Linear transmission between malleus and stapes in cases with incus necrosis.

OBJECTIVE: The outcome of cartilage interposition ossiculoplasty was assessed in cases of incus necrosis after posterior malleus repositioning in the plane of the stapes, in terms of hearing gain after ossicular reconstruction. METHODS: A retrospective observational study was conducted of 30 patients admitted to an Ain Shams University hospital from March 2021 to September 2021. All patients with ossicular disruption due to chronic suppurative otitis media and hearing loss of more than 40 dB were included in the study. Pure tone audiometry was conducted for each patient after three months, six months and one year post operation. RESULTS: The audiogram showed a post-operative air-bone gap of 20 dB or less in 83.33 per cent of patients (n = 25) at three months post-operatively and in 80 per cent of patients after six months; after one year, the results remained the same. CONCLUSION: The use of cartilage interposition after malleus posterior mobilisation represents an excellent partial ossicular replacement technique.

The Sensitivity of the cVEMP Test in Detecting A Superior Semicircular Canal Dehiscence and the Influence of a Coexisting Incudal Lysis: A Case Report.

In this case report, the air-conducted cervical vestibular evoked myogenic potentials (AC cVEMP) test was only sensitive for the left superior semicircular canal dehiscence (SCD), even though the contralateral SCD was of equal length (2.5 mm). Furthermore, a lysis of the processus lenticularis incudis caused a real conductive hearing loss in the left ear. A diminished left AC cVEMP was thus expected, but the opposite was shown (increased corrected amplitude, lowered detection threshold). The patient only experienced hearing loss, so middle ear surgery was performed to repair the lysis. The postoperative AC cVEMP showed a further "uncovering" of the SCD with increased corrected amplitude on the left but no vestibular symptoms. The significance of an SCD should be interpreted with caution, even when the AC cVEMP and the imaging are significant. Furthermore, AC cVEMPs should not be considered as evidence for the absence or presence of conductive hearing loss.

SEM BSE 3D Image Analysis of Human Incus Bone Affected by Cholesteatoma Ascribes to Osteoclasts the Bone Erosion and VpSEM dEDX Analysis Reveals New Bone Formation.

Bone erosion is considered a typical characteristic of advanced or complicated cholesteatoma (CHO), although it is still a matter of debate if bone erosion is due to osteoclast action, being the specific literature controversial. The purpose of this study was to apply a novel scanning characterization approach, the BSE 3D image analysis, to study the pathological erosion on the surface of human incus bone involved by CHO, in order to definitely assess the eventual osteoclastic resorptive action. To do this, a comparison of BSE 3D image of resorption lacunae (resorption pits) from osteoporotic human femur neck (indubitably of osteoclastic origin) with that of the incus was performed. Surface parameters (area, mean depth, and volume) were calculated by the software Hitachi MountainsMap© from BSE 3D-reconstructed images; results were then statistically analyzed by SPSS statistical software. Our findings showed that no significant differences exist between the two groups. This quantitative approach implements the morphological characterization, allowing us to state that surface erosion of the incus is due to osteoclast action. Moreover, our observation and processing image workflow are the first in the literature showing the presence not only of bone erosion but also of matrix vesicles releasing their content on collagen bundles and self-immuring osteocytes, all markers of new bone formation on incus bone surface. On the basis of recent literature, it has been hypothesized that inflammatory environment induced by CHO may trigger the osteoclast activity, eliciting bone erosion. The observed new bone formation probably takes place at a slower rate in respect to the normal bone turnover, and the process is uncoupled (as recently demonstrated for several inflammatory diseases that promote bone loss) thus resulting in an overall bone loss. Novel scanning characterization approaches used in this study allowed for the first time the 3D imaging of incus bone erosion and its quantitative measurement, opening a new era of quantitative SEM morphology.

Incus Necrosis and Blood Supply: A Micro-CT and Synchrotron Imaging Study.

