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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.
The threshold force inducing the stapedial movements was investigated in laboratory and clinic. The measurement was performed by use of the own made dynamometer. The threshold force was between 0.058-0.059 G. The application of this tool during the stapedial surgery may be practical and useful.
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In 29 ears of 24 patients with auditory ossicle malformation, but without external ear abnormalities, who were operated on at our clinic in the 10 years between June 1993 and June 2002, we studied the condition of ossicles, preoperative examination, surgical procedures, and postoperative hearing improvement. Our study did not include patients with cholesteatoma or those with only fixed stapes but without ossicular deformity. Samples were 12 ears of 11 men and 17 ears of 13 women. We clinically distinguished 3 major categories: (i) discontinuity between the incus and stapes with mobile stapes, (ii) congenital fixation of the stapes with ossicular deformity, and (iii) congenital fixation of the malleus and deformity of the incus with mobile stapes. We classified each category into minor abnormalities based on the condition of the long process of the incus, the superstructure of the stapes, and the stapes footplate. We conducted auditory ossicle reconstruction by mobilization of the malleus and incus in 2 ears, by type III tympanoplasty in 5 ears, by type IV tympanoplasty in 13 ears, and by stapes surgery in 8 ears. Improvement in hearing after the operation was observed in 25 of the 29 ears treated. In the classification of the auditory ossicle malformation without external ear abnormalities, we should evaluate discontinuity or fixation of the ossicles and their deformity. This requires that varied ossicular reconstruction be prepared for surgery, but the possibility of hearing improvement is high, so intensive treatment is needed in many cases of auditory ossicle malformation.
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The late results of one stage operation for middle ear tymanosclerosis in 73 patients during the period January 1965 to December 1980 are presented. Mean observation time was 11.2 years (range 3-20.2 years), with a follow-up rate 86 per cent. Among 64 patients with stapes fixation, 59 had removal of tympanosclerotic masses and stapes mobilization, and five cases underwent stapedectomy. The series was divided into six groups and the results analyzed. The best and most stable results occurred in the group with stapes mobilization and an intact ossicular chain followed by the group with stapes mobilization and Type II tympanoplasty with incus interposition. The poorest late results were obtained in ears with lacking stapes crura and stapes mobilization, and in ears subjected to stapedectomy. No case of post-operative sensorineural hearing loss occurred. We recommend that care is taken to preserve an intact ossicular chain at stapes mobilization performed at the same stage as myringoplasty. Also in ears with a defective ossicular chain but intact stapes with tympanosclerotic fixation we recommend stapes mobilization in one stage. In ears with fixation of the stapes footplate and defective crura, we recommend stapedectomy or stapedotomy in two stages.
OBJECTIVE: To compare the effectiveness of three surgical techniques for otosclerosis. METHOD: Retrospective analysis was made of patients with otosclerosis who had received surgical treatment during 1993-2005. There were totally 70 patients (76 ears) in which 30 patients (33 ears) underwent total stapedectomy with original stapes, 24 patients (27 ears) underwent small fenestra stapedotomy with Teflon piston artificial stapes and 16 patients (16 ears) underwent stapes mobilization or elevation. Both the hearing results including closure of postoperative air-bone gap and change of postoperative bone conduction threshold at different frequencies and percentages of postoperative vertigo control are compared statistically among three general groups and among two subgroups(stapes mobilization group with 5 cases/ 5 ears and stapes elevation group with 11 cases/ 11 ears). RESULT: There were no statistically significant differences in postoperative speech pure tone average threshold in closing air-bone gap among three groups. Compared with ears treated by otal stapedectomy with original stapes, ears treated by small fenestra stapedotomy and stapes mobilization or elevation, more decreased air-bone gap and lower rates of post-operative sensorineural hearing loss (SNHL) and dizziness at high frequencies were found. CONCLUSION: Although the acceptable effects were found in 3 groups, the better hearing threshold at high frequencies and lower incidence of complications can be obtained in patients with otosclerosis underwent small fenestra stapedotomy and stapes mobilization or elevation. It is suggested that small fenestra stapedotomy with Teflon piston artificial stapes is an ideal surgical treatment for otosclerosis.
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.
