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PubMed1998

[Postoperative results of stapes revision].

BACKGROUND: In this retrospective study indications, intraoperative findings, reconstruction techniques and postoperative hearing results in revision stapes surgery were evaluated. PATIENTS: Between March 1988 and January 1996, 150 patients underwent stapes revision. Indications for surgery were the presence of conductive hearing loss (132), dizziness (12), sensorineural hearing loss (3), deafness (2), and tinnitus (1). RESULTS: Intraoperative findings were lateral migration of the implant, regrowth of bone in the oval window niche, erosion of incus, cholesteatoma, and others. In most cases a new prosthesis (gold piston) was inserted between incus and vestibulum. In cases with incus erosion, a malleovestibulopexy was performed. Seventy-three percent of patients who underwent revision stapes surgery because of conductive hearing loss showed a hearing improvement of 20 dB or more. All patients who underwent revision stapes surgery because of dizziness reported an improvement of their symptoms postoperatively. CONCLUSIONS: Revision stapes surgery should be approached by experienced surgeons, because the risk of severe sensorineural hearing loss is higher than at the time of primary stapedectomy. Informed consent is mandatory.

Adolescent↗
PubMed2000

Tympanoplasty with ionomeric cement.

Patients with isolated erosion of the long incus process suffer from severe hearing loss caused by lack of continuity of the ossicular chain. This study is a retrospective evaluation of the hearing results using two different surgical procedures. Since January 1993, 12 consecutive patients with isolated erosion of the long incus process have been treated with a new surgical technique in which the ossicular chain was rebuilt with ionomeric cement. The results in hearing performance (mean pure-tone average (PTA) 0.5, 1 and 2 kHz) were evaluated pre- and post-surgery, and compared to those in a group of 20 historical controls who underwent surgery in 1991 and 1992 using incus autograft interposition. Among the 12 index patients, 7 (58%) achieved improvement in PTA of > 10 dB, in 3 there was no difference and in 2 a slight decline. Among the 20 controls, 14 (70%) achieved improvement in PTA of > 10 dB, in 4 there was a slight improvement and in 2 a decline. The difference was not statistically significant. Hearing improvement using ionomeric cement in type II tympanoplasty was satisfactory. Reconstruction of the ossicular chain with ionomeric cement is recommended, as the procedure is easy to perform, presents less risk of damage to the stapes and cochlea, requires less extensive surgery and does not exclude other surgical methods in cases of reoperation.

Adolescent↗
PubMed1992

A microanalytical study on human auditory ossicles in normal and pathological conditions.

A microanalytical study of human auditory ossicles was performed in 11 normal adults, 13 infants, 13 foetuses, 7 middle ear cholesteatoma, 7 chronic otitis and 1 facial nerve schwannoma. Malleus and incus ossification is initiated in the foetal period, the Ca/P ratio reaching a value of 1.8-1.9 in the 29-gestation-week foetus and continues in the infant period until adult, except for the marginal area of the malleus head which appears mineralized in the infant. The normal Ca/P ratio for malleus is 2.10, and 2.19 for incus. In the stapes, mature Ca/P ratio values (2.11) appear in the footplate of the 23-gestation-weeks foetus. Stapes ossification continues in its head and crura, but never reaches malleus and incus values. We have confirmed that there is a relationship between Ca/P ratio and sulphur values in the ossification process; so when the first increases the second decreases. Finally, in our pathological material we have not found any significant alteration of Ca/P ratio, sulphur or other elements studied.

Adult↗
PubMed2003

Stapes prosthesis attachment: the effect of crimping on sound transfer in otosclerosis surgery.

