Tympanosclerosis involving the ossicular chain: mobility of the stapes in association with hearing results

A novel technique in treatment of advanced tympanosclerosis: results of malleus replacement and loop prostheses combination; pure endoscopic transcanal approach

PURPOSE

The objectives of the present clinical trial are to describe our surgical technique for advanced tympanosclerosis (TS) and to present the comparison of pre-and postoperative audiometric results.

METHODS

21 patients suffering from advanced TS (Only type III and IV patients according to Wielinga-Kerr classification) were enrolled in this prospective study. A pure transcanal endoscopic approach was preferred for all patients included in the study. Titanium malleus replacement prosthesis (MRP) and polytetrafluoroethylene (PTFE) loop prosthesis combination were used to bypass fixed ossicles to achieve sound transmission to the inner ear. Pre-and postoperative pure tone audiometry (PTA) measurements and air-bone gap (ABG) results compared, and surgical technique was considered successful if postoperative ABG was less than 20 dB.

RESULTS

Six of the 21 patients had been operated on before and the tympanic membrane (TM) was intact. The remaining 15 of the 21 patients were the primary cases, and TM perforation repair and ossiculoplasty using combination of the MRP and PTFE loop prosthesis were performed at single-staged operation. The average preoperative ABG values significantly improved from 37.1 ± 6.2 to 14.5 ± 1.2 dB postoperatively (p < 0.001). The mean preoperative air conduction threshold (ACT) significantly decreased from 51.7 ± 11.4 to 28.5 ± 9.1 dB (p < 0.001).

CONCLUSION

TS surgery is still a controversial issue particularly in stapes footplate fixation. However, our surgical and audiological results in this study are quite promising. The combination of titanium MRP and PTFE loop prosthesis for restoring sound transmission in advanced TS cases is reliable, effective and novel treatment option via endoscopic transcanal approach.

Endoscopic transcanal management of tympanosclerosis

OBJECTIVES

The objectives of this study are to describe our experiences in endoscopic transcanal management of tympanosclerosis, to explain our surgical approaches to reconstruct the sound conduction system and to analyze the hearing results obtained with our surgical approaches.

STUDY DESIGN

A retrospective cohort study, using medical records of 28 cases that underwent endoscopic transcanal tympanoplasty surgery due to tympanosclerosis from January 2016 to January 2020.

SETTINGS

Private otology clinic PATIENTS: Twenty-eight ears of 26 patients were enrolled into study. Patients were grouped according to Wielinga-Kerr classification and only type II, III and IV patients were included in the study.

INTERVENTIONS

Exclusively transcanal endoscopic surgery was performed in all cases. Primary goal was to mobilize the affected ossicles by removing the offending TS and reconstruct the ossicular chain. Malleostapediopexy was preferred when attic by-pass procedures were needed. Glass ionemer bone cement was used to reconstruct the ossicular defects.

OUTCOME MEASURES

Preoperative and postoperative pure tone average of air conduction and bone conduction and air-bone gap results were evaluated. Operation was considered successful if postoperative ABG < 20 dB was achieved. Complications and graft take rate were also evaluated.

RESULTS

Single-staged surgery was performed in 23 of 28 cases (82.1%). Graft take rate was 93%. The mean preoperative ABG significantly decreased from 33.9 ± 5.19 to 12.55 ± 5.52 dB postoperatively for 23 cases who had single-staged surgeries (p < 0.001, Wilcoxon signed rank test) at the end of the mean follow-up period of 23 months. For this group, the mean preoperative AC-PTA significantly improved from 48.64 ± 9.30 to 22.93 ± 7.45 dB (p < 0.001, Wilcoxon signed rank test) postoperatively with a mean PTA improvement of 25.71 ± 6.02 dB. Success criterion was achieved in 22 of 23 cases (95.7%). There was no sensorineural hearing loss, facial nerve paralysis and postoperative vertigo after the surgical procedures. All patients had been discharged within the first 24 h.

CONCLUSIONS

Surgical treatment of tympanosclerosis is still a controversial issue. Endoscopic surgery seems a safe technique for the management of tympanosclerosis. Single-stage surgery is possible in most of the cases with a satisfactory hearing result. We speculate that addition of endoscopic view may increase the single-stage surgery ratio.

Is ossicular chain fixation predictable for tympanosclerosis on preoperative temporal bone computed tomography?

PURPOSE

To report the predictability of ossicular chain (OC) fixation on preoperative temporal bone computed tomography (TBCT) in chronic otitis media (COM) with tympanosclerosis (TS).