BACKGROUND: Incus necrosis is a common complication following stapes surgery and is associated with impaired microcirculation. The objective of this study was to investigate the vascular anatomy of the human incus by using light microscopy, micro-computed tomography (micro-CT), and synchrotron phase-contrast imaging (SR-PCI) for a novel three-dimensional (3D) analysis of the middle ear, mucosal folds, major vascular pathways, and intraosseous vascular bone channels. METHODS: One-hundred-and-fifty temporal bones from the Uppsala collection were analyzed under light microscopy. Twenty temporal bones underwent high-resolution micro-CT scanning, and an additional seven specimens underwent SR-PCI at the Canadian Lightsource in Saskatoon, Canada. One of these specimens was from an individual who had undergone stapes surgery. Data were processed with volume-rendering software to create 3D reconstructions using scalar opacity mapping for bone transparency, cropping, and soft tissue analyses. RESULTS: Micro-CT and SR-PCI with 3D rendering revealed the extensive vascular plexus within the un-decalcified incus bone communicating with the exterior surface. The relationship between the vessels, lenticular process, and incudostapedial joint were clearly observed. SR-PCI allowed for histologic-level detail while preserving the specimen and its 3D relationships. CONCLUSION: SR-PCI with 3D reconstructions confirmed the main vascular supply to the lenticular process along the intraosseous lenticular vessels. This is the first synchrotron analysis of a patient having undergone stapes surgery, and it suggests that incus necrosis associated with stapes surgery may be caused by a disruption of the lenticular blood flow induced by the prosthesis loop, and not by strangulation of mucosal vessels as has been previously described.

An Ameloblastoma in the Middle Ear.

An ameloblastoma is a locally aggressive odontogenic tumour that commonly develops from the odontogenic epithelium within the jawbone. Here we present for the first time a case of a rare primary ameloblastoma in the middle ear cavity, along with some consideration of its treatment and a new classification. A 65-year-old woman presented with a left middle ear cavity tumour. Pathological examination led to the diagnosis of an ameloblastoma. We resected the tumour along with an extensive part of the middle ear mucosa, which made it difficult to have an adequate margin. It is recommended that the remaining bone be ground 2-3 mm beyond the visible margin after resecting the gross tumour. Therefore, several cases are treated with conservative surgery, including physicochemical treatment. This factor should be considered when designing treatment strategies as good alternatives in cases where resection with an adequate margin is difficult.

Does The Type of Ossicular Chain Lesion Affect Outcomes in Chronic Suppurative Otitis Media Without Cholesteatoma?

OBJECTIVES: We evaluated the pattern of ossicular chain (OC) lesion in chronic suppurative otitis media (CSOM) without cholesteatoma and its impact on outcomes in primary and revision surgeries. MATERIALS AND METHODS: This was a retrospective chart review. Patients who underwent tympanoplasty due to CSOM with OC defect between 2010 and 2015 were included in the study. RESULTS: OC lesions were found during 40 of 147 tympanoplasties performed due to CSOM. The preoperative air-bone gap (ABG) was greater in both discontinuity and fixation cases than in cases with CSOM with an intact OC (p<0.001). Twenty-nine patients were followed up postoperatively, after excluding four patients with stapes footplate fixation, in whom stapedotomy was not performed simultaneously. Among the 29 patients, the audiological results were similar in cases of discontinuity and fixation regarding gap change, residual ABG, and the rate of successful ossiculoplasty. Primary tympanoplasties provided better results according to postoperative ABG and the rate of successful ossiculoplasty than revision surgeries (p<0.05); however, similar patterns of OC lesions were found during primary and revision surgeries. CONCLUSION: Both OC discontinuity and fixation occur in CSOM in a similar distribution in primary tympanoplasties and revision surgeries. The type of OC lesion does not affect outcomes. Primary surgeries provide better results, but that is not due to a difference in the character of the OC lesion.

Revision Stapes Surgery: A Novel Technique of Overcoming Erosion of the Long Process of Incus Using Hydroxylapatite Cement and Shape Memory Piston.

BACKGROUND: Stapes surgery is performed to treat hearing loss in patients with otosclerosis. Erosion of the long process of incus can occur postoperatively and requires demanding revision surgery to further improve the hearing. The authors describe a novel method of performing revision stapes surgery where there is erosion of the long process of incus. METHODS: A retrospective case series analysis of a database of revision stapes operations performed by one surgeon between July 2013 and December 2017 at a tertiary center was carried out. 26 cases were identified where there was significant erosion of long process of incus. The ossicular chain in these cases was reconstructed using a novel technique of using cement to fix the piston prosthesis to the incus remnant. The full technique is described herein. The pre- and postoperative audiometric data were analyzed. RESULTS: Mean preoperative air bone gap (ABG) was 29.3 dB and mean postoperative ABG was 9.9 dB. Of the 22 patients with recorded postoperative masked bone conduction thresholds, 16 had ABG closure to < 10 dB (72.7%). CONCLUSION: We have shown highly favorable outcomes using this novel technique in addressing erosion of the long process of incus in revision cases for patients with otosclerosis.

Predictable prosthesis length on a high-resolution CT scan before a stapedotomy.

OBJECTIVE: (1) To assess the correlation between preoperative high-resolution CT (HRCT) imaging measurement from the long process of the incus to the footplate and the length of intraoperative selected prosthesis. (2) To determine if HRCT has a predictive value of prolapsed facial nerve during stapedotomy. MATERIALS AND METHODS: We evaluated in our tertiary care center, in a retrospective case series, 94 patients undergoing primary stapedotomy. Preoperative temporal bone HRCT scans were reformatted in the plane of the stapes to measure on the same section the distance between the long process of the incus and the footplate. Measurement was performed by otolaryngology resident and neurotologist. We analyze the interobserver correlation and the mean length measured on the HRCT to the selected prosthesis size intraoperatively. RESULTS: Mean HRCT measurement of the incus long process/footplate distance assessed by the otolaryngology resident and neurotologist was 4.34 and 4.38 mm, respectively. Interobserver correlation was statistically significant [intraclass correlation coefficient (ICC) of 0.679 (p < 0.001)]. Mean selected prosthesis length intraoperatively was 4.36 mm. Correlation between the mean selected length prosthesis and the mean HRCT measurement was also statistically significant [ICC of 0.791 (p < 0.001)]. Postoperatively, a statistical improvement was shown in air conduction (p < 0.001), bone conduction (p < 0.001) and air-bone gap reduction (p < 0.001). 2 cases of facial nerve covering one-half of the oval window were identified by HRCT and confirmed intraoperatively. CONCLUSION: HRCT is a valuable tool to predict preoperatively the length of the stapedotomy prosthesis. Moreover, it might be helpful to identify a potential prolapsed facial nerve, to confirm the diagnosis of otosclerosis and to rule out other abnormalities. Ultimately, it may optimize the stapedotomy procedure planning.

Revision stapes surgery after stapedotomy: A retrospective evaluation of 75 cases.

We retrospectively evaluated a series of 75 surgical revisions after stapedotomy for the treatment of otosclerosis, carried out between 2001 and 2015. Intraoperative findings, causes of failure, and surgical solutions using an angular prosthesis, Causse prosthesis, and glass-ionomer cement were reviewed. Audiometric results performed the day before revision surgery and 1 to 2 months postoperatively were also examined. An incus necrosis was discovered in 65 patients; 55 of whom had partial necrosis of the long process of the incus and 10 with total necrosis. In 5 patients, a dislocation of the foot of the piston alone was recognized, and in 5 patients, a prolapsed facial nerve associated with dislocation of the prosthesis was observed. In this series, the air-bone gap was closed to <10 dB in 89.3%. This percentage differs from that reported in the literature (50 to 60%). No significant postoperative sensorineural hearing loss (>15 dB) was observed in this series. Revision stapes surgery is more difficult and demanding than the first stapes surgery. Revision is a consequence of a delayed erosion of the long process of the incus or a consequence of a poorly performed surgery. Operating in a standardized way, despite the change in basic anatomic conditions, can lead to functional results similar to those of primary surgery.

Risk Factors of Recurrence in Pediatric Congenital Cholesteatoma.