In a type IV tympanoplasty, the stapes footplate is directly exposed to incoming sound while the round window is "shielded," usually with a fascia graft. Postoperative hearing results are quite variable, with air-bone gaps ranging from 10 to 60 dB. A cadaveric human temporal bone preparation was developed to investigate the middle ear mechanics of this operation to identify causes of variable results and to test predictions of a recently described theoretic model of type IV tympanoplasty. The ear canal, tympanic membrane, malleus, and incus were removed so as to expose the stapes and round window to the sound stimulus. A "cavum minor" chamber (air space adjacent to the round window) was constructed around the round window niche. The round window could be isolated from sound by placing an acoustic shield over this chamber. The mechanical properties of the shield, cavum minor, annular ligament, and round window membrane were varied experimentally. Stapes velocity as determined by an optical motion sensor was used as a measure of hearing level. The largest stapes velocity occurred with a mobile stapes and round window, a stiff shield, and a well-aerated cavum minor. Partial fixation of the stapes or round window caused a decrease in stapes velocity. Acoustic shields of conchal cartilage or Silastic silicone rubber sheeting (approximately 1 mm thick) provided near-optimal shielding. A temporalis fascia shield resulted in a stapes velocity 10 to 20 dB less than that seen with a cartilage or Silastic silicone rubber shield at low frequencies. A cavum minor air space as small as 16 microL was sufficient for unrestricted stapes motion, provided the air was in contact with the round window membrane. These results qualitatively matched predictions of our model, but there were some quantitative differences. The clinical implications of our results are that in order to optimize postoperative hearing, the surgeon should 1) preserve normal stapes mobility, preferably by covering the footplate with a very thin split-thickness skin graft, not a fascia graft; 2) reinforce a fascia shield with cartilage or Silastic silicone rubber; 3) create conditions that promote aeration of the round window niche; and 4) preserve the mobility of the round window membrane.
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OBJECTIVES: Our objective was to analyze the results of tympanosclerosis surgery using over-underlay tympanoplasty and to find out the effect of single-stage surgery on hearing results. MATERIALS AND METHODS: Forty-two patients who were operated on for tympanosclerosis between July 1998 and February 2002 were included in the study. These were one-stage tympanoplasties, because second-stage operations and revisions were not included. Operative records and audiograms of the patients were obtained. Of the patients, 48% had bilateral tympanosclerosis. In three (7.1%) of the patients, tympanosclerosis and cholesteatoma occurred concomitantly. The cog was present in eight (20%) of 40 mastoidectomies. Körner's septum was present in nine (22.5%) patients. The graft take rate was 95.2%. RESULTS: The pre- and postoperative air-bone gap values of the patients were not significantly different (p > 0.05). Thirty-three percent of the patients met the successful hearing criteria (air-bone gap <20 dB). However, 47% had an air-bone gap closure between 20 dB and 30 dB, whereas 20% had a gap of more than 30 dB. CONCLUSION: Single-stage surgery does not result in a satisfactory hearing improvement in most of the patients with tympanosclerosis. Only one third of the patients, most of whom had a mobile stapes, had satisfactory hearing results. Mobilization of a fixed stapes is not an effective option for hearing restoration in tympanosclerosis. Second-stage surgery for stapedectomy and placement of a prosthesis-like piston or total ossicular replacement prosthesis should be considered to obtain better hearing results in tympanosclerosis.
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CONCLUSION: The preoperative bone conduction level provides not only prognostic information but also information on the mobility of the stapes in tympanosclerosis. The surgical results depend upon the stapes mobility. OBJECTIVES: We aimed to evaluate operative findings and hearing results of tympanosclerosis involving the ossicular chain, in order to understand the pathophysiology and to establish better surgical treatment of tympanosclerosis. PATIENTS AND METHODS: Between January 1998 and March 2004, 29 patients (29 ears) with tympanosclerosis involving the ossicular chain underwent tympanoplasty at our hospital. Patients with myringosclerosis only, or with an associated cholesteatoma, were excluded from this study. The clinical and operational records and pre- and postoperative pure tone audiograms were reviewed retrospectively. RESULTS: Intact canal wall tympanoplasty was applied to all 29 patients. A non-staged operation was performed on 21 patients, and a staged operation was performed on the remaining 8 patients. In 25 patients (86.2%), the sclerotic lesion of the ossicles was located in the epitympanum. In the remaining four, the sclerotic lamella coated only the ossicular chain. On average, the preoperative air conduction hearing level of 57.9 dB was significantly improved to 46.3 dB after tympanoplasty. The success rate of middle ear surgery was 65.5% (19 of 29 patients), according to the criteria of the Otological Society of Japan. In 16 patients (55.2%), the mobility of the stapes was preserved (group A), while in the remaining 13 patients (44.8%), the stapes was fixed (group B). The mean preoperative bone conduction of 25.5 dB in group A was significantly better than that of 37.2 dB in group B. The hearing result significantly improved in group A but not in group B. The success rates were 75% (12 of 16 patients) in group A and 53.8% (7 of 13 patients) in group B.