Titanium prosthesis or autologous incus for total ossicular reconstruction in the absence of the stapes suprastructure and presence of mobile footplate

Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results

PURPOSE

To describe the surgical procedure of exclusive endoscopic ossiculoplasty (EEO) with autologous grafts and evaluate audiological results, focusing on the advantages or drawbacks compared to the corresponding microscopic technique.

METHODS

A retrospective review of consecutive adult and pediatric patients affected by chronic otitis media (COM) with or without cholesteatoma who underwent EEO was conducted. Only autologous ossiculoplasty was included in the study. The procedure was performed by experienced surgeons of our institution between November 2014 and September 2019. Hearing outcomes were evaluated using postoperative air-bone gap (ABG) and success rates in different subgroups of patients and different types of ossiculoplasty (OPL) were analyzed. Our results were finally compared with the existing literature regarding both microscopic and endoscopic ossicular chain reconstruction.

RESULTS

In total, 74 endoscopic ossicular chain repair procedures performed within the study period met the inclusion criteria. Of these, 21 were pediatric patients (28%) and 53 were adults (72%). Surgical reconstruction procedures included 43 partial ossicular reconstructions (POR) and 31 total ossicular reconstructions (TOR). The postoperative ABG improved significantly compared to preoperative measurements, and the mean ABG closure was 7.85 dB HL (p = 0.00064). No statistically significant differences in audiological outcomes between TOR/POR techniques and pediatric/adult groups were found in our study cohort, with p values of 0.10 and 0.88, respectively.

CONCLUSIONS

At present, EEO can be considered a valid surgical option for re-establishing a functioning ossicular chain with acceptable hearing restoration in children and adults. Further reports in wider case series are required to confirm these results.

Ossicular Chain Reconstruction With Titanium Prostheses: A Systematic Review and Meta-Analysis

OBJECTIVES

This review sought to establish expectations for hearing improvement with specifically titanium partial (PORP) and total ossicular replacement prostheses (TORP) to give surgeons an acceptable goal for postoperative hearing results and to counsel patients on their expected results.

DATABASES REVIEWED

MEDLINE/PubMed, EMBASE, and Cochrane Library.

METHODS

A systematic review of the literature was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (MEDLINE/PubMed, EMBASE, Cochrane library) were searched using relevant key search terms to identify studies evaluating outcomes of titanium prostheses. A title/abstract and full article review was then done, and the results from the remaining studies were analyzed with Review Manager 5.4 Software to perform a meta-analysis using a random-effects model.

RESULTS

Forty articles were analyzed after full article review based on the inclusion and exclusion criteria. For PORPs, the average improvement in air-bone gap (ABG) and pure-tone average were 12.1 and 13.5 dB, respectively. For TORPs, the average improvements in ABG and pure-tone average were 16.7 and 17.0 dB, respectively. Preoperatively, the average ABG was 7.0 dB better for PORP than TORP patients, and postoperatively, the ABG improved an average of 4.9 dB more for the PORP cohort. Seventy percent of PORPs and 57% of TORPs subjects had a postoperative ABG less than 20 dB.

CONCLUSIONS

Overall, reconstruction of the ossicular chain with titanium prostheses reliably improves patients' hearing outcomes, and this study gives relevant information for counseling patients preoperatively on realistic hearing outcomes.

Comparison of Surgical Outcomes Between Ossicle-Cartilage Composite Graft and Synthetic Ossicular Prosthesis for Ossicular Reconstruction

OBJECTIVE

To propose a modified technique of ossiculoplasty using an ossicle-cartilage composite graft (OCCG) and compare its hearing outcome and protrusion rate with those of a synthetic prosthesis.

METHODS

Autologous tragal or homologous septal cartilage was combined with an ossicle to create an umbrella shape OCCG. A total of 302 ossiculoplasty surgeries performed in a single university hospital between 1997 and 2006 were retrospectively reviewed based on the prosthesis type-OCCG or polymaleinate ionomeric prosthesis (IONOS®). Data includes demographic profiles, audiometric outcomes, intraoperative findings, and post-operative complications and was categorized by the follow-up periods.

