OSSICULOPLASTYDR N JANARDHAN

PROF&HOD OF ENT NMCH

NELLORE

MIDDLE EAR OSSICLES

Middle EarTransformer Mechanism BY 3 WAYS

1) CATENARY LEVER(ear drum)

Buckling mechanism of TM

Force is transmitted from centre of TM.

TM memb doesn’t move as a plate.

This causes high pressure with low displacement.

2.OSSICULAR LEVER(lever ratio):Length of the handle

of malleus 1.3 times longer than long process of incus.

3.HYDRAULIC LEVER(areal ratio):Average area of TM

is larger(60mmsq0 than foot plate area(3.2mmsq)(OW).

Effective vibratory area of TM 65% that is 45mmsq.

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Transformer in Diseased StateEffect on Ossicular coupling

Ossicular Discontinuity Ossicular Fixity

Effect on Acoustic coupling Loss of Round Window shieldingEffect of Stapes, Cochlear & RW

Impedance

Middle ear aeration / fluid

OSSCICULOPLASTYIt is surgical repair of the ossicular chain to

restore the advantage of the conduction mechanism or middle ear transformer mechanism in tympanoplasty

The surgical repair includes to reconstruct the diseased or dislocated or fixed osscicular chain .

The material for this surgery may be with the availble healthy osscicles or auto grafts or allogenic grafts or synthetic material

Indications for OssciculoplastyDiscontinuity O.C

TraumaErosion by chronic otitis media/ cholesteatoma

(most common) Eroded incudostapedial joint (80% of patients) Eroded for absent incus Partially or fully eroded stapes

FixationMalleus head ankylosis (idiopathic)Ossicular tympanosclerosisScar bands due to inflammaty middle ear disease

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Ossicular status Austin / Kartush Classification

Types Ossicular chain status

0 M+I+S+ A M+S+ B M+S- C M-S+ D M-S- E Ossicular head

fixation F Stapes fixation

Tuesday, July 17, 2012

WULLSTEIN CLASSIFICATION Type I with restoration of the normal

middle ear.

Type II. Ossicular chainpartially destroyed . Skin graft laid

against the ossicles after removal of the bridge.

Type III.Myringostapediopexy producing a shallow middle ear and a columella effect.

Type IV. Round window protection Type V. Closed middle ear with round

window protection; fenestra in the horizontal semicircular canal covered

by a skin graft

Nodol and Schuknecht modification of the wullstein classification Type I – myringoplasty (intact and mobile

ossicular chain)Type II – use of prosthesis to connect a

discontinuity between the long process of incus and stapes head.

Type III – subdivided into three categoriesType III stapes columella – placement of TM graft

on to the stapes headType III minor columella – strut from stapes head

to manubrium/ TM.Type III major columella – strut from stapes foot

plate to manubrium / TM.

MATERIALS USED IN OSSICULAR RECONSTRUCTIONBIOLOGIC MATERIALS: 1.Autograft or Homograft ossicles, 2.Cortical bone, 3.Teeth, 4.Cartilage.

Autografts Bone – ossicles, cortical bone( locally available ,

rigid, easy shaping and sizing)

Cartilage- unstable, loses rigidity, resorption

Advantages:Low extrusion rateNo risk of transmitting diseaseLow costNo necessity for reconstitutionFully biocompatible

Disadvantages

1.Prolonged operative time to obtain and shape2.Resorption 3.Fixation. 4.Recurrence of the disease

HOMOGRAFTS/ALLOGRAFTS Ossicles / cartilage/dura From either living or cadavers of from

other s, after denaturing the biological active acomponents of the material

Methods of homograft preservation70% ethyl alcohol0.02% Aqueous Cialit, (Sodium 2-

ethylmercurithiobenzoxazole-carboxylate)4% Buffered formaldehyde fixation and

0.5% buffered formaldehyde preservation.

Advantages: Easily availability, low cost and good

biocmpatibility

Disadvantages

Must be stored in special conditionsRisk of transmitting diseases (eg, AIDS,

Creutzfeldt-Jakob disease, Mad cow disease or Bovine spongeform encephalopathy)

Synthetic material grafts

METALS

: titanium, gold and stainless

steel,platinum,silver

Advantages:Readily availablePresculpturedFree from infectiious diseases

Disadvantages:More expensiveHigher extrusion rate (controversial)Migration

Applebaum I S prosthesis

Titanium I S prosthesis (KURZ angular)

IDEAL PROSTHESIS Biocompatible, Stable, Safe, Easily insertable, and Capable of yielding optimal sound

transmission

GLUES AND ADHESIVESTissue gluesMecrylate(COAPT-1)Bucrylate(COAPT)Eubucrylate(Histo-Acryl)

Fibrin gluesTissucol/Tisseel ( human fibrinogen &

factor XIII with thrombin ca cl2/aprontinin sol.)

