Effects of preloads on middle-ear transfer function and acoustic reflex in ossiculoplasty with PORP.

INTRODUCTION: Surgical outcomes in ossiculoplasty with partial ossicular replacement prostheses (PORPs) are greatly influenced by the amount of preload imposed on the PORP. In this study, the attenuation of the middle-ear transfer function (METF) was experimentally investigated for prosthesis-related preloads in different directions, with and without concurrent application of stapedial muscle tension. Different PORP designs were assessed to determine functional benefits of specific design features under preload conditions. METHODS: The experiments were performed on fresh-frozen human cadaveric temporal bones. The effect of preloads along different directions were experimentally assessed by simulating anatomical variance and postoperative position changes in a controlled setup. The assessments were performed for three different PORP designs featuring either a fixed shaft or ball joint and a Bell-type or Clip-interface. Further, the combined effect of the preloads towards the medial direction with tensional forces of the stapedial muscle was assessed. The METF was obtained via laser-Doppler vibrometry for each measurement condition. RESULTS: The preloads as well as the stapedial muscle tension primarily attenuated the METF between 0.5 and 4 kHz. The largest attenuations resulted from the preload towards the medial direction. The attenuation of the METF with stapedial muscle tension was reduced with concurrent PORP preloads. PORPs with a ball joint resulted in reduced attenuation only for preloads along the long axis of the stapes footplate. In contrast to the clip interface, the Bell-type interface was prone to lose coupling with the stapes head for preloads in the medial direction. CONCLUSIONS: The experimental study of the preload effects indicates a direction-dependent attenuation of the METF, with the most pronounced effects resulting from preloads towards the medial direction. Based on the obtained results, the ball joint offers tolerance for angular positioning while the clip interface prevents PORP dislocations for preloads in lateral direction. At high preloads, the attenuation of the METF with stapedial muscle tension is reduced, which should be considered for the interpretation of postoperative acoustic reflex tests.

Three-dimensional quasi-static displacement of human middle-ear ossicles under static pressure loads: Measurement using a stereo camera system.

The time delay and/or malfunctioning of the Eustachian tube may cause pressure differences across the tympanic membrane, resulting in quasi-static movements of the middle-ear ossicles. While quasi-static displacements of the human middle-ear ossicles have been measured one- or two-dimensionally in previous studies, this study presents an approach to trace three-dimensional movements of the human middle-ear ossicles under static pressure loads in the ear canal (EC). The three-dimensional quasi-static movements of the middle-ear ossicles were measured using a custom-made stereo camera system. Two cameras were assembled with a relative angle of 7° and then mounted onto a robot arm. Red fluorescent beads of a 106-125 µm diameter were placed on the middle-ear ossicles, and quasi-static position changes of the fluorescent beads under static pressure loads were traced by the stereo camera system. All the position changes of the ossicles were registered to the anatomical intrinsic frame based on the stapes footplate, which was obtained from µ-CT imaging. Under negative ear-canal pressures, a rotational movement around the anterior-posterior axis was dominant for the malleus-incus complex, with small relative movements between the two ossicles. The stapes showed translation toward the lateral direction and rotation around the long axis of the stapes footplate. Under positive EC pressures, relative motion between the malleus and the incus at the IMJ became larger, reducing movements of the incus and stapes considerably and thus performing a protection function for the inner-ear structures. Three-dimensional tracing of the middle-ear ossicular chain provides a better understanding of the protection function of the human middle ear under static pressured loads as immediate responses without time delay.

Contribution of the flexible incudo-malleal joint to middle-ear sound transmission under static pressure loads.

The incudo-malleal joint (IMJ) in the human middle ear is a true diarthrodial joint and it has been known that the flexibility of this joint does not contribute to better middle-ear sound transmission. Previous studies have proposed that a gliding motion between the malleus and the incus at this joint prevents the transmission of large displacements of the malleus to the incus and stapes and thus contributes to the protection of the inner ear as an immediate response against large static pressure changes. However, dynamic behavior of this joint under static pressure changes has not been fully revealed. In this study, effects of the flexibility of the IMJ on middle-ear sound transmission under static pressure difference between the middle-ear cavity and the environment were investigated. Experiments were performed in human cadaveric temporal bones with static pressures in the range of +/- 2 kPa being applied to the ear canal (relative to middle-ear cavity). Vibrational motions of the umbo and the stapes footplate center in response to acoustic stimulation (0.2-8 kHz) were measured using a 3D-Laser Doppler vibrometer for (1) the natural IMJ and (2) the IMJ with experimentally-reduced flexibility. With the natural condition of the IMJ, vibrations of the umbo and the stapes footplate center under static pressure loads were attenuated at low frequencies below the middle-ear resonance frequency as observed in previous studies. After the flexibility of the IMJ was reduced, additional attenuations of vibrational motion were observed for the umbo under positive static pressures in the ear canal (EC) and the stapes footplate center under both positive and negative static EC pressures. The additional attenuation of vibration reached 4~7 dB for the umbo under positive static EC pressures and the stapes footplate center under negative EC pressures, and 7~11 dB for the stapes footplate center under positive EC pressures. The results of this study indicate an adaptive mechanism of the flexible IMJ in the human middle ear to changes of static EC pressure by reducing the attenuation of the middle-ear sound transmission. Such results are expected to be used for diagnosis of the IMJ stiffening and to be applied to design of middle-ear prostheses.

A New Stapes-Head Coupler for the Vibrant Soundbridge System.

INTRODUCTION: The Vibrant Soundbridge (MED-EL Medical Electronics, Austria) is an active middle ear implant with a floating mass transducer (FMT) for patients with conductive, sensorineural, or mixed hearing loss. While the FMT is vertically aligned above the stapes head (SH) with the current Vibroplasty Clip coupler (MED-EL Medical Electronics), the new SH coupler was developed to mount the FMT on the inferior side of the stapes and to fit in the reduced middle ear space after canal-wall-down mastoidectomy. METHODS: Using 11 human cadaveric temporal bones (TBs), placements of the new SH couplers on the stapes were examined, and effective stimuli to the cochlea were evaluated by measuring piston-like motion of the stapes footplate with a current of 1 mA on the FMT. The results were assessed in comparison with the Vibroplasty Clip coupler. RESULTS: The new SH coupler showed perfect coupling on the stapes in 9 out of 11 TBs. A small gap between the SH and the plate of the connection link part was unavoidable in 2 TBs but had negligible effect on vibrational motion of the stapes. Vibrational motion of the stapes with the new SH coupler was reduced at frequencies above 3 kHz compared to the corresponding motion with the current Vibroplasty Clip coupler, but the relative attenuation over all 11 cadaveric temporal bones was <10 dB. CONCLUSIONS: The new SH coupler provides an alternative with more stable fixation when placement of the current Vibroplasty Clip coupler is limited due to insufficient space after canal-wall-down mastoidectomy, while still delivering effective stimuli to the cochlea.

Preliminary experience and feasibility test using a novel 3D virtual-reality microscope for otologic surgical procedures.

BACKGROUND: Current surgical microscopes suffer from inherent constraints in achievable viewing angles and require manual interaction to control settings. Overcoming these limitations may provide benefits for otologic surgical procedures. OBJECTIVES: We present a first feasibility and usability assessment of a novel commercial surgical microscope featuring a virtual-reality interface and hands-free control of a robot-mounted 3D-camera. MATERIALS AND METHODS: Ex vivo feasibility tests were conducted in a human cadaveric head sample based on common otologic procedures. Usability metrics were obtained from feedback forms. In a first clinical case, the device was used to perform a tympanoplasty in a 68-year-old patient with a subtotal tympanic membrane perforation. RESULTS: Overall practicability of using the device for otologic procedures could be confirmed in the ex vivo tests. Beneficial aspects of the novel system which were subjectively encountered in the ex vivo tests and the first clinical case included hands-free control, visualization quality, and teaching potential. CONCLUSIONS AND SIGNIFICANCE: The novel virtual reality 3D-microscope bears potential to provide benefits for various otologic procedures, which will be evaluated more quantitatively in clinical follow-up studies.

Multiphoton imaging for morphometry of the sandwich-beam structure of the human stapedial annular ligament.

BACKGROUND: The annular ligament of the human stapes constitutes a compliant connection between the stapes footplate and the peripheral cochlear wall at the oval window. The cross section of the human annular ligament is characterized by a three-layered structure, which resembles a sandwich-shaped composite structure. As accurate and precise descriptions of the middle-ear behavior are constrained by lack of information on the complex geometry of the annular ligament, this study aims to obtain comprehensive geometrical data of the annular ligament via multiphoton imaging. METHODS: The region of interest containing the stapes and annular ligament was harvested from a fresh-frozen human temporal bone of a 46-years old female. Multiphoton imaging of the unstained sample was performed by detecting the second-harmonic generation of collagen and the autofluorescence of elastin, which are constituents of the annular ligament. The multiphoton scans were conducted on the middle-ear side and cochlear side of the annular ligament to obtain accurate images of the face layers on both sides. The face layers of the annular ligament were manually segmented on both multiphoton scans, and then registered to high-resolution µCT images. RESULTS: Multiphoton scans of the annular ligament revealed 1) relatively large thickness of the core layer compared to the face layers, 2) asymmetric geometry of the face layers between the middle-ear side and cochlear side, and variation of their thickness and width along the footplate boundary, 3) divergent relative alignment of the two face layers, and 4) different fiber composition of the face layers along the boundary with a collagen-reinforcement near the anterior pole on the middle-ear side. CONCLUSION AND OUTLOOK: Multiphoton microscopy is a feasible approach to obtain the detailed three-dimensional features of the human stapedial annular ligament along its full boundary. The detailed description of the sandwich-shaped structures of the annular ligament is expected to contribute to modeling of the human middle ear for precise simulation of middle-ear behavior. Further, established methodology in this study may be applicable to imaging of other middle-ear structures.