RESULTS

Ossicle-cartilage composite graft was used for 175 patients and IONOS® for 127 patients. The mean post-operative air-bone gap (ABG) of the OCCG group was 22.36 dB, which was better than the IONOS® group of 25.08 dB (P = .015). The successful ABG closure rate of less than 20 dB was also higher in the OCCG group compared to the IONOS® group (38.3% vs 26.8%, P = .036). The ABG between the pre- and post-operative conditions exhibited a significant difference between the 2 groups (P = .006). In the data divided into 3 groups according to the follow-up period, the OCCG group showed a better outcome in the long-term follow-up with 0 cases of protrusion during the follow-up period in the OCCG group compared to 8 cases of the IONOS® group (P = .018).

CONCLUSION

Ossiculoplasty with OCCG exhibited satisfactory audiometric outcomes and low complication rates. Ossicle-cartilage composite graft can be a good option with sufficient informed consent and preliminary screening of transmitted diseases.

Incus Autograft Partial Ossicular Reconstruction Prosthesis vs. Titanium Angular Clip Prosthesis in Patients with Incudostapedial Joint Erosion Caused by Chronic Otitis Media; A Randomized Clinical Trial

Chronic otitis media (COM) is a common disease that can cause damage to the middle ear ossicles and thus lead to conductive hearing loss. The purpose of this study was to compare two methods of incus partial ossicular reconstruction prosthesis (PORP) and reconstruction with titanium angular clip prosthesis in patients with incudostapedial joint erosion. In this interventional randomized clinical trial carried out in a tertiary referral hospital, patients with chronic otitis media and incudostapedial joint erosion who were candidates for surgery, were randomly allocated into two groups of incus PORP surgery and reconstruction with a titanium angular clip prosthesis. Audiometry was performed for the patients prior to and six months after surgery. Pre- and post-operative air-bone gap (ABG) and bone conduction (BC) thresholds were calculated and means were compared by analysis of variances (ANOVA). A P value of <0.05 was considered statistically significant. The study consisted of 24 and 14 subjects in the incus PORP and angular clip groups, respectively. There was no statistically significant difference between the mean pre- and post-operative ABG, BC thresholds and ABG reduction in the compared groups. Considering issues such as high cost and inaccessibility of titanium angular clips in all centers, incus PORP may be a more acceptable method.

Utilization of incus with bone cement for total ossicular reconstruction

Background: Total ossicular chain reconstructions are performed to connect mobile stapes footplate and tympanic membrane. Data on the use of incus for total ossicular reconstruction is quite limited in the literature. Objective: The main objective of this study is to describe a novel surgical method that utilizes incus with bone cement to stabilize the ossicular chain for total ossicular reconstruction. Materials and methods: 16 patients who underwent total ossicular reconstruction using our method were included in this study. We evaluated hearing by comparing preoperative and postoperative air-bone gap (ABG), air conduction (AC) and bone conduction (BC). The percentage of patients achieving ABG ≤20 dB was determined. Results: The mean preoperative ABG was 35.3 ± 8.2 and postoperative ABG decreased significantly to 23.7 ± 7.6 (p < .001). The mean preoperative AC (57.5 ± 10) decreased significantly postoperatively to (46.5 ± 13.3)(p = .014). There was not any difference between pre- and post-operative BC. We achieved successful hearing results (ABG ≤ 20dB) in 44% of patients. Conclusion: The use of incus with bone cement stabilization for total ossicular reconstruction seems a feasible option. Good hearing outcomes, and low cost, complication, and extrusion rate may be the main reasons to prefer this method.

Canal wall down versus canal wall up surgeries in the treatment of middle ear cholesteatoma

Background/aim

To compare outcomes of canal wall up (CWU) and canal wall down (CWD) techniques in the treatment of middle ear cholesteatoma.

