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Ossicular prosthesisOssicular prosthesis
Presenter- Dr.Abhineet jainPresenter- Dr.Abhineet jain
Moderator –Dr .Manjunath D.Moderator –Dr .Manjunath D.
IntroductionIntroduction
Etiology of ossicular disruption
EtiologyEtiology
 Discontinuity
– Trauma
– Erosion by chronic otitis media/ cholesteatoma (most
common)
• Eroded incudostapedial joint (80% of patients)
• Absent incus
• Absent incus and stapes superstructure
 Fixation
– Malleus head ankylosis (idiopathic)
– Ossicular tympanosclerosis
– Scar bands in chronic otitis media
Nodol and Schuknecht modification ofNodol and Schuknecht modification of
the wullstein classificationthe 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.
Mirko toss classificationMirko toss classification
 Type I – Myringoplasty (intact ossicula chain)
 Type II – Ossiculoplasty in defective ossicular chain but
with Stapes present. Includes 1. interposition
technique.2.transposition technique3.pexis
 Type III- ossiculoplasty in cases with absent or severely
defective, stapedial arch, if columella techniques are used.
 Type IV – no ossiculoplasty .includes cavum minor
technique or sound protection technique.
 Type VA – fenestration of the lateral semicircular canal in
cases with no ossicles and fixed foot plate..
 Type VB – platenectomy in cases with fixed footplate
Preoperative AssessmentPreoperative Assessment
 The goal of ossicular chain reconstruction is better
hearing, most typically for conversational speech.
 Bringing the operative ear to within 15 dB of the
contralateral ear will enhance binaural input to
auditory centers; A patient's perceived hearing
improvement is best when the hearing level of the
poorer-hearing ear is raised to a level close to that
of the better-hearing ear.
 In patients with severe mixed hearing loss,
ossicular reconstruction can be considered,
because it may enhance the use of amplification.
ContraindicationsContraindications
Acute infection of the ear is the only true
contraindication.
Acute infection will most likely result in
poor healing, prosthesis extrusion, or both.
Relative contraindications include
persistent middle ear mucosal disease,
tympanic membrane perforation, and
repeated unsuccessful use of the same or
similar prostheses.
PROSTHESISPROSTHESIS
MATERIALSMATERIALS
Autogenous incus
Cortical bone
Allogenous incus
Tragal cartilage
Conchal cartilage
Biocompatible materials
Incus prosthesisIncus prosthesis
Autogenous incus is best even in cases of
cholesteatoma provided no body erosion.
Minimal risk of resorption and extrusion.
Shape of incus prosthesis varies with
distance between stapes head and handle.
Should it have an acetabulum ,or in contact
with drum or malleus.
Size should be checked repeatedly during
drilling.
Ossicluloplasty in detail
Bone prosthesisBone prosthesis
 Cortical bone is
chiseled off.
 L-shape columella
made out of it is thin
with sharp edges.
 Allogenous cortical
bone from tibia
treated with
chloroform-methanol
and freeze dried.
Cartilage prosthesisCartilage prosthesis
 Easy to harvest and cut.
 Very less fixation to
surrounding.
 Perichondrium preserve
vascularity.
 Thin in one layer to bridge
gap up to graft.
 After years it become
fibrotic and sound
transmission decreases.
Biocompatible materialsBiocompatible materials
Polyehylene,Teflon
Porous plastic
Ceramics
Glass ionomer cement
Metals
PORPPORP
Partial replacement prosthesis is that is
used to bridge the gap between TM or
handle of malleus and stapes head.such
condition is usually created after incus and
incudo stapedial joint erosion.
It has a tubular shaft and a plateform of
smooth edges and variable thickness.
Polyehylne,teflonPolyehylne,teflon
1st
prosthesis material used.
Extrusion rates were as high as 30-50% in
1st
year.
Due to stiffness of materials, head of stapes,
ant. Crura of stapes get resorbed after long
term contact.