OBJECTIVE: To examine the risk factors of recurrence in pediatric congenital cholesteatoma. STUDY DESIGN: Retrospective chart review. SETTING: University hospital. PATIENTS: Sixty-seven patients having tympanic type of congenital cholesteatoma under 15-years old at surgery. INTERVENTIONS: Canal wall-up tympanomastoidectomy (n = 30) or transcanal atticotomy/tympanoplasty (n = 37) was performed depending on cholesteatoma extension, 16 of which were followed by second-look surgery. Preoperative computed tomography (CT) before second-look surgery or follow-up CT was performed to detect residual recurrence 1 year after the surgery. Cholesteatoma found at the second surgery was also included in the recurrence. All patients had no recurrent cholesteatoma at the last follow-up (median, 61 mo after surgery). MAIN OUTCOME MEASURES: Possible predictive factors were compared between the groups. RESULTS: Residual cholesteatoma and retraction cholesteatoma occurred in 21 and 6%, respectively. There was no significant difference in age, sex, and type of cholesteatoma (open or closed) between the groups; however, Potsic stage and status of stapes involvement were more advanced in the residual cholesteatoma group. All residual lesions could be detected by follow-up CT or by second-look surgery. All of four retraction cholesteatoma patients were male, young at the surgery and in stage IV. CONCLUSION: Recurrence mostly occurred as residual cholesteatoma, suggesting that CT is recommended as a follow-up tool for congenital cholesteatoma. Advanced lesions had the risk of residual cholesteatoma, suggesting that complete removal of epithelium is important. Although rare, young advanced-stage patients had risk of retraction cholesteatoma and therefore normal mucosa should be preserved as much as possible for these patients.

Revision Stapedectomy with Necrosis of the Long Process of the Incus: Does the Degree of Necrosis Matter? A Retrospective Clinical Study.

OBJECTIVE: To discuss the different modalities for managing necrosis of the long process of the incus in revision stapedectomy on the basis of the degree of necrosis and compare the results with those reported in the literature. MATERIALS AND METHODS: Thirty-six patients underwent revision stapedectomy with the necrosis of the long process of the incus from 2009 to 2016. The patients were divided into three groups on the basis of the degree of necrosis. For group A (minimal necrosis), augmentation technique with bone cement was performed. For group B (partial necrosis), the cement plug technique was performed. For group C (sever necrosis), malleus relocation with malleovestibulopexy was performed using reshaped necrosed incus. Air and bone conduction thresholds at frequencies of 500-3000 Hz were reviewed pre- and postoperatively using conventional audiometry. The air-bone gap (ABG) and bone conduction thresholds were measured. RESULTS: Postoperative ABG was reduced to <10 dB in 28 cases (77.8%) and <20 dB in all cases (100%). There was no significant change in postoperative bone conduction thresholds. The mean patient follow-up duration was 23 (range, 18-36) months. The cement plug technique was used in 75% of cases. CONCLUSION: Managing necrosis of the long process of the incus in revision stapedectomy should be considered according to the degree of necrosis. The cement plug technique is considered to be a reasonable option in most cases. Malleus relocation with malleovestibulopexy is an effective alternative to prosthesis.

Incidence, 10-year recidivism rate and prognostic factors for cholesteatoma.

OBJECTIVE: Cholesteatoma patients have a high risk of recurrence with complications, and knowledge exchange is a prerequisite for improving treatment. This study aimed to apply appropriate statistics to provide meaningful and transferable results from cholesteatoma surgery, to highlight independent prognostic factors, and to assess the incidence rate. METHODS: Incidence rates were assessed for the district of Aarhus, Denmark. From 147 patients operated on mainly with canal wall up mastoidectomies for debuting cholesteatomas, 10-year Kaplan-Meier recidivism rates were calculated and independent prognostic factors for the recidivism were identified by Cox multivariate regression analyses. RESULTS: Incidence rate was 6.8 per 100 000 per year. The 10-year cumulative recidivism rate was 0.44 (95 per cent confidence interval, 0.37-0.53). Independent prognostic factors for the recidivism were: age below 15 years (hazard ratio = 2.2; p > z = 0.002), cholesteatoma localised to the mastoid (hazard ratio = 1.7; p > z = 0.04), stapes erosion (hazard ratio = 1.9; p > z = 0.02) and incus erosion (hazard ratio = 1.9; p > z = 0.04). CONCLUSION: The recidivism rate is influenced by several factors that are important to observe, both in the clinic and when comparing results from surgery.

Dissection of the Auditory Bulla in Postnatal Mice: Isolation of the Middle Ear Bones and Histological Analysis.

In most mammals, auditory ossicles in the middle ear, including the malleus, incus and stapes, are the smallest bones. In mice, a bony structure called the auditory bulla houses the ossicles, whereas the auditory capsule encloses the inner ear, namely the cochlea and semicircular canals. Murine ossicles are essential for hearing and thus of great interest to researchers in the field of otolaryngology, but their metabolism, development, and evolution are highly relevant to other fields. Altered bone metabolism can affect hearing function in adult mice, and various gene-deficient mice show changes in morphogenesis of auditory ossicles in utero. Although murine auditory ossicles are tiny, their manipulation is feasible if one understands their anatomical orientation and 3D structure. Here, we describe how to dissect the auditory bulla and capsule of postnatal mice and then isolate individual ossicles by removing part of the bulla. We also discuss how to embed the bulla and capsule in different orientations to generate paraffin or frozen sections suitable for preparation of longitudinal, horizontal, or frontal sections of the malleus. Finally, we enumerate anatomical differences between mouse and human auditory ossicles. These methods would be useful in analyzing pathological, developmental and evolutionary aspects of auditory ossicles and the middle ear in mice.

Revision stapes surgery for lysis of the long process of the incus: comparing hydroxyapatite bone cement versus malleovestibulopexy and total ossicular replacement prosthesis.

The objective of the study was to report audiological results in revision stapes surgery, comparing hydroxyapatite (HAP) bone cement, malleovestibular (MV) prosthesis, and total ossicular replacement prosthesis (TORP). The study is a retrospective case review conducted in a tertiary referral center. Patients treated for revision stapes surgery from 2010 to 2014, where a lysis of the long process of the incus (LPI) was observed with the use of HAP bone cement, MV prosthesis, or a TORP were included in the study. The main outcomes measured were pre- and postoperative bone conduction (BC) and air conduction (AC) pure-tone averages (PTA) (0.5, 1, 2, 3 kHz), including high frequencies BC (HFBC) (1, 2, 3, 4 kHz) and air-bone gap (ABG). 107 revision stapes surgery were performed in 96 ears. Main cause of failure was LPI lysis in 38 cases (39.6 %). 31 patients were analyzed: HAP bone cement was used in 11 patients (Group I), MV prosthesis in ten patients (Group II), and TORP in ten patients (Group III). The mean post-operative ABG was 10.7 dB (±7.4) (p = 0.003), 10.7 dB (±8.8) (p = 0.001), and 16.9 dB (±9.8) (p = 0.001), respectively. There were no significant differences between groups. In Group I, the mean change in HFBC revealed an improvement of 5.6 dB (±7.9) (p = 0.03), while in Group III there was a significant deterioration of the thresholds of 5.8 dB (±7.6) (p = 0.04). There were no cases of post-operative anacusis. In revision stapes surgery when LPI is eroded, we recommend to perform a cement ossiculoplasty for stabilizing a standard Teflon piston when LPI is still usable, the LPI lengthening with cement being not recommended. When LPI is too eroded, we prefer performing a malleovestibulopexy, and reserve TORP for cases with a bad anatomical presentation.

[Clinical analysis of tympanosclerosis: characteristics and treatment].

OBJECTIVE: To explore the clinical characteristics, diagnosis and surgical management of tympanosclerosis. METHOD: The data of 73 patients who underwent surgery for tympanosclerosis were retrospectively analyzed with respects to the clinical characteristics, diagnosis and management. RESULT: Seventy-three patients with tympanosclerosis (involving 73 ears) , including 17 patients with sclerosis of tympanic membrane (type I), 23 patients with fixed Malleus-incus complex (type II), 8 (type III) with fixed stapes, and 25 (type IV) with extensive typannosclerosis. Sclerosis was seen most frequently in the malleus, incus and attic, followed by the tympanic membrane, incudomalleolar joint and other regions. Audiometry was performed for all the patients 1 weeks before and 1 year( the least) after operation, which were (51.70 ± 14.93)dB HL and (36.24 ± 11.58) dB HL respectively, with success rate 83% (61/73). CONCLUSION: Most of the patients suffer from conductive hearing loss. Teatment of the sclerosis around stapes is a key point. Acording to the sites of lesion and hearing level, hearing structures should be reconstructed by the rules of tympanoplasty and stapes surgery.

Histological Changes of the Middle Ear Ossicles Harvested during Cholesteatoma Surgery.

BACKGROUND: In the cholesteatoma surgery ossicles can be replaced to reconstruct middle ear function. It is important that these ossicles are free of squamous epithelium, to prevent residual disease. This study focuses on the histological findings of the malleus and incus harvested during cholesteatoma surgery. MATERIALS AND METHODS: Eighty middle ears ossicles were examined in vivo and histologically to consider the relationship of cholesteatoma to ossicles, grade of bone destruction and invasion of cholesteatoma to deeper layers of bone. RESULTS: Serious ossicular destruction was observed more frequently in incus compared to malleus (p=0.0065). Difference of ossicles destruction between children and adults was not significant (p=0.3032). Deep invasion of cholesteatoma into the vascular spaces or inner core of the bone was not observed. CONCLUSIONS: Autograft ossicles from cholesteatomatous ears should not necessarily be rejected for reconstruction of the ossicular chain. Regarding the histological finding, the authors suggest mechanical cleaning of the ossicle surface to eliminate residual disease.

The incudomalleolar articulation in Down syndrome (trisomy 21): a temporal bone study.

HYPOTHESIS: One reason for conductive hearing loss (HL) in patients with Down syndrome (DS) is structural anomalies in the incudomalleolar joint (IMJ) that impair sound transmission. BACKGROUND: The majority of hearing losses in patients with DS are conductive. One reason is the high incidence of inflammatory processes such as otitis media. However, in some patients, the middle ear seems to be normal. The assumption of structural disorders causing a HL is supported by a previous study revealing structural abnormalities of the incudostapedial joint (ISJ) in these patients. METHODS: In a retrospective analysis, histologic sections of the IMJ of 16 patients with DS were compared with 24 age- and sex-matched subjects with normal middle ear ossicles. The length of 8 parameters of the IMJ were measured at 3 positions and compared between the 2 groups. RESULTS: Age (p = 0.318) and sex distribution (p = 1) for the DS group and the matched controls were comparable. The IMJs (p < 0.001) and the cartilage of patients with DS are significantly wider in most measurements compared with controls. However, the joint space is not significantly different in the 2 groups. CONCLUSION: Conductive HL might be caused by a significantly wider IMJ in patients with DS supporting the findings of a previous study reporting similar findings for the ISJ. The etiology of these findings is unclear. Patients with DS have a high prevalence of deficient collagen synthesis. Immunohistochemical analysis may be needed to investigate the collagen structure of the ISJ and IMJ in patients with DS.

Autologous total ossicular replacement prosthesis.

OBJECTIVE: To develop an autologous total ossicular replacement prosthesis with sustainable hearing results. METHODS: The ears of 40 patients, who had chronic otitis media with absent suprastructure of the stapes and long process of the incus, were repaired using the autologous total ossicular replacement technique. Post-operative results were evaluated after 6 and 12 months on the basis of average pure tone air conduction and average air-bone gap measured at 0.5, 1, 2 and 3 kHz. RESULTS: Successful rehabilitation of pure tone average to 30 dB or less was achieved in 75 per cent of patients, and air-bone gap to 20 dB or less was attained in 82.5 per cent of patients. Overall mean improvement in air-bone gap was 23.9 ± 8.5 dB (p < 0.001). Mean improvements in air-bone gap were significantly greater (p < 0.05) in the tympanoplasty only group (27.3 ± 6.6 dB) and the intact canal wall tympanoplasty group (25.9 ± 6.3 dB) than in the canal wall down tympanoplasty group (16.3 ± 8.9 dB). CONCLUSION: This paper describes an autologous total ossicular replacement prosthesis that is biocompatible, stable, magnetic resonance imaging compatible and, above all, results in sustainable hearing improvement.