Bone mineral density of the incus body and long process in patients with chronic otitis media and its relationship with functional outcome in type II tympanoplasty.

BACKGROUND: Inflammatory conditions such as chronic otitis media (COM) can cause irreversible impairments in the microarchitecture and functions of the incus, which subsequently leads to conductive hearing loss. OBJECTIVES: To investigate bone mineral density (BMD) of the incus body (IB) and long process (ILP) on preoperative temporal CT in COM patients with and without incudo-stapedial joint discontinuity (ISJD), and also to determine the association between BMD values and the postoperative air-bone gap (ABG) in the ISJD group. MATERIAL AND METHODS: The mean IB density (IBD)/occipital bone density (OBD) and ILP density (ILPD)/OBD values were compared between the patients with and without ISJD. The correlation between ABG gain and preoperative incus density values was assessed in the ISJD group. RESULTS: The mean IBD/OBD and ILPD/OBD values were significantly higher in patients with intact ISJ. There was a moderate positive correlation between postoperative ABG gain and ILPD/OBD values in the ISJD group. CONCLUSION AND SIGNIFICANCE: The decrease in BMD of the incus may involve ILP as well as IB in patients with ISJD caused by ILP lysis in COM. A higher preoperative ILPD/OBD was correlated with a higher postoperative ABG gain in COM patients with ISJD.

Study of Morphological and Anthropometric Features of Human Ear Ossicles.

To study the morphology and anthropometry of human ear ossicles from cadaveric temporal bone and to study the variations of the human ossicles from ossiculoplasty point of view. 38 sets of ear ossicles were collected, each containing malleus, incus and stapes, from temporal bone dissection done in Vasantrao Pawar medical college, Nashik. They were studied under microscope & anthropometrical, morphological evaluation done. Malleus showed variations in handle where 61% were straight and 39% curved. Weight of malleus ranged from 0.03-0.06 gm. The length ranged from 5.5 to 8.2 mm. Incus showed morphological variation in lenticular process which was present in 73% incii. Weight of incus ranged from 0.04 to 0.09 gm, average length of long process 3.5 mm, width of body 4 mm. In stapes variations was seen with head of stapes which was absent in 21% bones. With increasing awareness about postop hearing status, this study will add up in knowledge of morphological and anthropometric variations that exists in Indian population, help otologists to understand middle ear dynamics better which will improve results of ossiculoplasty.

Reconstructive ossiculoplasty options in primary cholesteatoma surgeries with an intact stapes.

PURPOSE: In primary cholesteatoma patients, incus destruction with an intact and mobile stapes is a frequent finding. Different techniques have been described to restore the ossicular chain, including incus interposition, stapes augmentation and type III tympanoplasty. Controversy about postoperative hearing results in open versus closed surgical techniques exist. METHODS: We performed a retrospective analysis of clinical, surgical and audiometric data of patients with primary cholesteatoma surgery operated between 2010 and 2020, and a mobile stapes and one-stage ossicular reconstruction. Pre- and post-operative audiograms were compared for the different surgical groups, mainly focusing on postoperative air-bone gap. Mastoid pneumatization and ventilation was also considered. RESULTS: The mean postoperative air-bone gap (0.5-4 kHz) of the 126 included patients was 20 dB. Hearing after type III tympanoplasty (26 dB) was worse than incus interposition (19 dB) and stapes augmentation (20 dB). Hearing after an open (23 dB) versus closed (19 dB) surgical technique was significantly different. No improvement in air-bone gap was observed for the higher frequencies. CONCLUSION: A residual postoperative air-bone gap should be considered after primary cholesteatoma surgery with intact and mobile stapes. Incus interposition in closed cavity operation is the optimal situation, but open cavity surgery should not be avoided because of hearing. Extent of the disease is prioritized and poorer ventilation before and after surgery may affect postoperative hearing.

Anatomic and morphometric examination of auditory ossicles in sheep.

