Autoclaving of the middle ear ossicles in an animal experimental model.

CONCLUSION: Autoclaving the ossicles for 4 min at 134°C impacts superficial devitalization and elimination of the squamous epithelium on the surface of the ossicles. Bone maintains the integrity, firmness, and lamellar structure and ossicles are integrated into the middle ear without any adverse reactions. OBJECTIVE: Sixteen guinea pigs were used to explore the effect of autoclaving on middle ear ossicles. METHODS: Harvested incudomallear complex was autoclaved for 4 min at 134°C and implanted back into the middle ear cavity. Exploration of the middle ear was carried out 30 days after implantation. Results were compared with a control group of 16 non-autoclaved ossicles. RESULTS: Autoclaved ossicles maintained their integrity, firmness, shape, and lamellar structure with Haversian systems. Autoclaving substantially decreased the vitality of the ossicles. The middle ear mucosa overgrew on the ossicular surface. No adverse reactions of soft tissue against ossicles occurred. Although the autoclaved ossicles were implanted with tympanic membrane (squamous epithelium) the histological examination did not demonstrate any residuum of squamous epithelium. In the control group we proved the presence of squamous epithelium on the manubrium surface in all cases; all ossicles were vital without signs of ostitis.

Titanium versus autograft ossiculoplasty.

CONCLUSION: In this comparative series, hearing results were superior with titanium compared with autograft ossiculoplasty in the absence of a stapes superstructure. However, in the presence of a stapes superstructure, titanium ossiculoplasties gave superior results to autografts only when comparing an air-bone gap of < 10 dB. OBJECTIVE: To compare the hearing outcomes of autograft versus titanium ossiculoplasty at 1 year. METHODS: Two consecutive groups of patients with chronic suppurative otitis media with and without cholesteatoma suitable for ossiculoplasty, either primarily or as a staged procedure, were recruited for the study. A total of 52 consecutive patients who underwent an autograft ossiculoplasty were compared with 51 consecutive patients who underwent a titanium ossiculoplasty. Hearing results were statistically compared at 1 year between the two groups using the four frequency average (FFA) of 0.5/1/2/4 kHz and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) four frequency average of 0.5/1/2/3 kHz. The results were analysed statistically. RESULTS: A statistically significant number of titanium TORP ossiculoplasties achieved an air-bone gap closure to within < 20 dB compared with the autograft equivalent group (p = 0.039 FFA; p = 0.016 AAO-HNS). The number of titanium PORP ossiculoplasties achieving an air-bone gap closure to within < 10 dB compared with the autograft equivalent group was also statistically significant (p = 0.006 FFA; p = 0.002 AAO-HNS).

Autologous ossiculoplasty following temporal bone fracture.

OBJECTIVE: This study aimed to investigate the outcomes of autologous ossiculoplasty following temporal bone fracture. METHODS: We analysed 10 patients who underwent autologous ossiculoplasty following temporal bone fracture from 1993 to 2006. Average results for air conduction, bone conduction and air-bone gap were calculated, using both a three- and a four-frequency average, in order to evaluate the effect of the operation. RESULTS: The average follow-up time was 24.4 months. Dislocation of the incus was the most common operative finding. The average three- and four-frequency post-operative air-bone gaps were 12.0 dB (standard deviation 8.3) and 13.8 dB (standard deviation 7.7), respectively. The average air-bone gap improvements were 24.5 dB (standard deviation 13.8) and 24.4 dB (standard deviation 12.1), respectively. Eighty per cent (eight of 10) of the patients had socially acceptable hearing in the operated ear. However, only 50 per cent achieved closure of the air-bone gap to within 10 dB. CONCLUSION: Methods of maximising the stability of the reconstructed ossicular chain should be further studied.

[Middle ear surgery in Mongolia--first results with middle ear prostheses]. / Erste Erfahrungen mit Prothesen in der Mittelohrchirurgie in der Mongolei.