Materials and methods

Medical records of 76 patients who had a primary surgery due to middle ear cholesteatoma between July 2015 and November 2017 were reviewed retrospectively. Hearing thresholds, speech discrimination scores (SDS), recurrences, and revision surgeries of CWU and CWD surgeries were compared.

Results

Of 76 cholesteatoma cases, 40 (52.6%) had a CWU and 36 (47.4%) had a CWD operation. Postoperatively, the mean air conduction thresholds were significantly better in CWU compared to CWD surgeries (P = 0.016). The presence of the stapes and the type of reconstruction material used did not have a significant effect on auditory success rates (P = 0.342 and P = 0.905, respectively). Auditory success was affected by the status of the middle ear mucosa as well. The recurrence and revision rates did not differ between the surgical techniques (P > 0.05).

Conclusion

Status of the middle ear mucosa and external auditory canal are important factors affecting the outcomes in cholesteatoma. Instead of a CWD surgery, a CWU surgery seems applicable in cases of cholesteatoma when the bone in the external auditory canal is not eroded by the disease.

Manubrio-incudo-stapedioplasty for reconstruction of Austin-Kartush type B ossicular defects

OBJECTIVE

Manubrio-incudo-stapedioplasty functional outcomes were compared to those of other methods for reconstructing Austin-Kartush type B ossicular defects.

METHODS

Forty-two patients underwent Austin-Kartush type B ossicular defect reconstruction using: manubrio-incudo-stapedioplasty (13 patients), an autologous incus (19 patients) or a titanium ossicular replacement prosthesis (10 patients). For manubrio-incudo-stapedioplasty reconstruction, the malleus head was removed, the manubrium was relocated posteriorly and the incus short process was placed on the mobile footplate. The manubrium was placed on the incus body groove and bone cement was applied to stabilise the manubrium-incus junction. Pre- and post-operative hearing thresholds were assessed.

RESULTS

The air-bone gap decreased from 25.9 ± 6.0 dB to 12.3 ± 5.0 dB (p &lt; 0.05) in the manubrio-incudo-stapedioplasty group. The hearing gain was 13.6 ± 5.2 dB for manubrio-incudo-stapedioplasty, 3.4 ± 14.2 dB with the autologous incus, and 3.3 ± 11.07 dB with the titanium ossicular replacement prosthesis. Hearing improvement was greater for manubrio-incudo-stapedioplasty compared to the other reconstruction methods (p &lt; 0.05).

CONCLUSION

Manubrio-incudo-stapedioplasty resulted in satisfactory hearing outcomes in patients with Austin-Kartush type B ossicular defects. This technique can be considered a stable, inexpensive and effective method to reconstruct Austin-Kartush type B ossicular defects.

Anatomical and functional results of ossiculoplasty using titanium prosthesis

Titanium ossicular chain replacement prosthesis is often used for rehabilitation of the columellar effect in otologic surgeries. This retrospective study aims to analyse the anatomical and functional results of surgeries in which a titanium prosthesis was used. Two hundred and eighty procedures in 256 patients operated on in a tertiary referral center were analysed. Aetiologies, preoperative audiograms, peroperative data and postoperative outcomes at 2 and 12 months postoperatively were reviewed. Chronic suppurative otitis media with or without cholesteatoma was the main aetiology (89%). There was no difference in anatomical results between partial and total ossicular replacement prosthesis, with an overall dislocation rate of 6%, and an overall extrusion rate of 3%. Regarding functional results, a postoperative air-bone gap ≤ 20 dB was achieved in 65% of cases, with a better result for partial compared to total ossiculoplasty (p = 0.02). A significant difference in air bone gap closure was found when comparing aetiologies, with a higher air-bone gap closure in malformation cases compared to chronic suppurative otitis media with cholesteatoma or retraction cases (p = 0.03). Ossiculoplasty using titanium prosthesis is a safe and effective procedure for rehabilitation of hearing loss, which allows reaching an air-bone gap ≤ 20 dB in the majority of patients.

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses

Objective

(1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subject and Methods

This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years.

Results

In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant ( P < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%).

Conclusion

Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR.