The benefit of trans-attic endoscopic control of ossicular prosthesis after cholesteatoma surgery

Extrusion and Dislocation in Titanium Middle Ear Prostheses: A Literature Review

Titanium middle ear (ME) prostheses are widely used in surgical practice due to their acoustic properties. However, they present a significant drawback shared by all synthetic materials currently in use for ME reconstruction: they can be rejected by the organism of the host. In this study, we aim to review the current literature on titanium partial ossicular replacement prostheses (PORPs) and total ossicular replacement prostheses (TORPs) extrusion and dislocation. Eighty articles were analysed after a full article review based on the inclusion and exclusion criteria. The most common indication for reconstruction was chronic otitis media with cholesteatoma. The average extrusion or dislocation rate was 5.2%, ranging from 0 to 35%. The average improvements in the air-bone gap were 12.1 dB (1.6 dB to 25.1 dB) and 13.8 (-0.5 dB to 22.7 dB) for the PORP and TORP groups, respectively. The data reported on this topic are highly variable, demonstrating that functional outcomes are difficult to predict in clinical practice. We believe that the current limitations could be overcome with technological developments, including bioengineering research focused on promoting prosthesis adaptation to the ME environment.

A retrospective study of audiological outcomes after endoscopic tympanoplasty and tympanomastoidectomy in patients with cholesteatoma

OBJECTIVES

To investigated whether endoscopic tympanoplasty and tympanomastoidectomy could present satisfying audiological outcomes for cholesteatoma patients.

METHODS

This was a retrospective study of 83 patients with cholesteatoma who underwent endoscopic tympanoplasty and tympanomastoidectomy between 2019 and 2021. The preoperative and postoperative audiological evaluations were performed. The evaluation methods included air conduction (AC), bone conduction (BC), and air-bone gap (ABG) procedures.

RESULTS

Eighty-three patients were included in the study, all of whom underwent endoscopic tympanoplasty and tympanomastoidectomy. Forty-seven patients presented postoperative ABG≤20 dB (59.49%). The frequencies tested included low-frequency (LF), middle-frequency (MF), high-frequency (HF), and pure-tone average (PTA). All three audiological parameters significantly decreased after surgery (P < 0.05) at every frequency, except for BC-LF (P > 0.05). There were also significant differences between the preoperative and postoperative proportions of degree of hearing (P < 0.05). Additionally, shifts in AC, BC, and ABG were linearly related to preoperative AC, BC, and ABG. Lastly, postoperative ABG-PTA presented differently depending on preoperative stapes superstructure conditions (present: 15.81 ± 11.23 dB, absent: 22.94 ± 12.20 dB, P = 0.009).

CONCLUSIONS

Our study of endoscopic tympanoplasty and tympanomastoidectomy presented complete audiological outcomes for cholesteatoma patients. It had a positive surgery success rate and improved AC, BC, and ABG at every frequency except BC-LF. Additionally, AC-LF and AC-MF improved to a greater degree than AC-HF due to these procedures. Moreover, the linear regression analyses demonstrated that preoperative ABG-PTA was the most efficient audiological indicator for surgery. Likewise, the preoperative condition of the stapes superstructure was proved to be the most efficient anatomical indicator for hearing outcomes.

Comparison of Long-Term Microscopic and Endoscopic Audiologic Results After Total Ossicular Replacement Prosthesis Surgery

OBJECTIVE

To compare short-term and long-term outcomes after transcanal endoscope-assisted with microscope-assisted ossiculoplasty using the Fisch titanium total prosthesis (FTTP).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Pediatric (<18 yr of age) and adult patients undergoing ossiculoplasty with the FTTP between January 2016 and December 2019.

INTERVENTION

Transcanal endoscope-assisted (n = 30) or microscope-assisted (n = 76) ossiculoplasty with the FTTP. In the microscopic group, 48 were performed through the ear canal and 28 by retroauricular approach.

MAIN OUTCOME MEASURE

Short-term (3 mo) and long-term (average 20.2 mo) PTA 0.5-2kHz air and bone conduction thresholds were evaluated.

RESULTS

In total, 106 patients were included. Nine of 30 (30.0%) of endoscopic and 15 of 76 (19.7%) of microscopic patients were pediatric. Endoscopic preoperative air conduction PTA 0.5-2kHz was 52.1 ± 15.8 dB and 52.2 ± 17.9 dB for the microscopic group ( p > 0.05). Three months postoperative endoscopic air conduction PTA 0.5-2kHz was 37.6 ± 17.4 dB (14.5 dB improvement) and 44.6 ± 19.9 dB (7.6 dB improvement) in the microscopic group ( p > 0.05). Three months postoperative endoscopic PTA 0.5-2kHz ABG was 26.8 ± 16.6 dB and 28.4 ± 14.7 dB in the microscopic group ( p > 0.05). Latest follow-up endoscopic air conduction PTA 0.5-2kHz audiogram (mean follow-up, 20.6 ± 10.4 mo) was 36.1 ± 18.2 dB (16.0 dB improvement) and 40.1 ± 16.8 dB (12.1 dB improvement) in the microscopic group (mean follow-up, 19.9 ± 10.3 mo)( p > 0.05). For endoscopic air conduction PTA 0.5-2kHz , between the 3 months and latest follow-up audiogram, 25.0% showed improvement, 50.0% remained stable, and 25.0% deteriorated. In the microscopic group, 26.7% improved, 46.6% remained stable, and 26.7% deteriorated ( p > 0.05).