It is important to know the morphometry of the auditory ossicles for middle ear surgical applications. The present study aims to investigate the morphometric measurements of sheep auditory ossicles and the relationship between these ossicles. In this study, 100 malleus, incus and stapes of 50 Akkaraman sheep were examined using at trinocular stereo microscope and a total of 19 morphometric measurements were taken. The mean values of the morphometric measurements were obtained, and correlation analysis was performed between each part of each auditory ossicle. Similarities were found between the measurements of the lengths of the malleus, manubrium mallei and incus, and the width of the base of the stapes with morphometric measurements in human auditory ossicles. A significant positive correlation was found between the length of the malleus with the length of the manubrium mallei, between the length of the incus with the lengths of the long crus and corpus incudis, between the length of the stapes with the lengths of the rostral crus, caudal crus, caput stapedis, and the length and width of the intercrural foramen. Due to the anatomic similarities between sheep and human auditory ossicles, it was concluded that the auditory ossicles of sheep are suitable for use in the training of human ear surgery applications.

Importance of Diameter of Long Process of Incus in Stapedotomy-New Findings From In Vivo Study

Abstract Introduction Stapes surgery for otosclerosis is a precise surgical procedure. To achieve excellent hearing results, a firm and stable attachment of the prosthesis to the long process of incus (LPI) is necessary. The present study provides details on the attachment site in two dimensions to choose an appropriate prosthesis and to ensure firm attachment for better surgical outcomes. Objective To study the diameter of the LPI and its relevance in determining the piston, used in stapes surgery by an in vivo method. Methods This study was conducted in 41 patients who underwent stapedotomy, where both Anteroposterior (AP) and Mediolateral (ML) diameters of the LPI were measured at the site of attachment of the piston using specially designed instruments, intraoperatively. Radiological data were obtained to measure the LPI diameter from the normal ears of 46 patients. It was measured from both the right and left side, hence 92 LPI diameters were obtained. Results The most commonly used site for prosthesis attachment is between 1-1.5 mm away from the tip of the LPI. We found great variability in the diameters of LPI in the attachment site, with the AP diameter ranging between 0.6 -1.5mm and the ML diameter ranging between 0.5mm-1.2mm. Conclusion Pistons by design have characteristics of gripping incus that will vary between types. Based on LPI dimensions, ideal piston types with appropriate inner loop diameters are suggested in this study. HRCT before surgery should include measurements of the LPI as a guide to the choice of the prosthesis during surgery.

Comparison of dislocation rates of Teflon and Titanium stapes prostheses: a retrospective survival analysis on 855 patients.

BACKGROUND: Stapes prosthesis dislocation is the first cause of revision stapes surgery. To our knowledge, there is no data about stability of the incus attachment of manual crimped prosthesis of different materials. This study aimed to compare the dislocation incidence between titanium and fluoroplastic stapes prostheses. METHOD: A monocentric retrospective cohort study was conducted between January 2013 and June 2022 in a tertiary-care center. All patients that underwent a primary stapes surgery with manually crimped fluoroplastic or titanium prostheses were included. Prosthesis dislocation from the incus was identified intraoperatively or with CT scan. The incidence of stapedial prosthesis dislocation over time was estimated using the Kalbfleisch and Prentice survival analysis method. Other indications for revision surgery prior to prosthesis dislocation were considered as competing events. Differences in the cumulative incidence functions between the fluoroplastic group and the titanium group was assessed using the Gray's test. RESULTS: Eight hundred and fifty-five patients underwent primary stapes surgery during the study period. Fluoroplastic prosthesis was used in 758 (88.7%) cases and titanium prosthesis in 97 (11.3%) cases. Median follow-up was 51.7 months (28.4-80.1). Dislocation was observed in 23 (3.0%) patients with fluoroplastic prosthesis and none (0.0%) in the titanium group. The probability of prosthesis dislocation at two years after surgery was 3.5% in the Teflon group and 0.0% in the Titanium group. No significant difference was found in the cumulative incidence of prosthesis dislocation between the fluoroplastic group and the titanium group (p = 0.12). CONCLUSIONS: Despite lack of statistical power, our results suggest a trend in a more stable incus attachment of manually crimped titanium stapes prosthesis compared to fluoroplastic over time. Further prospective randomized studies could be valuable to assess our findings.

Importance of Diameter of Long Process of Incus in Stapedotomy-New Findings From In Vivo Study.

Introduction Stapes surgery for otosclerosis is a precise surgical procedure. To achieve excellent hearing results, a firm and stable attachment of the prosthesis to the long process of incus (LPI) is necessary. The present study provides details on the attachment site in two dimensions to choose an appropriate prosthesis and to ensure firm attachment for better surgical outcomes. Objective To study the diameter of the LPI and its relevance in determining the piston, used in stapes surgery by an in vivo method. Methods This study was conducted in 41 patients who underwent stapedotomy, where both Anteroposterior (AP) and Mediolateral (ML) diameters of the LPI were measured at the site of attachment of the piston using specially designed instruments, intraoperatively. Radiological data were obtained to measure the LPI diameter from the normal ears of 46 patients. It was measured from both the right and left side, hence 92 LPI diameters were obtained. Results The most commonly used site for prosthesis attachment is between 1-1.5 mm away from the tip of the LPI. We found great variability in the diameters of LPI in the attachment site, with the AP diameter ranging between 0.6 -1.5mm and the ML diameter ranging between 0.5mm-1.2 mm. Conclusion Pistons by design have characteristics of gripping incus that will vary between types. Based on LPI dimensions, ideal piston types with appropriate inner loop diameters are suggested in this study. HRCT before surgery should include measurements of the LPI as a guide to the choice of the prosthesis during surgery.

Considerations on Ossicular Reconstruction Using Lenticular Prosthesis for the Necrosed Lenticular Process During Endoscopic Tympanoplasty in Chronic Otitis Media (Mucosal) Cases.

Purpose: To evaluate hearing outcome and fate of LPIRP (lenticular process of incus replacement prosthesis) prosthesis in the reconstruction of erosion of long process of the incus. Methods: In this retrospective descriptive study 17 patients with erosion of long process of incus who were operated (reconstructed with LPIRP prosthesis) between January 2015 to December 2017 in a tertiary care center were included. The hearing outcome was evaluated by comparing mean PTA and mean ABG preoperatively and postoperatively at the end of 3 months and 18 months. The graft uptake rate, reperforation, and extrusion of the prosthesis were assessed using otoendoscopy. Results: Preoperative mean PTA was 53.8 dB while mean postoperative PTA was 36.6 dB and 33.4 dB at the end of 3 and 18 months respectively (p-value ˂ 0.05). The mean preoperative ABG was 30.2 dB while the postoperative mean was 13.4 dB and 11.2 dB at the end of 3 months and 18 months respectively (p < 0.05). Extrusion with re-perforation was seen only in one case 1/17 (5.8%). Conclusion: LPIRP has all the characteristics for an ideal middle ear implant which is a cost-effective alternative in the reconstruction of an eroded long process of the incus. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03317-5.

Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results.

PURPOSE: To describe the surgical procedure of exclusive endoscopic ossiculoplasty (EEO) with autologous grafts and evaluate audiological results, focusing on the advantages or drawbacks compared to the corresponding microscopic technique. METHODS: A retrospective review of consecutive adult and pediatric patients affected by chronic otitis media (COM) with or without cholesteatoma who underwent EEO was conducted. Only autologous ossiculoplasty was included in the study. The procedure was performed by experienced surgeons of our institution between November 2014 and September 2019. Hearing outcomes were evaluated using postoperative air-bone gap (ABG) and success rates in different subgroups of patients and different types of ossiculoplasty (OPL) were analyzed. Our results were finally compared with the existing literature regarding both microscopic and endoscopic ossicular chain reconstruction. RESULTS: In total, 74 endoscopic ossicular chain repair procedures performed within the study period met the inclusion criteria. Of these, 21 were pediatric patients (28%) and 53 were adults (72%). Surgical reconstruction procedures included 43 partial ossicular reconstructions (POR) and 31 total ossicular reconstructions (TOR). The postoperative ABG improved significantly compared to preoperative measurements, and the mean ABG closure was 7.85 dB HL (p = 0.00064). No statistically significant differences in audiological outcomes between TOR/POR techniques and pediatric/adult groups were found in our study cohort, with p values of 0.10 and 0.88, respectively. CONCLUSIONS: At present, EEO can be considered a valid surgical option for re-establishing a functioning ossicular chain with acceptable hearing restoration in children and adults. Further reports in wider case series are required to confirm these results.

The ear region of the Philippine flying lemur Cynocephalus volans (Placentalia, Dermoptera).