OBJECTIVES/HYPOTHESIS: Although in stapes surgery successful hearing improvement may be achieved in the majority of patients, unsatisfactory closure of the air-bone gap can be recorded. One of many reasons for unexpected failures of stapes surgery may be the insufficient crimping of a stapes prosthesis onto the incus. The objectives of the study were to assess the amount of sound transmission loss in response to the quality of prosthesis crimping and to identify a required loop attachment pattern to obtain good sound transmission results. STUDY DESIGN: Experimental. METHODS: A temporal bone model was developed to measure the sound transmission properties between incus and prosthesis on 17 fresh human temporal bones. The attachment of a titanium stapes piston was assessed without crimping, followed by loose crimping and tight fixation to the incus, using scanning laser Doppler interferometry, endoscopic photography, micro grinding technique, and scanning electron microscopy. An algorithm had to be developed to simulate acoustical stimulation using electromechanical stimulation. RESULTS: Optimal tight crimping of the stapes piston revealed consistent good sound transfer function ranging from 0 to 7 dB loss, and loss remained, on average, at 2 dB. The mean transmission losses for conditions of loose crimping and no crimping were surprisingly small (within 10 dB). However, these unusual crimping conditions allowed a wide range of losses up to 28 dB. A close coupling at least at two opposite points was obligatory to obtain consistently good results. CONCLUSIONS: Perfect hearing reconstruction necessitates ideal crimping of a prosthesis to obtain consistently good results. However, the final functional gain depends on many different intraoperative and postoperative factors.

Acoustic Stimulation↗
PubMed2004

Ossicular reconstruction using bone cement.

OBJECTIVE: The objective of this study was to describe our results of ossicular reconstruction using bone cement. STUDY DESIGN: We conducted a retrospective review of 264 patients with chronic suppurative otitis media operated on since 1999. SETTING: Academic tertiary referral center. PATIENTS: : Two hundred sixty-four patients with chronic suppurative otitis media underwent mastoidectomy with tympanoplasty. Eighty patients had incudostapedial disarticulation secondary to infection and or cholesteatoma and were reconstructed using an incus interposition graft (n = 31), a partial ossicular prosthesis (POP; n = 31), or more recently, bone source (n = 18). This study evaluates the results of the ossiculoplasties using bone source. INTERVENTION: Ossicular discontinuity was repaired using bone cement. MAIN OUTCOME MEASURE: Audiometric studies pre- and postintervention were compared. One to 3 years of follow up are provided. RESULTS: Preoperative air-bone gaps ranged from 18 dB to 60 dB and averaged 33 dB. Postoperative air-bone gaps ranged from 1 to 24 dB and averaged 10 dB. No patients have experienced any increase in their persistent conductive hearing loss. The pre-/postoperative hearing loss comparisons showed statistically significant hearing improvement. There were no complications. CONCLUSION: The use of POPs and incus interposition grafts is fraught with the possibility of migration and resultant recurrent conductive hearing loss. Using bone cement to reconstruct the ossicular chain restores the integrity of the ossicular chain in the most natural of ways. This reconstruction technique provides an excellent alternative to currently accepted methods and should be considered for incus-stapes disarticulation. There has been no dissolution of the bone source and the results have persisted thus far.

Adolescent↗
PubMed2005

First experience with a new stapes clip piston in stapedotomy.

OBJECTIVE: Hearing results after 23 implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated. This new type of stapes piston was designed to avoid the crimping onto the incus in stapedotomy. This one clip fits all designs and enables solid fixation by clicking the prosthesis onto the long process of the incus without crimping. STUDY DESIGN: A retrospective pilot study was carried out by microcomputer of the preoperative and postoperative audiological results of patients in whom the titanium-clip stapes piston prosthesis was implanted. SETTING: Ear, nose and throat department of Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. PATIENTS: 23 Patients underwent a stapedotomy for hearing improvement suffering from otosclerosis. implantations of a newly designed titanium-clip stapes piston prosthesis (the àWengen Clip Piston prosthesis) in patients with otosclerosis were evaluated. INTERVENTION(S): The stapedotomy was performed with the àWengen Clip Piston prosthesis. MAIN OUTCOME MEASURE(S): Pre and postoperative audiograms were used to evaluate the hearing gain improvement with the new stapes piston. Especially we looked at the airbone gap closure and the sensorineural hearing after the surgical procedure and compared these with the ones before surgery. RESULTS: The hearing results showed a closure of the pure-tone average air-bone gap to within 10 dB in 56.6% of cases (10 of 23 implantations) and to within 20 dB in 100% (23 of 23 implantations). A residual air-bone gap of greater than 20 dB was seen in the present pilot study. Postoperative overclosure of bone-conduction thresholds was discovered only for the frequency of 2 kHz. Sensorineural hearing loss greater than 10% did not occur, and there was no decline in the speech discrimination. CONCLUSIONS: The use of a newly designed titanium-clip stapes piston prosthesis with a diameter of 0.4 mm gives good results in cases of stapedotomy for otosclerosis. The titanium-clip design is a new development in the evolution of stapes piston prostheses. Surgical introduction, placement, and fixation are not always easy, depending on the anatomy of the middle ear and the thickness of the fixation area on the long process of the incus.

Audiometry↗
PubMed2006

A new tool for testing ossicular mobility during middle ear surgery: preliminary report of four cases.

OBJECTIVE: We developed an ossicular vibration tester for the objective and quantitative assessment of ossicular mobility, which is one of the most critical factors affecting postoperative hearing after tympanoplasty. METHODS: Our device consists of three components: a probe shaft with a curved tip to be attached to the target ossicle, a vibration exciter to activate the probe, and a piezoelectric sensor to detect vibrations of the probe. These components are encased in a stainless steel holder, allowing easy hand manipulation during ear surgery. The probe is activated with an electric signal at around 1,600 Hz. The system is controlled with a laptop computer, and the results are presented as the ratio of the ossicular resistance (ROR) to a reference value as a percentage. One measurement takes 10 ms. The device was applied in four selected patients during ear surgery. RESULTS: Several measurements in two of the cochlear implantees showed a greater difference in the RORs of the stapes (15-20% in Case 1 and 35-45% in Case 2), whereas the RORs of the malleus and incus were within the same range. This was thought to correspond to the partial cochlear calcification noted in Case 2. In Case 3, who underwent surgery because of otosclerosis, the ROR of the stapes was high, ranging from 70 to 80%. When measured for the malleus-incus fixation anomaly (Case 4), the ROR of the malleus and incus was in the range of 60 to 70%. Owing to the limited surgical view, the ROR of the stapes could not be measured. No problems related to the measurements with this device were noted. CONCLUSION: The design, principles, measuring procedures, and preliminary results of our new tool for testing ossicular mobility are reported. Measuring the ossicular mobility during surgery may provide important information for deciding the surgical procedures.

Adolescent↗
PubMed2006

In vitro model for intraoperative adjustments in an implantable hearing aid (MET).

OBJECTIVE: Assessment of the optimal static preloading of Otologics Middle Ear Transducer (MET) Ossicular Stimulator, when coupled to the incus. BACKGROUND: The MET Ossicular Stimulator is a partially implantable electromagnetic middle ear hearing device that transmits vibrations to the ossicular chain. The vibration patterns were measured with laser-Doppler vibrometry. STUDY DESIGN: Experimental. MATERIAL: We used three human cadaveric temporal bones (TB) and one MET ossicular stimulator. METHODS: Laser-Doppler vibrometry was used for the selection of TBs. The cochlea was subsequently extirpated from the posterior side to measure the vibrational patterns (VP) of the footplate. Three TBs with different VP were selected based on data obtained from volunteers with normal hearing (n = 110): one TB with a VP larger than +1 SD, one TB with a VP in the range of +/-1 SD, and 1 TB with a VP smaller than -1 SD. Transfer functions were calculated between VP of the measurement points at the coupling rod, umbo, incus, and footplate. The TBs were subsequently defrosted. The MET was implanted and coupled to the ossicular chain. Different coupling loads were measured at the incus, the umbo, and the footplate. RESULTS: Optimal transfer function between the MET transducer and the oval window was achieved during contact when the coupling rod advanced 0.0625 mm (90 degrees rotation). Additional advances of 0.0625 mm (180 degrees turn = 0.125 mm) resulted in a decreased vibrational amplitude, ranging between 20 and 40 dB below 3 kHz. The lowest linear distortion occurred up to 10 kHz during direct contact without advancing the coupling rod.

Acoustic Impedance Tests↗
PubMed1982

Homograft ossicles in tympanoplasty.

