OSSICULOPLASTY

OSSICULOPLASTY DR. AJAY MANICKAMJUNIOR RESIDENTMS ENTRG KAR MEDICAL COLLEGE

THE OSSICULOPLASTYReconstruction 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

History 1957 ossicular repositioning was describedPlastic prosthesis high extrusion, stapes footplate fistulaHomografts convenient but viral or prion disease riskWire prosthesis - stainless steel wires, platinum better tolerated but displaced over time

An Ideal prosthesisDurableBiocompatibleEasy to manipulate material

Plastipore Alloplast made from High Density Polyethylene sponge (HDPS)TORP, PORPThermal fused HDPS PolycelHowever its necessary to cover plastipore with cartilage to minimize extrusion

Ceramic Implants1979Bio inert and bio activeUnfortunately higher extrusion

HydroxylapatiteBioactive implant with ca2+ and phosphorous to human boneOsseointegerationCan come into direct contact with tympanic membrane

Hybrid prosthesis Tolerance of tympanic membrane contact Flexibility of plastiporeHybrid prosthesis with hydroxyl apatite head shafts made of teflon, platinum or stainless steelBone cements limited erosions

Pre operative assesmentOtoscopy, HRCT, audiometryIntraoperative decisions more important

The planning

Healthy ears or chronic diseased earsIf active disease priority to make middle ear mastoid disease free

Factors resulting in successS Surgery (open or closed mastoid)P Prosthesis typeI Infection +/-T Tissue healthE Eustachian tube function

AUSTINS CLASSIFICATIONMalleus handle (M+, M-)Stapes superstructure (S+, S-)Type A (M+, S+)Type B (M+, S-)Type C (M-, S+)Type D (M-, S-)

Wullstein classificationType 1 no need for reconstructionType 2 graft placed over remaining malleus/long pro incusType 3 (1) minor columellaType 3 (2) major columellaType 4 graft over stapes footplateType 5 graft over an open oval window sound transmission to pass to fenestrated LSCC

Principles of ossiculoplastyT Tension with which implant placedR Round window protectionA Angle (45 90) C Centred (prosthesis to TM)S Space (>0.3ml, N= 1ml)

Type A

Favourable relationshipUnfavourable relationship

Favourable relationshipLenticular process of incus is eroded and the manudrium is in close proximity Interpositioning graftDrilled with 0.5 mm diamond burrSculpted incus must exceed the size of gapMalleus must be pushed anterolaterally

Favourable relationship

Unfavourable relationshipManubrium positioned far anterior to stapes superstructurePORP is suggested in such conditionsSmaller defect hydroxylapetite bone cement

Type B & Type DTORPLong term results unsatisfactory as the medial slurt can be displacedCartilage shoe is helpful size of oval window niche, hole in center to accommodate TORP

Type B & D TORP

Type B & D

Type CPORPCartilage graft placed medial to TM effective in reducing the extrusion rates of Titanium and Hydroxylapatite

Type C PORP

Factors to be coordinatedAnterior mesotympanum to be packed with gelfoam and TM positionedGraft gently elevatedProsthesis placementCartilage interpositionGraft to final position

Malleus fixation syndromeDifficult to diagnose preoperativelyTympanosclerosisChr. InfectionTraumaPagets diseaseLigament ossificationOtosclerosisCongenital & Idiopathic disorders

Approach Atticotomy Absorbable esterified hyaluronate is interposed and left in place

Revision surgeryLong term success results are goodControl of chronic disease and ET dysfnCT scan defines betterLASER to lyse adhesionsLots of adhesion silastic sheeting over promontoryFailed TORP inspect fistula - repair with graft

Special conditions

Myringostapediopexy Short columella ossiculoplasty allogenic septal spur cartilage or autogenic/allogenic incus graftSteps of surgery

Shaping of cartilage graftAllograft septal spur cartilageSuperior contact surface should be slopingMargins should be smoothInferior drilled and socket created for stapes head

Myringoplatinopexy Absence of stapes superstructure, with or without malleus difficult for reconstructionMalleus transpositionLong columella technique

Long columellaShaping of malleus handle removed and reshapedCartilage graft superior surface enough contact with margins blunted, inferior part is blunted to fit to footplate area without touching facial promontory

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

Long columella ossiculoplasty

Cartilage graft Cartilage graftBiocompatibleInexpensiveEasy to handleDisadvantages challenging, prion disease, HIV transmission, extrusion rates, necrosis of cartilage

ConclusionFactors of success SPITEPrinciples of ossiculoplasty TRACSAUSTIN & WULLSTEINCareful attention must be played to principles of ossiculoplasty so that there is assurance of better hearing outcome for the patient

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