CONCLUSION

Our study shows that hearing results with the Fisch titanium total prosthesis are in line with literature. Endoscope-assisted total ossiculoplasty proves to be a suitable technique with comparable results to the microscopic approach.

Development and Validation of a Prognostic Model to Predict Hearing Recovery for Patients With Chronic Otitis Media

OBJECTIVE

To explore the factors affecting postoperative hearing recovery in chronic otitis media (COM) patients, establish a clinical prediction model for hearing recovery, and verify the accuracy of the model.

METHODS

Data of patients with COM who were admitted to our hospital between January 1, 2012 and September 30, 2020 were retrospectively analyzed. We collected data on relevant clinicopathological characteristics of patients. The patients were randomly divided into the development cohort and validation cohorts. A postoperative air-bone gap (ABG) ≤20 dB was defined as successful hearing recovery. Univariate and multivariable logistic regression analyses were used to investigate the association of several prognostic factors with hearing recovery. These factors were then used to establish a nomogram. The model was subjected to bootstrap internal validation and performance evaluation in terms of discrimination, calibration, and clinical validity.

RESULTS

This study included 2146 patients with COM: the development cohort comprised 1610 patients (mean [standard deviation; SD] age, 44.1 [14.7] years; 733 men [45.5%]) and the validation cohort included 536 patients (mean [SD] age, 42.9 [14.4] years; 234 men [43.7%]). Multivariable logistic regression analysis showed that age, duration of onset, styles of surgery (tympanoplasty, canal wall up-CWU, or canal wall down-CWD), ossicular prosthesis, granulation or calcified blocks around the ossicular chain, ossicular chain integrity, duration of drilling, eustachian tube dysfunction, mixed hearing loss, semicircular canal fistula, and second surgery were associated with hearing recovery. A nomogram based on these variables was constructed. The area under the curve was 0.797 (95% confidence interval [CI], 0.778-0.812) in the development cohort and 0.798 (95% CI, 0.7605-0.8355) in the validation cohort.

CONCLUSIONS

This study demonstrated the various clinical factors correlated with hearing recovery in patients with COM. The nomogram developed with these data could provide personalized risk estimates of hearing recovery to enhance preoperative counseling and help to set realistic expectations in patients.

Otoendoscopy in the Office and Operating Room

Since its introduction into the field of otology in 1967 endoscopes are gaining acceptance in evaluation and treatment of middle ear disease. Endoscopes offer a wide field view enabling looking "around the corner" with reduced need for soft tissue and bone removal. Outcomes of middle ear surgery for cholesteatoma and need for second-look procedures are improving because of the addition of endoscopic evaluation. Trainee education using the endoscope improves knowledge of middle ear anatomy. The portability of the endoscopic unit allows performing ear surgery in remote locations.

Study on the Prosthesis Structural Design and Vibration Characteristics Based on the Conduction Effect of Human Middle Ear

As a bridge from the sound signal in the air to the sound perception of the inner ear auditory receptor, the tympanic membrane and ossicular chain of the middle ear transform the sound signal in the outer ear through two gas-solid and solid-liquid conversions. In addition, through the lever principle formed by three auditory ossicle structure, the sound was concentrated and amplified to the inner ear. However, the sound transmission function of the middle ear will be decreased by disease, genetic, or trauma. Hence, using middle ear prosthesis to replace the damaged ossicles can restore the conduction function. The function realization of middle ear prosthesis depends on the vibration response of the prosthesis from the tympanic membrane to the stapes plate on the human auditory perception frequency, which is affected by the way the prosthesis combined with the tympanic membrane, the material, and the geometric shape. In this study, reasonable prosthetic structures had been designed for different types of ossicular chain injuries, and the frequency response characteristics were analyzed by the finite element method then. Moreover, in order to achieve better vibration frequency response, a ball structure was designed in the prosthesis to simulate its amplification function. The results showed that the middle ear prostheses constructed by different injury types can effectively transfer vibration energy. In particular, the first- and second-order resonant frequencies and response amplitudes are close to each other when ball structure models of different materials are added. Instead, the resonance frequency of the third stage formed by aluminum alloy ball materials is larger than that of the other two, which showed good response features.