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© Borgis - New Medicine 4/2004, s. 112-113
Henryk Skarżyński1, Paulina Młotkowska-Klimek1, Bożena Skarżyńska2, Maciej Mrówka
Ossicular chain reconstruction in a damaged incudo-stapedial joint
1International Centre of Hearing and Speech, Institute of Physiology and Pathology of Hearing, Warsaw, Poland
Head: Prof. Henryk Skarżyński MD, PhD
2Department of Anatomy, Medical University, Warsaw, Poland
Head: Prof. Bogdan Ciszek MD, PhD
The aim of this study was to evaluate functional results of the ossicular chain reconstruction in patients with incudo-stapedial joint destruction. Discontinuity of this joint is one of the most common results of chronic infection of the middle ear. The authors assessed 573 patients who had undergone surgical treatment using autogenous and alloplastic materials. Functional results were evaluated in two patient groups: those with reconstructed anatomical continuity of the ossicular chain, and those with non-anatomical reconstructions. The authors found more beneficial results in anatomical reconstructions with alloplastic materials, especially glassionomeric cement.
Incudo-stapedial joint destruction is one of the most common causes of conductive hearing loss resulting from chronic inflammatory changes of the middle ear (1, 2, 3, 4). Retraction of the tympanic membrane in the posterior quadrants, cholesteatoma, lesions in the mesotympani, iatrogenic trauma or congenital malformations, are direct causes of discontinuity in this part of the ossicular chain (5, 6, 7). Patients requiring the joint reconstruction constitute a substantially numerous group in the material at the Department of Otorhinolaryngosurgery, the International Centre of Hearing and Speech, Warsaw; they need effective surgical methods to provide them with good functional results.
In order to assess the procedure, the authors analyzed the results obtained in a large group of patients surgically treated for conductive and mixed hearing loss.
A total of 573 patients with incudo-stapedial joint destruction were surgically treated at the Otorhino-laryngosurgical Clinic, International Centre of Hearing and Speech, between 1999-2001. Preoperative measure-ments at the standard frequencies of 500, 1000, 2000 and 4000 Hz showed an air-bone gap ranging from 15 dB to 40 dB. Among patients with typical patterns of joint destruction without a tympanic membrane perforation or atrophy, 20% of subjects had no conductive hearing loss owing to the tympanic membrane adjoining to the stapedial suprastructure, which provided adequate sound transmission.
Two strategies were employed in the treatment which included 402 surgical operations to reconstruct damaged parts of the incus and stapes with alloplastic material (glassionomeric cement), and 171 re-constructions of the structure chains, joining the tympanic membrane and internal ear, by means of Partial Ossicular Reconstruction Prosthesis (PORP), bone plates and fragments of cartilage.
The reconstruction of the anatomical continuity of the ossicular chain consisted of the reconstruction of the incus, as well as its joining with the head of the stapedial suprastructure, or its remnants. Glassiono-meric cement was used intraoperatively. During the non-anatomical reconstructions, the PORP columella was made of various materials (remnants of stapes, glassionomeric and titanium prostheses), or the stapes was covered with bone plates and fragments of cartilage. The patients were followed up for one year postoperatively; otoscopy and audiology were performed to assess the functional results. Hearing tests were performed at 1 month, 6 months, 1 year, 2 and 3 years after the operation. To assess hearing benefits an average was established on the basis of the air-bone gap results measured for the four mentioned frequencies.
The following causes of the ossicular chain destruction within the incudo-stapedial joint were recognized intraoperatively:
– chronic otitis media with tympanic membrane retraction 209 (36.5%),
– chronic otitis media with cholesteatoma 194 (34%),
– iatrogenic trauma due to otosurgical procedures 17 (3.0%),
– congenital malformations 21 (3.7%).
Postoperative patient evaluation showed that among 402 anatomical reconstructions, long-term hearing results, with a closure of the air-bone gap, were achieved in 393 ears (97%). In 9 ears (3%), hearing results were not permanent because of a disrupted cement connection (8 ears), and an extruded prosthesis (1 ear). A normal stapedius muscle reflex was present in many cases of anatomical reconstruction, i.e. in patients with a reconstructed long crus of the incus, and connection of the incus and the joint disc at the incudo-stapedial joint. Reoperations were performed in nine patients and included reconstruction of a part of the second and/or third ossicles. In one ear, additional myringoplasty with the perichondrium was performed. Proper hearing results and closure of the air-bone gap are usually measured for four standard frequencies; in a year this may reach 15-20 dB.
In 171 non-anatomical reconstructions, long-term hearing results were obtained in 118 ears (69%), a lack of long-term hearing results was found in 53 ears (31%). Failure included a PORP columella dislocation in 16 ears (9%) and in 37 patients (22%) the joint made with a piece of cartilage or bone plate absent.
Patients with unsatisfactory hearing results required reoperation. Reconstruction with glassionomeric cement was performed at the second stage of operation. In the group of 171 ears, the closure of the air-bone gap was obtained in 156 ears (91.2%), a 15-20 dB decrease in the air-bone gap was achieved in 11 ears (6.4%). The results were found to be unsatisfactory only in four ears (2.4%).
The principle of anatomical continuity of the ossicular chain is one of the main rules to be followed in tympanoplasty. If there is no such possibility, other alternative connections have to be made. The type of the material used in the reconstruction depends on local conditions and the surgeon´s experience (8). A satisfactory and long-term functional ossicular chain reconstruction in incudo-stapedial joint destruction may be achieved due to its anatomical as well as non-anatomical reconstruction, which also provides sound transmission (9; 10; 11; 12; 13; 1, 8, 14, 3). We assume that the results of otosurgical treatment of a damaged incudo-stapedial joint may depend on the status of other parts of the middle ear, including the mobility of other ossicles, condition of the ependyma, patency of the auditory tubes. It also depends on the materials available (mainly alloplastic) as well as the surgeon´s experience. Other authors seem to support this view (11, 8, 14).
The results of the incudo-stapedial joint reconstruction obtained by our team are comparable to those reported by other authors (10, 11, 12, 14, 3).They have proved to be much more satisfactory than the results obtained by Brackmann (9), which shows the progress in otosurgical techniques observed over the recent years. The case of the extruded prosthesis mentioned above confirms House´s report that such events are infrequent (13). The use of glassionomeric cement resulting in the closure of the air-bone gap in 97% of operated ears initiates a new era in the Polish otosurgery.
Alloplastic materials used in otosurgery provide an effective total reconstruction of damaged parts of the ossicular chain within the incudo-stapedial joint with preservation of the stapedial muscle reflex.
The best method offering the most satisfactory results consists of the total reconstruction of the long limb of the incus and its fixation to the head of the stapes or to the remnants of the stapes suprastructure.
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