RECONSTRUCTION OF THE INCUDOSTAPEDIAL JOINT AFTER REMOVAL OF CHOLESTEATOMA

Piotr H. Skarzynski,1,2,3 Marek Porowski,1,4 Maciej Mrowka,1,4 Magdalena B. Skarzynska,3 Roman Barylyak,1,4 Monika Matusiak,1,4 Henryk Skarzynski1,4

1Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2Otolaryngology and Rehabilitation Clinic, Physiotrapy Faculty, Medical University of Warsaw, Nadarzyn, Poland; 3Institute of Sensory Organs, Kajetany, Poland; 4World Hearing Center, Nadarzyn, Poland

Introduction

One of the most common causes of conductive hearing loss (CHL) resulting from chronic inflammation from the middle ear is damaged incudostapedial joint.1,2 Retraction in the rear quadrants of tympanic membrane, cholesteatoma at the mesotympanum, iatrogenic injuries (very rare) and congenital malformation are direct cases of lack of continuity in the ossicular chain at that part.3,4 This study presents surgical procedures in ossicular chain reconstruction, especially after the incidence of cholesteatoma.

Material and method

There were 1147 patients with a damaged incudostapedial joint from the World Hearing Center Institute of Physiology and Pathology of Hearing, during the period 2010–2011. In the pre-operative period the conductive component referred to as air-bone gap was in the range of 15–40 dB SPL, measured at 500, 1000, 2000, 4000 Hz. In the group of patients with evident otoscopic features of a damaged incudostapedial joint, but without tympanic membrane perforation or atrophy of the tympanic membrane, in 20% there was no conductive component of hearing loss (tolerance CHL< 10 dB SPL). This was caused by direct adhesion of the tympanic membrane to the suprastructure of the stapes, what ensured the effective transmission of sounds. There were two methods of surgical procedure: 1) Surgical reconstruction of damaged parts of joint with alloplastic material and glass-ionomeric cement (804 surgeries); 2) Reconstruction when there was perforation of the string connecting structure between the tympanic membrane and the inner ear (343 surgeries). Prosthetic ossicular reconstruction procedures (PORP), total ossicular replacement prosthesis (TORP), bone plate, and cartilage flake were used. After removal of cholesteatoma (when present), the surgeon performed restoration of the incus and its connection between the head or the remnant of the suprastructure of the stapes. During surgery, glass-ionomeric cement was prepared. During non-anatomical reconstructions, PORP-columellas were performed with different materials like remnant of incus, glass-ionomeric prosthesis and titan prosthesis. After surgical treatment, the follow-up period was minimum one year with periodical otoscopic and audiologigal control, and functional results were analyzed. Pure-tone audiometry was performed one month, six months, and one year post-operatively. Post-surgical results were obtained by Pure-Tone Audiometry with frequencies 500, 1000, 2000, 4000 Hz.

Intra-operatively there was confirmed damage of the incudostapedial joint:

409 (36.5%) – chronic otitis media with retraction of tympanic membrane;

388 (34%) – cholesteatoma;

63 (5.3%) – injuries of middle ear;

34 (3%) – iatrogenic injuries due to otosurgical maneuvers;

42 (3.7%) – congenital malformations.

After analysis of patients with the first surgical strategy – reconstruction of incudostapedial joint – among 804 surgeries, sustainable results with reduction of air-bone gap to a level below 5dB SPL were achieved in 97% (786 ears). In nine ears (3%) the hearing result was not sustainable because of disconnection of the connection made with glass-ionomeric cement (eight ears) and extrusion of titan prosthesis (one ear). In many cases it was possible to observe the stapedius muscle reflex after surgery, for example when a reconstruction was performed in which the long process of the incus was connected with the articular disc incudostapedial joint. In nine cases there was re-surgery to reconstruct the connection between incus and stapes. In one case the incus was connected with the perichondrium by myringioplasty.

Of 343 non-anatomical reconstructions, sustainable results were achieved in 237 ears (69%) and no sustainable results were achieved in 106 ears (31%). Lack of good results was caused mainly by dislocation of columella-PORP type in 32 cases (9%) and inability to make a connection with bone plate or cartilage flake in 74 cases (22%). That group of patients underwent resurgery with glass-ionomeric cement (73%) and titan prosthesis (27%) – for example MNP (Kurz). The final results after one year were: the air-bone gap was closed in 91.2% (312 ears); reduction to 10–20 dB SPL in 6.4% (22 ears). Only in 2.4% (8 ears) the results were not satisfactory.

Conclusions

We underline that the surgical issue is to reconstruct the ossicular chain. Sometimes this is not possible, especially in cases of advanced cholesteatoma. It was proven that the ossicular chain could be successfully reconstructed with anatomical reconstruction.5,6 In our opinion good results not only depend on surgical technique, although this is the most important, but also on other factors like movability of other elements of the ossicular chain and the condition of surrounding tissues and the Eustachian tube in the middle ear. Access to different types of prostheses is also very important. The possibility of adaptation of the prostheses to fit individual patients allows us to expect better results. Developing technologies with various materials allow surgeons to choose adequate materials and techniques to obtain the best results after reconstructive surgery.

References

1.Wang LF, Ho KY, Tai CF, Kuo WR, Traumatic ossicular chain discontinuity – reported of two cases. Kaohsiung J Med Sci 15(8):504–509, 1999

2.Tange RA. Ossicular reconstruction in cases of absent or inadequate incus, congenital malformation of the middle ear and epi-tympanic fixation of the incus and malleus. ORL J Otorhinolaryngol Relat Spec 58(3):143–146, 1996

3.Tos M. Pathology of the ossicular chain in various chronic middle ear diseases. J Laryngol Otol 93(8):769–780, 1979

4.Kim DW, et al. Continuity of the incudostapedial joint: a novel prognostic factor in postoperative hearing outcomes in congenital aural atresia. Acta Otolaryngol 131(7):701–707, 2011

5.House JW, Teufert KB. Extrusion rates and hearing results in ossicular reconstrution. Otolaryngol Head Neck Surg 125(3):135–141, 2001

6.Hashimoto S, Yamamoto Y, Satoh H, Takahashi S. Surgical treatment of 52 cases of auditory ossicular malformations. Auris Nasus Larynx 29(1):15–18, 2002


Address for correspondence: Piotr H. Skarzynski, Institute of Physiology and Pathology of Hearing, Zgrupowania AK Kampinos 1,01–943 Warsaw, Poland. p.skarzynski@ifps.org.pl

Cholesteatoma and Ear Surgery – An Update, pp. 271–272

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands