Malleus handle: determinant of success in ossiculoplasty

doi:10.1016/j.amjoto.2009.02.014

American Journal of Otolaryngology

Volume 31, Issue 4, July–August 2010, Pages 235-240

https://doi.org/10.1016/j.amjoto.2009.02.014 Get rights and content

Abstract

Objective

The purpose of this study is to identify prognostic factors affecting outcome in ossicular chain reconstruction (OCR).

Study design and setting

This study is a retrospective case series of electronic database at an academic institution.

Materials and methods

We reviewed 209 cases of chronic supportive otitis media performed from January 2000 through December 2007 and collected demographic, clinical, audiologic, and outcome information. Univariate analyses of group differences in terms of postoperative air-bone gap (ABG) changes were evaluated by analysis of variance. Multiple regression analyses were used to examine the relationship between postoperative ABG and the independent variables.

Results

There were 105 cases of OCR the met the inclusion criteria (44 primary and 61 revision tympanoplasties), with an average follow-up of 19 months. The diagnoses were chronic suppurative otitis media without cholesteatoma in 36 cases and cholesteatoma in 69 cases. The mean preoperative ABG was 34 ± 15 dB, and the mean postoperative ABG was 20 ± 14 dB (P < 0.001). Of the independent variables analyzed, the type of procedure (ie, OCR performed during second-look tympanoplasty vs canal wall up vs canal wall down), preoperative ABG, and status of malleus handle were predictive of the success of OCR.

Conclusions

Favorable prognostic factors in OCR include smaller preoperative ABG and the presence of an intact malleus handle.

Introduction

The goal of ossicular chain reconstruction (OCR) is hearing restoration. The literature is extensive with studies comparing techniques, materials, and patient factors that influence OCR outcome. Factors that provide prognostic indications are important for the surgeon to appreciate so as to better counsel their patients. Austin [1] developed a prognostic staging system based on the presence of the malleus handle and the stapes suprastructure. Based on their results, the absences of both the malleus handle and stapes suprastructure carry the worst prognosis. Bellucci [2] developed a classification system based on the status of the middle ear and the presence of otorrhea. This staging system identifies 4 prognostic groups for successful ossiculoplasty, and cases with the worse prognosis were those associated with persistent otorrhea and nasopharyngeal malformations. Black [3] developed the SPITE method of assessment where 5 prognostic factors were identified: surgical, prosthetic, infection, tissue, and eustachian tube. Kartush [4] developed the middle ear risk index, which incorporates both the Austin and Bellucci grading systems as well as including other risk factors. Values are assigned to each risk factor with the worst possible prognosis, which includes the clinical situation of a persistently wet ear with nasopharyngeal abnormality, no ossicles, revision surgery, and the presence of cholesteatoma. The Kartush staging system was analyzed against a series of patients by Dornhoffer [5], whereby the ossiculoplasty outcome parameter staging index was developed. Yung et al [6] analyzed a large series of patients who had undergone ossiculoplasties at 6 months and 5 years postoperatively. He found the absence of the malleus handle, and otorrhea were the most unfavorable factors 6 months postoperatively, whereas absence of the malleus handle was the only unfavorable factor 5 years postoperatively. Also, De Vos et al [7] found the status of the malleus handle to significantly affect postoperative air-bone gap (ABG).

There have been very few studies that have used linear or logistic regression models to analyze prognostic factors in OCR [5], [6], [8], [9]. The purpose of this study is to use regression models to assess the prognostic indications of demographic, audiologic, clinical, and disease factors influencing the outcome of OCR in patients with chronic suppurative otitis media with and without cholesteatoma. These were consecutive cases performed by a single surgeon at a tertiary care academic institution with data collected systematically and prospectively.

Section snippets

Materials and methods

After obtaining institutional review board approval, an electronic database of 209 consecutive cases was reviewed on patients who had undergone surgery for chronic suppurative otitis media from January 2000 to December 2007. All cases were performed by the senior author. The database was analyzed for those patients who met the inclusion criteria for this study: (1) diagnosis of chronic suppurative otitis media with and without cholesteatoma, (2) minimum follow-up of 3 months, and (3) having on

Results

One hundred five patients met the inclusion criteria for this study: 44 primary cases and 61 revision cases. There was no sex predilection (male to female ratio of 1.05:1). The mean age at the time of surgery was 38 years, with a range of 6 to 77 years. The average follow-up was 19 months (range, 3–84 months). Table 1 shows the patients' demographic and clinical data.

