Visualization of bone formation in sheep's middle ear by using fluorochrome sequential labelling (FSL).

One factor for the lacking integration of the middle ear stapes footplate prosthesis or the missing healing of stapes footplate fractures could be the known osteogenic inactivity. In contrast, it was recently demonstrated that titanium prostheses with an applied collagen matrix and immobilised growth factors stimulate osteoblastic activation and differentiation on the stapes footplate. Regarding those findings, the aim of this study was to evaluate the potential of bone regeneration including bone remodeling in the middle ear. Ten one-year-old female merino sheep underwent a middle ear surgery without implantation of middle ear prostheses or any other component for activating bone formation. Post-operatively, four fluorochromes (tetracycline, alizarin complexion, calcein green and xylenol orange) were administered by subcutaneous injection at different time points after surgery (1 day: tetracycline, 7 days: alizarin, 14 days: calcein, 28 days: xylenol). After 12 weeks, the temporal bones including the lateral skull base were extracted and histologically analyzed. Fluorescence microscopy analysis of the entire stapes with the oval niche, but in particular stapes footplate and the Crura stapedis revealed evidence of new bone formation. Calcein was detected in all and xylenol in 60% of the animals. In contrast, tetracycline and alizarin could only be verified in two animals. The authors were able to demonstrate the osseoregenerative potential of the middle ear, in particular of the stapes footplate, using fluorescence sequence labelling.

Low-cost simulation model for ultrasound-guided punch biopsy and puncture: Construction manual and photo examples.

PURPOSE: Ultrasound-guided puncture and punch biopsy pose a particular challenge in ultrasound examination training. These techniques should be learned and performed several times using a simulation model that is as realistic as possible before being applied to patients. While the use of agar-agar-based models is extensively documented in the literature, there is a discernible gap in publications specifically addressing their use in punch biopsy and puncture. The aim was to develop a cost-effective model for the simulation of ultrasound-guided interventions. MATERIALS AND METHODS: The developed simulation model is based on the vegetable gelatine agar-agar. The agar-agar powder is boiled in water and colored. Various objects are added to the mass. Blueberries, olives, tomatoes, and cornichons imitate solid structures. Liquid-filled balloons are used to simulate cystic structures. Adding stones can make the exercises more difficult due to hyperechoic reflexes with distal shadowing. RESULTS: With the model, ultrasound-guided puncture and punch biopsies could be successfully simulated, and ultrasound images can be generated for this purpose. The cost of a single model is about 2 euros. Production takes less than 2 hours, including cooling. The pure processing time is 30 minutes. The durability of the models is limited by mold, which occurs after 5 days when stored at room temperature and after 5 weeks in the refrigerator. CONCLUSION: It was shown that it is possible to produce an inexpensive agar-agar-based ultrasound model in a short time and with easily available ingredients to learn ultrasound-guided puncture and punch biopsies.

Virtual Quality Control in Middle Ear Surgery: Is Image-guided Tympanoscopy a Valuable Tool for Depicting Borderline Situations?

HYPOTHESIS: Before modern imaging was introduced, revision surgery was the only way to evaluate possible reasons for inadequate improvement in hearing after ossicular replacement during reconstructive middle ear surgery. BACKGROUND: The aim of this study was to evaluate freely navigable virtual tympanoscopy using different computed tomographic modalities. We compared cone-beam computed tomography (CBCT), flat panel computed tomography (FPCT), and conventional computed tomography in helical mode (CTH), volume mode (CTV), and ultra high resolution mode (CTD). METHODS: Four temporal bone specimens were reconstructed with partial or total ossicular replacement prostheses. The best functional results for prosthetic coupling were achieved under the control of laser Doppler vibrometry (LDV). Afterward, a progressive step-by-step decoupling of the prostheses was carried out. Different prosthesis positions were evaluated by LDV as well as different computed tomographic modalities with 3D reconstruction of each dataset. RESULTS: Anatomical structures were better depicted and the best position and coupling of inserted prostheses were achieved using CBCT. All imaging techniques could be used to control the position of middle ear prostheses, but CBCT provided the highest resolution and the best image quality in both 2D and 3D reformations and in 3D-animated video representation. CONCLUSION: Compared with several other imaging modalities, CBCT was best at depicting miscellaneous coupling problems. Noninvasive detection of coupling problems caused by minimal loss of contact between prostheses and middle ear ossicles will influence the clinical outcome. This early detection will help to determine whether revision surgery is needed.