Homograft ossicles have been utilized in reconstructive middle ear surgery since 1964. In the first few years, simple repositioning of the incus was the method used. Due to the shortcomings of this procedure, a sculptured ossicle, the notched incus, was introduced in 1970 and this has gradually evolved into two standardized and reliable prostheses. In 1972 hearing results were published on the first 122 cases. An expanded study in 1977 reported in detail on 361 ears. The current study reports the results of 326 patients operated upon during the 5 year period of 1976 through 1980 and compares them with the previous studies. The overall hearing results are very similar for both series with little change being noted in the failure rate. However, in the successful categories progress seems to have been made in that a greater percentage of the fair to good results has been shifted to the excellent category. A new concept of ossicular reconstructions is demonstrated with the introduction of the notched incus with high and low profile, to compensate for differences in the stapedial mallear relationship.

Audiometry↗
PubMed1997

[Dynamic behavior of guinea pig middle ear].

The dynamic behavior of the middle ear was studied in living guinea pigs by using a laser Doppler vibrometer coupled to a compound microscope. Placing glass microbeads 20 microns in diameter on four points of the tympanic membrane and six points of the ossicles, their velocity amplitudes were measured under a constant stimulus of 65 dB SPL. Velocity responses of the four points on the tympanic membrane differed over the frequency range from 0.1 kHz to 3 kHz. At low frequencies, the malleus and incus rotated around an axis running from the malleus head to the incus short process. At middle frequencies, the whole ossicle had a piston-like motion. At high frequencies, the malleus and incus rotated around a vertical axis running through the ossicles, while the stapes had a hinge-like movement.

Animals↗
PubMed2000

Surgical treatment of tympanosclerosis.

OBJECTIVE: To report the hearing results of the surgical treatment of tympanosclerosis. STUDY DESIGN: A retrospective review of surgically treated cases of tympanosclerosis. SETTING: A tertiary referral center. PATIENTS: One hundred fifteen patients with middle ear tympanosclerosis operated on between 1987 and 1996, with an average age of 36 years (range 18-59 years). Cases were classified into four groups according to Wielinga and Kerr. Those with an associated cholesteatoma were excluded. INTERVENTION: Depending on the ossicular status, either mobilization of the major ossicles or epitympanic bypass procedure, mobilization of the stapes or stapedectomy. MAIN OUTCOME MEASURES: The postoperative pure-tone average was compared with the preoperative levels by use of conventional audiometry. The air-bone gap was measured. RESULTS: The average postoperative air-bone gap was 18.0+/-10.21 dB in the type II group (attic fixation of the malleus-incus complex with a mobile stapes). 21.8+/-9.5 dB in the type III group (mobile malleus-incus complex, if present, with stapes footplate fixation), and 22.92+/-10.03 dB in the type IV group (fixation of both the stapes footplate and the malleus-incus complex). Patients with a fixed malleus and mobile stapes had significantly better hearing results than those with stapes fixation (p = 0.042, Mann-Whitney U test). CONCLUSION: In ossicular attic fixation, atticotomy and mobilization of ossicles yielded better results than did the epitympanic bypass procedure. The difference, however, did not reach statistical significance. Patients with fixed stapes treated with stapedectomy displayed good hearing results immediately after surgery, but the air-bone gap deteriorated after some time.

Adolescent↗
PubMed2006

[Landmark of facial nerve in middle ear surgery].

