixation removed via a transmastoid approach, the preoperative air-bone gap (ABG) attained 25.2 dB, and the postoperative ABG at 1 year followup was 9.1 dB. In the group of ossiculoplasty, the average preoperative ABG reached 26.5 dB, and the postoperative ABG at 1-year follow-up was 8.2 dB.

CONCLUSION

There was no statistically significant difference (p = 0.79) between the 2 surgical techniques used to improve hearing in malleus head fixation.

[Verification of malleus head fixation : computed tomography as diagnosis standard]

Malleus head fixation and otosclerosis causing conductive hearing loss are often difficult to differentiate by clinical features. Up to now exploratory anterior tympanotomy was necessary to distinguish these pathologies. The case of a 22-year-old male suffering from conductive hearing loss of the right ear is presented. Otosclerosis was suspected and high-resolution CT scanning of the petrous bone was performed. The diagnosis was confirmed radiologically by the detection of an isolated malleus head fixation. Instead of explorative anterior tympanotomy, radiological and audiological controls were combined for the follow-up.

Fixation and detachment of superior and anterior malleolar ligaments in human middle ear: experiment and modeling

The aim of this study is to investigate the function of the superior malleolar ligament (SML) and the anterior malleolar ligament (AML) in human middle ear for sound transmission through simulations of fixation and detachment of these ligaments in human temporal bones and a finite element (FE) ear model. Two laser vibrometers were used to measure the vibrations of the tympanic membrane (TM) and stapes footplate. A 3-D FE ear model was used to predict the transfer function of the middle ear with ligament fixation and detachment. The results demonstrate that fixations and detachments of the SML and AML had different effects on TM and stapes footplate movements. Fixation of the SML resulted in a reduction of displacement of the TM (umbo) and the footplate at low frequencies (f<1000 Hz), but also caused a shift of displacement peak to higher frequencies. Fixation of both SML and AML caused a reduction of 15 dB at umbo or stapes at low frequencies. Detachment of the SML had almost no effect on TM and footplate mobility, but AML detachment had a minor effect on TM and footplate movement. The FE model was able to predict the effects of SML and AML fixation and detachment.

Otosclerosis: etiopathogenesis and histopathology

Otosclerosis is a disease of the bony labyrinth manifesting clinically as a progressive conductive hearing loss, a mixed-type hearing loss, or a sensorineural hearing loss. The age of onset of the hearing loss caused by otosclerosis is principally between 15 and 40 years. Although histopathological inner ear changes due to otosclerosis have been very well documented, the true etiopathogenesis of the disease has yet to be described despite intensive research. Both genetic and environmental factors have been implicated, however.

A new approach for malleus/incus fixation: no prosthesis necessary

OBJECTIVE

To describe a novel approach to manage malleus/incus fixation.

STUDY DESIGN

Retrospective review of 363 patients with conductive hearing loss operated on since 1996.

SETTING

Academic tertiary referral center.

PATIENTS

Three hundred sixty-three patients with conductive hearing loss, an intact tympanic membrane, and without history for chronic infection underwent middle ear exploration. Three hundred forty-three had otosclerosis and underwent laser stapedotomy; the remaining 20 patients had laser release of their malleus/incus fixation.

INTERVENTION

Twenty patients are presented in this paper. Nineteen patients were diagnosed with malleus fixation before surgery. One patient had a total perforation and mobility of the ossicular chain was not verified preoperatively. This patient was, intraoperatively, noted to have complete ossicular fixation. Conductive hearing loss was identified using audiometry and tuning forks. Nineteen of the 20 patients had the diagnosis confirmed using micropneumotoscopy and noting immobility of the malleus. A transcanal approach was used, and the malleus/incus fixation was released using a laser. This space was expanded upon using a drill. A 1.5-2.0 mm space was created where the ossicular fixation existed, thereby reducing the likelihood of refixation.

MAIN OUTCOME MEASURE

Audiometric studies before and after intervention were compared. One to seven years of follow up are provided.

RESULTS

Preoperative air-bone gaps ranged from 18 dB to 51 dB and averaged 33 dB. Postoperative air-bone gaps ranged from 1-36 dB and averaged 13 dB. No patients have experienced refixation. There were two complications: one perforation requiring a tympanoplasty and one patient sustaining a 20 dB high-frequency sensorineural loss, most likely secondary to inadvertent drill contact to the ossicular chain.

CONCLUSION

When fixation of the malleus and/or incus is found, treatment options exist. A common technique involves removal of the incus and head of the malleus and reconstruction with an incus interposition or a partial ossicular prosthesis. Another technique proposed by the senior author (M.D.S.) is maintenance of the normal anatomy and use of the potassium-titanyl-phosphate laser and drill to free the ossicles and widen the epitympanum. This series shows successful closure of the air-bone gap with this technique.