Retrospective investigation of the prognostic value of the ß1 integrin expression in patients with head and neck squamous cell carcinoma receiving primary radio(chemo)therapy.

This retrospective study evaluated the expression of ß1 integrins and associated proteins as prognostic markers for primary radio(chemo)therapy outcome of patients with locally advanced head and neck squamous cell carcinomas (HNSCC). Tissue microarrays were prepared from 224 HNSCC patients undergoing curative primary radio(chemo)therapy from 1996 to 2005. Staining intensities of ß1 integrin and its downstream-proteins FAK, phosphorylated FAK as well as the ß1 integrin ECM ligands fibronectin and collagen type-I were determined. Their association to the primary endpoint loco-regional control and the secondary endpoints overall survival and freedom from distant metastasis was analyzed by Cox regression. None of the considered molecular parameters showed a significant association with loco-regional control and freedom from distant metastasis. Patients with p16 positive tumors or tumors with a low intensity of fibronectin showed significantly higher overall survival in univariable regression. In multivariable regression including additional clinical parameters, however, these parameters were not significantly associated with overall survival. Our study in a HNSCC patient cohort treated with primary radio(chemo)therapy does not reveal a prognostic value of ß1 integrin expression.

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.

Retrospective Analysis of Hearing-Impaired Adult Patients Treated With an Active Transcutaneous Bone Conduction Implant.

OBJECTIVE: To determine the therapeutic success and safety of an active transcutaneous bone conduction implant (tBCI) in adult patients with conductive or mixed hearing loss. STUDY DESIGN: Retrospective case review. SETTING: Five university hospitals in Frankfurt, Hannover, Dresden, Würzburg, and Vienna. PATIENTS: Data were analyzed from 61 patients (31 women, 30 men) with a mean age of 50 years (min. 26, max. 80). Forty patients had mixed, and 21 conductive hearing loss. Typical etiologies were history of otitis media (n = 20) and cholesteatoma (n = 17). INTERVENTIONS: Implantation of the active tBCI. MAIN OUTCOME MEASURES: Data were analyzed for the following time points: up to 6 months postoperatively ("short-term"), 6 to 37 months postoperatively ("long-term"), and the last available measurement per patient ("most recent"). Pure-tone audiometry (air and bone conduction, AC and BC) and sound field thresholds with warble tones (WT), word recognition scores with Freiburger monosyllables (WRS), as well as speech reception thresholds (SRT) using the Oldenburg sentence test (OLSA) in quiet (SRT) and in noise (signal-to-noise ratio, SNR) were collected. RESULTS: No significant changes in air- and bone-conduction thresholds were observed after implantation. A mean WRS improvement of 54% using the active tBCI was shown at the short-term assessment, i.e., a mean score of 79% compared with 25% in the unaided condition. Results remained stable, with a mean score of 75% at the long-term assessment. SRT in noise improved by 3.6 dB SNR in the implanted ear at the short-term assessment. Overall six adverse events and four serious adverse events were reported, resulting in a rate of 9.84 and 6.56%, respectively. CONCLUSION: The tBCI clearly improves speech intelligibility in patients with conductive or mixed hearing loss, showing stable results up to 1 year post-implantation.

Function, Applicability, and Properties of a Novel Flexible Total Ossicular Replacement Prosthesis With a Silicone Coated Ball and Socket Joint.

HYPOTHESIS: A total ossicular replacement prosthesis (TORP) with a silicone coated ball and socket joint (BSJ) is able to compensate pressure changes and therefore provide better sound transmission compared with rigid prostheses. BACKGROUND: Dislocation and extrusion are known complications after TORP reconstruction, leading to revisions and recurrent hearing loss. Poor aeration of the middle ear, scar tension, and static pressure variations in conjunction with rigid prosthesis design causes high tension at the implant coupling points. METHODS: A novel TORP prototype with a silicone coated BSJ has been developed. Experimental measurements were performed on nine fresh cadaveric human temporal bones of which five were used for a comparison between rigid TORP and flexible TORP tympanoplasty. The middle ear transfer function was measured at ambient pressure and at 2.5 kPa, both positive and negative pressure, applied in the ear canal. RESULTS: The flexible TORP design yields a better transmission of sound after implantation and at negative pressure inside the tympanic cavity, compared with rigid TORP. In average, it provides an equivalent sound transfer like the intact middle ear. At positive pressure, the flexible TORP performs slightly worse. Both performed worse than the intact middle ear, which is related to an uplifting of the prostheses. CONCLUSION: The findings may be considered preliminary as this experimental study was limited to just one of the many different possible situations of tympanoplasty and it involved a small sample size. Nevertheless, the results with the flexible TORP were promising and could encourage further investigations on such prostheses.

Living with otosclerosis: disease-specific health-related quality-of-life measurement in patients undergoing stapes surgery.

INTRODUCTION: Otosclerosis is associated with hearing disability, leading to communication deficits and social and psychological restrictions. The objective of our study was to analyze disease-specific health-related quality of life (HRQOL) after stapes surgery and compare the outcome of HRQOL with audiometric parameters. SUBJECTS AND METHODS: Our clinical case study was conducted at two tertiary referral centers. All the 37 patients who had undergone stapes surgery were analyzed clinically and by audiometric testing (pure tone and speech audiometry) in the pre- and postoperative settings. Disease-specific HRQOL was assessed by the validated Stapesplasty Outcome Test 25 (SPOT-25) pre- and postoperatively. The subjective hearing disability was evaluated by the hearing handicap inventory for adults (HHIA). The postinterventional benefit was measured by the Glasgow Benefit Inventory (GBI). RESULTS: Disease-specific HRQOL improved significantly after stapes surgery in all scales of the SPOT-25. Postoperatively, the total score and the subscore "hearing function" correlated well with the audiometric data. The subscores "tinnitus", "social restrictions", and "mental condition" did not show significant association with audiometric parameters. The comparison of pre- and postoperative HHIA offered a significant improvement in the hearing disability. The scores of the HHIA correlated very well with the audiometric data. The GBI showed a postoperative benefit for each individual patient. CONCLUSION: Stapes surgery leads to a significant improvement in the hearing handicap and of disease-specific HRQOL. The audiometric parameters were shown as not being a sufficient indicator of social and mental well-being. HRQOL outcome measuring instruments should be used routinely in clinical practice to provide an individualized postoperative assessment.

Impact of Prosthesis Length on Tympanic Membrane's and Annular Ligament's Stiffness and the Resulting Middle Ear Sound Transmission.

HYPOTHESIS: Prosthesis' length creates tension in ossicular reconstructions, which directly effects the middle ear sound transmission. BACKGROUND: Relatively long prostheses are often used to stabilize the middle ear reconstruction to prevent dislocation. Thereby, tension on the flexible components such as the tympanic membrane (TM) and the annular ligament (AL) is increased. Only little is known on the amount of displacement-related stiffening of the TM and AL, as well as the consecutive reduction in middle ear transfer function (METF). METHODS: An expandable total ossicular replacement prosthesis was tensionfree inserted in nine cadaveric temporal bones between the malleus handle and the stapes footplate. Upon heat activation the prosthesis was lengthened, thus inducing tension on the reconstruction. The METF was assessed before and after elongation. TM's and AL's stiffness were determined by measuring their force-displacement characteristics. RESULTS: Upon activation the prostheses were elongated between 50 and 200 µm. A frequency-dependent METF reduction was measured with a decrease of 5 to 25 dB below 1.0 kHz. At frequencies >2.0 kHz the reduction was less prominent or the METF showed even an improvement of up to 10 dB. TM's stiffness remained constant during the elongation-induced displacement, whereas the AL's stiffness increased. The METF reduction below 1.0 kHz correlated with the increasing AL's stiffness. CONCLUSION: Tension has a significant impact on the METF after middle ear reconstruction. As little tension as possible should be used to enable best sound transmission. Stabilization of prosthesis should be achieved with dislocation devices to ensure secure coupling to the ossicular remnants without creating additional tension.

Hearing outcome after sequential cholesteatoma surgery.