BACKGROUND: Medical care of the Mongolian population is still far behind the standard of industrialised countries. Also in the field of otorhinolaryngology there are clear deficits in regard to an adequate diagnosis and treatment of difficult cases. Microsurgery of the ear is still in the very beginning due to missing essential equipment and surgical skills of the few ORL-units that exists in the country. The integration of tympanoplastic procedures into surgical routine is the main goal of a support programme that exists between the medical faculties of the universities of Wuerzburg (Germany) and Ulan Bator (Mongolia). The aim of this work is to present the outcome of these operations in Mongolia. METHODS AND PATIENTS: As a result of the continuous education and support programme it was possible to perform 90 tympanoplastic procedures between 2005 and 2006 in the local ORL center of Ulan Bator (EMJJ-clinic). The focus of this report is on the postoperative audiological outcome following reconstruction of the ossicular chain either using autologous ossicles or middle ear prostheses. Besides, prostheses made of polyethylene or Teflon (Russian production) as well as titanium prostheses (Kurz Company, Germany) were implanted. RESULTS: The final evaluation of the audiological results was performed 6 month postoperatively. The titanium prostheses provided the most favourable hearing improvement (mean 26 dB) when compared to the other materials (polyethylene 7 dB, Teflon 18 dB), but also compared to the autologous ossicles (8,6 dB). CONCLUSIONS: The standard tympanoplastic procedures, which were developed over decades, proved to be highly reliable also in a country with reduced medical care. The hearing results obtained especially with titanium prostheses demonstrated, that this highly biocompatible alloplastic material is the most suitable and reliable for middle ear reconstruction also in a difficult surrounding.

Revisiting the risks involved in using homograft ossicles in otological surgery.

Despite the fact that cartilage, cortical bone and corneal homograft tissue is still widely used in South Africa and that there has never been a reported case of human immunodeficiency virus or Creutzfeldt-Jakob disease infection transmission via this route, otolaryngologists are still reluctant to use homograft ossicles. In third world countries, such as South Africa, where ossicular prostheses are not always readily available due to financial constraints, the question arises as to whether we should be reconsidering the use of homograft ossicles. This review examines the risk of developing Creutzfeldt-Jakob disease or acquiring human immunodeficiency virus following the use of homograft ossicles during ossicular reconstruction, and discusses sterilization techniques that have proven effective in eradicating the human immunodeficiency virus and prions. For decades, homograft ossicles have been used worldwide in otological surgery, especially in patients lacking suitable autograft ossicles. There has never been a reported case of transmission of the human immunodeficiency virus, and no cases of transmissible spongiform encephalopathy have been reported in the literature after otological surgery involving only the use of homograft ossicles. There have only been two documented otological cases of Creutzfeldt-Jakob disease; these involved the use of cadaveric dura mater and pericardium for tympanic membrane grafting. The human immunodeficiency virus is easily inactivated by simple sterilisation techniques, and there is a statistically insignificant risk of transmitting this virus if proper sterilisation protocols are followed.

Histopathology of ossicular grafts and implants in chronic otitis media.

OBJECTIVES: We describe the histopathology of ossicular grafts and implants so as to provide insight into factors that may influence functional results after surgery for chronic otitis media. METHODS: Histopathologic observations were made on 56 cases: 50 surgical specimens and 6 temporal bone cases in which the graft was sectioned in situ. RESULTS AND CONCLUSIONS: Autogenous malleus, incus, and cortical bone grafts behaved in a similar manner and maintained their morphological size, shape, and contour for extended periods of time, at least up to 30 years. These histopathologic observations support the continued use of autograft ossicular and cortical bone grafts for middle ear reconstruction. Cartilage grafts developed chondromalacia with resulting loss of stiffness and showed a tendency to undergo resorption. Synthetic prostheses made of porous plastic (Plastipore, Polycel) elicited foreign body giant cell reactions with various degrees of biodegradation of the implants. Prostheses made of hydroxyapatite and Bioglass were enveloped by a lining of connective tissue and mucosal epithelium. The Bioglass material was broken down into small fragments and partially resorbed by a host response within the middle ear. These results warrant caution in the use of prostheses made of porous plastic or Bioglass.

[Use of autotransplants and implants in ossiculoplasty].

The paper presents a comparative analysis of efficacy of ossiculoplasty (OP) using different transplants. A total of 202 operations were performed. Prostheses made of the fragments of the auditory ossicles, or a cortical layer of the temporal bone (n=81), of nail plate (n=56), titanium implants (n=65) were applied. A satisfactory result was achieved in 72-87% ossiculoplasties. Functional outcomes of OP did not vary significantly with type and material of the prosthesis. Main causes of poor OP results were fixation or displacement of the prosthesis with fibrous tissue; in case of titanium prostheses -- perforation of the tympanic membrane with prosthesis extrusion.

