Measurement of middle ear transfer function in temporal bones using electromagnetic excitation: Comparison to sound excitation and evaluation of influencing factors.

Hearing a sound produces vibrations of the ossicles in the middle ear, which can be measured in the micrometer to nanometer range. Destruction of middle ear structures results most commonly from chronic inflammatory diseases. In these cases, passive and active middle ear implants are used for reconstruction of the ossicular chain. The positioning of the implants depends primarily on the surgeon's experience. So far, no objective assessment has been conducted to affirm if the chosen positioning is the best in each specific case. We have established a new method, allowing us to measure the middle ear transfer function (METF) intraoperatively. Using the new method, a magnet is placed on the umbo of the malleus handle and is stimulated by a coil positioned underneath the head. The resulting vibration is measured on the stapes footplate using Laser Doppler vibrometry (LDV). Acoustic and electromagnetic excitation show comparable METF in lower frequencies, which differ up to 10 dB in frequencies over 1 kHz. The position of the coil does not play a relevant part in the METF, whereas the location of the magnet on the tympanic membrane highly impacts the METF. This technique demonstrates reproducible results. Electromagnetic excitation is comparable to sound excitation and is suited for measuring the METF. A stable positioning of the magnet on the umbo is essential in order to acquire valid data.

Feasibility Study of a Mechanical Real-Time Feedback System for Optimizing the Sound Transfer in the Reconstructed Middle Ear.

OBJECTIVE: To evaluate electromechanical excitation as an alternative excitation mode for middle ear transfer function (METF) measurements as well as real-time feedback in prosthetic ossicular reconstruction. METHOD: In eight human cadaveric temporal bones, the ossicular chain was excited using acoustic and mechanical (floating mass transducer, FMT) stimulation to determine the METF. After disconnecting the ossicular chain and reconstruction with partial or total prosthesis the METFs were measured again. Continuous FMT stimulation was then applied to improve the prosthesis' position using real-time feedback of the METF. RESULTS: Mechanical stimulation of ossicular vibration showed characteristic differences to acoustic excitation resulting from the force characteristics of the FMT. Furthermore, the interspecimen METF variability was greater with electromechanical than acoustic stimulation because of interspecimen variability in the FMT coupling conditions. When the METF with FMT excitation was used as a real-time feedback tool, a measurable improvement in the quality of ossicular reconstruction could be achieved. CONCLUSIONS: Mechanical excitation is an effective and suitable alternative stimulation method in experimental METF measurements. The system provides real-time feedback for ossicular reconstruction in the experimental setting. Some influencing factors still need to be distinguished for reliable measurements. However, the method does not yet meet the requirements for clinical application as an intraoperative, real-time monitoring tool. However, the system could be an excellent model for high-end cadaveric temporal bone training in ossiculoplasty.

A New Intraoperative Real-time Monitoring System for Reconstructive Middle Ear Surgery: An Experimental and Clinical Feasibility Study.

HYPOTHESIS: Electromagnetical excitation of ossicular vibration is suitable for middle ear transmission measurements in the experimental and clinical setting. Thereby, it can be used as a real-time monitoring system for quality control in ossiculoplasty. BACKGROUND: Positioning and coupling of middle ear prosthesis are a precondition for good postoperative hearing results, but at the same time completely dependent upon the surgeon's subjective judgment during surgery. We evaluated an electromagnetically driven measurement system that enables for in vitro and in vivo transmission measurements and thus can be used as a real-time monitoring tool in ossicular reconstruction. METHODS: For electromagnetical excitation a magnet was placed on the umbo of the malleus handle and driven by a magnetic field. The induced stapes displacement was picked up by laser Doppler vibrometry on the footplate. Measurements were performed on the intact ossicular chain in five cadaveric temporal bones and during five cochlear implant surgeries. Additionally, two ossiculoplasties were performed under real-time transmission feedback with the monitoring system. RESULTS: Experimentally, the equivalent sound pressure level of the electromagnetic excitation was about 70 to 80 dB which is 10 to 20 dB less than the acoustic stimulation. In the intraoperative setup the generated stapes displacements were about 5 to 20 dB smaller compared with the temporal bone experiments. Applied as real-time feedback system, an improvement in the middle ear transfer function of 4.5 dB in total and 20 dB in partial ossicular reconstruction were achieved. CONCLUSION: The electromagnetical excitation and measurement system is comparable to the gold standard with acoustical stimulation in both, the experimental setup in temporal bones as well as in vivo. The technical feasibility of the electromagnetical excitation method has been proven and it is shown that it can be used as a real-time monitoring system for ossiculoplasty in the operation room.

Evaluation of implantable actuators by means of a middle ear simulation model.

The extension of indication of implantable hearing aids to cases of conductive hearing loss pushed the development of these devices. There is now a great variety of devices available with different actuator concepts and different attachment points to the middle ear or inner ear fluid. But there is little comparative data available about the devices to provide an insight into advantages and disadvantages of different types of actuators and attachment points at the ossicular chain. This paper investigates two principle (idealized) types of actuators in respect of attachments points at the ossicular chain and direction of excitation. Other parts of implantable hearing aids like microphone, amplifier and signal processing electronics were not incorporated into this study. Investigations were performed by means of a mathematical simulation model of the middle ear (finite element model). Actuator performance and theoretical gain were calculated by harmonic analysis in the frequency range of 100-6000 Hz and were compared for the different situations. The stapes head proofed to be an ideal attachment point for actuators of both types as this position is very insensitive to changes in the direction of excitation. The implantable actuators showed higher ratio of equivalent sound pressure to radiated sound pressure compared to an open hearing aid transducer and should therefore allow for more functional gain.

Experimental investigation of rotational tomography in reconstructed middle ears with clinical implications.

A large air-bone-gap after ossiculoplasty may be due to a malpositioned or displaced prosthesis. Rotational tomography (RT) has the potential to provide high-resolution images of implants without artifacts and with less radiation dosage than CT scan. Twenty-seven temporal bone specimens underwent measurements of middle ear transfer function using Laser-Doppler-Vibrometry (LDV) before and after placement of ossicular replacement prostheses (PORPs, TORPs) made of titanium. RT was performed on all specimens. RT allowed 3-dimensional viewing of the temporal bone, accurate localization of implants within the reconstructed middle ear and determination of angles between the inserted prostheses and the tympanic membrane (TM) and/or the malleus handle (MH). Presence or absence of contact between the implant and the TM, malleus or stapes could be clearly visualized. Displaced prostheses were readily identified. The functional LDV-measurements for TORPs showed a trend favoring coupling to the malleus handle, while for PORPs, coupling to the TM was favored. For PORPs, sound transmission was worse with increasing angles between the PORP and stapes superstructure (p<0.05). Following our experimental results RT is an innovative, relevant and useful imaging technique to obtain immediate postoperative feedback after ossicular reconstruction and to precisely determine the position of middle ear implants.

New aspects in the clinical diagnosis of otosclerosis using laser Doppler vibrometry.

HYPOTHESIS: Laser Doppler vibrometry (LDV) applied to umbo motion measurement in healthy and otosclerotic ears shows statistically tested differences. BACKGROUND: The LDV is a research tool that measures middle ear function by registering sound-induced tympanic membrane velocity. Its possible application in the diagnosis of different middle ear disorders, especially otosclerosis, is currently being evaluated. Established diagnosis can identify various ossicular chain pathologies in most cases but is still sometimes contradicted by the findings of surgical middle ear exploration. METHODS: We used a fractionally modified LDV setting as previously reported to evaluate 150 normal-hearing ears and 49 ears with conductive hearing loss. In a first step, the impact of age variation on the umbo transfer function was investigated by dividing the normal-hearing population into 3 age groups. In a second step, the control group was compared with patients with conductive hearing loss; certain patterns in the umbo transfer function were especially investigated by discriminant analysis. RESULTS: Mean magnitude of the oldest group was found to be significantly higher than the other 2 groups, but it was not possible to diagnostically classify the 3 groups. Discriminant analysis revealed the linear term of a cubic polynom to significantly best describe the umbo transfer function in normal ears (p < 0.0005; partial eta = 0.866) and in otosclerotic ears (p < 0.0005; partial eta = 0.799). Separating otosclerotic ear from normal-hearing ear evidence suggests a sensitivity of 82% and specificity of 92%. CONCLUSION: Evaluation of LDV magnitude curve patterns gives helpful information in the diagnosis of otosclerosis but does not suffice as a single diagnostic tool.

Partial ossicular reconstruction: comparison of three different prostheses in clinical and experimental studies.

OBJECTIVE: To compare the reconstruction results of a long incus process defect using 3 different partial ossicular replacement prostheses (PORP). STUDY DESIGN: Temporal bone experiments and retrospective case review. SETTING: Tertiary referral center. EXPERIMENTAL MATERIAL AND PATIENTS: The experimental study was performed on 18 temporal bones; 66 patients with retraction pockets, chronic otitis media with or without cholesteatoma. INTERVENTIONS: Ossiculoplasty using 3 different PORP: titanium angle prosthesis, autologous incus interposition, and titanium clip prosthesis. MAIN OUTCOME MEASURES: Laser Doppler vibrometry in temporal bones measured transmission properties of the PORP. Patients were retrospectively assessed up to 5 years after surgery. Audiologic data were analyzed for preoperative and postoperative air conduction and air-bone gap at 0.5, 1, 2, 3, and 4 kHz. Statistical analyses compared the outcome in the experimental and clinical setting. RESULTS: Experimentally, the titanium PORP showed similar transmission properties because the overall difference to the intact specimen was -4.14 +/- 0.59 dB for the titanium angle prosthesis and -4.61 +/- 0.57 dB for the titanium clip prosthesis. The transmission after an autologous incus interposition was significantly worse (-9.32 +/- 0.39 dB, p < or = 0.001) compared with the other prostheses. Patients' mean postoperative air-bone gap was 25.5 +/- 1.2 dB and less than 20 dB in at least 66% of cases without any significant differences between the groups. CONCLUSION: In the clinical setting, the confounding factors that influence the acoustic outcome after partial ossiculoplasty obscure the prosthesis-related transmission factors that can otherwise be derived in the experimental setting. The results do not generally favor the use of 1 specific prosthesis, rather they suggest that the correct choice of a prosthesis be based on the anatomic and pathophysiologic conditions found in the individual patient.

Laser Doppler vibrometry of the middle ear in humans: derivation dependence, variability, and bilateral differences.

OBJECTIVE: Derivation dependence, inter- and intrasubject/intertest variability, bilateral differences of the eardrum vibration characteristics have been investigated using laser Doppler vibrometry (LDV). MATERIAL AND METHODS: A total of 31 normally hearing adults were examined. In each subject, both ears were consecutively stimulated by the chirp acoustic stimulus that covered 500-3700-Hz frequencies. The laser beam was directed to and the reflection was consecutively picked up from the tympanic membrane surface. RESULTS: LDV curves derived from different eardrum loci possessed dissimilar characteristics. The derivation area dependence was particularly apparent for the stimulus frequency constituents above 1500 Hz. The intersubject variability of LDV parameters exceeded the intrasubject/intertest one. The intersubject divergences looked selectively distinct for the frequencies over 2000 Hz. Under repeated recordings, LDV parameters remained stable. The intertest differences, if appeared, concerned predominantly the magnitudes of separate frequency bands. LDV waveforms registered by experienced and beginner investigators were alike. Bilaterally derived LDV curves regularly differed from each other. In individual cases, the bilateral divergences approximated the intersubject deviation. CONCLUSIONS: The derivation area on the eardrum should be taken into account when estimating the actual LDV recording. Over repeated recordings in separate individuals, LDV waveforms are stable while the experience of investigator has slight if any influence on the principal LDV characteristics. Due to bilateral differences in the middle ear transfer function, in LDV testing of the ear suspected to the pathology, LDV recording from the opposite healthy ear could hardly be taken as an appropriate reference sample.

Noise exposure of the inner ear during drilling a cochleostomy for cochlear implantation.

OBJECTIVES: Inserting an electrode array into the cochlea may cause inner ear trauma, which has to be minimized, particularly in cochlear implant patients with substantial residual hearing. Another potential inner ear trauma has, to a large extent, been neglected so far: the acoustic trauma that can occur during cochleostomy using different techniques. In this study, the noise exposure of the inner ear during the drilling procedure was re-evaluated. In experiments on temporal bones, quantitative measurements of sound pressure level (SPL) were carried out while a cochleostomy for cochlear implantation was drilled. STUDY DESIGN: Experimental study. MATERIALS AND METHODS: Acoustic measurements during different drilling procedures were carried out on four human temporal bone preparations equipped with microphones attached to the round window. Special calibrations were carried out, which allowed determination of SPLs affecting the cochlea during the drilling procedure. RESULTS: The highest SPLs measured on the cochlea were recorded when a still-intact endosteal membrane was touched by the burr. The SPL exceeded 130 dB and reached a level almost comparable with the situation when the ossicular chain is touched by a running burr. CONCLUSIONS: In the drilling procedure for a cochleostomy, the inner ear may be affected by very high SPLs, particularly if the endosteal membrane is left intact and comes into contact with the running burr. Of course, the resulting SPLs depend on the drilling speed and the size and characteristics of the burr (larger burrs cause higher SPLs); however, we are of the opinion that the cochlear function is at risk, anyway, if special precaution is not exercised. Even when working with reduced drilling speed, the surgeon should be aware of the high risk in the form of an acoustic trauma, which may endanger residual hearing. Recommendations in terms of "soft surgery" are given in the paper (e.g., the use of microhooks instead of a drill to remove the very last shell of bone covering the cochlea).