The objective of this study was to assess hearing outcome after sequential cholesteatoma surgery stratified for exclusively transcanal technique (ETC), combined transcanal and transmastoidal technique (TCM) and canal wall down surgery (CWD) and to analyze the impact of ossicular reconstruction technique (partial ossicular replacement prostheses/PORP and total ossicular replacement prostheses/TORP) on hearing outcome. This study is a retrospective case review and clinical case study conducted in a tertiary referral center. Patients who underwent 376 cholesteatoma surgeries (2007-2009) and 92 ears in clinical re-examination at least 12 months postoperatively were included. Sequential cholesteatoma surgery with ETC, TCM, or CWD; ossiculoplasty with PORP or TORP were the interventions administered. Pre- and postoperative air-bone gap (ABG) and air conduction threshold (AC) for 0.5-3 kHz were the main outcome measures. Overall, the mean preoperative ABG decreased from 25.3 ± 1.3 to 19.8 ± 0.9 dB with a mean ABG closure of 5.4 ± 1.3 dB (p ≤ 0.001). According to surgical technique, the postoperative ABG after CWD 23.5 ± 2.1 was significantly worse compared to ETC (17.3 ± 1.0 dB, p < 0.05) and TCM (19.4 ± 1.3 dB). A significant ABG closure was observed after ETC (6.8 ± 2.0 dB, p < 0.01) and TCM (6.5 ± 2.0 dB, p < 0.01) contrary to CWD (2.1 ± 2.9 dB, p > 0.05). Patients receiving PORP showed a significantly less ABG postoperatively (19.0 ± 0.9 dB, p ≤ 0.05) compared to the TORP group (24.1 ± 2.5 dB). However, a significant hearing gain was assessed after PORP- (4.7 ± 1.6 dB, p ≤ 0.01) and TORP- implantation (10.4 ± 3.7 dB, p ≤ 0.01). Sequential cholesteatoma surgery allowed for an excellent hearing outcome postoperatively. An intact posterior canal wall and a present stapes suprastructure were identified to predict a significantly superior hearing result. In addition to the technical and prosthetic considerations, the audiological outcome was confounded by the attending middle ear pathology.

Health-related quality of life measurement after cholesteatoma surgery: comparison of three different surgical techniques.

The objective of this study was to compare health-related quality of life (HRQOL) after sequential cholesteatoma surgery including exclusively transcanal technique (ETC), combined transcanal transmastoidal technique (TCM) and canal wall down surgery with obliteration (CWD). It was a clinical case study conducted in a tertiary referral center. 97 patients at least 12 months after cholesteatoma surgery were included. Interventions included sequential cholesteatoma surgery with ETC, TCM or CWD; ossiculoplasty with partial and total ossicular replacement prostheses. HRQOL assessed by Chronic Otitis Media Outcome Test 15 including an overall score and three subscores ('ear symptoms', 'hearing function' and 'mental health') as well as a general evaluation of HRQOL and the frequency of physician consultations, audiometric outcome related to HRQOL were the main outcome measures. Patients, who had undergone sequential cholesteatoma surgery, showed moderate restrictions in HRQOL postoperatively. Stratified for the three surgical techniques, patients receiving ETC tended to report lower restrictions in HRQOL. The ETC group offered a significantly lower value in the subscore 'ear symptoms'. The 'hearing function' was attributed to be the most restriction criteria for all techniques. The overall score and all subscores correlated moderately with the postoperative air conduction threshold. The strongest correlation coefficient was achieved for the subscore 'hearing function' (r(s) = 0.49, p < 0.001). Sequential cholesteatoma surgery offers acceptable moderate restrictions in HRQOL postoperatively. Patients receiving canal wall down surgery with obliteration showed equivalent limitations in HRQOL compared to closed techniques (ETC, TCM). The postoperative air conduction threshold was shown not to be a sufficient indicator for HRQOL. Therefore, disease-specific validated and reliable measuring instruments for HRQOL should be transferred from clinical research to clinical practice to provide an individualized postoperative assessment after cholesteatoma surgery.

Sound transfer of active middle ear implants.