The placental order Dermoptera, which includes two extant species, the Philippine and Sunda flying lemurs, Cynocephalus volans and Galeopterus variegatus, respectively, is generally held to be the sister group of Primates. Yet, little has been reported on their cranial anatomy. Here, the anatomy of the ear region is described and illustrated for a juvenile and adult C. volans based on CT scans. The inclusion of a juvenile is essential as nearly all cranial sutures are fused in the adult. Soft tissues are reconstructed based on sectioned histological pre- and postnatal specimens previously reported by the author. Numerous unusual features are identified, including: a small parasphenoid beneath the basisphenoid, a tensor tympani fossa on the epitympanic wing of the squamosal, a cavum supracochleare for the geniculate ganglion of the facial nerve that is not enclosed in the petrosal bone, a secondary facial foramen between the petrosal and squamosal, a secondary posttemporal foramen leading to the primary one, a subarcuate fossa that is floored in part by a large contribution from the squamosal, a body of the incus larger than the head of the malleus, and a crus longum of the incus that lacks an osseous connection to the lenticular process. Documentation of the anatomy of the Philippine flying lemur ear region is an essential first step in morphological phylogenetic analyses where features of the basicranium are widely sampled.

Long Process Incus necrosis in Revision Stapedotomy: Retrospective Clinical Study.

OBJECTIVES: We describe our experience with long process incus (LPI) necrosis in revision stapedotomy and discuss the different management methods proposed in the literature to identify surgical techniques that can lead to satisfactory results over time. METHODS: Twenty-two stapedotomy revisions, in 21 patients with the necrosis of the long process of the incus, are performed from 1997 to 2017. In cases of erosion or minimal necrosis of LPI, a new prosthesis of the same type or an angled prosthesis was applied higher on the residual incus stump. In cases of partial necrosis of LPI, a Donaldson type ventilation tube reshaped and placed on the residual incus stump to stabilize prosthesis, or glass ionomer bone cement was used. In cases of subtotal necrosis of LPI, a cup piston prosthesis in polycel was applied on incus residual stump. Pre- and postoperative (≥1 year) pure tone audiometry was performed for all cases. Air conduction threshold, bone conduction (BC) threshold, and air-bone gap (ABG) were documented according to the American Academy of Otolaryngology Head and Neck Surgery Committee of Hearing and Equilibrium guidelines. RESULTS: At 1-year follow-up, postoperative ABG was reduced to ≤10 dB in 13 (59%) cases and ≤20 dB in 19 (86.4%) cases. The mean postoperative ABG significantly decreased in each group. There was no significant change in postoperative BC thresholds, and there were no cases with postoperative SNHL. CONCLUSION: Excellent functional results can also be achieved in cases of long incus process necrosis. The choice of technique should be considered according to the degree of necrosis. Piston replacement with the same type or angled type prosthesis, in cases of erosion or minimal LPI necrosis, and modified Donaldson type ventilation tube, in cases of partial LPI necrosis, provided excellent hearing results.

Comparison between incus short process and long process coupling of the vibrant soundbridge in human temporal bones.

OBJECTIVE: The Vibrant Soundbridge (VSB) is one of the most widely used implantable hearing devices. It consists of a vibrating floating mass transducer (FMT) that is connected to a middle ear structure. The standard coupling devices for sensorineural hearing loss are short process (SP) or long process (LP) couplers. DESIGN AND STUDY SAMPLE: This study directly compared the electro-mechanical performance of the SP- and LP-coupled FMT of the VSB in the same temporal bone specimen (n = 10). We measured velocity magnitudes and total harmonic distortions (THD) of the stapes (ST) and the round window (RW) using laser Doppler Vibrometry (LDV). RESULTS: Comparison shows a maximally 10 dB higher magnitude for the LP coupler at ST and RW for frequencies below 600 Hz, whereas the SP coupler shows a maximally 20 dB higher magnitude at the ST and RW for frequencies above 600 Hz. THD show similar behaviour with less distortion at 500 Hz for the LP coupler and less distortions for the SP coupler in higher frequencies. CONCLUSIONS: Our experiments showed that the SP coupling may be mechanically favourable, in terms of magnitude and distortion, for the transmission of FMT vibrations at higher frequencies.

Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition.

OBJECTIVES: to compare hearing outcomes between endoscopic transcanal rebridging with bone cement and endoscopic transcanal incus interposition in patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). METHODS: This retrospective study was performed on 83 ears of 83 consecutive patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). According to the extent of incus long process erosion and subsequent ossiculoplasty technique, patients were divided into 2 groups. Patients in group 1 had erosion involving up to two thirds of the length of the incus long process and underwent endoscopic transcanal rebridging with bone cement. Patients in group 2 had erosion involving more than two thirds of the length of the incus long process and underwent endoscopic transcanal incus interposition. RESULTS: Hearing gain (mean ± standard deviation) was 21.39 ± 2.15 dB in group 1 and 19.71 ± 6.12 dB in group 2. A significantly greater hearing gain was achieved in bone cement group than in incus interposition group (P value < 0.001). Successful hearing outcome (post-operative air bone gap closure within 20 dB) was achieved in 81.6% and 71.1% of patients of group 1 and group 2 respectively. CONCLUSION: Endoscopic transcanal rebridging with bone cement offers greater hearing gain than endoscopic transcanal incus interposition. The two techniques remain reliable and cost-effective techniques in management of patients with incus long process defects. The main limitation of this study was the short follow-up period. Further studies with relatively long-term follow-up are strongly recommended.

Chorda tympani nerve course and feasibility of its preservation during atresiaplasty for congenital aural atresia.

Objectives: The association between the chorda tympani nerve (CTN) and atresiaplasty has not been investigated. This study aimed to describe the course of the CTN observed during atresiaplasty for congenital aural atresia (CAA) and explore the feasibility of CTN preservation. Methods: In this retrospective study, six consecutive patients who underwent atresiaplasty in a tertiary academic center were included. The course of the tympanic segment of the CTN and its preservation feasibility were evaluated. Atresiaplasty was performed using an anterior approach. The average Jahrsdoerfer score was 8.7 points (range, 8-9 points). Results: The CTN was located in the atretic plate in all patients. It emerged from an average of 5.6 mm (range, 5.2-6.1) inferior to the incus buttress and crossed the middle ear in an anterior-superior direction. The distance between the neck of the malleus and the CTN varied in the absence of the malleus handle. However, when the malleus handle developed, the CTN passed between the incus and the malleus handle. The CTN was preserved in two of the six patients. They had a Jahrsdoerfer score of 9 and grade I microtia. Conclusion: The CTN was located in the atretic plate, emerging from an average distance of 5.6 mm inferior to the incus buttress. The incus buttress might serve as a good anatomical landmark to identify and preserve the CTN. CTN preservation is feasible in atresiaplasty candidates with a Jahrsdoerfer score of 9 and auricular deformity of grade I. Level of Evidence: 4.

An Unusual Cause of Hearing Loss: Incudal Osteoma.

Osteoma is common in the temporal bone but extremely rare in the middle ear cavity and incus. Computed tomography plays an important role in the diagnosis of this slow growing benign osseous mass. The treatment of this lesion, which usually causes conductive type hearing loss, includes follow-up and surgery according to the patient's condition.

Revision Stapes Surgery.

Purpose of Review: This review briefly covers the history of stapedectomy, discusses the indications and problems encountered with revision surgery, and provides case examples with solutions. Recent Findings: Revision surgery is challenging and successful outcome even in the most experienced specialists is 45-71%, which is far less than that of primary surgery. Summary: Careful evaluation of the reasons for reoperation, anticipation of the common problems, and patient education on reasonable expectations are all very important for success.

Morphological and Morphometrical Aspects of the Auditory Ossicles in the European Badger (Meles Meles).

Given the scarce morphological data regarding the middle ear anatomy of this species, the paper attempts to describe the morphological and morphometrical data of the auditory ossicles in the badger. The study was performed using the standard morphological investigations and provides a complete morphological description of the ossicular assembly (malleus, incus and stapes) with some comparative features and attempts to provide a complete set of standardized metrical data for each ossicle. A more-detailed attempt to compare some functional aspects in the light of combined metrical ratios is also implied.

Hearing Outcome in Ossiculoplasty With Autologous Incus and Teflon Prosthesis in Chronic Otitis Media: a Comparative Study.

To observe and compare the functional outcome in term of hearing gain in ossiculoplasty with autologous incus and Teflon made TORP/PORP in cases of chronic otitis media (COM) with ossicular disruption. 60 patients of COM between age of 11-50 years who had ossicular disruption were included in the study. They were divided into two groups of 30 patients/ group: group 1 included those patients who had mucosal COM and group 2 included those who had squamous COM. They were further subdivided into 3 subgroups each as per the ossiculoplasty material used. Pre-operative pure tone audiometry (PTA) was done. They all were followed-up at 3 months after surgery and at that time PTA was done. Pre-and post-operative hearing was compared and hearing improvement was calculated in term of air-bone gap (ABG). Out of 60 cases, 16 cases marked as failure of ossicular reconstruction as post-operative A-B gap was > 30 dB. Among these 16 cases, 7 were those patients whom ossiculoplasty was done using autologous incus and in rest 9 patients PORP/TORP was used. Success rate of ossiculoplasty using refashioned incus was 76.66% whereas Teflon TORP/PORP had success rate of 70.00%. We conclude that hearing improvement after ossiculoplasty with autologous incus is better as compare with that obtained by Teflon TORP/PORP. Also, it is a cost-effective method.

Exclusive Two Handed Endoscopic Cartilage Type 3 Tympanoplasty with Endoscope Holders.

In present world of contemporary techniques of microscopic ear surgery and single handed endoscopic ear surgery, we propose the technique of two handed endoscopic tympanoplasty using endoscope holders. The aim of the study  is to evaluate the functional and anatomical results of our technique of endoscopic type 3 cartilage tympanoplasty using endoscope holder. It is a Retrospective Non Randomized Clinical Study. A total of 67 endoscope holder assisted exclusively two handed endoscopic type 3 cartilage tympanoplasties performed from December 2014 to March 2017 with our technique were included in the study. Patients with pars tensa retractions and perforations with absent incus were included in the study. Those with cholesteatoma were excluded from the study. Full thickness tragal cartilage disc of 3 × 3 mm dimensions with a circular slot of 1 mm to fit onto the head of the stapes was used for reconstruction. Tympanic membrane reconstruction was done along with attic reconstruction, using sliced tragal cartilage of 0.5 mm thickness. Patients were assessed at 6, 12 and 24 months for graft status. In early follow up period ranging from 24 to 52 months, the graft take up was seen in 64 ears with three perforations giving a success rate of 95.52%. The pre-operative air-bone gap was 42.6 ± 3.26 dB and the post-operative air-bone gap at 6 months, 1 and 2 years was 18.36 ± 3.46 dB, 19.42 ± 4.32 dB and 19.53 ± 4.33 dB respectively. The study reports good air-bone closure to 20 dB postoperatively following type 3 endoscopic tympanoplasty using endoscope holder. Slotted cartilage graft is definitely an excellent option for ossiculoplasty in cases of absent incus providing a stable assembly. Level of evidence: Level 4.

Progressive Sensorineural Hearing Loss in Vibrant Soundbridge Users Requiring Cochlear Implantation.

Less than 20% of patients with sensorineural hearing loss (HL) provided with the Vibrant Soundbridge (VSB) experience a progressive HL and warrant cochlear implantation (CI). The aim of this study was to identify possible predictors of progressive HL prior to VSB implantation. This retrospective study included all consecutive ears with sensorineural HL provided with the VSB between 1998 and 2016. The patient cohort was divided in a study group comprising patients who underwent CI (CI group) after years of VSB usage and those who did not require VSB replacement during the observational time (control group). Pre- and postoperative pure-tone audiometry thresholds were compared among the two groups. Fifteen out of 81 VSB devices (18.5%) required a CI. The CI group had higher preoperative air-conduction (AC) thresholds than the control group (64.3 ± 8.9 dB vs. 56.3 ± 12.9 dB; p = 0.007) at the time of the VSB implantation. On average, the CI group was significantly younger (39.1 ± 12.3 years vs. 52.6 ± 16.2 years; p = 0.003). In conclusion, VSB users with higher preoperative AC thresholds and younger age at the time of VSB implantation might be at risk for progressive HL within the upcoming eight years and need a further CI surgery. Preoperative counseling is particularly advisable in this patient group.