CONTRAINDICATIONSAcute infection of the ear is the only true

contraindication. ( poor healing, prosthesis extrusion)

Relative contraindications :

1.persistent middle ear mucosal disease.2. tympanic membrane perforation.3.repeated unsuccessful use of the same or

similar prostheses.

Types of ossciculoplastyPrimary : ossiculoplasty and mastoidectomy

done simultaneously

Secondary: Staging ossiculoplasty: first eradication of the disease by mastoidectmy and ossciculoplasty after 6 m0nths or one year

REQUIREMENTS OF PRIMARY OSSICULOPLASTYPresence of normal or minimal

hypertrophied ME mucosaDiseased ME mucosa over the promontory

is removed but normal or hypertrophied mucosa at the ET orifice or hypotympanic area

Patent ET orificeMobile Stapes FP

TECHNIQUES OF OSSICULOPLASTY

In this situation, a standard PORP can be used

Mobile stapes and mobile malleus, but absent incus

Dornhoffer interpositional PORP

Incus sculptured and used

PENNINGTON

Cont…Double dowel technique

WEHRS

Mobile stapes and fixed malleus, but absent incus:the head of the malleus can be amputatedPORP can be used to connect the handle of

the malleus/tympanic membrane with the stapes.

Incus necrosis and mobile stapes and malleus

bone cement in ossicular reconstruction have shown good hearing results (air-bone gap ≤20 dB) in 90% of patients.

When a significant amount of incus necrosis is found, a titanium incus/bridge prosthesis can be used

Kurz angular prosthesis (Plester)

Fixed footplate and mobile malleus and incusA standard stapedectomy or stapedotomy is

performed.

Absent stapes superstructure, but mobile footplate, incus,and malleus

a stapes prosthesis can be crimped to the incus and placed on the footplate.

Foreshortened incus and a fixed footplate or prior stapedectomy

1.the incus discarded, the footplate removed or fenestrated,and TORP placed.

2. Winkle prosthesis that attaches to the foreshortened incus and extends into a small fenestra in the footplate.

Fixed stapes and fixed or mobile malleus, but absent incus:

An incus replacement prosthesis wrapped around the manubrium of the malleus, and the malleus head amputated.

More recently, a titanium prosthesis with a ball joint has been developed

Total fixation of the ossicular chainincus is discarded, a

fenestra created in the footplate, and

the head of the malleus amputated after the prosthesis has been clipped to the manubrium

TORPTotal ossicular

replacement prosthesis, positioned on the stapes footplate covered with pressed tragal perichondrium, when the malleus is not present

Total ossicular replacement prosthesis with incised oversewn cartilage, notched to fit under the malleus handle to prevent migration

Total ossicular replacement prosthesis positioned over an open vestibule covered by pressed perichondrium

Double Cartilage Block

Obtaining tragal cartilage for double cartilage block ossicular reconstruction.

Composite of cartilage preparation incising cartilage to, but not through, the attached perichondrium and final placement of the double cartilage block with attached perichondrium onto stapes, slightly elevating the tympanic membrane (grafted or not

Composite of preparation to obtain additional height and placement using a triple cartilage block.

Cartilage Preparationroutinely used to interface between the

prosthesis and the overlying tympanic membrane

The prosthesis is tilted posteroinferiorly, the cartilage is placed over the anterior edge of the platform, and both are gently rocked back into position, maintaining slight tension on the tympanic membrane.

Cartilage shoe in oval window niche with prosthesisin position on mobile footplate

Placement of Prosthesisthe prosthesis be under slight tension and at

a favourable angle.The prosthesis should fit perfectly without

tension before placement of the cartilage.Before placing the prosthesis, the middle ear

is partially filled with a middle ear packing material.

Bone cement cannot be used on the footplate, however. Instead, a cartilage punch (Kurz) is used to create a “cartilage shoe.

POSTOPERATIVE CAREThis dressing is removed on the patient’s first

postoperative day. The patient is instructed to keep the ear dry. Four weeks postoperatively, the patient is

instructed to instill antibiotic ear drops

Complications

Tear of the annular ligament with a perilymphatic fistula.

Severe or total sensorineural hearing loss. (great care and precision.)

The functional results of ossiculoplasty are improved by

1. Atticotomy2. Middle ear and Eustachian tube

sheeting3. Reconstruction of posterosuperior

canal wall and reinforcement of posterosuperior tympanic membrane

4. Transmastoid drainage 5. Staging

MY TECHNIQUES

References Text book of Otolaryngology – Head & Neck

Surgery : Charles W Cummings, 4th ed , vol 4, 3058 – 74

Manual of Middle Ear Surgery : Mirko Tos, vol 1The Otolaryngologic Clinics of North America :

Aug 1994; Ossiculoplasty, vol 27, No 4Surgery of the Ear : Glasscock – Shambough, 5th

edScott Brown otolaryngology 7th editionInternet Journal articles

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