Implantable hearing aids are gaining importance for the treatment of sensorineural hearing loss and also for mixed hearing loss. The various hearing aid systems, combined with different middle ear situations, give rise to a wide range of different reconstructions. This article attempts to summarize the current knowledge concerning the mechanical interaction between active middle ear implants (AMEIs) and the normal or reconstructed middle ear. Some basic characteristics of the different AMEIs are provided in conjunction with the middle ear mechanics. The interaction of AMEIs and middle ear and the influence of various boundary conditions are discussed in more detail.

Cholesteatoma recidivism: comparison of three different surgical techniques.

OBJECTIVE: To compare cholesteatoma recidivism rates after exclusive transcanal technique (ETC), combined transcanal and mastoidal technique (TCM, both subsets of intact canal wall technique, ICW), and canal wall down surgery (CWD). STUDY DESIGN: Retrospective case review and clinical case study SETTING: Tertiary referral center. PATIENTS: 406 cholesteatoma surgeries (2007-2009), 116 ears in clinical re-examination at least 1 year postoperatively. INTERVENTION: Sequential cholesteatoma surgery with ETC, TCM, or CWD. MAIN OUTCOME MEASURES: Cholesteatoma recidivism, residual and recurrent disease, localization of recidivism, validity of clinical findings. RESULTS: Out of 406 patients, ETC was performed in 227 (56%), TCM in 122 (30%), and CWD in 57 (14%) cases. Recidivism rates after ICW (15%) and CWD (16%) were almost similar. Recidivism was more frequent after ETC (11%) than after TCM (25%). Residuals were observed in 2% after ETC, 6.5% after TCM, and 7% after CWD. Incidence of recurrent disease was 9% for ETC, 18% for TCM, and 9% for CWD. Preferred localization of recidivism was the tympanic cavity after ETC (92%) and CWD (56%) and the mastoid cavity after TCM (53%). The clinical re-examination showed no further recidivistic disease. CONCLUSIONS: Sequential surgery is an effective and successful strategy in cholesteatoma eradication, providing a similar recidivism rate compared to following cholesteatoma retrograde and resection of the posterior canal wall. Lower recidivism after ETC was observed as a consequence of limited disease and the postoperative middle ear status determined the higher rate of recurrence after TCM. Therefore, the restricted visualization of the middle ear during ICW surgery does not increase the rate of recidivism, compared with CWD, as described in other studies. Cholesteatoma recidivism is mainly attributed to the surgeon's experience that outweighs the chosen strategy.

The ostrich middle ear for developing an ideal ossicular replacement prosthesis.

The aim of the study was to investigate the validity of the avian middle ear model for researching the tympanoplasty mechanics. We studied the morphological details, acoustic transmission and quasi-static behavior of the ostrich tympano-ossicular system. The stained specimens of the ostrich middle ear were examined under a light microscope. The sound transfer function and quasi-static performance of the ostrich middle ear were evaluated using laser Doppler vibrometry. The application of pressure to the tip of the extracolumella causes a buckling movement of the ossicle between the cartilaginous and bony parts. Histologically, the intracolumellar connection can be identified as a junction zone between bone and hyaline cartilage. Sound conduction through the human middle ear is less effective than it is through the ostrich middle ear. The greatest difference (35 dB) was observed in the low-frequency region. Because the extracolumella bends, the medial displacements of the eardrum were not fully transmitted to the footplate. The amplitude of the ostrich columella footplate quasi-static medial displacements significantly exceeded that of the human footplate in both intact and reconstructed middle ears. The ostrich middle ear is a suitable model for designing total ossicular replacement implants. The main protective mechanism in the ostrich middle ear under quasi-static stress is a buckling movement of the extracolumella. The total ossicular prostheses of the new generation should contain an elastic element that allows an adaptation to greater quasi-static eardrum movements.

Microsurgical skills training with a new tympanoplasty model: learning curve and motivational impact.