METHODS

Fifty-six patients who had surgery for COM in our ear, nose and throat clinic between 2015 and 2017 were included in this retrospective case-control study. The patients were equally divided into two groups as those with TS and without TS. The complaint of preoperative otorrhea, values of incudostapedial joint (ISJ) angulation on preoperative TBCT scans, postoperative long-term hearing results, and postoperative complications were compared between the two groups.

RESULTS

There was a statistically significant difference between the ISJ angulations of the operated and healthy sides in the COM group with TS (102.27 ± 7.92 and 91.90 ± 5.59 degrees, respectively, p < 0.001). However, no statistically significant difference was observed between the ISJ angulation of the operated and healthy sides in the COM group without TS (95.04 ± 4.86 and 94.35 ± 4.57 degrees, respectively, p > 0.05). In addition, when the ISJ angulations of the operated sides of the two groups were compared, it was statistically significantly higher for the TS group compared to the non-TS group (102.27 ± 7.92 and 95.04 ± 4.86 degrees, respectively, p < 0.001).

CONCLUSION

Increased ISJ angulation may indicate OC fixation. COM cases with TS can be predicted by the measurement of ISJ angulation on preoperative TBCT.

Impact of the demographic and aetiological factors and intraoperative findings on postoperative outcomes in chronic otitis media surgery

Background/aim

Surgical success is related with many factors belonging to both the patient and the disease. This study aims to analyse the preoperative and intraoperative characteristics, the postoperative results, and the factors affecting the surgical success in different types of chronic otitis media (COM).

Materials and methods

A total of 1510 ears of 1398 patients who underwent COM surgery were included in the study. Postoperative results were obtained from 376 ears of 356 patients who had been followed after surgery. The demographic characteristics of the patients, such as age and sex, operative findings, preoperative audiological examination results, and final audiometric and otoscopic examination findings, were retrospectively obtained from the archives of the department.

Results

The most frequent diagnosis was simple COM (39.9%), and the most frequently performed surgery was tympanoplasty without mastoidectomy (46.6%). The overall hearing success rate was found to be 75.8%. Postoperative hearing success was significantly associated with the chronic otitis subgroup, ossicular pathologies, and the condition of the middle ear mucosa. Postoperative graft take rate was found to be 78.6%. Graft success was statistically significantly higher in patients with normal middle ear mucosa. Performing mastoidectomy, the presence of patency in aditus ad antrum, and being a paediatric case had no impact on graft success.

Conclusion

Factors affecting the success of COM surgery include age, chronic otitis subgroup, location and size of perforation, the condition of the middle ear mucosa, and the level of the ossicular disease. These factors should be known and an appropriate treatment plan should be prepared.

[The role of stapedoplasty in the treatment of hearing impairment in the patients presenting with tympanosclerosis]

The present study included the examination and surgical treatment of 50 adult patients presenting with tympanosclerotic fixation of the stirrup. The patients comprising the first subgroup (n=25) underwent the two-stage treatment during the period from 1990 to 2009. The final phase of the treatment consisted of the implantation of different kinds of stirrup prostheses placed on the venous autograft that closed the oval window of the vestibule following partial or total instrumental stapedectomy. The second subgruop was composed of the patients (n=25) who were given the two- or three-stage surgical treatment during the period from 2009 till 2014 the final phase of which was performed following the same procedures as in the first subgroup but with the use of the surgical CO₂-laser instead of the conventional instrumental methods. The pathomorphological studies carried out at different stages of the surgical treatment have demonstrated the necessity of isolation of the vestibular fluid for the purpose of implantation of the stirrup prostheses with a view to preventing cochlear complications. The results of the present study give evidence of the efficiency of stapedoplasty with the application of the autocartilaginous prostheses of the stirrup implanted on the venous autografts to close the oval window of the vestibule with the reduction of the bone-air interval down to less than 20 dB. The performance of this procedure with the use of the instrumental technique produced a favourable outcome of the treatment in 71.4% of the patients presenting with tympanosclerosis. The use of the laser-assisted approach further increased the efficiency of the treatment up to 76%. Moreover, the latter method allows to avoid the reaction of the inner ear to the surgical intervention during the early postoperative period and results in the faster averaged reduction of the bone-air interval in comparison with the patients treated with the application of the instrumental technique.

[The prevalence of tympanosclerosis and the effectiveness of its surgical treatment]

The objective of the present study was to characterize the epidemiological variants of tympanosclerosis and the effectiveness of the surgical treatment of the patients presenting with this condition. We have undertaken the analysis of the results of 1965 surgical interventions on the patients suffering from different forms of chronic otitis media (COM) performed during the period from 2009 till 2014 with a view to determining the frequency of tympanosclerosis (TSC). In 542 cases, it proved possible to evaluate the intraoperative findings, stages and methods of reconstructive surgery, the anatomical and functional outcomes and effectiveness of the intervention. At present, the signs of tympanosclerosis are identified in 27.6% of the patients presenting with chronic otitis media including 88.7% and 11.3% suffering from the perforating and non-perforating forms of this pathology, respectively. In 74% of the cases its manifestations are diagnosed in the patients having the tubotympanic form of COM. In 53.3% of the patients TSC foci are responsible for the fixation of the ossicular chain whereas in 46.7% of the cases the auditory ossicles retain mobility. As many as 88.6% of the patients underwent the one-step surgical intervention, 10.7% were managed using two-step surgery, and 0.7% of the patients were given the three-stage treatment. Type I tympanoplasty was performed in 62% of the patients, type III tympanoplasty in 30.4%, and various types of stapedoplasty in 4.6% of the cases. The favourable anatomical and functional outcomes at the first stage of the surgical intervention with the use of the autogenous tissues for tympano- and ossiculoplastic surgery were achieved in 87.9% of the patients on the average (by means of the closure of the tympanic defect in 92.2% and by re-fixation of the selected elements of the ossicular chain in 17.3%of the cases). The anatomical and functional effectiveness of the second-stage surgical intervention was estimated at 93.1%.

The effect of stapes fixation on hearing results in tympanosclerosis treated by mobilization

We aimed to investigate the effect of stapes fixation on hearing results in patients who underwent mobilization surgery due to tympanosclerosis (TS). Seventy-nine patients were retrospectively analyzed and divided into two groups. Forty-four (55.7%) patients with mobile stapes were classified as group 1, and 35 (44.3%) patients with fixed stapes were classified as group 2. Improvement of the air-bone gap (ABG) to become less than 20 dB and the pure-tone average (PTA) by at least 10 dB postoperatively were accepted as success criteria. The PTA and ABG levels were significantly improved in both groups. The pre- and post-operative PTAs were 46.57 ± 15.55 and 25.84 ± 15.47 dB, respectively, in group 1 (p = 0.001). The pre- and post-operative PTAs were 55.64 ± 12.69 and 36.20 ± 14.47 dB, respectively, in group 2 (p = 0.001). The pre- and post-operative ABG levels were 35.36 ± 10.53 and 16.91 ± 8.54 dB, respectively, in group 1 (p = 0.001). The pre- and post-operative ABG levels were 41.68 ± 8.78 and 22.20 ± 10.03 dB, respectively, in group 2 (p = 0.001). A gain ≥10-dB in the PTA in groups 1 and 2 was found in 34 (77.2 %) and 23 (65.7%) patients, respectively, and the difference between the groups was not significant (p = 0.684). The post-operative AGB in groups 1 and 2 was less than 20 dB in 32 (72.7%) and 21 (60%) patients, respectively, and the difference between the groups was not significant (p = 0.733). No significant negative effect of stapes fixation on post-operative hearing results in TS was detected. Successful results can be obtained with a mobilization procedure, even if the stapes is fixed.

Altered response of fibroblasts from human tympanosclerotic membrane to interacting mast cells: implication for tissue remodeling

Several lines of evidence suggest that a tympanosclerotic (TMS) lesion often develops secondary to acute and chronic otitis media. Histological findings indicate that fibroblasts and inflammatory cells, including mast cells, play a key role in the tympanosclerotic plaque formation. However, details on the functional characteristics of tympanosclerotic fibroblasts (Fs(TMS)) are scanty. Therefore the aim of our study was to examine the activity of human fibroblasts from tympanosclerotic lesions and to evaluate the influence of stimulated by crosslinking of IgE receptor mast cells (HMC-1(FcɛRI)) on fibroblast functional behavior. We observed that fibroblasts from normal tympanic membrane (Fs(TM)) released less TNF-α, TGF-β1 and IL-6 compared to Fs(TMS). Fs(TMS) but not Fs(TM) upon interaction with HMC-1(FcɛRI) released increased quantities of TNF-α and TGF-β1. Exposing the fibroblast to HMC-1(FcɛRI) cells resulted in an increased synthesis of proteins including collagen. We noted that the COL2A1 transcript level increased ∼5- and ∼12-fold in Fs(TM) and Fs(TMS) co-cultured with HMC-1(FcɛRI), respectively. Both Fs(TM) and Fs(TMS) upon maintenance in the primary culture released significant quantities of matrix metalloproteinase 9 (MMP-9). However, Fs(TMS) released ∼5-fold more MMP-9 activity compared to the Fs(TM) cultures. The mast cell-induced release of TNF-α, TGF-β1 and MMP-9 sustained for a longer time in Fs(TMS) cultures compared to Fs(TM). Concluding, our data strongly indicate that increased fibroblast sensitivity to mast cell stimulation greatly contributes to the excessive fibrosis and pathological remodeling of the tympanic membrane. We postulate that the persistency of the Fs(TMS) activated state could be an important factor in the pathogenesis of tympanosclerosis.

