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Epitympanic fixation of the incus and malleus may be surgically corrected by transcanal atticotomy and removal of the fixed incudomalleolar mass. Restoration of serviceable hearing has resulted in five of six cases by repositioning the natural incus or using a homograft incus.
To achieve better hearing after incus replacement surgery, the ossicle-cup prosthesis is introduced. This prosthesis incorporates part of a Teflon Robinson's stapes prosthesis into the body of an incus. The ossicle-cup prosthesis has a dynamic joint with the stapes capitulum, as well as a variable height above the stapes. Preliminary hearing results of 45 cases show air-bone gap closure of 67% within 10 dB and 98% within 20 dB.
Ossicular necrosis is often associated with chronic adhesive otitis media. An unusual abnormality discovered in an incus removed during tympanoplasty is reported. The long process appears to have been grooved by pressure from the chorda tympani. An alternative theory to explain the vulnerability of the long process of the incus is suggested.
Chronic inflammations of the middle ear are characterised by perforation of the tympanic membrane as well as hearing loss, due to disintegration in the incudostapedial joint. Usually the perforation is easily restored by means of available modern procedures; on the other hand, failure of the reconstruction of the ossicular chain, especially of the incudostapedial joint, is not uncommon. Hence, the improvement of hearing capacity is transitory, since later, due to scars, graft lateralisation results in a dislocation of the primarily reconstructed ossicular chain. The patient's hearing capacity is then as poor as it has been before surgery. The aim of this study is to demonstrate the ways of satisfactory reconstruction of the incudostapedial joint by means of glass-ionomer cement: 1. Scar tissue connecting the ossicles in slight defects of the incudostapedial joint can be stabilised by glass-ionomer cement leading to a reasonable sound transmission. 2. If the incus has to be removed in case of a more serious defect, the columella can be properly fixed to the stapes by means of glass-ionomer cement without the risk of scar-induced lateralisation. 3. The fixation of the stapes prosthesis' wire loop to the incus can be effectively achieved by glass-ionomer cement.
This report presents the results of 210 cases over a 10-year period using PORPs, TORPs, and notched incus homografts (NIH), for ossicular reconstruction in chronic ear surgery. There were 192 adults and 18 children. The surgical technique utilized temporalis fascia in an underlay technique with canal skin covering the outer surface of the fascia. Intact canal wall mastoid-tympanoplasty, as a one-stage procedure, was used for most cases. Homograft nasal cartilage was placed between the Plasti-Pore prosthesis and the graft. Notched incus homografts were prepared prior to surgery and stored in 4% formalin. There were 149 mastoid-tympanoplasties and 61 tympanoplasties performed. Revision of our cases was performed in 16.6%. Within 3 months of surgery, 86% of adults, and 44% (8/18) of children had dry, healed ears free of disease. The graft take rate was 96%. In adults, a total of 99 NIH, 50 TORPs, and 43 PORPs were implanted. In adults, the closure of the air-bone gap to 20 dB or less occurred in 58% using TORPs, 67% using PORPs, 76% using NIH-Partial replacement, and 20% using NIH-Total replacement. Excluding the cases that failed for reasons other than conductive hearing loss, the results improved to 69% for TORPs, 77% for PORPs, 77% for NIH-P, and 27% for NIH-T. In adults, the extrusion rate was 5.5% for Plasti-Pore and 3% for NIH. In children, the extrusion rate was 17% for Plasti-Pore prostheses. From this study, it appears that PORPs and TORPs with homograft nasal cartilage are satisfactory prostheses for chronic ear surgery in adults. In children, Plasti-Pore prostheses should be avoided unless the ear is healed, aerated, and stable. NIHs are good prostheses when the stapes is intact, but they are inferior to the TORP when placed on the footplate. Also, the NIH requires preparation prior to surgery and may be difficult to obtain. We plan to continue using PORPs and TORPs in chronic ear surgery until a better technique is found, or the complication rate becomes unacceptable.
Experimental incus transplants were performed in cats. The gross findings and histologic data were recorded and correlated to the use of four preservation methods for homografts (alcohol, Cialit, formalin, and freezing). The formalin preserved incudes produced the least middle ear reaction and ossicular fixation. These incudes also exhibited a uniform perivascular bone remodeling throughout the homograft while the bones preserved in Cialit and alcohol were replaced much faster and ossicular chain fixation occurred. The incus bones preserved by freezing were better tolerated than the Cialit and alcohol ones but not as well as the formalin ones.
The surfaces of immobilised incus and malleus joints were studied with the scanning electron microscope. The hyaline cartilage showed arthritic changes similar to osteoarthritic big joints of the body. A direct radiologic magnification technique could likewise demonstrate typical arthritic signs. Comparing findings from histologic studies in the literature, we could demonstrate that the intact hyaline cartilage degenerates if the ossicles are immobilised. The minimal static friction of the intact smooth joint surface is a prerequisite for its assumed role namely protection of the inner ear against hazardous pressure changes. A hypothesis is developed to the effect that the movement of the ossicles, necessary for lubrification and nutrition of the hyaline cartilage, is maintained by the two middle-ear muscles. Their function, which had not been explained so far could thus be interpreted--besides a possible effect on sound transmission--as preserving the intact joint surfaces of the ossicles. Nature seems to set great store by the importance of the middle ear joints, as shown by the development of a new joint structure in an implanted homoio-incus.