Ossicluloplasty in detail
Porous plasticPorous plastic
It includes-porous
polyethylene,proplast,teflon plus vitrified
carbon,plasti- pore,polycel.
Porous nature enables them in principle to
be infilterated by living tissue, leading to
effective integration and biocompatibility.
Cartilage covering the plateform may or
may not be used.
Ossicluloplasty in detail
CeramicsCeramics
A non organic crystalline material with
good biocompatibility.
Types-bio inert ceramic made up of
aluminum dioxide.
Attachement to head of stapes can be
improved by drilling groove in to shaft to fit
over stapes tendon and large hole in to shaft
to allow in growth of fibrous tissue.
Ossicluloplasty in detail
Bioactive ceramicsBioactive ceramics
It includes glass ceramics and calcium
phosphate ceramics.
Glass ceramics-it is silicon
oxide,ex.BIOGLASS, CERAVITAL.
Ceravital-develops an osteogenic surface
reaction after bone paste over plateform,
favourable for fixation.CARTILAGE
interposition is CONTRAINDICATED.
Calcium phosphateCalcium phosphate
ceramicsceramics
 Calcium phosphate,tricalcium
phosphates,hydroxyapatite.
HYDROXYAPATITE-integrates perfectely
with surrounding bone and is IDEAL for
middle ear reconstruction.
DENSE form-for ossiculoplasty .
MACROPORE form-for cavity
obliteration, as it is filled with fibrous tissue
and replaced by bone in 3 months
Ossicluloplasty in detail
Glass ionomer cementGlass ionomer cement
A glass powder with a polyacrylic acid.
To prepare, acid is forced in to glass
powder filled capsule and mixwd for 15
sec.this paste is workable for 5 min,in this
time it is transferred to site of surgery
where it binds to bone.
The prosthesis has good biocompatibility ,is
bioinert and no biodegradability.
Ossicluloplasty in detail
MetalsMetals
Geralsch wire basket prosthesis-stainless
steel wire.
Resembles physiological condition with a
large area laterally at drum and small at
stapes with good sound transmission.
Ossicluloplasty in detail
Ossicluloplasty in detail
Gold prosthesisGold prosthesis
Biocompatible ,easy to shape.
Major problem is softness of gold that
compromises rigidity, precise shape and
size.
BELL prosthesis as PORP.
ANTENNA prosthesis as TORP.
Ossicluloplasty in detail
TitaniumTitanium
As far back as 1993, a group of surgeons
designed the total (Arial) prosthesis and the
partial (Bell) prosthesis.
These are available commercially from
Kurz.
In 1996, Spiggle and Theis introduced new
titanium prostheses that can be trimmed
intraoperatively to the appropriate length
Properties of titanium make it possible to
manufacture an extremely fine and light
prosthesis with rigidity.
Differential processing of material surfaces
triggers various tissue reactions.rough
milled surface are most appropiate in areas
of contact of cartilage or stapes.
Smoother the surface,less connective tissue
reaction.
Ossicluloplasty in detail
TORPTORP
Total ossicular replacement prosthesis used
as columellae to bridge the gap between
mobile footplate and TM or malleus handle.
As used in type 3 tympanoplasty,the
outcome and long term prognosis with
columella is poorer as it is associated with
more pronounced disease and
mastoidectomy
The risk of fixation is more.
Polyethylene,teflonPolyethylene,teflon
Columella with tube and
a small plateform.
Very high extrusion
rates.
Porous plasticPorous plastic
 Columella with tube
and broad plateform.
 Shaft may be of teflon.
 Cartilage –
perichondrium graft
may be used to cover
the plateform.
Polycel columellaPolycel columella
 Malleable TORP
containing stainless
steel wire.
 Shaft is thin ,can be
bent in various planes
at various
levels,trimmed to
various length.
Peg TORPPeg TORP
 Peg top has a peg on
top of plateform to
which a cartilage can
be mounted.
