ossiculoplasty-160619120459.pptxghhghgvvvh

Ossicle repair

1. OSSICULOPLASTY DR. AJAY MANICKAM JUNIOR RESIDENT MS ENT RG KAR MEDICAL COLLEGE

2. THE OSSICULOPLASTY Reconstruction of the ossicular chain – aims to surgically optimize the middle ear transformer mechanism. Sound from the environment is conducted to inner ear fluid with minimal loss

3. History 1957 – ossicular repositioning was described Plastic prosthesis – high extrusion, stapes footplate fistula Homografts – convenient – but viral or prion disease risk Wire prosthesis - stainless steel wires, platinum better tolerated but displaced over time

4. An Ideal prosthesis Durable Biocompatible Easy to manipulate material

5. Plastipore Alloplast made from High Density Polyethylene sponge (HDPS) TORP, PORP Thermal fused HDPS – Polycel However its necessary to cover plastipore with cartilage to minimize extrusion

6. Ceramic Implants 1979 Bio inert and bio active Unfortunately higher extrusion

7. Hydroxylapatite Bioactive implant with ca2+ and phosphorous to human bone Osseointegeration Can come into direct contact with tympanic membrane

8. Hybrid prosthesis Tolerance of tympanic membrane contact Flexibility of plastipore Hybrid prosthesis with hydroxyl apatite head shafts made of teflon , platinum or stainless steel Bone cements – limited erosions

9. Pre operative assesment Otoscopy , HRCT, audiometry Intraoperative decisions more important

10. The planning Healthy ears or chronic diseased ears If active disease – priority to make middle ear mastoid disease free

11. Factors resulting in success S – Surgery (open or closed mastoid) P – Prosthesis type I – Infection +/- T – Tissue health E – Eustachian tube function

12. AUSTIN’S CLASSIFICATION Malleus handle (M+, M-) Stapes superstructure (S+, S-) Type A (M+, S+) Type B (M+, S-) Type C (M-, S+) Type D (M-, S-)

13. Wullstein classification Type 1 – no need for reconstruction Type 2 – graft placed over remaining malleus/long pro incus Type 3 (1) minor columella Type 3 (2) major columella Type 4 – graft over stapes footplate Type 5 – graft over an open oval window sound transmission to pass to fenestrated LSCC

14. Principles of ossiculoplasty T – Tension with which implant placed R – Round window protection A – Angle (45 – 90) C – Centred (prosthesis to TM) S – Space (>0.3ml, N= 1ml)

15. Type A Favourable relationship Unfavourable relationship

16. Favourable relationship Lenticular process of incus is eroded and the manudrium is in close proximity Interpositioning graft Drilled with 0.5 mm diamond burr Sculpted incus must exceed the size of gap Malleus must be pushed anterolaterally

17. Favourable relationship

18. Unfavourable relationship Manubrium positioned far anterior to stapes superstructure PORP is suggested in such conditions Smaller defect – hydroxylapetite bone cement

19. Type B & Type D TORP Long term results unsatisfactory as the medial slurt can be displaced Cartilage shoe is helpful – size of oval window niche, hole in center to accommodate TORP

20. Type B & D TORP

21. Type B & D

22. Type C PORP Cartilage graft placed medial to TM effective in reducing the extrusion rates of Titanium and Hydroxylapatite

23. Type C PORP

24. Factors to be coordinated Anterior mesotympanum to be packed with gelfoam and TM positioned Graft gently elevated Prosthesis placement Cartilage interposition Graft to final position

25. Malleus fixation syndrome Difficult to diagnose preoperatively Tympanosclerosis Chr. Infection Trauma Paget’s disease Ligament ossification Otosclerosis Congenital & Idiopathic disorders

26. Approach Atticotomy Absorbable esterified hyaluronate is interposed and left in place

27. Revision surgery Long term success results are good Control of chronic disease and ET dysfn CT scan – defines better LASER to lyse adhesions Lots of adhesion – silastic sheeting over promontory Failed TORP – inspect fistula - repair with graft

28. Special conditions

29. Myringostapediopexy Short columella ossiculoplasty – allogenic septal spur cartilage or autogenic/ allogenic incus graft Steps of surgery

30. Shaping of cartilage graft Allograft septal spur cartilage Superior contact surface should be sloping Margins should be smooth Inferior drilled and socket created for stapes head

31. Myringoplatinopexy Absence of stapes superstructure, with or without malleus difficult for reconstruction Malleus transposition Long columella technique

32. Long columella Shaping of malleus – handle removed and reshaped Cartilage graft – superior surface enough contact with margins blunted, inferior part is blunted to fit to footplate area without touching facial promontory

33. Placement Mobility of footplate is confirmed, rectangular temporalis fascia kept over footplate and spread partly on facial canal and promontory Shaped ossicle placed between footplate and neotympanum – supported by gelfoam

34. Long columella ossiculoplasty

35. Cartilage graft Cartilage graft Biocompatible Inexpensive Easy to handle Disadvantages – challenging, prion disease, HIV transmission, extrusion rates, necrosis of cartilage

36. Conclusion Factors of success – SPITE Principles of ossiculoplasty – TRACS AUSTIN & WULLSTEIN Careful attention must be played to principles of ossiculoplasty so that there is assurance of better hearing outcome for the patient

37. THANK YOU