A twelve-year experience with banked homograft ossicles has developed into a system of presculptured incus allografts adapted for the correction of many ossicular defects encountered in tympanoplasty and revision stapes surgery. The standardized preparation of a number of variations of modeled incus prostheses for an operating room bank by a well-trained ear homograft laboratory technician has been an effective and time-saving technique.
The average postoperative air-bone gap after interposition of an incus between tympanic membrane and stapes footplate is too high in case of missing crura of the stapes, it is 27 dB. The interposition of an artificial prosthesis, according to Shea and beeing made of "Platipore", leads to a statistically based lower air-bone gap with a mean of 20 dB. Concerning the change of bone conduction, there is no difference between these two methods of operation. The rate of artificial prosthesis which are perforating the tympanic membrane, increases after seven months up to 15%, but only 4% of the incuses invade the plane of the tympanic membrane after 22 months.
Our clinical study proves whether or not the warning is justified not to reimplantate autologic ossicula in cholesteatoma operations in order to avoid recidives. After interposition of the autologic incus in 18 patients we found cholesteatome recidives--originating from the incus--in two cases. According to histological studies, even the most careful preparation cannot avoid that some cells of the epithelium remain on the ossicula, from which a cholesteatoma recidive may develop. Clinical studies show rather low rates of recidives compared with the histological findings. Possibly remaining squamous epithelium cells in autologic ossicles need not always cause recidives. Clinical and histological studies lead to the demand that because of the possibility of cholesteatoma recidives autologic ossicula should not be reimplated in cholesteatoma operations.
Hydroxylapatite is a calcium bioceramic that has the same chemical composition as living bone, Ca10 (PO4) 6 (OH) 2. Since 1970 it has been used as a material in reconstructive prostheses and augmentation of lost tissues in various surgical specialties including maxillofacial surgery, plastic surgery, otolaryngology, and orthopedics. For over 20 years the author has used autograft and homograft ossicles in tympanoplasty. These incudi have been modified into prostheses that were utilized in ossicular reconstruction. During this time two principle prostheses have evolved, the notched incus with short and long processes. The short process prosthesis is used with an intact stapes, whereas the notched incus with long process carries the sound pressure directly to the stapedial footplate. These prostheses have been successful in improving and maintaining hearing following tympanoplasty. Unfortunately, however, the use of human tissue has certain limitations: it is not readily accessible and has a limited shelf life. Furthermore, clinicians are wary of using homograft tissue as concern over the AIDS virus spreads. Therefore it was felt prudent to develop a manmade prosthesis that would as nearly as possible match the advantages of living bone. Hydroxylapetite most nearly met those qualifications.
In 34 posttraumatic incus dislocations, the initial sensorineural hearing loss (primary) after the trauma and that 11 years after trauma (late) were analyzed. Primary hearing loss measurements following the trauma showed that 53% of patients had sensorineural hearing loss of more than 10 dB for at least one of the frequencies from 1,000 to 4,000 cps, 18% for more than 30 dB. For late hearing loss after the trauma, the corresponding percentages were 50% and 15%, respectively. No reliable progression of the posttraumatic sensorineural hearing loss was found, although a few exceptions were seen. It may be concluded that sensorineural hearing loss is not a progressive disorder of the inner ear.
Depressions in the bone surface of the normal human incus long process are found with great frequency. This paper reviews the frequency and distribution of these depressions, discusses their histologic appearance, and speculates upon their significance. While their clinical significance is unclear, they may be related to several conditions encountered in otologic practice.
The histological reactions to the implantation of allogenetic incus after conservation in Cialit or after controlled deepfreezing are described. After 5 months the incusses of both conservation technics show the same good tendency of revitalisation. Therefore the controlled deep-freezing technic does not offer an advantage compared to the Cialit conservation method at least for the present state of knowledge.
This is a case of conductive hearing loss with the normal tympanic membrane due to fibrosis caused by potential inflammation of the long process of the incus. High resolution CT was a useful tool for the detection of ossicular disorder.
Incus replacement or transposition was performed in 82 rats. Findings were similar in that a degree of vitality was retained or regained, though more slowly in boiled implants. Gelatin sponge induced fibrosis. Activity rapid at first ceased later. Generally replanted includes seemed stable.
Hearing results and causes of failure with three types of ossicular reconstruction techniques over an intact stapes, during second-stage intact canal wall tympanoplasty, are reported herein. The three types of reconstruction are: fitted autologous incus (38 cases); Plastipore PORP with cartilage (41 cases); Plastipore PORP without cartilage (32 cases). A residual air-bone gap within 15 dB. was found in 63.2 per cent of fitted includes, in 41.5 per cent of PORPs with cartilage, and in only 37 per cent of PORPs without cartilage. Eighty-four per cent fitted incudes, 63 per cent PORPs with cartilage and 44 per cent PORPs without cartilage yielded a residual air-bone gap within 25 dB. Extrusion has been the main cause of failure among Plastipore prostheses.
The authors report on a series of 25 patients who, in the process of undergoing tympanoplasty, were noted to have erosion of the long process of the incus. This was repaired with bone pâté in an attempt to restore ossicular continuity. The methods and results are presented and the prospects for the future are discussed.