Endoscopic versus microscopic ossiculoplasty: Does the functional outcome vary according to the type of osciculoplasty?

Abstract Objective: To compare functional outcome of microscopic and endoscopic approach regarding type of ossiculoplasty. Methods: In this retrospective study, cases who had undergone type-II and type-III tympanoplasty between February 2007 to September 2019 were divided into two groups according to the type of approach as microscopic and endoscopic. In cases with type-II reconstruction; Partial Ossicular chain Replacement Prosthesis (PORP), incus interposition and bone cement were used in order of frequency. Whereas in cases with type-III reconstruction, only Total Ossicular chain Replacement Prosthesis (TORP) was used. The average Air Bone Gap (ABG) was determined pre- and post-operatively for the calculation of Air Conductance Gain (ACG). The ACG, pre- and post-operative ABG values of each group were compared with regard to the type of ossiculoplasty. Results: A total of 79 cases consisting of 32 females and 47 males who had undergone type-II and type-III tympanoplasty were enrolled. No statistically significant difference between microscopic and endoscopic approach was found in terms of ACG (p = 0.42), pre-(p = 0.23) and postoperative ABG (p = 0.99). We did not find any significant difference in terms of ACG, pre- and postoperative ABG between two approaches for type-II and type-III reconstructions (p>0.05). Conclusions: According to the current study, endoscopic approach in type-II and type-III reconstruction is at least reliable as microscopic approach regarding functional outcome. Since both techniques have similar functional results, other factors (anatomic characteristics, habitude of the surgeon and duration of the surgery) should be considered when choosing the technique. Level of evidence: In the current paper we present a retrospective comparative study of two different approaches of a particular type of otologic surgery. Level of evidence corresponds to level III.

Reconstruction of the Long Process of the Incus by Use of Glass Ionomer Cement: Our Experience

Abstract Introduction Chronic suppurative otitis media is one of the most common causes of reversible conductive hearing loss which can lead to necrosis of the ossicles. The incus, especially its long process, is the most common ossicle affected. Objectives The present study aims to assess the use of glass ionomer cement for the reconstruction of the long process of the incus. Methods The present study was conducted on 27 patients with chronic suppurative otitis media with central perforation with dry and quiescent ears with an eroded long process of the incus submitted to tympanoplasty. The audiological evaluations were done on all patients, including preoperative and postoperative evaluation of the airbone gap; the average pure tone threshold was done 6 months postoperatively. Results The average air pure tone threshold was 42.8 dB preoperatively and 22.5 dB postoperatively. The postoperative air pure tone thresholds were significantly smaller than the preoperative values (p < 0.01). The air-bone gap was 30.5 dB at 500 Hz, 31.6 dB at 1 KHz, and 24.1 dB at 2 kHz preoperatively, and 7.7 dB at 500 Hz, 7.2 dB at 1 KHz, and 7.1 dB at 2 kHz postoperatively at the end of 6 months of follow-up. There were significant hearing gains in the air-bone gap (p < 0.001). Conclusion Glass ionomer cement is a useful and effective material for bridging the defect of the long process of the incus.

Surgical Management of Retraction Pockets: Does Mastoidectomy have a Role?

Abstract Introduction Retraction pocket is a condition in which the eardrum lies deeper within the middle ear. Its management has no consensus in literature. Objective To assess the role of mastoidectomy in the management of retraction pockets added to a tympanoplasty. Methods Prospective study of patients with retraction pocket and referred to surgery. The patients were randomly assigned to two groups: one managed with tympanoplasty and mastoidectomy and the other group with tympanoplasty only. The minimum follow-up considered was 12 months. The outcomes were: integrity of eardrum, recurrence, and hearing status. Results This study included 43 patients. In 24 cases retraction occurred in the posterior half of the eardrum, and in 19 patients there was clinical evidence of ossicular interruption. The two groups of treatment were composed by: 21 patients that underwent tympanoplasty with mastoidectomy and 22 patients had only tympanoplasty. One case of the first group had a recurrence. In 32 cases patients follow up was longer than 48 months. The average air-bone gap changed from 22.1 dB to 5 dB. The percentage of air-bone gap improvement was assessed at 60 % in those patients treated with mastoidectomy, and 64.3 % in those without it (p > 0.5). Conclusion Tympanoplasty and ossiculoplasty should be considered to treat atelectatic middle ear and ossicular chain interruption. Mastoidectomy as a way to increase air volume in the ear seems to be a paradox; it does not add favorable prognostic factor to management of retraction pockets.

Ossicular chain reconstruction in chronic otitis media: hearing results and analysis of prognostic factors / Reconstrução da cadeia ossicular na otite média crônica: resultados auditivos e análise de fatores prognósticos

Abstract Introduction The goal of ossiculoplasty is to improve hearing and the success of this procedure depends on several factors. Objective Analyze the hearing results in patients with chronic otitis media undergoing ossicular chain reconstruction, as well as predictive factors for successful surgery. Methods Charts of patients undergoing ossiculoplasty between 2006 and 2016 were reviewed. Sixty-eight patients were included, totaling 72 ears. The following data was analyzed: gender, age, smoking status, laterality, pathology, audiometric exams, type of surgery, previous surgery, characteristics of the middle ear, otorrhea and ossicular chain status. Patients were also classified according to two indices: middle ear risk index and ossiculoplasty outcome parameter staging. The results were evaluated by comparing the air-bone gap before and after surgery. The success of reconstruction was defined as air-bone gap ≤20 dB and the improvement of speech reception Thresholds, calculated through the mean frequencies 0.5, 1, 2 and 3 kHz. Results Reconstruction success rate was 61%. The mean preoperative air bone gap was 34.63 dB and decreased to 17.26 dB after surgery. There was a correlation between low risk in middle ear risk index and ossiculoplasty outcome parameter staging indices with postoperative success. The most frequently eroded ossicle was the incus and the type of prosthesis most used was tragal cartilage. In the patients without incus, we achieved success in 74.2% of the surgeries. In the absence of the stapes, the success rate decreased to 63.3%. In the absence of the malleus, 85% of the patients had and air bone gap ≤20 dB. Conclusion We achieved good audiometric outcomes in ossiculoplasty and the results are comparable to other centers. Ossicle status influenced postoperative results, especially in the presence of stapes. We also concluded that the indexes analyzed may help to predict the success of the surgery.

Resumo Introdução A ossiculoplastia tem como objetivo a melhoria da audição e o sucesso desse procedimento depende de diversos fatores. Objetivo Analisar os resultados auditivos em pacientes com otite média crônica submetidos a reconstrução da cadeia ossicular, bem como os fatores preditivos de sucesso cirúrgico. Método Prontuários de pacientes submetidos a ossiculoplastia entre 2006 e 2016 foram revistos. Sessenta e oito pacientes foram incluídos, total de 72 orelhas. Os seguintes dados foram analisados: sexo, idade, tabagismo, lateralidade, doença, exames audiométricos, tipo de cirurgia, cirurgia prévia, características da orelha média, otorreia e estado da cadeia ossicular. Os pacientes também foram classificados de acordo com dois índices: índice de risco da orelha média e estadiamento do parâmetro de desfecho da ossiculoplastia. Os resultados foram avaliados comparando o gap aéreo-ósseo antes e após a cirurgia. O sucesso da reconstrução foi definido como gap aéreo-ósseo ≤ 20 dB e a melhoria dos limiares de recepção de fala, calculados pelas frequências médias de 0,5, 1, 2 e 3 kHz. Resultados A taxa de sucesso da reconstrução foi de 61%. O gap aéreo-ósseo pré-operatório médio foi de 34,63 dB e diminuiu para 17,26 dB após a cirurgia. Houve correlação entre baixo risco no índice de risco para orelha média e os índices de estadiamento do parâmetro de desfecho da ossiculoplastia com sucesso pós-operatório. O ossículo com erosão mais frequente foi a bigorna e o tipo de prótese mais utilizada foi a cartilagem tragal. Nos pacientes sem bigorna o sucesso foi alcançado em 74,2% das cirurgias. Na ausência do estribo, a taxa de sucesso diminuiu para 63,3%. Na ausência do martelo, 85% dos pacientes apresentaram gap aéreo-ósseo ≤ 20 dB. Conclusão Melhora significativa da audição foi observada em pacientes submetidos à ossiculoplastia, os resultados foram comparáveis aos de outros centros. O "status" dos ossículos influenciou os resultados pós-operatórios, principalmente a presença do estribo. Também concluímos que os índices analisados podem ajudar a prever o sucesso da cirurgia.

