Partial vs. total footplate removal in stapedectomy: a comparative study.

A comparative study of the postoperative stapedectomy results for 264 ears with partial footplate removal (PFR) and for 106 ears with total footplate removal (TFR) was performed with reference to decibel gain in three specific frequency ranges, air-bone gap closure, speech threshold and speech discrimination and incidence of postoperative complications. The data confirm a small but consistently greater decibel gain for PFR cases in the 2000-8000 Hz range; the decibel gain in the 250-1000 Hz range is virtually identical for PFR and TFR cases. Air-bone gap closure and speech results also indicate a somewhat better average result in PFR as compared TFR cases. The permanency of speech discrimination results is examined.

Adenoma of the middle ear.

Benign adenoma of the middle ear emerged as a distinct entity following a review of 20 cases as reported from the Armed Forces Institute of Pathology in 1976. We report 4 additional cases and note that the pathologic diagnosis is not so clear cut. Benign primary adenoma may be confused with adenocarcinoma, ceruminoma, and glomus tumor. The otologic surgeon must take a hard look at the clinical signs and symptoms to determine if they are compatible with the diagnosis of primary middle ear adenoma. While middle ear adenoma has recently been implicated as a cause of facial paralysis (including a case herein), bone destruction should never be found in concert with this neoplasm.

Adult-onset fluid in the tympanomastoid compartment. Diagnosis and management.

Fluid in the tympanomastoid compartment having its onset in adulthood may be caused by three pathogenic mechanisms. Serous otitis in vacuo is the result of blockage of the eustachian tube and the most frequent cause is neoplastic disease. Adult serous effusion is a disorder of unknown cause characterized by active secretion of serous fluid from the mucous membrane lining the tympanomastoid compartment. Cerebrospinal fluid otorrhea is the result of a CSF fistula in the tympanomastoid compartment and may be caused by congenital anomalies, acquired diseases, and trauma. The differential diagnosis demands a systematic approach beginning with history and examination and progressing as necessary through a series of diagnostic procedures that may include pressure-equilizing tube insertion, fluorescein dye test, and surgical exploration.

Primary malleus fixation: diagnosis and treatment.

Primary malleus fixation occurs in an otherwise normal middle ear without evidence of congenital deformity and without chronic inflammatory changes. It occurs in the latter decades of life and is frequently associated with sensorineural presbycusis. We believe it is a ligament ankylosis with osteoarthritis related to the aging process. The diagnosis of malleus fixation is facilitated through the use of a modified Siegle pneumatic otoscope in conjunction with the Zeiss binocular microscope. The literature pertaining to this subject as well as the more historical reports are reviewed. Goodhill has written extensively on malleus fixation. The audiologic test results in the fixed malleus cases reviewed for this study often presented a misleading picture, sometimes mimicking stapedial otosclerosis with a characteristic Carhart's notch and sometimes indistinguishable from sensorineural presbycusis. Usually speech discrimination scores fell in the very good to excellent range. Weber tests, whether performed by tuning forks or audiometrically, almost always lateralized to the suspect ear. Impedance frequently failed to conform to the expected fixed malleus pattern of low static compliance and absent acoustic reflexes; there was an equal number of low compliance and normal range compliance tympanograms and 15% of the total number of our cases had abnormally high compliance tympanograms. Stapedial reflexes are normally expected to be absent with lateral ossicular fixation, but this was not a consistent finding with contralateral test stimulation. The decision for surgical treatment is dependent on the audiological findings and the potential hearing gain. The technique described consists of the removal of the incus and the head of the malleus and the reconstruction of a sound conducting pathway from the handle of the malleus to the mobile stapes or from the mobile stapes to the under surface of the tympanic membrane using a prosthesis-ossicle arrangement. Malleus fixation occurs far more often than it is diagnosed. Surgical correction can result in a worthwhile hearing gain even when the air-bone gap is narrow or nonexistent. The technique of ossicular reconstruction is dictated by the anatomical findings. Some form of autograft ossicular reconstruction from the malleus handle to the stapes is most frequently utilized. Otosclerosis with stapes fixation sometimes causes a lateral ossicular fixation due to degenerative disease and fibrosis. In this instance a stapedectomy is performed as the primary procedure with subsequent revision as necessary to eliminate the lateral obstruction.

Pneumatic otoscopy and impedance studies in middle ear diagnosis.

The direct inspection of the tympanic membrane and its movement with Siegle pneumatic otoscopy through the binocular microscope and the electroacoustic measurements of impedance at the tympanic membrane give valuable information in the diagnosis of tympanic membrane and middle ear disorders. Problems such as otosclerosis and tympanosclerosis with ossicular chain fixation, ossicular discontinuities, ossicular chain prosthesis defects and perilymph fistulas, and the problems of middle ear fluid can be identified and differentiated. Frequently a precise diagnosis can be determined prior to surgical exploration. The use of these instruments enables the otologist to anticipate surgical findings and plan a specific procedure, thereby avoiding operative surprises. The routine use of the pneumatic otoscope and an electroacoustic impedance bridge is recommended in every case of suspected tympanic membrane or middle ear disorder, particularly where an operation is being considered. The combined information obtained through use of the two diagnostic techniques is almost always greater than that obtained by either instrument alone. Pressure recordings were made in a series of examinations with the pneumatic otoscope using the ear microscope. These pressures, both positive and negative, are acceptable and well within the range utilized by clinical electroacoustic impedance bridges. Contraindications to the use of pneumatic otoscopy and the electroacoustic impedance bridge are discussed.

Ossicular reconstruction in tympanoplasty - mobile stapes without crural arches, fixed stapes with and without crural arches.

A description of ossicular reconstruction in problems with the stapes using autograft and/or homograft ossicles is given. The inverted stapes is employed for otosclerosis and tympanosclerosis. The two ossicle reconstruction is used in cases of a mobile footplate with absent crural arches. The reshaped incus is repositioned between the malleus handle and oval window when the stapes is fixed and there also exists a lateral ossicular chain defect. Loose connective tissue is an effective seal for the oval window and is a means of stabilizing ossicular functions.