Ossiculoplasty

classification,grafts,various techniques

1. OSSICULOPLASTY DR N JANARDHAN PROF&HOD OF ENT NMCH NELLORE

2. MIDDLE EAR OSSICLES

3. Middle Ear Transformer Mechanism BY 3 WAYS 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.

4. 2.OSSICULAR LEVER(lever ratio ): Length of the handle of malleus 1.3 times longer than long process of incus.

5. 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.

6. 7 Transformer in Diseased State Effect on Ossicular coupling Ossicular Discontinuity Ossicular Fixity Effect on Acoustic coupling Loss of Round Window shielding Effect of Stapes, Cochlear & RW Impedance Middle ear aeration / fluid

7. OSSCICULOPLASTY It 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

8. Indications for Ossciculoplasty Discontinuity O.C Trauma Erosion by chronic otitis media/ cholesteatoma (most common) Eroded incudostapedial joint (80% of patients) Eroded for absent incus Partially or fully eroded stapes Fixation Malleus head ankylosis (idiopathic) Ossicular tympanosclerosis Scar bands due to inflammaty middle ear disease

9. www.nayyarENT.com 10 Ossicular status Austin / Kartush Classification Types Ossicular chain status 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

10. WULLSTEIN CLASSIFICATION Type I with restoration of the normal middle ear. Type II . Ossicular chain partially 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

11. 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 categories Type III stapes columella – placement of TM graft on to the stapes head Type III minor columella – strut from stapes head to manubrium / TM. Type III major columella – strut from stapes foot plate to manubrium / TM.

12. MATERIALS USED IN OSSICULAR RECONSTRUCTION BIOLOGIC MATERIALS: Autograft or Homograft ossicles , Cortical bone, Teeth, Cartilage.

13. Autografts Bone – ossicles , cortical bone( locally available , rigid, easy shaping and sizing) Cartilage - unstable, loses rigidity, resorption Advantages: Low extrusion rate No risk of transmitting disease Low cost No necessity for reconstitution Fully biocompatible

14. Disadvantages Prolonged operative time to obtain and shape Resorption Fixation. Recurrence of the disease

15. HOMOGRAFTS/ALLOGRAFTS Ossicles / cartilage/ dura From either living or cadavers of from other s, after denaturing the biological active acomponents of the material

16. Methods of homograft preservation 70% ethyl alcohol 0.02% Aqueous Cialit , (Sodium 2-ethylmercurithiobenzoxazole-carboxylate) 4% Buffered formaldehyde fixation and 0.5% buffered formaldehyde preservation.

17. Advantages: Easily availability, low cost and good biocmpatibility Disadvantages Must be stored in special conditions Risk of transmitting diseases ( eg , AIDS, Creutzfeldt-Jakob disease, Mad cow disease or Bovine spongeform encephalopathy)

18. Synthetic material grafts

19. Advantages: Readily available Presculptured Free from infectiious diseases Disadvantages: More expensive Higher extrusion rate (controversial) Migration

20. Applebaum I S prosthesis Titanium I S prosthesis (KURZ angular)

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

22. GLUES AND ADHESIVES Tissue glues Mecrylate (COAPT-1) Bucrylate (COAPT) Eubucrylate ( Histo -Acryl) Fibrin glues Tissucol / Tisseel ( human fibrinogen & factor XIII with thrombin ca cl2/ aprontinin sol.)

23. CONTRAINDICATIONS Acute infection of the ear is the only true contraindication. ( poor healing, prosthesis extrusion) Relative contraindications : persistent middle ear mucosal disease. tympanic membrane perforation. repeated unsuccessful use of the same or similar prostheses.

24. Types of ossciculoplasty Primary : ossiculoplasty and mastoidectomy done simultaneously Secondary : Staging ossiculoplasty : first eradication of the disease by mastoidectmy and ossciculoplasty after 6 m0nths or one year

25. REQUIREMENTS OF PRIMARY OSSICULOPLASTY Presence of normal or minimal hypertrophied ME mucosa Diseased ME mucosa over the promontory is removed but normal or hypertrophied mucosa at the ET orifice or hypotympanic area Patent ET orifice Mobile Stapes FP

26. TECHNIQUES OF OSSICULOPLASTY In this situation, a standard PORP can be used Mobile stapes and mobile malleus , but absent incus Dornhoffer interpositional PORP

27. Incus sculptured and used

28. PENNINGTON

29. Cont… Double dowel technique

30. WEHRS

31. Mobile stapes and fixed malleus , but absent incus : the head of the malleus can be amputated PORP can be used to connect the handle of the malleus /tympanic membrane with the stapes.

32. 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 .

33. When a significant amount of incus necrosis is found, a titanium incus /bridge prosthesis can be used Kurz angular prosthesis ( Plester )

34. Fixed footplate and mobile malleus and incus A standard stapedectomy or stapedotomy is performed.

35. Absent stapes superstructure, but mobile footplate, incus , and malleus a stapes prosthesis can be crimped to the incus and placed on the footplate .

36. 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.

37. 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

38. Total fixation of the ossicular chain incus is discarded, a fenestra created in the footplate, and the head of the malleus amputated after the prosthesis has been clipped to the manubrium

39. TORP Total ossicular replacement prosthesis, positioned on the stapes footplate covered with pressed tragal perichondrium , when the malleus is not present

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

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

42. Double Cartilage Block Obtaining tragal cartilage for double cartilage block ossicular reconstruction.

43. 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

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

45. Cartilage Preparation routinely 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.

46. Cartilage shoe in oval window niche with prosthesis in position on mobile footplate

47. Placement of Prosthesis the 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.

48. POSTOPERATIVE CARE This 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

49. Complications Tear of the annular ligament with a perilymphatic fistula. Severe or total sensorineural hearing loss. (great care and precision.)

50. The functional results of ossiculoplasty are improved by 1. Atticotomy 2. Middle ear and Eustachian tube sheeting 3. Reconstruction of posterosuperior canal wall and reinforcement of posterosuperior tympanic membrane 4. Transmastoid drainage 5. Staging

51. MY TECHNIQUES

52. References Text book of Otolaryngology – Head & Neck Surgery : Charles W Cummings, 4 th ed , vol 4, 3058 – 74 Manual of Middle Ear Surgery : Mirko Tos , vol 1 The Otolaryngologic Clinics of North America : Aug 1994; Ossiculoplasty , vol 27, No 4 Surgery of the Ear : Glasscock – Shambough , 5 th ed Scott Brown otolaryngology 7 th edition Internet Journal articles

53. THANK YOU