​Post-operative Auditory Gain in Patients Undergoing Intact Canal Wall Mastoidectomy and Ossiculoplasty with Primary Malleus Transposition (Rotation) Ossiculoplasty

Background: The absence of the long process of the incus with or without the absence of the stapes superstructure accountsfor >80% of the ossicular deformities encountered during surgery for chronic suppurative otitis media. Instead of using variousinterposing prosthesis in vogue to simplify ossicular reconstruction, to reduce time and cost, and to improve functional outcomesby retaining the catenary lever function of the handle of malleus, malleus is used by repositioning it. The present study evaluatesauditory gain after 1-year post-operative follow-up.Aim of the Study: This study aims to conduct audiological evaluation of patients who underwent malleus repositioningossiculoplasty over a period of 36 months.Materials and Methods: A total of 56 patients undergoing cortical mastoidectomy and ossiculoplasty in a tertiary care hospital inKerala over a period of 3 years were included in the study. Pure tone audiometry done, pure tone average (PTA) was calculatedfor the speech frequencies (500 HZ, 1000 HZ, and 2000 HZ). Air-bone gap was calculated and tabulated. Ossicular statusduring surgery was typed according to Austin[17] and Kartush[18] classification.Procedure: Malleus transposition and assembly with stapes were done. All the data were tabulated and analyzed usingstandard statistical methods.Observations and Results: Among 56 patients, 29 (51.78%) were males and 27 (48.21%) were females. The mean auditorygain in PTA among all the operated patients was 24.65 ± 1.20 dB. Mean air-bone gap closure was 26.30 ± 3.10 dB.Conclusions: Malleus relocation is a safe and efficient technique for ossicular reconstruction. The ideal position of the relocatedmalleus allows easier and more stable placement of middle ear ossicular grafts or prostheses. It helps to reduce operative timeand cost and to improve functional outcomes by retaining the catenary lever function of the handle of malleus.

Use of incus as an interposition graft in ossiculoplasty for type IIb tympanoplasty.

Background: In cases of chronic suppurative otitis media, the most common cause for the discontinuity in the ossicular chain is erosion of lenticular or long process of incus. To study hearing results, sequel and complications of using autologous incus as interposition graft in type IIb osiculoplasty. Methods: We studied 30 patients who required ossiculoplasty using autologous incus. The pre-operative audiograms were done. Post operatively patients were followed up to 2 years during which complete otological examination with audiogram was done. Results: According to the American Academy of Otolaryngology-Head and Neck Surgery guidelines, a successful hearing result is the one with post-operative air-bone gap of 20 decibels or less. Hence, by this standard our success rate is 77 percent and in all of our patients we have air-bone gap closure to below 30 decibles. Average closure in air-bone gap (gain) in our patients is 25.9 decibles with average pre-operative and post-operative air-bone gap being 47.70 decibles and 16.9 decibles there was no extrusion of incus. 3 patients had residual perforation and 2 patients had retracted grafts. All the patients with retracted grafts or residual perforation had oedematous middle ear mucosa and Eustachian tube dysfunction and high MER index. Conclusions: Autologous incus is an excellent interposition graft for ossiculoplasty. There is no risk of transmission of disease and no extra cost involved. Higher values of Middle Ear Risk Index, oedematous middle ear mucosa and Eustachian tube dysfunction are poor prognostic factor for success of ossiculoplasty.

Surgical management of middle ear cholesteatoma and reconstruction at the same time / Manejo quirúrgico del colesteatoma del oído medio y reconstrucción en un solo tiempo