Long-term outcome of ossiculoplasty using autogenous mastoid cortical bone

OBJECTIVE

To observe the long-term outcome of ossiculoplasty using autogenous mastoid cortical bone in chronic otitis media in-patients.

METHODS

Sixty-one ears of 57 in-patients with chronic otitis media, with or without cholesteatoma, underwent type III tympanoplasty using autogenous mastoid cortical bone as the prosthetic material. Twenty-one ears were treated by canal wall down mastoidectomy and 40 ears by canal wall up mastoidectomy. The follow-up period was 3 to 6 years (average 4.2 years). Pure tone averages for thresholds at 0.5, 1, 2 and 3 kHz were calculated using standard conventional audiometry.

RESULTS

The pre-operative mean air-bone gap of 31.6 dB, for all ears, was reduced to 20.3 dB post-operatively. For the 40 canal wall up ears, this value decreased from 30.8 dB to 19.9 dB, and for the 21 canal wall down ears it decreased from 33.0 dB to 21.0 dB. The differences between the pre- and post-operative mean air-bone gap values were significant.

CONCLUSION

No cases of extrusion, necrosis or resorption were exhibited for the autogenous mastoid cortical bone prosthesis. A significant hearing improvement was obtained in the majority of cases and this remained stable over time.

Labyrinthine fenestration for stapes fixation in chronic ear disease others than otosclerosis

The objective of this study is to assess the results of labyrinthine fenestration for fixed stapes in chronic ear disease. Using a prospective database, pre- and postoperative audiometric data from patients undergoing labyrinthine fenestration for fixation of the stapes in chronic ear disease others than otosclerosis between 2002 and 2012 were evaluated. Twenty-three labyrinthine fenestrations in chronic ear disease were performed (17 malleo-stapedotomies, 4 incus-stapedotomies, 1 neo-malleus-stapedotomy, 1 TORP-stapedotomy). Overall, the mean short-term (2 months) and long-term (42 months) postoperative air-bone gap (0.5-3 kHz) were 17.5 and 16.5 dB, respectively; long-term air-bone gap of <20 dB was obtained in 73 % of patients. There was no significant difference in air-bone gap closure between tympanosclerotic and post inflammatory osteogenic fixation of the stapes (p = 0.267). Hearing benefit success using the 'Belfast rule of the thumb' was achieved in 48 %. Normal bilateral hearing was achieved in 17 % and bilateral symmetric hearing impairment in 26 %. Only in 4 %, bone conduction worsened by more than 5 dB. Labyrinthine fenestration is an option in selected cases of stapes fixation in chronic ear disease and provides hearing gain without significant risk for sensorineural hearing loss. In those already selected cases, hearing benefit success 'Belfast rule of the thumb' is achieved only in half of the cases. This and the possible alternatives, should therefore be discussed preoperatively.

[Treatment of tympanosclerosis]

Tympanosclerosis is a scarring process with a remarkable variability in its localization within the middle ear. It can lead to conductive hearing loss in many cases. It is usually caused by recurrent chronic inflammation of the middle ear. It is generally accepted that functionally relevant tympanosclerotic findings of the middle ear structures should be treated by surgery. Depending on the extent of the surgical resection, the tympanic membrane and the ossicular chain must be reconstructed individually. In cases of isolated myringosclerosis with no hearing loss, no surgery is required. When the ossicular chain is affected by the sclerosis, sound conduction can often be restored only by interposition of grafts. Stapes footplate fixation can be treated by a stapesplasty. Tympanosclerosis of the oval window combined with other chronic inflammation usually requires two-stage surgery. Tympanosclerotic findings without any clinical symptoms should not be removed. The fitting of conventional or implantable hearing aids is the only treatment if chain reconstruction fails or is impossible.