Allograft tympanoplasty.

Tympano-ossicular allografts are human transplants of the tympanic membrane alone or with the ossicles included. The authors review its use in their department since the introduction of the technique 40 years ago by J. Marquet. The advantages of the technique (near normal anatomical and physiological reconstruction) are discussed, as well as its disadvantages (time consuming harvesting, risk of disease transmission). Some technical modifications for specific indications have been adapted in our department and are described in detail. The authors believe that the tympano-ossicular allograft is the material of choice in extensively diseased middle ears destroyed by chronic otitis media with or without cholesteatoma.

Timpanoplastía tipo III / Type III tympanoplasty

La timpanoplastía tipo III es una técnica quirúrgica reconstructiva de los mecanismos de conducción del oído medio cuando existe una discontinuidad incudo-estapedial. Según la patología osicular existente, las timpanoplastías tipo III se subdividen en clásica, III A y III B. Se realiza un estudio retrospectivo de 29 cirugías (27 pacientes) correspondientes al período 1993-2003. El abordaje quirúrgico más frecuente fue el retroauricular, y la fascia temporal fue el tejido más utilizado para reparar la membrana timpánica. El defecto osicular encontrado más a menudo fue la erosión de la apófisis larga del yunque, en el 57,7 por ciento de los casos. La osiculoplastía más frecuente fue la maleoloestapediopexia con interposición de yunque (51,9 por ciento). Se obtuvo un éxito anatómico de 88,9 por ciento, y un éxito auditivo de 69,2 por ciento. Las timpanoplastías III A se asociaron, en forma no significativa, a un mayor éxito auditivo que las III B. La conservación de la pared posterior del conducto auditivo externo se asoció significativamente a un mejor resultado auditivo. No se demostró diferencias entre las diferentes alternativas de osiculoplastía en timpanoplastías III A, mientras que en las 3 B, el uso de prótesis sintética (TORP) exhibió un mejor resultado que la utilización de autoinjertos.

[Bioimplants--characteristics and use]. / Bioimplantate--Eigenschaften und Anwendungshinweise.

Bioimplants are materials of human or animal origin that are offered after conservation or preparation to the tissue replacement. They are used in the different fields of ENT with very good successes. On the basis of its origin, the infection security plays a large role next to the general demands on an implant. The materials related today and its fields of application are discussed.

[Reconstruction of the superstructure of the stapes in guinea pigs with biovitro ceramic and silicone foil]. / Rekonstruktion des Steigbügeloberbaus beim Meerschweinchen mit einer Biovitrokeramik und Silikonfolie.

BACKGROUND: The reconstruction of the stapes superstructure is still a problem. Efforts for the fixation of implants on the footplate did not show satisfying results yet. METHODS: In 6 guinea pigs a biovitro ceramic (Bioverit) was placed on the stapes footplate after removal of the superstructure. The exclusive bony fixation of the implants on the footplate should be achieved by the use of silicone foils. For control purposes replantation of autologous ossicles was done in one group of 3 animals and a sham operation was performed without any use of implants in the other group of 6 guinea pigs. RESULTS: After 21 weeks not only bony fixation of the implant with the footplate was observed, but furthermore with the wall of the middle ear. Bone formation was detected along the silicone foils. In the first control group of animals we found bony fixation of the replanted ossicles and even a bow-shaped reconstruction of the stapes superstructure in the second. CONCLUSIONS: The guinea pig was not an ideal model for questions of middle ear reconstructions due to its enormous potential for bone formation. In this animal model bony fixation of glass-ceramic with the stapes-footplate could be induced.

[Tympanoplasty with the use of autologous tissue]. / Operacje tympanoplastyczne z zastosowaniem materialu autogennego.

There are presented results of 87 tympanoplasties performed in the Department of Otolaryngology Medical Academy in Bialystok from 1997 to 1998. In 35 (40.02%) of treated ears there were cholesteatoma, granulation or (and) polyps. Tympanosclerosis, diffuse synechiae and mucosal discharge (non-reacting to pharmacotherapy) were also encountered during surgery. 65 (74.8%) of patients were operated on by closed methods including reconstruction of tympanic membrane, ossicular chain, posterior and superior wall of external canal using autologous tissue such as temporalis fascia, adipose tissue, cartilage, perichondrium or bone. In operations using open methods, post-operative cavities were reduced using musculo-fascial transplants or bone to decrease the space of the antrum and mastoid process. Tympanic membrane and ossicular chain were repaired at the same time. Drainage of post-operative cavities was performed in some cases which lasted 3-8 weeks. Anatomical and functional results of surgery were good in 62 (71.2%) of cases. The pathologic condition in the middle ear had a significant influence on the post-operative results. Unsuccessful results of tympanoplasty were due to recurrences of cholesteatoma, adhesion, diffuse tympanosclerosis, infection and secretory middle ear mucosa.

Autoclaving the ossicles provides safe autografts in cholesteatoma.

OBJECTIVE: The choice of the graft in ossicular chain reconstruction during middle ear surgery for cholesteatoma is a subject still discussed on. In order to clarify the discussion of reuse of the autologous ossicles obtained during middle ear surgery for cholesteatoma, we evaluated the probability of residual disease histologically and the safety of the ossicles after autoclavization, the most promoting alternative method to eradicate residual cholesteatoma and infection on them. METHODS: The specimens used in this study were eroded twenty-seven ossicles (22 incuses, 5 malleoli) which were removed from the 27 consecutive patients operated because of cholesteatomatous middle ear disease. They were grouped as follows: Group 1, Fifteen ossicles examined histopathologically directly. Group 2, Five ossicles autoclaved for 20 min at 134 degrees C and then examined histopathologically. Group 3, Five ossicles autoclaved for 20 min at 134 degrees C after mechanical surface cleaning by a fine diamond drill, examined histopathologically. Group 4, Two ossicles removed from two different patients were placed in their mastoid cavities in order to be examined after access in the second-look operation. While one ossicle was only autoclaved, the other was mechanically cleaned by a drill before autoclavization (for 20 min at 134 degrees C). The ossicles were examined histopathologically after the removal at the second stage operation performed 12 months later. RESULTS: In Group 1, all ossicles showed evidence of periosteal thickening. Additional findings were surface cholesteatoma or epithelia in 13 ossicles, surface inflammation in 12 ossicles, granulation tissue in 10 ossicles, osteitis in six ossicles. In Group 2, all five ossicles had preserved their lamellar structure but, no vital cells were seen. The lacunes that had the osteocytes was almost completely empty. The inflammatory cells were eliminated from the ossicles. In Group 3, ossicles were found well preserved with their lamellar structures and contours, with empty lacunes and eliminated inflammatory cells. In Group 4, in two ossicles of this group the lacunes were replaced by the new migrated viable osteocytes with evidence of new bone formation and neovascularisation. No new inflammatory focus or epithelia were found on the surfaces of the ossicles. The shape and the contour of the ossicles remained unchanged. CONCLUSION: In cholesteatoma surgery, ossicles with minimal erosion and adequate thickness can be used after autoclavization. In this study, it was observed histopathologically that the autoclaving autologous ossicles before ossiculoplasty in cholesteatomatous middle ear is a safe and reliable method.

Laser stapedotomy minus prosthesis (laser STAMP): absence of refixation.

