Long term results of the titanium clip prosthesis.

The objective of the study is to evaluate the long term results of ossiculoplasty using the clip titanium partial ossicular replacement prosthesis. This study retrospectively reviews the partial ossiculoplasty conducted using clip titanium partial ossicular replacement prosthesis at a tertiary referral center. Audiometric outcomes and intraoperative findings were postoperatively measured from revision surgery of 47 ears (20 women, 27 men, mean age 43 years) averaging 6.5 years. The overall air-bone gap decreased from 25.7 dB preoperatively to 16.8 dB 6.5 years postoperatively (p ≤ 0.001, η p2  = 0.210). An air-bone gap of <20 dB was present in 28 % of ears preoperatively and increased to 72 % postoperatively. In revision (n = 30) and primary tympanoplasties (n = 17), the preoperative air-bone gaps were reduced from 28.9 and 20.1 to 18.7 dB (p ≤ 0.001, η p2  = 0.240) and 13.2 dB (p = 0.033, η p2  = 0.192), respectively. In canal wall down (n = 15) procedures and tympanoplasties with intact canal wall (n = 32), the mean air-bone gaps diminished from 28.9 to 18.1 dB (p = 0.02, η p2  = 0.245) and 24.2 to 16.1 dB (p ≤ 0.001, η p2  = 0.221), respectively. In our own revision tympanoplasties (n = 8) and second look operations (n = 6), we found that the prostheses were safe to remove without any deleterious effects. Two prostheses were dislocated from the stapes' head due to recurrent cholesteatoma. Therefore, it can be concluded that ossiculoplasty using the clip partial ossicular replacement prosthesis allows for good and reliable long term hearing results. Also, the flexible strips reveal no adverse effects on the encompassed stapes' head and do not complicate revision surgery.

The value of digital volume tomography in assessing the position of cochlear implant arrays in temporal bone specimens.

OBJECTIVES: Radiological evaluation of the position of cochlear implant (CI) devices is an upcoming method for quality control after CI surgery. First, results of imaging of the middle and inner ear with digital volume tomography (DVT) show considerable advantages such as exceptional image quality, thin slice thickness, and low radiation dose. The aim of this study was to evaluate whether DVT is an appropriate method for postoperative imaging of CI patients and to identify the exact position of the implant array within the cochlear by multiple measurements. DESIGN: Thirteen formalin-fixed temporal bone specimens were implanted with a CI array and scanned in DVT. To determine the exact electrode position, these specimens were ground and stained for microscopic measurements. The measurements on grindings acted as a referee and were compared with the measurements in DVT scans. The statistical analysis between the two measurement protocols was performed using the Bland-Altman method. RESULTS: Best achievable agreement between DVT scans and histological reference was shown. Mean differences between DVT and grindings from -1.55 to -65.40 microm were calculated. All means are within the region of accuracy. General positioning of the implant into the cochlea could be verified in all specimens. The exact position of the implanted array within the cochlear scalae could be recognized correctly in 11 of 13 cases in DVT. It was possible to identify shiftings between the tympanic and vestibular scalae in all cases. CONCLUSION: DVT seems to be a convenient technique for postoperative position control after cochlear implantation.

Long-term Results of the Cartilage Shoe Technique to Anchor a Titanium Total Ossicular Replacement Prosthesis on the Stapes Footplate After Type III Tympanoplasty.

Importance: Multiple techniques for a more secure and stable anchoring of the foot of a total ossicular replacement prosthesis (TORP) on the footplate have been proposed. To address this issue, a technique was developed that fits a cartilage shoe into the oval niche to guide the base of the prosthesis into a preformed central perforation. Objective: To evaluate the long-term results of the cartilage shoe technique used to anchor a titanium TORP on the stapes footplate in patients after type III tympanoplasty. Design, Setting, and Participants: Medical record review of total ossiculoplasties at a single center. The study included all patients who had undergone a tympanoplasty using a TORP between January 1, 2004, and December 31, 2008, at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Cologne, Cologne, Germany. Main Outcomes and Measures: Hearing thresholds were determined by a 4-frequency (500-4000 Hz) pure-tone average air-bone gap (PTA-ABG). Intraoperative findings from revision surgery and second-look operations are reported. Results: Forty-two ears were eligible for follow-up examination, averaging 6.8 years (range, 4.8-9.1 years) after surgery, that comprised otoscopy and audiometry. The mean age of 22 women and 20 men was 42.8 years (age range, 6-78 years). The overall PTA-ABG decreased from a mean (SD) of 33.0 (8.4) decibels (dB) before surgery to a mean (SD) of 22.0 (10.1) dB after surgery (P ≤ .001, η = 0.402). Before surgery, 64% (27 of 42) of the patients had a PTA-ABG exceeding 30 dB, which was 30 dB or less in 76% (32 of 42) of the patients after surgery. After canal wall down (n = 18) and tympanoplasties with intact canal wall (n = 24), the PTA-ABG was reduced from a mean (SD) of 33.0 (8.9) dB to 24.6 (11.2) dB (P = .01, η = 0.271) and from a mean (SD) of 32.0 (7.3) dB to 19.6 (9.2) dB (P ≤ .001, η = 0.511), respectively. For transmeatal revision ossiculoplasty (n = 33), the PTA-ABG improved from a mean (SD) of 32.0 (8.6) dB to 21.0 (10.2) dB (P ≤ .001, η = 0.389), similar to primary ossiculoplasty (n = 9), with a mean (SD) of 33.0 (5.5) dB PTA-ABG before surgery and a mean (SD) of 21.0 (9.8) dB PTA-ABG after surgery (P = .005, η = 0.478). Intraoperative findings from revision surgery (n = 11) during the study period and second-look procedures (n = 7) showed that the cartilage shoe prevented a lift off the footplate in all but 2 patients, even in the presence of recurrent cholesteatoma. Conclusions and Relevance: The use of the cartilage shoe that anchors a titanium TORP on the stapes footplate can be advocated for good and reliable long-term results after total ossiculoplasty.

Combined endoscopic and transcutaneous approach for immobile parotid stones.

CONCLUSION: Salivary stones in the parotid gland that are not amenable to endoscopic extraction can safely be removed by a combined, endoscopic-external approach. OBJECTIVE: Limitations for endoscopic removability of salivary stones from the parotid gland are immobile stones in the deeper salivary duct system. A combined endoscopic and transcutaneous approach gives access to these stones with possible preservation of the parotid gland. METHODS: A total of 10 consecutive patients were treated using the combined approach for the management of sialolithiasis of the parotid gland. The patients had previously undergone a sialendoscopy under local anesthesia and were proven to have large, immobile salivary stones in the salivary duct. RESULTS: In all patients, the procedure was successfully conducted with extraction of impacted stones. In 60% of the patients, a temporary stenting of the salivary duct was performed. All patients showed good clinical results with restored drainage of the salivary duct system and preserved gland function.

Comparison of digital volume tomography and high-resolution computed tomography in detecting superior semicircular canal dehiscence--a temporal bone study.

CONCLUSION: In detecting a thin bony coverage of a superior semicircular canal (SSC), digital volume tomography (DVT) scans in Poeschl projection seem to be superior to high-resolution computed tomography (CT) scans. Still, a definite diagnosis of SSC dehiscence (SSCD) is not possible with any radiologic imaging technique. OBJECTIVE: To compare CT and DVT to find out whether DVT is equal, better or worse in showing a thin bony layer on top of an SCC. METHODS: In 11 human temporal bone specimens, the SSC was microscopically blue-lined leaving a thin bony coverage on top of it. All specimens were assessed with both high-resolution CT and DVT. After reconstructing the images in Stenvers and Poeschl projections, all images were evaluated by five independent examiners experienced in radiologic imaging of the temporal bone using a four-point ordinal scale, from 1 (distinct dehiscence) to 4 (distinct coverage). RESULTS: The mean score for all CT scans was 2.58 compared with 3.22 for DVT scans (p = 0.000). Poeschl projection showed a mean score of 3.25 compared with 2.55 for Stenvers projection (p = 0.000). The best imaging modality was found to be DVT scans in Poeschl projections, with a mean score of 3.60.

Radiologic examinations in human temporal bone specimens using digital volume tomography and high-resolution computed tomography after implantation of middle ear prosthesis and cochlear implant electrode array.

INTRODUCTION: Adequate imaging of the middle ear and its surrounding structures is an essential preoperative part in ear surgery. In the past, the main disadvantage of computed tomography (CT) scanners was the decreased diagnostic quality due to metallic artifacts. Furthermore, these scanners showed mostly an inferior image quality compared to digital volume tomography (DVT) in the temporal bone. It was the aim of this experimental study to compare the image quality of a state-of-the-art dual-source 2 × 128-slice CT scanner to DVT in temporal bone specimen. MATERIALS AND METHODS: Metallic prosthesis (PORP, TORP, stapes piston, cochlear implant electrode array) and an autologous incus were implanted in temporal bone specimen to analyze the diagnostic quality concerning the characterization of anatomic structures. Three further temporal bones were scanned without any preparation. Independently, 2 otologists and 2 radiologists scored the image quality of defined anatomic structures, using a range from 4 (excellent) to 0 (no diagnostic value). RESULTS: The general score for DVT was 2.67, whereas CT reached a score of 2.76. The diagnostic value for hard contrast objects was 3.0 for DVT and 2.9 for CT, whereas the score for soft tissue was 1.1 for DVT and 2.3 for CT. Almost no quality reduction of the display of anatomic structures caused by metallic artifacts could be detected in both diagnostic modalities. DISCUSSION: Both DVT and high-resolution CT allow good overall image quality in temporal bones, with discrete advantages for digital volume tomographic scans in terms of the image quality of hard contrast objects like bony structures or metallic implants.

The sandwich cartilage shoe technique for ossicular reconstruction in a case of an unsecure stapes footplate.

This article describes a new surgical method for total ossicular reconstruction in a case of a broken stapes footplate. We developed the technique of the "cartilage shoe sandwich," which consists of two surgical steps. First, the closure of the oval window is achieved by a cartilage shoe without a central perforation. During this surgical intervention, the prearrangement of a secure placement of a total ossicular replacement prosthesis is provided by a second cartilage with a central hole that is plugged with silicone. In a staged procedure, the silicone plug is removed and the ossicular reconstruction can be performed. The audiological results of the first patients show a stable inner ear function with an air-conduction gain of 9 dB. The technique described herein has proven to be safe and reliable in total ossicular reconstruction in the event of an unsecure stapes footplate.

Analysis of the fossa olfactoria using cone beam tomography (CBT).

CONCLUSION: A cone beam tomography (CBT) examination of the olfactory area with its different variants allows development of an individual anatomical-radiological risk profile of the ethmoid and the identification of so-called 'dangerous ethmoids.' OBJECTIVE: Preoperative imaging performed with high-resolution CBT is imperative for analysis of the risk of injuring the olfactory fossa during sinus surgery. This study aimed to analyze the relevant parameters. METHODS: This was a retrospective, single-center study of 141 patients. The Accu-I-Tomo F17 was used. Keros type, the point of the anterior ethmoid artery, and the angle between the lateral lamella and the cribriform plate (α(lc)) were evaluated. RESULTS: The Keros types were distributed as follows: type I, 13% (α(lc): 131°); type II, 64% (α(lc): 116°); type III, 23% (α(lc): 108°) (p < 0.001). The angle of the olfactory fossa and the position of the anterior ethmoid artery (free course: α(lc)=112° vs integrated into the skull base: α(lc)= 120°) was significantly different. DISCUSSION: Surgical procedures in Keros type III where the height of the lateral lamella is much longer than in type II or type I, with an angle of nearly 107° between the lateral lamella and the cribriform plate, are expected to be safer in comparison with Keros type II with 116° and Keros type I with 131°.

Digital volume tomography (DVT) measurements of the olfactory cleft and olfactory fossa.

CONCLUSION: Preoperative imaging is important, because of the small size of the cribriform plate, different anatomical variants of the olfactory fossa in varied patients and unequal width of the cribriform plate in the anterior and posterior third. OBJECTIVE: Digital volume tomography (DVT) is a rather new imaging technique for the diagnosis of diseases of paranasal sinuses. This technology is dedicated to the evaluation of the distinctive structures of the anterior skull base due to the high resolution of the DVT. Based on the Keros classification this anatomic area was analyzed radiologically and also in relation to the uncinate process. METHODS: The investigation was performed on 111 patients. The Accu-I-tomo F17 was used. Patients with total nasal polyposis and patients who had undergone sinus surgery were excluded from the study. RESULTS: Keros type I was found in 11.25% of the patients, type II in 68.05% and type III in 20.7%. Significant asymmetry of the olfactory fossa was identified in nine patients (8.1%). The width of the olfactory cleft varied from 0 to 3.25 mm. No relation between Keros type and a particular onset of the uncinate process to orbit, skull base or middle turbinate could be detected.

Digital volume tomography (DVT) as a diagnostic modality of the anterior skull base.

CONCLUSION: Because of high resolution and the relatively lower costs in comparison with modern helical CT scanners, digital volume tomography (DVT) can be recommended in the diagnosis of the nasal cavity and paranasal sinuses. OBJECTIVES: DVT is an advancement of panoramic tomography and is based on the principles of rotational tomography. It enables high resolution visualization of osseous structures. The slices can be displayed in three orthogonal planes that can be changed in angle arbitrarily. Data volumes of up to 12×17 cm can be examined with a new generation of the DVT. The aim of this study was to point out the potential of DVT in the anterior skull base. SUBJECTS AND METHODS: DVT scans with a cylindrical size of 10 cm in diameter and 10 cm in height were performed in 23 patients. The identification of surgical key landmarks (uncinate process, middle turbinate, ethmoidal bulla, agger nasi cells, Haller cells, frontal recess, anterior ethmoidal artery in its relationship to the skull base, the cribiform plate of the sphenoidal sinus in relation to the optic nerve, and the internal carotid artery) was evaluated. RESULTS: Display of the essential surgical key landmarks was possible in all patients.