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Revision Ossiculoplasty

Revision Ossiculoplasty

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Published by: api-19500641 on Nov 26, 2009
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Revision Ossiculoplasty
Ravi N. Samy, MD, FACS*,
Myles L. Pensak, MD, FACS

The Neuroscience Institute, Department of Otolaryngology,
University of Cincinnati/Cincinnati Children\u2019s Hospital Medical Center,
Cincinnati, OH, USA

Although ossiculoplasty was attempted initially in the early 1900s, it was not until the era of Wullstein[1] and Zollner[2] in the 1950s that it became commonplace and relatively well understood. Since then, there have been numerous technologic advances and a gain in the understanding of ossicu- loplasty, also known as ossicular chain reconstruction (OCR). However, even in primary cases performed by an experienced otologic surgeon, suc- cessful OCR with resulting long-term stability can be a daunting task. This is even more true for the occasional otologic surgeon and for revision cases. Typically, the most common condition requiring revision OCR is chronic suppurative otitis media (COM) with or without cholesteatoma. Pri- mary and revision OCR is performed also for blunt and penetrating trauma- induced conductive hearing loss (CHL), congenital defects (eg, atresia), and benign and malignant tumors. Typically, reconstruction in ears with COM is more di\ufb03cult than in ears without infection.

The anatomic goal of OCR is to restore the middle ear transformer mech- anism. OCR is not performed if cochlear function is poor, particularly with regards to word discrimination. OCR is also contraindicated in an only hearing ear; a hearing aid is the preferred option in this instance. Patients with bilateral CHL should have the worse hearing ear operated on \ufb01rst; an alternative to this approach is to operate on the more diseased ear in pa- tients with bilateral COM[3].

The goal of revision OCR is the same as for primary OCR: to obtain both objective (audiologic, clinical examination) and subjective success. Although some surgeons avoid revision OCR in the pediatric population because of concerns about the aggressive recurrence of chronic ear disease (particularly in those under the age of 5 years), others perform OCR to minimize the

* Corresponding author.
E-mail address:ravinsamy@mac.com(R.N. Samy).
0030-6665/06/$ - see front matter\u00d3 2006 Elsevier Inc. All rights reserved.
Otolaryngol Clin N Am
39 (2006) 699\u2013712
potential for de\ufb01cits in acquiring language and to improve speech produc-
tion and school performance.
Several issues must be considered before proceeding with revision OCR:
\ue000Realistic expectations for the patient and surgeon, including chance for

\ue000Eradication of chronic ear disease or cholesteatoma
\ue000Possibility of staging to maximize chances of success
\ue000Discussion of alternative methods of sound ampli\ufb01cation (ie, hearing

aids, including bone-anchored hearing aid (BAHA) placement)

The only surgically attainable goal may be control of infection, particu- larly in revision procedures involving COM. In some patients, ampli\ufb01cation may be indicated, instead of an attempt at revision OCR[3]. To maximize the chances of success of revision OCR, the surgeon must understand the factor or factors that may have contributed to failure of the initial OCR, in- cluding persistent or recurrent COM, excessive \ufb01brosis, eustachian tube dys- function (ETD), and poor surgical technique[4]. The surgeon must also consider each of the following anatomic factors as potential contributors to OCR failure, singly or in combination: middle ear, mastoid, tympanic membrane (TM), remnant ossicular chain, and type of prosthesis. However, success correlates more often to middle ear or mastoid pathology and aera- tion than to the prosthesis itself[5].

Preoperative evaluation and prognosis assessment

A thorough preoperative history is performed \ufb01rst. Comorbidities (eg, di- abetes, coronary artery disease, and so forth) must be considered. The ben- e\ufb01ts of surgery must outweigh the risks of surgery and anesthesia. Preoperative clearance by a primary care physician, specialist (eg, cardiolo- gist), and anesthesiologist may be warranted. Patients are advised against smoking, to prevent postoperative wound healing complications and to erad- icate the negative e\ufb00ect smoking has on eustachian tube function and middle ear disease[6]. All available outside records, including the prior operative re- port, should be reviewed. A detailed head and neck physical examination, with emphasis on the otologic portion, is performed. Otomicroscopic evalu- ation with pneumatic otoscopy and tuning fork tests is conducted. Detailed audiologic testing with pure-tone air and bone conduction, tympanometry, speech recognition, and word recognition is performed. In revision cases, CT scanning (in the axial and coronal planes, 0.5 mm or 1 mm cuts, and bone windows) is performed. The scan can assist in determining areas of tegmen erosion, facial nerve dehiscence, otic capsule erosion, and prosthesis position. MRI with gadolinium can be ordered if there is concern about encephalocele formation or impending intracranial complications.

The chances of surgical success are related to the severity of pre-existing
chronic ear disease, ETD, and other complicating factors. Strati\ufb01cation

systems have been developed for prognosis and to compare results among patients, surgeons, and prostheses. Classi\ufb01cation systems developed for prognostic purposes are used variably, and include factors such as middle ear disease (granulation tissue, e\ufb00usion, otorrhea), smoking, presence of a perforation, cholesteatoma, ossicular defects, and previous surgery. The greater the number of adverse factors, the less the chance of a good post- operative hearing result. These patients may do much better with a hearing aid. The goal of a classi\ufb01cation system is to improve preoperative assess- ment and prognostication for an individual patient, and to allow better comparisons among di\ufb00erent prostheses, surgeons, and for research and re- porting purposes. One such method of assessment was reported by Black

[7]in 1992, who reviewed 535 ossiculoplasties. He identi\ufb01ed 12 features

and divided them into \ufb01ve groups: S-surgical, P-prosthetic, I-infection, T- tissue, E-Eustachian tube (SPITE). He compared the results for his patients implanted with plastipore prostheses with the results for those implanted with hydroxylapatite (HA) prostheses; he found no signi\ufb01cant di\ufb00erence between the two groups, when accounting for the di\ufb00erent factors.

Eustachian tube

A properly functioning eustachian tube is the most important factor in the creation and maintenance of aeration in the middle ear space. Without adequate eustachian tube function, one cannot obtain a long-term improve- ment in hearing results with revision OCR. Adequate eustachian tube func- tion ultimately will determine the size of the middle ear space. The minimal amount of air required in the middle ear space for OCR is approximately 0.4 mL. The type of surgical approach used also a\ufb00ects middle ear volume (and the size of the prosthesis needed). For example, canal wall down techniques narrow the middle ear space.

ETD contributes to OCR failure by narrowing the middle ear space and contributing to prosthesis extrusion. Methods to treat and improve ETD in- clude treatment of allergies, laryngopharyngeal re\ufb02ux, smoking, and ob- struction of the middle ear and nasopharyngeal ori\ufb01ces (eg, due to granulation tissue/hypertrophic mucosa and adenoid hypertrophy, respec- tively). Direct medical or surgical treatment of the eustachian tube to im- prove function has been proposed (eg, tuboplasty); however, it remains to be seen whether these options will adequately treat this elusive problem for the long term. Another option to alleviate ETD is to place a ventilation tube at the time of OCR or postoperatively, if needed. Some surgeons tend to avoid placement of ventilation tubes because of the possibility of in- creased risk of otorrhea and the need for water precautions.

Although ETD plays the most important role in chronic ear disease and a\ufb00ects OCR results, no manner exists in which to quantify eustachian tube function objectively. Evaluation of contralateral ear function, assessment of TM position and mobility, the existence of retraction pockets, the ability of


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