 Peg stem has a peg on
distal end of shaft to fit
in to stapedotomy,so
used in
noninfective,intact
drum ear with good
tubal function.
Ceramic columellaCeramic columella
 L shaped or angled
with 1-3 groove in the
plateform.
 Small holes at shaft to
fix fibrous tissue.
 Head may or may not
be covered with
cartilage.
Hydroxyapatite columellaHydroxyapatite columella
Metal columellaMetal columella
 Gold  Stainless steel wire
Hybrid prosthesisHybrid prosthesis
Combination of various materials to achieve
different properties of shaft and plateform
to avoid or reduce the risk of prosthesis
fixation,extrusion,stability.
Usind a plasti pore,polycel shaft provide
malleability while plateform of
hydroxyapatite provides fixation to TM.
Ossicluloplasty in detail
Compound columellaCompound columella
Plateform is made up of cartilage or
bone(ossicle,cortical).
Relatively large plateform,but functinal
efficacy is not sure.
Shaet is of teflon,plasti-pore,polycel.
Ossicluloplasty in detail
Mechanics of forceMechanics of force
transmissiontransmission
Which Prosthesis?Which Prosthesis?
An otologic surgeon must choose his
prosthesis based on the best chance of
successful hearing restoration and the
lowest chance of complications.
Ossicluloplasty in detail
Ossicluloplasty in detail
Methods of prosthesis preservationMethods of prosthesis preservation
 70% ethyl alcohol
 0.02% Aqueous Cialit, (Sodium 2-
ethylmercurithiobenzoxazole-carboxylate)
 4% Buffered formaldehyde fixation and 0.5% buffered
formaldehyde preservation.
 4% Buffered formaldehyde fixation and 0.02% aqueous
Cialit preservation.
 0.5% Buffered glutaraldehyde fixation and 0.02% aqueous
Cialit preservation.
 Freeze-drying and ethylene oxide gas sterilization
 4% Buffered formaldehyde fixation followed by freeze
drying and ethylene oxide gas sterilization.
Defining SuccessDefining Success
Attempts have been made to standardize
reporting 1995 guidelines of the AAO-CHE
Pre and postoperative air-conduction and
bone-conduction thresholds are measured
at 4 designated frequencies (0.5, 1, 2, and 3
kHz), then averaged
Success is defined as a mean postoperative
air-bone gap of less than 20 dB and is the
main outcome considered for this talk
Prognostic FactorsPrognostic Factors
It is clear that optimal results depend not
only on the qualities of the prosthesis, but
also on the environment in which it is
placed and the surgical techniques used.
Prognostic FactorsPrognostic Factors
 Austin (1972) defined four groups in which the
incus had been partially or completely eroded:
 A, malleus handle present, stapes superstructure
present (60% occurrence)
 B, malleus handle present, stapes superstructure
absent (23%)
 C, malleus handle absent, stapes superstructure
present (8%)
 D, malleus handle absent, stapes superstructure
absent (8%)
Prognostic FactorsPrognostic Factors
 Kartush (1994) proposed a scoring system called
the middle ear risk index (MERI) to form an index
score to determine the probability of success in
hearing restoration surgery.
 MERI is used to describe the preoperative middle
ear environment at the time of ossiculoplasty
 It incorporates different classifications of middle
ear disease and ossicular status, including Austin’s
Ossicluloplasty in detail
Ossicluloplasty in detail
Prognostic FactorsPrognostic Factors
Ossicular chain status, mucosal status,
otorrhea, +/- mastoidectomy, and revision
surgery were all significant prognosticators.
Of note, presence of the stapes
superstructure was not influential.
Dornhoffer proposed the Ossicular
Outcomes Parameters Staging (OOPS)
All studies of prognostic factors identify
middle ear mucosal status and presence of
malleus handle as important predictors of
successful hearing restoration.