OBJECTIVE: To re-evaluate landmarks for facial nerve in middle ear surgery through temporal bone dissection and facial nerve surgery. METHODS: Some relative landmarks were found through 44 facial nerves dissection in cadaver and 106 cases of facial nerve decompression surgery. RESULTS: (1) Landmarks for vertical segment of the facial nerve: the vertical line in combined point between posterior and middle 1/3 horizontal semicircular canal clews the posterior edge of facial nerve; the prolong line of superior radian of incus short process clues to the anterior edge of the facial nerve, the facial nerve and horizontal semicircular canal are almost in the same plane. (2) Landmarks for horizontal segment of the facial nerve: the facial nerve tracks forward inferior to short process of incus and anterior to horizontal semicircular canal carina in 30 angel. The facial nerve, locating posterior and superior to cochleariform process and parallel with it, forms the step of middle-superior tympanic cavity and tracks forward to geniculate ganglion. (3) location of geniculate ganglion: The same distance prolong line of stapes head to cochleariform process clues to geniculate ganglion. (4) Location of the chorda tympani nerve: chorda tympani nerve, leaving tympanic sulcus at 3 clock of bone canaline left ear and at 9 clock of bone canaline right ear, tracks forward along tympani sulcus and then cross between long process of incus and manubrium. It lies in the border of pars tensa and pars flaccid and is about 5 - 8 mm from the stylomastoid foramen to where the chorda tympani nerve leaves the facial nerve. There is no difference of facial nerve structure in temporal bone dissection and in surgery. CONCLUSIONS: The fixed landmarks of middle ear are the frame of reference of facial nerve, in which horizontal semicircular canal is most invariable; and the safety of surgery will be improved by the reference of the facial nerve.

Ear, Middle↗
PubMed2006

[The use of palisade technique in tympanoplasties after Heermann].

INTRODUCTION: The palisade tympanoplasties-technique with using of tragal and conchal autografts for reconstruction of the tympanic membrane and the auditory canal wall was described. MATERIAL AND METHODS: The operation started with the endaural incision. Tragal and conchal autograft palisade fragments with perichondrium for reconstruction of the tympanic membrane and the auditory canal wall have been used up to 1996 in 15,300 cases. We placed palisaded cartilage fragments parallel to the manubrium of the malleus in type I tympanoplasties and in type II or III procedures parallel to the long process of the incus. The "tunnel plasty" in the eustachian tubal entrance is performed with "simmering", "architrave" and "anti-architrave" to keep the tubal entrance open. This "tunnel plasty" results in a nice reconstruction of the tympano-meatal niche. The "annulus-stapes plate" in type III tympanoplasties replaces the function of the incus, crossing the promontory and reducing adhesions. This annulus-stapes bridge is fixed with a further palisade cartilage, "step plasty", which connects the "tunnel-plasty" with "annulus-stapes plate". The palisade-epitympanum-antrum plasty allows ventilation of the antrum via a tunnel constructed of well-fitting parallel pieces of cartilage fixed by self-tension (no glue) and replacing the bony canal wall. The "columella-tunnel plasty" has an L-shaped notch in the "annulus-stapes plate" fixing a columella of cartilage, placed in the oval window. Only in a case with a narrow oval window niche, a type IV palisade plasty can be performed or a prosthesis placed. RESULTS: The "annulus-stapes cartilage plate" is more stable reconstruction in type III tympanoplasties than are incus of foreign body interpositions. Adhesions on the promontory are found more often with fascia than with cartilage fragments. Histologic study of autograft cartilage showed good preservation of cartilage cells even 26 years after transplantation. CONCLUSIONS: The use of palisade cartilage technique brings very good functional and better long-term results.

Audiometry↗
PubMed1989

Ossicular reconstruction in ears with cholesteatoma.

Ossicular reconstruction in ears with cholesteatoma is similar to ears without cholesteatoma involvement. The important difference is that all cholesteatoma must be meticulously and completely removed or the reconstruction will fail. Special prostheses of bone or hydroxyapatite are used to rebuild the conductive mechanism. If only the incus is absent, an incus replacement prosthesis is employed between the malleus and intact stapes. When the stapedial superstructure is also missing, the incus-stapes prosthesis is utilized. These prostheses are interlocking in that a notch created in the top of the body of the implant engages the malleus and a cup in the lower part slips over the stapedial head, or a shaft extends to the stapedial footplate when the stapedial crura are missing. In either case the patient hears by direct columellar pressure from the new tympanic membrane to the fluids of the inner ear. Care is taken to preserve the patient's tissues and anatomy for use in reconstruction. If the patient's malleus or posterior bony wall must be sacrificed to eradicate the disease, these structures are immediately rebuilt with homograft tissue so that an orderly rebuilding of the conductive components may proceed. If the cholesteatoma has been extensive or infected and the middle ear mucosa is of poor character, definitive reconstruction is delayed to a second stage.