The mean preoperative ABG was 33.9 ± 12 dB (range, 5–59 dB), and the mean postoperative ABG was 20.8 ± 13 dB (range, 0–57 dB)

Discussion

In the current study, we used univariate and regression analysis to evaluate demographic, audiologic, and clinical factors in OCR. There are many studies in the literature that have tried to define prognostic indicators in OCR. However, most of these studies are based on a small number of patients and did not use regression analysis to study the combination of variables based on outcome. The present study analyzed many potential prognostic factors using univariate and multivariate models in a

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Real-time monitoring of middle ear prosthesis coupling
2023, Hearing Research
In reconstructive middle ear surgery, acoustic quality has received a high level of attention in recent years. Careful intraoperative selection and positioning of passive middle ear prostheses during tympanoplasty with ossiculoplasty is essential to ensure satisfactory sound transmission and postoperative hearing outcome. The reconstruction quality of the ossicular chain (OC) can be evaluated intraoperatively using a surgical assistance system which is based on a real-time monitoring system (RTM system) that acquires the transmission (middle ear transfer function (METF)) with electromagnetic excitation of the OC. In this experimental study, the METF with electromagnetic excitation of the (reconstructed) OC was compared to usual acoustic excitation and the benefit of the RTM system was investigated for the implantation of partial (PORP) and total (TORP) prostheses.
Laser Doppler vibrometry (LDV) was used to measure the middle ear transfer function (METF) in 18 human temporal bones (TB). The RTM system uses electromagnetic excitation of the OC with a magnet placed on the umbo. Comparatively, measurements with the usual acoustical excitation, using an earphone in the external auditory canal, were performed. The measurements began with the intact OC, followed by real-time monitoring guided OC reconstruction with PORP and TORP. In addition, during the simulation of an intraoperative setting, the influence of the influence of opening (tympanomeatal flap lifted and pushed anteriorly) and closing (tympanomeatal flap folded back) the tympanic membrane on the measurements with the RTM system was determined.
Electromagnetic and acoustic excitation of the intact and the reconstructed OC provided comparable METF. The application of the RTM system significantly improved the quality of the OC reconstruction. The METF increased by up to 10 dB over the entire frequency range during implantation of the PORP with positioning control by the RTM system. When using the TORP, the METF could be improved by up to 15 dB. The opening of the tympanomeatal flap did not affect the measurements with the RTM system at the reconstructed OC.
In this TB study, we demonstrated that the quality of OC reconstruction (improved METF as a benchmark for improved transmission) could be significantly increased by means of a RTM system. Intraoperative studies should now be conducted to investigate to which quantitative extent the intraoperative reconstruction quality can be improved and whether or not this improvement also manifests in an increased (long-term) hearing outcome. This will enable conclusions to be drawn about the contribution of the intraoperative reconstruction quality to the (long-term) hearing outcome in the context of the conglomerate of various factors influencing the postoperative hearing outcome.
Middle ear status in cholesteatoma: Associations among preoperative computed tomography scans, audiological assessments, and intraoperative endoscopic findings
2022, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
The effect of age on ossiculoplasty results: A retrospective evaluation of 60 cases
2020, Auris Nasus Larynx
Citation Excerpt :
Presence of malleus has a predictive value in the success of ossiculoplasty because of its position. Several authors declared that presence of malleus has a valuable prognostic factors in ossiculoplasty success [21–23]. Otherwise, prognostic values of the presence of stapes suprastructure remains controversial issue in ossiculoplasty.
There are only a few studies evaluating ossiculoplasty results in the pediatric age group. Although the effect of different factors on the results of ossiculoplasty is investigated, the effect of age on ossiculoplasty results is not known. In this study, the effect of age on ossiculoplasty results has been investigated.
This retrospective clinical study was performed in 60 patients (30 female, 30 male; mean age 15.5 ± 14.3 years, range 9–57 years) who underwent ossiculoplasty. The cases were divided into two groups according to their age. Group A consisted of pediatric cases younger than 18 years of age and group B consisted of adult subjects (>18 years). The comparison of the groups was made by taking into consideration the air-bone gap in the 3rd and 12th weeks of the pre- and postoperative period.