Options for POR and TOROptions for POR and TOR
 With such a variety of options and materials
available for reconstructing the ossicular chain,
the otologic surgeon must consider using the
method that provides the best hearing result with
the least chance of complications.
 The ideal study for comparison of techniques
would be a single surgeon directly comparing
techniques or materials on patients who had been
risk stratified by a validated prognostic index,
with reporting of complication rates and long-
term follow up.
THANK YOUTHANK YOU

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Ossicluloplasty in detail

  • 1. Ossicular prosthesisOssicular prosthesis Presenter- Dr.Abhineet jainPresenter- Dr.Abhineet jain Moderator –Dr .Manjunath D.Moderator –Dr .Manjunath D.
  • 3. EtiologyEtiology  Discontinuity – Trauma – Erosion by chronic otitis media/ cholesteatoma (most common) • Eroded incudostapedial joint (80% of patients) • Absent incus • Absent incus and stapes superstructure  Fixation – Malleus head ankylosis (idiopathic) – Ossicular tympanosclerosis – Scar bands in chronic otitis media
  • 4. Nodol and Schuknecht modification ofNodol and Schuknecht modification of the wullstein classificationthe 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.
  • 5. Mirko toss classificationMirko toss classification  Type I – Myringoplasty (intact ossicula chain)  Type II – Ossiculoplasty in defective ossicular chain but with Stapes present. Includes 1. interposition technique.2.transposition technique3.pexis  Type III- ossiculoplasty in cases with absent or severely defective, stapedial arch, if columella techniques are used.  Type IV – no ossiculoplasty .includes cavum minor technique or sound protection technique.  Type VA – fenestration of the lateral semicircular canal in cases with no ossicles and fixed foot plate..  Type VB – platenectomy in cases with fixed footplate
  • 6. Preoperative AssessmentPreoperative Assessment  The goal of ossicular chain reconstruction is better hearing, most typically for conversational speech.  Bringing the operative ear to within 15 dB of the contralateral ear will enhance binaural input to auditory centers; A patient's perceived hearing improvement is best when the hearing level of the poorer-hearing ear is raised to a level close to that of the better-hearing ear.  In patients with severe mixed hearing loss, ossicular reconstruction can be considered, because it may enhance the use of amplification.
  • 7. ContraindicationsContraindications Acute infection of the ear is the only true contraindication. Acute infection will most likely result in poor healing, prosthesis extrusion, or both. Relative contraindications include persistent middle ear mucosal disease, tympanic membrane perforation, and repeated unsuccessful use of the same or similar prostheses.
  • 8. PROSTHESISPROSTHESIS MATERIALSMATERIALS Autogenous incus Cortical bone Allogenous incus Tragal cartilage Conchal cartilage Biocompatible materials
  • 9. Incus prosthesisIncus prosthesis Autogenous incus is best even in cases of cholesteatoma provided no body erosion. Minimal risk of resorption and extrusion. Shape of incus prosthesis varies with distance between stapes head and handle. Should it have an acetabulum ,or in contact with drum or malleus. Size should be checked repeatedly during drilling.
  • 11. Bone prosthesisBone prosthesis  Cortical bone is chiseled off.  L-shape columella made out of it is thin with sharp edges.  Allogenous cortical bone from tibia treated with chloroform-methanol and freeze dried.
  • 12. Cartilage prosthesisCartilage prosthesis  Easy to harvest and cut.  Very less fixation to surrounding.  Perichondrium preserve vascularity.  Thin in one layer to bridge gap up to graft.  After years it become fibrotic and sound transmission decreases.
  • 13. Biocompatible materialsBiocompatible materials Polyehylene,Teflon Porous plastic Ceramics Glass ionomer cement Metals
  • 14. PORPPORP Partial replacement prosthesis is that is used to bridge the gap between TM or handle of malleus and stapes head.such condition is usually created after incus and incudo stapedial joint erosion. It has a tubular shaft and a plateform of smooth edges and variable thickness.