Introduction: In the surgical management of cholesteatoma, one can opt for a closed technique (simple mastoidectomy) or open surgery (radical mastoidectomy). Open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery combines the advantages of both techniques, namely, adequate surgical exposure, eradication of cholesteatoma, and anatomical reconstruction of the middle ear structures. Objective: To evaluate the surgical results in the management of cholesteatoma through the technique of open mastoidectomy with reconstruction of the posterior wall and the middle ear in a single surgery. Methods: Prospective analytical observational study conducted between 2009 and 2012 with patients undergoing this surgical technique in the Hospital Universitario del Valle [University Hospital of Valle], performing preoperative clinical monitoring and quarterly postoperative tomography with previous assessments of hearing and pre- and postoperative audiometry. Results: Forty-five patients were studied. Mean postoperative follow-up was 28 months. Surgical success was achieved in 93.3% of patients, as measured by clinical and radiological follow-up. Hearing preservation was found after reconstruction of the hearing mechanism, based on measured audiometry, i.e., pure-tone average (PTA), using the statistical test for paired samples between preoperative and postoperative PTA. (95%CI -1.47-12.15). Residual cholesteatoma was present in 6.6% of cases; three to four times lower than the rate reported in the literature. Conclusions: This type of surgery can be considered a successful technique in the treatment of cholesteatoma in selected cases.

Introducción: El manejo del colesteatoma es quirúrgico. Se puede optar por una técnica cerrada (mastoidectomía simple) o técnica abierta (mastoidectomía radical). La mastoidectomía abierta con reconstrucción de la pared posterosuperior y reconstrucción del oído medio en un solo tiempo quirúrgico reúne las bondades de ambas técnicas: una adecuada exposición quirúrgica, erradicación del colesteatoma y reconstrucción anatómica de las estructuras del oído medio. Objetivo: Evaluar los resultados quirúrgicos en el manejo del colesteatoma con la técnica de mastoidectomía abierta con reconstrucción de la pared posterosuperior y el oído medio en un solo tiempo quirúrgico. Métodos: Estudio analítico observacional prospectivo realizado entre 2009-2012 con pacientes sometidos a esta técnica quirúrgica en el Hospital Universitario del Valle, realizándose un seguimiento clínico preoperatorio y postoperatorio trimestral, y evaluaciones previas con tomografía de oído y audiometría pre y postoperatoria. Resultados: Se estudiaron 45 pacientes. La media de seguimiento postoperatorio fue de 28 meses. Se alcanzó éxito quirúrgico en el 93.3% de los pacientes medidos por el seguimiento clínico y radiológico. Se encontró preservación de la audición después de la reconstrucción del mecanismo auditivo, medido con audiometría basada en el promedio tonal auditivo, mediante la prueba estadística para muestras pareadas entre la PTA preoperatoria y postoperatoria (IC95% -1.47-12.15). Se presentó colesteatoma residual en el 6.6%, tres a cuatro veces menor al reportado en la literatura. Conclusion: Este tipo de cirugía se puede considerar una técnica exitosa en el tratamiento de colesteatoma en casos seleccionados.

Morphometry of Human Fetal Ear Ossicles: A Human Cadaveric Study.

Aim: Most of the studies were on adult ossicles. In this present work, the aim is to study the morphometry of the ear ossicles in the human fetuses and use of the study in medical applications. Materials and Methods: This study is performed on 100 sets of middle ear ossicles, each set consisting of Malleus, Incus and Stapes, which were taken from 50 fetal cadavers left and right sides of both. Result: The morphometric data of malleus and incus in their length are 5.21mm and 4.85mm, the height of the stapes is 2.52mm. The indices of malleus, incus and stapes are 51.28, 67.54 and 88.12mm. Conclusion: The study of morphometry in the ear ossicles of the human fetal cadavers can be useful for prosthetic surgical reconstruction.

A comparative study of ossiculoplasty by using various graft materials.

Introduction: The use of ossicular graft material in the ossicular chain reconstruction has significantly improved the results in the hearing after the tympanoplasty and tympanomastoid surgery for the chronic otitis media. The ossicular chain transmits the vibration of tympanic membrane to the inner ear with impedance matching function failure to which results in > 50dB hearing loss of conductive variety. Material and Method: A Prospective study of 76 patients who underwent ossiculoplasty was done in the department of ENT & Head and Neck Surgery , Sir T. Hospital ,Bhavnagar, Gujarat between May 2007 to June 2009.Only patients with conductive hearing loss were included in study and underwent ossiculoplasty with using various graft material and assessment done by post operative closure of air bone gap. Most available graft material used are auto graft, cartilage and bone, and various biosynthetic materials like gold,Teflon,plastipore,titanium etc. Results: Majority of patients are middle age group with moderate conductive hearing loss. The comparison of hearing improvement between various graft materials at 2 month and 5 months post operatively were studied in the relation to the postoperative air bone gap closure shows that auto graft and gold prosthesis are cost effective with comparable results obtained as by expensive titanium and plastipore prosthesis. Discussion & Conclusion: The ossiculoplasty materials produce varying results. The titanium and plastipore are rather expensive for the Indian patients , particularly for the government hospital poor class patients. We have tried to evaluate the results using the economical and readily available graft materials like cartilage, bone and gold prosthesis for ossiculoplasty and compared its results with costly plastipore and titanium prosthesis. prosthesis

Audiologic Results of Ossiculoplasty Using Malleus Footplate Assembly: The Comparison between Autologous Incus and Hydroxyapatite

BACKGROUND AND OBJECTIVES: Absence of incus is one of the most common ossicular anomalies and also frequently found in chronic otitis media or chornic otitis media with cholesteatoma. Ossiculoplasty with malleus footplate assembly (MFA) can be an excellent option in the above situations. We reviewed our procedures and evaluated the hearing results of ossiculoplasty using the MFA. SUBJECTS AND METHODS: This study retrospectively reviews a series of 32 patients who underwent MFA ossiculoplasty between September 2001 and March 2010 in an academic tertiary referral center. The autologous incus or hydroxyapatite (HA) was used as materials for reconstruction. RESULTS: Thirteen of 32 patients (40.6%) had ossicular chain anomaly, 9 patients (28.1%) had congenital cholesteatoma and 8 patients (25.0%) had chronic otitis media with cholesteatoma and 2 patients (6.3%) had chronic otitis media. The patients with ossicular chain ano-maly showed the greatest air-bone gap (ABG) closure. Overall, postoperative ABG was 17.7+/-11.7 dB at postoperative 6 months and 19.7+/-14.3 dB at postoperative 1 year, compared with preoperative ABG of 37.9+/-9.3 dB. There was no statistical difference of ABG at postoperative 12 months, 24 months between MFA using incus (n=17) and HA (n=15)(p=0.300, and p=0.563). There was no meaningful difference of postoperative ABG between the patients with combined mastoidectomy (n=10) and those without mastoidecmoy (n=22)(p=0.555). No extrusions occurred. CONCLUSIONS: MFA can be an effective option in the case of absent incus expecting good postoperative hearing results.

Hearing Results of Tympanoplasties in 175 Patients with Chronic Otitis Media / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To report the hearing results of tympanoplasty for chronic otitis media with or without cholesteatoma. SUBJECTS AND METHOD: One hundred and seventy-five patients presenting chronic otitis media with or without cholesteatoma were involved in a retrospective study. Tympanoplasties were performed by the same surgeon over a 30-month period. Audiometric results were reviewed. Audiometric results according to the following techniques were measured: tympanoplasty type 1 (T1), interposition (Si) and/or columella (Sc) over stapedial head, and interposition or columella (Fic) over footplate. The follow-up period ranged from 6 to 32 months. Audiological parameters using the average of four frequencies were assessed pre- and post-operatively. RESULTS: Overall hearing results showed postoperative air-bone gaps (ABG) < or =20 dB in 69% of cases. ABG was closed to within 20 dB in 89% for T1, 67% for Sc, 58% for Si, and 30% for Fic. ABG was closed to within 30 dB in 95% for T1, 67% for Sc, 83% for Si, and 70% for Fic. There was a significant improvement between preoperative and postoperative ABGs. The overall improvement of the air-bone gap was 8+/-13 dB. There was no significant functional difference between different surgical techniques. CONCLUSION: Our hearing results after tympanoplasties were similar to those from other studies. The hearing results observed in this study confirmed that successful results can be obtained by applying the current principles and approach to ossicular reconstruction.

Assessment on the results of hearing improvement achieved through surgery, with partial ossicular reconstruction prothesis using bioceramic and autograft bone in patients with chronic otitis media

Background: In Viet Nam, chronic otitis media is a relatively common disease, accounting for 2-4% of the population. The most common sequalae of chronic otitis media is hearing deficiency. One of the most severe hearing deficiency causes of chronic otitis media is ossicular damages. In developed countries, the partial ossicular reconstruction prosthesis by various materials is relatively common.The partial ossicular reconstruction prosthesis is still limited in Viet Nam.Objectives: To assess the results of hearing improvement after the surgery of partial ossicular reconstruction prothesis and compare the effects of bioceramic and autograft bone. Subjects and method: A study was performed on 135 patients with chronic otitis media who were submitted to partial ossicular reconstruction prostheses with bioceramic and autograft bone at the National Ear Nose Throat Hospital. This was a prospective study. Results: PTA was 54.5 +/- 12.6 dB for four frequencies (0.5, 1, 2, and 3 kHz) in pre-operation, compared to 33.8 +/- 12.8 dB at 6 months after the operation. The ABG improvements for four frequencies and PTA with bioceramic and autograft bone were 18.28 +/- 11.85 dB, 17.99 +/- 10.42 dB, and 18.46 +/- 12.26 dB, 18.81 +/- 11.56 dB, respectively. Conclusions: The hearing levels and ABG were better in post-operation than those in pre-operation. The improvements of hearing levels after the ossiculoplasty using bioceramics was similar to those using autograft bone.

Post-Traumatic Conductive Hearing Loss / 대한이비인후과학회지

BACKGROUND: Injuries to the ear and temporal bone are ubiquitous, and proper early management is crucial. Violent closed-head injuries, particularly if the temporal bone is fractured, also commonly cause ossicular chain disruption. Significant ossicular chain damage usually produces a conductive hearing loss. Hearing loss due to ossicular disruption can be improved by surgery. OBJECTIVES: The cause, incidence, position of ossicular disruption, method of reconstruction and postopeartive results were studied in 23 cases with post-traumatic conductive hearing loss. MATERIALS AND METHODS: Over the past 5 years, a total of 23 patients undergoing exploratory tympanotomy with ossiculoplasty were investigated retrospectively. RESULTS: The male to female ratio was 3.6:1. The most common cause was longitudinal temporal bone fracture(87%) and the most common finding of ossicular injury was incudostapedial separation with fibrous band formation(65%). The type III tympanoplasty using autologous incus was the most common surgical reconstruction for hearing gain(78%). In 78% of the cases, hearing was restored within 10dB of postoperative air-bone gap in the speech range. CONCLUSION: Cases of post-traumatic conductive hearing loss following trauma, in which it is difficult to confirm the presence of pathological lesions by conventional hearing and imaging tests, are occasionally encountered, necessitating exploratory surgery. As it is possible to improve hearing loss significantly in most of these cases by performing a reconstruction of the ossicular chain, exploratory surgery shoud be extensively recommended for post-traumatic conductive hearing loss.

A Clinical Study of the Ossiculoplasty in the Chronic Otitis Media / 대한이비인후과학회지

Reconstruction of the middle ear conduction mechanism continues to pose a significant challenge to the otolaryngologist. To investigate the suitable material and surgical method to get optimal hearing gain in the middle ear surgery, two hundred and twenty-two cases of different kind of ossiculoplasty in patients suffering from chronic middle ear disease at the Severance hospital and Soh's ENT clinic from January 1989 to December 1994 were included in this retrospective study and we reviewed the previous reports about the ossiculoplasty at the department of otolaryngology, Yonsei University College of Medicine from January 1981 to December 1988. A successful hearing gain was defined as a post-operative air-bone gap of

A Clinical Study of the Ossiculoplasty in the Chronic Otitis Media with Cholesteatoma / 대한이비인후과학회지

The purpose of this study is to investigate the middle ear condition, surgical method and suitable material for optimal hearing gain in the middle ear cholesteatoma surgery. One thousand and thirty six cases of ossiculoplasty in patients suffering from chronic otitis media with cholesteatoma at the university hospitals in Korea from November 1984 to July 1996 were included in this retrospective study. Sixty two per cent of cases were successful according to the success criterion of a post-operative air-bone gap of >or= 30dB, 33.4 percent according to >or= 20dB, and 12.6 percent according to >or= 10dB. Good prognostic factors in the middle ear condition were healthy middle ear mucosa, patent eustachian tube orifice, and presence of superstructure of stapes. Two staged ossiculoplasty showed better result than one staged ossiculoplasty. There was no statistical difference of the hearing improvement between the open cavity mastoidectomy and the intact canal wall mastoidectomy techniques. Favorable materials for ossicular reconstruction were in decending order, polycel, ossicle, cartilage, and hydroxylapatite.