Post on 17-Feb-2017
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
www.nayyarENT.com 10
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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