OBJECTIVE: To determine what percentage of patients with otosclerosis could successfully undergo a laser stapedotomy minus prosthesis over a 5-year period, and to determine the percentage of patients in whom refixation develops during follow-up. STUDY DESIGN: Retrospective case review of 136 patients (137 ears) who underwent primary surgery for otosclerosis. SETTING: An otology/neurotology tertiary referral center. PATIENTS: Patients were chosen if they had clinical evidence of otosclerosis without a history of otologic surgery. INTERVENTIONS: A standard stapes approach was used for all patients. For the laser stapedotomy minus prosthesis, a hand-held laser probe was used to vaporize the anterior crus of the stapes and perform a linear stapedotomy across the anterior one third of the footplate. If otosclerosis was confined to the fissula ante fenestram, the stapes became completely mobile. The stapedotomy opening was sealed with an adipose tissue graft from the ear lobe. MAIN OUTCOME MEASURES: Pure-tone audiometry with appropriate masking and auditory discrimination testing was performed before surgery, 6 weeks after surgery, and every year thereafter. RESULTS: Of the 137 cases, favorable anatomy and minimal otosclerosis allowed 46 (33.6%) of these patients to undergo laser stapedotomy minus prosthesis. Fifty-seven patients (41.6%) could not undergo the procedure because of extensive otosclerosis. The remaining 34 patients (24.8%) did not receive laser stapedotomy minus prosthesis because of other anatomic or technical difficulties. Of the 34 patients in the laser stapedotomy minus prosthesis group with more than 4 months follow-up, the average air-bone gap was closed from a mean of 22 dB (SD 10 dB) to 6 dB (SD 4 dB) 6 weeks postoperatively. Follow-up periods ranged from 5 months to 53 months (mean 767 days, SD 437 days). The long-term air-bone gap improved slightly to an average of 5 dB (SD 6 dB) in comparison with the sixth postoperative week value. CONCLUSION: Laser stapedotomy minus prosthesis is a minimally invasive procedure, which over the follow-up period has a very low incidence of refixation, as evidenced by a lack of progressive conductive hearing loss. The success of this procedure depends on the correct selection of cases. This procedure has been successfully performed on 33.6% of patients undergoing primary stapes surgery. Laser stapedotomy minus prosthesis seems to be a viable alternative to conventional stapedotomy that yields good results without evidence of refixation over an extended time.

Anteroposterior approach with split ear canal for cochlear implantation in severe malformations.

OBJECTIVE: To present an anteroposterior approach with split ear canal technique in severe malformed ears in which cochlear implantation is not possible through the standard facial recess approach. SETTING: The operation was performed at Hacettepe University Medical Faculty, which is a tertiary care center. STUDY DESIGN: Case report. PATIENT: A 4-year-old female patient with severe Mondini malformation whose facial nerve was completely dehiscent and overlying the stapes and round window. INTERVENTION: The anteroposterior approach was used, and the middle ear was entered after the tympanomeatal flap was elevated. The posterior wall of the ear canal was split longitudinally with a diamond drill. The electrode was inserted easily through the ear canal and then transferred into the mastoid. CONCLUSION: The anteroposterior approach with split ear canal method may be used if, during facial recess, the landmarks in the middle ear (stapes, stapedius tendon, round window, and promontory) cannot be identified clearly because of an abnormal facial nerve (coursing anteriorly, preventing the use of a drill). It is an alternative for the canal wall down procedure.

An important procedure in ossiculoplasty: autoclaving the ossicles.

Autoclaving of the ossicles prior to ossiculoplasty is a very important procedure in surgery of cholesteatomatous chronic otitis media. Autoclaving allows the reuse of the ossicles removed from patients with cholesteatomatous chronic otitis media as an autograft. It also allows utilization of the malleus, incus and stapes taken from cadavers or of the uneroded malleus and incus removed from patients undergoing non-functional middle ear surgery chosen carefully with detailed history and laboratory analysis. The powerful disinfecting effect of the sterilising procedures of the homografts inactivates prion proteins which cause degenerative encephalopathies. In various studies, it has been concluded that autoclaving does not alter the matrix of the bone which is responsiable for its biophysical properties, whereas it removes all viable cells within the bone and dentures the soft tissue attached to the surface of the ossicle. We have also found confirming histological results in our two previous studies published in 1999 and 2001. It is usually recommended that soft tissue on the surface of the ossicles is removed before autoclaving. It is also sufficient to autoclave the ossicles at 134 degrees C, and at 2.5 atmosphere pressure for 5 minutes in a flash autoclave. The autoclaving time of the homograft ossicles must be longer, for 20 minutes. Following the autoclaving, these homograft ossicles should be kept at pH 5.6 for 3 days, then use a solution of 0.5% formaldehyde at pH 7 and 4 degrees C for 21 days and it should be washed with physiologic saline solution three times for 7 minutes before use. Depending on the results obtained from our planned comparative experimental study, there will be no need for additional formaldehyde fixation procedure after autoclaving and the autoclaved ossicles will be used immediately without preservation in formaldehyde solution for 24 days.