OBJECTIVES: To evaluate the microsurgical skills training on a tympanoplasty model with regard to the learning curve and the participants' motivation for a surgical specialty. STUDY DESIGN: Randomized controlled prospective study. SETTING: Department of Otolaryngology, Head and Neck Surgery, Medical Campus Carl Gustav Carus at the Technische Universität Dresden, Germany. SUBJECTS: Thirty randomly chosen fifth-year medical students divided into 2 groups. INTERVENTIONS: Group 2 (n = 16) had to perform an ossicular and tympanic membrane reconstruction on a tympanoplasty model on Days 1, 7, 14, and 21 and Group 1 (n = 14) on Days 1 and 21, while observing the procedure at Days 7 and 14. Six otosurgeons served as gold standard. Attempts and time of prosthesis placement and time for tympanic membrane reconstruction were recorded. Tremor frequency and amplitude were obtained at the same time points. An adjusted study interest questionnaire was used to assess students' motivation. RESULTS: Students in Group 2 showed a significant improvement in all reconstruction parameters over the study period compared with both, baseline measurement on first day and Group 1. However, the obtained learning curve did not reach the experts level. Tremor indices and students' motivation showed no correlation with the reconstruction parameters, whereas the training itself had a positive impact on students' interest in the surgical specialty. CONCLUSION: Training with the tympanoplasty model is suitable to acquire first microsurgical motor skills in otolaryngology and to arouse students' interest in the surgical field and otorhinolaryngology.

New total ossicular replacement prostheses with a resilient joint: experimental data from human temporal bones.

HYPOTHESIS: New flexible total ossicular prostheses with an integrated microjoint can compensate for large static displacements in the reconstructed ossicular chain. When properly designed, they can mimic the function of the joints of the intact chain and ensure good vibration transfer in both straight and bent conditions. BACKGROUND: Prosthesis dislocations and extrusions are frequently observed after middle ear surgery. They are mainly related to the altered distance between the coupling points because of large static eardrum displacements. METHODS: The new prostheses consist of 2 titanium shafts, which are incorporated into a silicone body. The sound transfer function and stapes footplate displacement at static loads were evaluated in human temporal bones after ossicular reconstruction using prostheses with 2 different silicones with different hardness values. The stiffness and bending characteristics of the prostheses were investigated with a quasi-static load. RESULTS: The sound transfer properties of the middle ears with the prostheses inserted under uncompressed conditions were comparable with those of ears with intact ossicular chains. The implant with the soft silicone had improved acoustic transfer characteristics over the implant with the hard silicone in a compressed state. In the quasi-static experiments, the minimum medial footplate displacement was found with the same implant. The bending characteristics depended on the silicone stiffness and correlated closely with the point and angle of the load incidence. CONCLUSION: The titanium prostheses with a resilient joint that were investigated in this study had good sound transfer characteristics under optimal conditions as well as in a compressed state. As a result of joint bending, the implants compensate for the small changes in length of the ossicular chain that occur under varying middle ear pressure. The implants require a stable support at the stapes footplate to function properly.

Experience with vibroplasty couplers at the stapes head and footplate.

OBJECTIVE: To report on experiences with implanting the Vibrant Soundbridge (VSB) coupled to the stapes head using a new Clip-Coupler or to the stapes footplate using a new OW-Coupler (CliP- or OW-Coupler Vibroplasty). STUDY DESIGN: Single subject, repeated measures. SETTING: Two university hospital ENT departments. PATIENTS: Fourteen German-speaking patients from 2 European study sites were implanted with either a CliP-Coupler or OW-Coupler attached to a VSB floating mass transducer (FMT). They were evaluated preoperatively and postoperatively for bone and air conduction thresholds with and without the implant, as well as speech perception tests. MAIN OUTCOME MEASURES: Measuring the efficacy and safety of OW- and CliP-Coupler-Vibroplasty as a method to treat mixed hearing loss. RESULTS: Bone conduction thresholds remained stable preoperatively and postoperatively. The patients' average speech perception performances at 65/80 dB (HL) increased from 0.8/13.8% to 63/82%. The pure tone audiograms showed an average improvement in air conduction thresholds after implantation with the VSB of 25 dB at 0.5 kHz to 50 dB at 4 kHz. CONCLUSION: OW- or Clip-Coupler-Vibroplasty using couplers was found to be a straightforward procedure, which produced good results in this group of patients.

Impact of partial mastoid obliteration on caloric vestibular function in canal wall down mastoidectomy.