There was no statistically significant difference between preoperative air-bone gaps of the groups (p = 0.086). In the third postoperative month, the air-bone gap gain of group A was statistically significantly higher than group B (p = 0.0001). The air-bone gap gain of group A was significantly higher than group B in the postoperative 12th month (p = 0.026). The air-bone gap gain of the patients with malleus in group A and group B was higher in the postoperative 3rd month than in the patients without malleus (all p values <0.05). There was no statistically significant difference between the air-bone gap gain in patients with the stapes suprastructure and the air-bone gap gain of the patients without stapes suprastructure in group A and group B in the postoperative 3rd month (p values >0.05).
The results of ossiculoplasty were found better in the pediatric age group. We think that ossiculoplasty should be carried out without delay in the pediatric age group.
Total and partial ossiculoplasty in children: Audiological results and predictive factors of efficacy
2019, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-Faciale
Étudier les résultats de l’ossiculoplastie dans une série pédiatrique et rechercher les facteurs prédictifs d’efficacité.
Nous avons inclus 75 enfants opérés entre 2001 et 2014 par 2 otologistes de l’unité pédiatrique du service d’Oto-Rhino-Laryngologie. Les critères suivants ont été analysés : données démographiques, diagnostic initial, antécédent de tympanoplastie, statut de l’oreille opposée (saine ou atteinte), seuils auditifs préopératoires, technique chirurgicale, constats peropératoires, statut ossiculaire à l’ouverture de la caisse. Les résultats auditifs ont été décrits selon les recommandations de l’American Academy of Otolaryngology-Head and Neck Surgery.
Nous avons inclus 75 patients. Dans le groupe de 48 prothèses totales (TORP), l’âge moyen était de 9,9 ans, le suivi médian de 2,7 ans. À moyen terme, 40 % avaient un Rinne ≤ 20 dB, 68 % une conduction aérienne (CA) ≤ 30 dB. Le gain en CA était de 14,6 dB et 8,7 dB respectivement à moyen et long terme. Il existait une relation statistique significative entre l’absence d’antécédent de tympanoplastie et le succès de l’ossiculoplastie. Le taux de succès était supérieur lors d’une première intervention comparé aux reprises chirurgicales. Dans le groupe des 27 prothèses partielles (PORP), l’âge moyen était de 9,5 ans, le suivi médian de 2,6 ans. À moyen terme, 75 % avaient un Rinne ≤ 20 dB et une CA ≤ 30 dB. Le gain en CA était de 9,3 dB et 5 dB respectivement à moyen et long terme. Aucun des facteurs étudiés n’a influencé la réussite fonctionnelle des PORP.
Cette étude suggère que l’ossiculoplastie totale obtient de meilleurs résultats au premier temps de tympanoplastie. La supériorité des résultats fonctionnels des PORP est confirmée.
Total and partial ossiculoplasty in children: Audiological results and predictive factors
2019, European Annals of Otorhinolaryngology, Head and Neck Diseases
Citation Excerpt :
Like Murphy et al. [8] and Quesnel et al. [18], we found better TORP results when preoperative hearing was normal or hearing loss was merely mild. Intact malleus handle was often reported to be an factor for success in adult ossiculoplasty [22–26], optimizing assembly stability by maintaining the cartilage and preventing extrusion [16,17]. In the present study, ossiculoplasty improved hearing, with a success rate of 75% for PORP and 68% for TORP at 12–18 months.
To assess ossiculoplasty results in children and screen for predictive factors of efficacy.
Seventy five children undergoing ossiculoplasty between 2001 and 2014 in a pediatric ENT department were included. The following data were collected and analyzed: demographic data, surgical indication, history of tympanoplasty, contralateral ear status (healthy, affected), preoperative hearing thresholds, surgical technique, intraoperative findings, and ossicular chain status at eardrum opening. Audiological results were reported according to American Academy of Otolaryngology-Head and Neck Surgery guidelines.
Forty eight patients were included in the total ossicular reconstruction prosthesis (TORP) group. Mean age at surgery was 9.9 years. Mean follow up was 2.7 years. Mean air-bone gap (ABG) closure to within 20 dB was achieved in 40% of cases at medium term (12 to 18 months after surgery). Air conduction (AC) threshold ≤ 30 dB was achieved in 68% of cases. AC threshold improved by 14.6 dB and 8.7 dB at medium and long-term follow-up, respectively. A significant correlation was found between success rate and absence of history of tympanoplasty. The success rate was higher for primary than for revision procedures. Twenty seven children were included in the partial ossicular reconstruction prosthesis (PORP) group. Mean age was 9.5 years, and mean follow-up 2.6 years. Mean air-bone gap (ABG) closure to within 20 dB was achieved in 75% of cases at medium term. AC threshold ≤ 30 dB was achieved in 75% of cases AC threshold improved by 9.3 dB and 5 dB at medium and long-term follow-up, respectively. No predictive factors for success were found in the PORP group.