Cholesteatoma↗
PubMed1997

[Functional surgery of cholesteatoma. I. Closed techniques].

A review was made of 138 ears treated with walled-up canal tympanoplasty for chronic otitis media with cholesteatoma. In 66.7% of the ears, two-stage operations were performed. Cholesteatomas were located in the attic (72.5%), mesotympanum (42.8%), antrum (39.1%), and mastoid (11.6%). The most common lesion of the ossicular chain was incus necrosis (61.6%). Total ossicular replacement prosthesis (TORP) (56.5%), partial ossicular replacement prosthesis (PORP) (21.7%), mastoid cortical bone autograft (13%), and incus autograft (8.7%) were used to reconstruct the ossicular chain. After three years, 56.5% of the operated cars were free of complications. The rest had the following complications: recurrence of cholesteatoma (17.4%), perforation of the neotympanum (12.5%), prosthesis extrusion (9.4%), and episodes of otorrhea (4.2%). The best functional results were obtained with autografts (cortical and incus) and TORP.

Adolescent↗
PubMed1997

A constancy of mineral contents in human auditory ossicles.

To determine element contents of auditory ossicles, the malleus and incus were removed from 27 subjects which died at the ages between 40 and 98 years old, and their elemental contents were analyzed by inductively coupled plasma atomic emission spectrometry. It was found that the relative contents (RCs) of calcium and phosphorus were very high in the malleus and incus. The RCs of calcium and phosphorus in the ossicles corresponded to one-and-a-half-fold amounts as compared with the spongy bone of human cervical vertebrae. The mass ratio of calcium per phosphorus in the ossicles was almost the same as that of crystalline calcium phosphate hydroxyapatite. Relationships between the aging and RCs of minerals and between both the sexes in the ossicle were examined. It was found that both the RCs of calcium and phosphorus in the malleus and incus were really constant at the age over 40 years old, and that there was no significant difference of the mineral contents between men and women.

Adult↗
PubMed1990

The biocompatibility of hydroxyapatite ceramic: a study of retrieved human middle ear implants.

The biocompatibility of 11 hydroxyapatite auditory canal-wall prostheses and 4 hydroxyapatite incus prostheses implanted for 4 to 40 months was evaluated by light microscopy, scanning electron microscopy, transmission electron microscopy, and Röntgen microanalysis. These 15 prostheses representing 4% of 375 prostheses, has been removed because of unresolved chronic middle ear infection, residual cholesteatoma, or poor fit. The findings confirmed earlier reports on the biocompatibility of hydroxyapatite in vitro, in animals, and in man. An electron-dense layer was found at the interface with bone and fibrous tissue, and a firm bond between the ceramic and bone at the hydroxyapatite ceramic/bone interface developed. Macropores became filled with bone and fibrous tissue, and the tissue in the individual pores was interconnected. Furthermore the incus prostheses were covered with an epithelium similar to that found in the human middle ear. Findings diverging from those made in other studies were the relatively large amount of exudate in the pores, an apparent increase of degradation during infection, and the accumulation of trace elements in one of the canal-wall prostheses. In all likelihood these three phenomena may be attributed to the unfavorable conditions to which these prostheses were exposed during implantation.

Biocompatible Materials↗
PubMed1980

Vestibular fenestration and stapedioplasty in congenital stapes and vestibular window abnormality.

In this paper the results of vestibular fenestration and stapedioplasty in cases of congenital stapes deformity and vestibular window abnormality are presented. The problems in the surgical reconstruction of the middle ear transmission system, especially the importance of the areal ratio between the tympanic membrane and the vestibular window and the ossicular lever action, are discussed. The following conclusions were reached: 1. The area of the new vestibular window should be greater than 2.0 x 1.0 mm, i.e., one third of normal. 2. Hearing gain was about 1.5 times better after incus-stapedioplasty than after malleus-stapedioplasty. It is recommended that an effort be made to adopt incus stapedioplasty whenever possible.

Adolescent↗