OBJECTIVE: To evaluate the influence of our technique of partial mastoid obliteration with autologous bone pâté covered by cartilage plates on vestibular stimulation. METHODS: Twenty-six patients who were treated for recurrent chronic otitis media by revision canal wall down tympanomastoidectomy and subsequent partial obliteration were invited for follow-up; 18 patients agreed to a complete follow-up including vestibular testing. Patients received questionnaires for evaluating preoperative and postoperative symptoms associated with vertigo. Examination comprised otomicroscopy, pure-tone audiometry, and caloric testing. RESULTS: Mean follow-up was 6 years. Before surgery, 54% of the patients reported vertigo on caloric stimuli such as wind, water, or suction cleaning of the tympanomastoid cavity. In all patients, these symptoms were suspended after partial mastoid obliteration. The postoperative obliterated cavity volume averaged 3.1 ml. All cavities after surgery appeared completely epithelialized and dry. The postoperative caloric vestibular tests revealed an average nystagmus count of 46 beats per minute compared with 72 beats before surgery. Thus, the partial mastoid cavity obliteration led to a mean nystagmus reduction of 36% in our study group. CONCLUSION: Our technique of partially obliterating tympanomastoid cavities with autologous bone pâté being covered by cartilage plates results in small cavities with complete epithelialization of all surfaces. Furthermore, obliteration of mastoid cavities confers protection to the labyrinthine organ, thereby reducing postoperative vertigo on caloric stimulation.

Osseointegration of titanium prostheses on the stapes footplate.

The success of middle ear reconstructive surgery depends on stable coupling between the prosthesis and residual ossicles. To establish a stable fixed point on the stapes footplate for subsequent prosthesis reconstruction, a titanium footplate anchor was coated with osteoinductive substances to induce a controlled osseointegration on the footplate. Various studies have shown that collagen-based matrices with and without bone growth and differentiation factors can induce and enhance bone formation and consequently increase implant stability. The ears of 23 one-year-old Merino sheep (n = 46) were divided into five groups and implanted with a specially designed footplate anchor. The surface of each implant was modified by applying a collagenous matrix (collagen I or II) either with immobilized bone morphogenic protein (BMP-4) or transforming growth factor-ss, respectively, to stimulate osteoblastic activation and differentiation on the stapes footplate with subsequent osseointegration. Polychrome labeling was used to assess new bone formation and remodeling during the study. After study termination on day 84, synchrotron radiation-based computed microtomography and histomorphometry were used to identify bone implant contact. Eight implants showed radiographical and/or histological evidence of integration by newly formed bone. An osseointegration could histologically be proven in two of these eight specimens, and additional ectopic bone formations were seen in another 21 specimens. In all animals, bone turnover on the footplate was proven by polychrome labeling. This study proves the general ability to induce a controlled osseointegration of titanium implants biologically activated with artificial extracellular matrices on their surfaces on the stapes footplate in a mammalian organism.

Cartilage plate tympanoplasty.

OBJECTIVES: The purpose of this work was to report our modified cartilage plate tympanoplasty technique ("tulip leaves") and to analyze its clinical outcome in primary and recurrent cases of chronic otitis media with and without cholesteatoma. STUDY DESIGN: Clinical retrospective study. METHODS: Patients being operated on with this technique at the University Department of Otorhinolaryngology, Dresden, Germany, between 1993 and 2001 were invited for survey, otomicroscopy, and pure-tone audiometry in 2003. Patients' charts were used to draw necessary conclusions. RESULTS: A total of 39 patients who were treated with this technique after canal wall down tympanomastoidectomy and cavity obliteration were included in this long-term analysis after a median follow-up of 6 years. Seventeen patients (44%) experienced chronic otitis media with cholesteatoma, whereas 22 (56%) of them had a diagnosis of chronic otitis media without cholesteatoma. At the time of examination, all patients displayed a closed tympanic membrane. However, retractions were observed in 19 patients (48%). One patient required (3%) revision surgery for recurrent cholesteatoma due to prosthesis extrusion during the study period. CONCLUSION: On the basis of this study, we recommend the tuliplike arrangement of thin but large auricular cartilage slices for the reconstruction of tympanic membrane defects in high-risk ears. This combination proved its high stability and long-lasting vitality in our long-term study. These characteristics are crucial for permanent disease removal and for reducing the risk of recurrent pathologic abnormality.