The present study suggested that total ossiculoplasty leads to better results when performed in first-line. It also confirmed that functional outcome is better in partial than total ossicular reconstruction prosthesis.
Ossiculoplasty in chronic otitis media: Surgical results and prognostic factors of surgical success
2017, Acta Otorrinolaringologica Espanola
Citation Excerpt :
Mills12 reported that the loss of the stapes arch was a factor causing a significantly worse outcome, but only 55 ossiculoplasties were analyzed. Albu et al.13 examined prognostic factors in 544 ossiculoplasties and concluded that the presence of the malleus handle and the mucosal status were the most important predictors in COMWC. Dornhoffer and Gardner12 reported the prognostic factors of 200 ossiculoplasties and concluded that mucosal status, presence of the malleus handle, otorrhea, mastoidectomy, and revision surgery were significant prognostic factors.
The goal of ossiculoplasty is to improve hearing. Successful ossiculoplasty depends on several factors. This retrospective study was carried out to analyze hearing results of ossiculoplasty in ears with chronic otitis media (COM) and evaluate clinical outcomes and factors predictive of hearing improvement.
We reviewed the results of 153 patients with COM (with cholesteatoma (COMC) and without cholesteatoma (COMWC)) who underwent ossiculoplasty between January of 2002 to December of 2011. Several potential prognostic factors were evaluated: cholesteatoma present vs absent; type of surgical procedure, state of the middle ear mucosa, state of the ossicular chain, type of prosthesis.
We analyzed 153 ossiculoplasties: 96 patients presented COMWC and 57 patients presented COMC. The ossiculoplasties were performed using autologous ossicles for the most part. All ossiculoplasties were carried out in one-stage surgery. In 38% of cases ossiculoplasty was combined with mastoidectomy; in the remaining 62% of cases, ossiculoplasty was performed without mastoidectomy. Ossiculoplasty was successfully achieved in 113 patients (74%). The presence of the stapes superstructure and normal mucosa were significant predictive factors of surgical success.
The majority of the ossiculoplasties improved hearing status satisfactorily. Multivariate analysis should be performed to investigate prognostic factors of favorable short-term hearing outcomes after ossiculoplasty. Better knowledge of these predictive factors may contribute to the surgeon's judgment and the information given to patients.
El objetivo de osiculoplastia es mejorar la audición y sus resultados funcionales dependen de varios factores. Se ha realizado un estudio retrospectivo para analizar los resultados funcionales de la osiculoplastia en enfermos con otitis media crónica (OMC) y evaluar los resultados clínicos y los factores pronósticos que influyen en la recuperación auditiva.
Revisión de los resultados de 153 pacientes con el diagnóstico de OMC (con colesteatoma [COMC] y sin colesteatoma [COMSC]) sometidos a osiculoplastia entre enero de 2002 y diciembre del 2011. Los factores pronósticos evaluados fueron: la presencia o no de colesteatoma, el tipo de técnica quirúrgica, el estado de la mucosa del oído medio, el estado de la cadena osicular y el tipo de prótesis.
Se han analizado 153 osiculoplastias: 96 pacientes presentaron COMSC y 57 pacientes presentaron COMC. En la mayoría de las osiculoplastias se utilizó material autólogo. Todas las osiculoplastias se realizaron en un único tiempo quirúrgico. En el 38% de los casos de las osiculoplastias se añadió la mastoidectomía; en el 62% restante de los casos la osiculoplastia se realizó sin mastoidectomía. Se ha lograda una mejoría de la audición en 113 pacientes (74%). La presencia de la supraestructura del estribo y de una mucosa normal fueron los factores pronósticos estadísticamente significativos en el suceso quirúrgico.
La mayoría de las osiculoplastias mejoró la audición de forma satisfactoria. El análisis multivariado permite evaluar cuáles los factores pronósticos de mejoría auditiva a corto plazo tras la realización de la osiculoplastia. Un mejor conocimiento de estos factores contribuye para la decisión del cirujano y la información a los pacientes.

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Original contributionMalleus handle: determinant of success in ossiculoplasty

Abstract

Objective

Study design and setting

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Otolaryngol Clinics of N Am

Otolaryngol Head Neck Surg

Ossicular reconstruction

Arch Otolaryngol Head Neck Surg

Selection of cases of tympanoplasty

Otolaryngol Clinics of N Am

Ossiculoplasty prognosis: the SPITE method of assessment

Am J Otolaryngol

Prognostic factors in ossiculoplasty: a statistical staging system

Otol Neurotol

Long-term results in ossiculoplasty: an analysis of prognostic factors

Otol Neurotol

Original contribution
Malleus handle: determinant of success in ossiculoplasty