  • 15. Polyehylne,teflonPolyehylne,teflon 1st prosthesis material used. Extrusion rates were as high as 30-50% in 1st year. Due to stiffness of materials, head of stapes, ant. Crura of stapes get resorbed after long term contact.
  • 17. Porous plasticPorous plastic It includes-porous polyethylene,proplast,teflon plus vitrified carbon,plasti- pore,polycel. Porous nature enables them in principle to be infilterated by living tissue, leading to effective integration and biocompatibility. Cartilage covering the plateform may or may not be used.
  • 19. CeramicsCeramics A non organic crystalline material with good biocompatibility. Types-bio inert ceramic made up of aluminum dioxide. Attachement to head of stapes can be improved by drilling groove in to shaft to fit over stapes tendon and large hole in to shaft to allow in growth of fibrous tissue.
  • 21. Bioactive ceramicsBioactive ceramics It includes glass ceramics and calcium phosphate ceramics. Glass ceramics-it is silicon oxide,ex.BIOGLASS, CERAVITAL. Ceravital-develops an osteogenic surface reaction after bone paste over plateform, favourable for fixation.CARTILAGE interposition is CONTRAINDICATED.
  • 22. Calcium phosphateCalcium phosphate ceramicsceramics  Calcium phosphate,tricalcium phosphates,hydroxyapatite. HYDROXYAPATITE-integrates perfectely with surrounding bone and is IDEAL for middle ear reconstruction. DENSE form-for ossiculoplasty . MACROPORE form-for cavity obliteration, as it is filled with fibrous tissue and replaced by bone in 3 months
  • 24. Glass ionomer cementGlass ionomer cement A glass powder with a polyacrylic acid. To prepare, acid is forced in to glass powder filled capsule and mixwd for 15 sec.this paste is workable for 5 min,in this time it is transferred to site of surgery where it binds to bone. The prosthesis has good biocompatibility ,is bioinert and no biodegradability.
  • 26. MetalsMetals Geralsch wire basket prosthesis-stainless steel wire. Resembles physiological condition with a large area laterally at drum and small at stapes with good sound transmission.
  • 29. Gold prosthesisGold prosthesis Biocompatible ,easy to shape. Major problem is softness of gold that compromises rigidity, precise shape and size. BELL prosthesis as PORP. ANTENNA prosthesis as TORP.
  • 31. TitaniumTitanium As far back as 1993, a group of surgeons designed the total (Arial) prosthesis and the partial (Bell) prosthesis. These are available commercially from Kurz. In 1996, Spiggle and Theis introduced new titanium prostheses that can be trimmed intraoperatively to the appropriate length
  • 32. Properties of titanium make it possible to manufacture an extremely fine and light prosthesis with rigidity. Differential processing of material surfaces triggers various tissue reactions.rough milled surface are most appropiate in areas of contact of cartilage or stapes. Smoother the surface,less connective tissue reaction.
  • 34. TORPTORP Total ossicular replacement prosthesis used as columellae to bridge the gap between mobile footplate and TM or malleus handle. As used in type 3 tympanoplasty,the outcome and long term prognosis with columella is poorer as it is associated with more pronounced disease and mastoidectomy The risk of fixation is more.
  • 35. Polyethylene,teflonPolyethylene,teflon Columella with tube and a small plateform. Very high extrusion rates.
  • 36. Porous plasticPorous plastic  Columella with tube and broad plateform.  Shaft may be of teflon.  Cartilage – perichondrium graft may be used to cover the plateform.
  • 37. Polycel columellaPolycel columella  Malleable TORP containing stainless steel wire.  Shaft is thin ,can be bent in various planes at various levels,trimmed to various length.
  • 38. Peg TORPPeg TORP  Peg top has a peg on top of plateform to which a cartilage can be mounted.  Peg stem has a peg on distal end of shaft to fit in to stapedotomy,so used in noninfective,intact drum ear with good tubal function.
  • 39. Ceramic columellaCeramic columella  L shaped or angled with 1-3 groove in the plateform.  Small holes at shaft to fix fibrous tissue.  Head may or may not be covered with cartilage.
  • 41. Metal columellaMetal columella  Gold  Stainless steel wire
  • 42. Hybrid prosthesisHybrid prosthesis Combination of various materials to achieve different properties of shaft and plateform to avoid or reduce the risk of prosthesis fixation,extrusion,stability. Usind a plasti pore,polycel shaft provide malleability while plateform of hydroxyapatite provides fixation to TM.
  • 44. Compound columellaCompound columella Plateform is made up of cartilage or bone(ossicle,cortical). Relatively large plateform,but functinal efficacy is not sure. Shaet is of teflon,plasti-pore,polycel.
  • 46. Mechanics of forceMechanics of force transmissiontransmission
  • 47. Which Prosthesis?Which Prosthesis? An otologic surgeon must choose his prosthesis based on the best chance of successful hearing restoration and the lowest chance of complications.
  • 50. Methods of prosthesis preservationMethods of prosthesis preservation  70% ethyl alcohol  0.02% Aqueous Cialit, (Sodium 2- ethylmercurithiobenzoxazole-carboxylate)  4% Buffered formaldehyde fixation and 0.5% buffered formaldehyde preservation.  4% Buffered formaldehyde fixation and 0.02% aqueous Cialit preservation.  0.5% Buffered glutaraldehyde fixation and 0.02% aqueous Cialit preservation.  Freeze-drying and ethylene oxide gas sterilization  4% Buffered formaldehyde fixation followed by freeze drying and ethylene oxide gas sterilization.
  • 51. Defining SuccessDefining Success Attempts have been made to standardize reporting 1995 guidelines of the AAO-CHE Pre and postoperative air-conduction and bone-conduction thresholds are measured at 4 designated frequencies (0.5, 1, 2, and 3 kHz), then averaged Success is defined as a mean postoperative air-bone gap of less than 20 dB and is the main outcome considered for this talk
  • 52. Prognostic FactorsPrognostic Factors It is clear that optimal results depend not only on the qualities of the prosthesis, but also on the environment in which it is placed and the surgical techniques used.
  • 53. Prognostic FactorsPrognostic Factors  Austin (1972) defined four groups in which the incus had been partially or completely eroded:  A, malleus handle present, stapes superstructure present (60% occurrence)  B, malleus handle present, stapes superstructure absent (23%)  C, malleus handle absent, stapes superstructure present (8%)  D, malleus handle absent, stapes superstructure absent (8%)
  • 54. Prognostic FactorsPrognostic Factors  Kartush (1994) proposed a scoring system called the middle ear risk index (MERI) to form an index score to determine the probability of success in hearing restoration surgery.  MERI is used to describe the preoperative middle ear environment at the time of ossiculoplasty  It incorporates different classifications of middle ear disease and ossicular status, including Austin’s
  • 57. Prognostic FactorsPrognostic Factors Ossicular chain status, mucosal status, otorrhea, +/- mastoidectomy, and revision surgery were all significant prognosticators. Of note, presence of the stapes superstructure was not influential. Dornhoffer proposed the Ossicular Outcomes Parameters Staging (OOPS)
  • 58. All studies of prognostic factors identify middle ear mucosal status and presence of malleus handle as important predictors of successful hearing restoration.
  • 59. Options for POR and TOROptions for POR and TOR  With such a variety of options and materials available for reconstructing the ossicular chain, the otologic surgeon must consider using the method that provides the best hearing result with the least chance of complications.  The ideal study for comparison of techniques would be a single surgeon directly comparing techniques or materials on patients who had been risk stratified by a validated prognostic index, with reporting of complication rates and long- term follow up.