Fixation of the anterior mallear ligament: diagnosis and consequences for hearing results in stapes surgery

In the search for possible causes of unfavorable results after stapes surgery, the study reported here focused on the anterior mallear ligament, since it has been previously reported that partial mallear fixation (PMF) leads to functional failure in 38% of cases of stapes revision surgery. The aims of the study were to identify effective methods for the diagnosis of PMF and experimentally assess the conductive hearing loss that results from PMF. The study included vibration amplitude measurements of the ossicles by laser Doppler interferometry (LDI) in 19 patients and 5 fresh human temporal bone (TB) specimens. Analysis of their dynamic behavior was performed by finite element modeling (FEM). Similar, significant changes of manubrium vibration patterns for PMF were found by FEM calculations, in TB experiments, and in patients. We could identify PMF either before operation, using LDI, or during operation, by manual palpation. In the TB experiments and FEM calculations, the attenuation of the stapes displacement due to an isolated PMF was approximately 10 dB and frequency-dependent. Untreated anterior mallear ligament fixation produced a persistent air-bone gap of approximately 10 dB after stapedioplasty.

The anterior and superior malleal ligaments in otosclerosis: a histopathologic observation

HYPOTHESIS

The aim of this study was to assess, in otosclerosis, whether the anterior and superior malleal ligaments show histologic changes that can lead to reduced malleal mobility and eventual fixation, and also to evaluate whether these changes are related to the degree of histologic otosclerosis.

BACKGROUND

Fixation of the malleus seems to be one of the most controversial clinical entities in the acquired condition of otosclerosis. It has even been postulated that persistent conductive deafness, or progression of conductive deafness after initial improvement after stapedotomy, could be due to unsuspected malleus fixation.

METHODS

Fifty eight temporal bones with known otosclerosis and 43 normal temporal bones were selected. In addition, 10 temporal bones of fetuses and children were also studied. Otosclerosis of the footplate and otic capsule was graded as none, mild, moderate, and severe. The histologic changes in the ligaments also were graded from none to severe.

RESULTS

The median ages of patients in the otosclerotic and normal groups were 62 and 60 years, respectively. In the anterior malleal ligament of the otosclerotic bones, 10% mild (+), 60% moderate (++), and 30% severe (+++) degrees of hyalinization were observed. In the anterior malleal ligament of the nonotosclerotic bones, 14% showed no hyalinization, 24% had only a tinge of hyalinization (minimal), 51% had mild (+) hyalinization, and 11% had moderate (++) hyalinization. Superior ligament hyalinization appears to be related to the severity of anterior ligament hyalinization. The severity of otosclerosis in the footplate or the otic capsule did not appear to be related to the severity of hyalinization.

CONCLUSION

From this study, it is apparent that otosclerotic bones have a significantly high incidence of hyalinization of the anterior malleal ligament. This seems to be related to the duration rather than the severity of otosclerosis. It is important to properly evaluate malleal mobility during all stapes surgery.

Malleus fixation: clinical and histopathologic findings

The goals of this study were to review important clinical and histopathologic features of malleus fixation. Ten clinical cases and 10 histopathologic cases of malleus fixation were identified. For the clinical cases, preoperative clinical data, surgical findings, and preoperative and postoperative audiometric findings were reviewed. Ninety percent of the clinical cases achieved significant reduction of the air-bone gap after operation. Two thirds of these cases had an air-bone gap of 10 dB or less, and the remainder had air-bone gaps between 20 and 28 dB after operation. For the temporal bone cases, clinical data, histopathologic findings, and other otologic diagnoses were reviewed. Malleus fixation can be idiopathic or a result of trauma, chronic otitis media, or developmental anomalies. It is a cause of hearing loss that is likely to be more common than the number of diagnoses would indicate. Certain audiometric findings may lead one to suspect the diagnosis. The surgical approach used depends on the individual anatomy, and surgery is usually highly effective in improving hearing.

Evaluation of eardrum laser doppler interferometry as a diagnostic tool

OBJECTIVES

Laser Doppler interferometry (LDI) of the eardrum allows noncontact optical analysis of its vibrations in response to sound. Although LDI has been widely used in research, it has not yet been introduced into clinical practice as an adjunctive test for otological workup. The aim of this study was to evaluate LDI as a diagnostic tool in the clinical sphere.

STUDY DESIGN

Prospective.

METHODS

A measurement system was developed based on a commercially available scanning He-Ne laser Doppler interferometer. The study included 129 eardrums of 79 subjects that were divided into 3 groups: 1) normal subjects and 2) patients with sensorineural and 3) conductive hearing loss (HL). All the patients suffering from conductive HL underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to the subgroups malleus fixation, incus luxation, and stapes fixation.

RESULTS

The modified LDI system allowed bilateral evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural HL were found. However, it was possible to distinguish between normal subjects and patients with conductive HL. Furthermore, the system had the ability to differentiate between various middle ear diseases. These groups differed statistically significantly in terms of manubrium vibration amplitude and resonance frequency. In malleus fixation significant differences in tympanic membrane movement patterns were found.

CONCLUSIONS

Our LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain.