OSSICULOPLASTY WITH

AUTOLOGOUS GRAFTS/RESHAPED
INCUS VS PROSTHETIC
MATERIALS:COMPARATIVE STUDY

DR ANJALI A R
 OSSICULOPLASTY
• Ossiculoplasty is defined as the reconstruction of the ossicular chain to
surgically optimize ME transformer .
• IDEAL PROSTHESIS :-
• Biocompatible
• Stable
• Safe
• Easily insertable, easy to manipulate
• Capable of yielding optimal sound transmission
• Selection of a particular prosthesis, must be based on several factors, including
compatibility and ease of configuring the prosthesis during surgery
• The goal of ossiculoplasty in individuals with conductive hearing loss is
to improve hearing.
• Success of ossiculoplasty is influenced by :-
• status of the middle ear mucosa and ossicles
• surgical technique
• Eustachian tube function
• Other factors affecting postoperative hearing results include :-
• patient age
• length of the prosthesis
• revision surgery
• Otorrhea
• tympanic membrane perforation
• cholesteatoma
 OSSICULAR RECONSTRUCTION
• MATERIALS USED ARE:-

ALLOPLASTIC
• Biocompatible-
BIOLOGICAL Teflon(PTFE),Protoplast,Sialastic,Stainless
Autologous/homograft ossicles steel,Ti,Au
Bone • Bioinert-derivatives of Al oxide
Cartilage • Bioactive-Bioglass,Ceravita,Hydroxyapatite
 AUTOLOGOUS GRAFT
• Include ossicles(incus, malleus),
cartilage(tragal,conchal,chondral), and cortical bone.
• Adv:
• They have a very low extrusion rate
• no risk of transmitting disease
• Biocompatibility
• no necessity for reconstitution.
• Disadv:-
• Prolonged operating time
• Displacement
• complete absorption
• small remnant size& possibility of harboring microscopic disease
 HOMOLOGOUS OSSICLES
• Healthy ossicles that were removed from patients for various reasons
during middle ear and mastoid surgery or from cadavers were stored in
alcohol and used for ossiculoplasty in other patients. –OSSICLE BANK
• Concerns about transferring prions of Creutzfeldt Jacob Disease as well as
the advent and ready availability of ossicular prostheses have minimised
this practice.
• However, some countries still permit allogeneic ossicles to be used based
on donor selection criteria and special processing methods.
 ALLOPLASTC PROSTHESIS
• Made up of plastic, ceramic, Teflon, wire prosthesis such as stainless steel, tantalum,
platinum, hydroxyapatite, and Ti are in use, but none had fit in the criteria of an ideal
graft.
• Adv:-
• Available pre-sculptured with every type and design
• Surgery time reduced
• No risk of residual disease
• Disadv:-
• High cost
• Ossicular necrosis
• Extrusion
• Extrusion of the prostheses is reported as high as 39% and can be significantly reduced by
placing cartilage or bone b/w the TM & the prosthesis
• TITANIUM
• Has been used as an excellent material for ossicular reconstruction.
• Has good long term success rates.
• high biocompatibility, osseointegration, biostability, , low ferromagnetism ,
light weight &rigid, making it a good sound conductor
Study1

INDIAN JOURNAL OF OTOLOGY DEC 2011

• AIM:-
• To analyze and compare the outcomes of ossiculoplasty in terms of hearing results and graft
take-up rates, using autograft incus and titanium middle ear prosthesis in patients with ossicular
chain erosion.
• Design: Randomized clinical trial.
• Materials and Methods:-
• Patients b/w 10 and 60 years of age
• history of chronic ear discharge with moderate conductive deafness (>40 dB HL)
• underwent detailed ENT examination f/b audiological and radiological assessment of
temporal bone
• those patients with evidence of ossicular erosion were subjected to ossiculoplasty with
autologous incus (group I) or titanium prosthesis (group II) randomly.
• The patients were followed up after 3 months to analyze the functional and anatomical
results.
• Results:-
• A total of 24 patients with ossicular chain defect were included in the study
• 12 patients underwent ossiculoplasty with autograft incus and 12 with titanium prosthesis.
• Postoperative hearing evaluation by pure tone audiogram was done after 3 months, which
showed successful hearing improvement in 58% of cases with autologous incus as compared to
33% cases with titanium prosthesis. Complications and extrusion rate were also higher in patients
with titanium prosthesis.
• Conclusion:-
• Hearing results after ossiculoplasty with autologous incus were
signifcantly better compared with those after titanium prosthesis.
Also, complications and extrusion rate were higher in patients with
titanium prosthesis.
• This indicates that ossiculoplasty with autoincus offers better hearing
results with minimal complications and extrusion rates as compared
to titanium prosthesis.
STUDY 2
• AIM:-
• To analyze and compare the outcomes of ossiculoplasty in
terms of hearing results, intra and post operative course,
using autograft incus and titanium middle ear prosthesis.
• Study design: Prospective cohort study

• Materials & Methods: 

• Patients with a history of chronic ear discharge and conductive deafness were
included in the study.
• Out of 21 patients with ossicular chain defect included in the study, 10
patients underwent ossiculoplasty with autograft incus and 11 with titanium
prosthesis.
• Pure tone audiogram was done after three months.
• Results:- 
• Three patients underwent only Tympanoplasty post operative PTA was 42 ±
5.292 dB (incus- 39 dB, titanium- 48dB) and hearing gain was 13.33 ± 12.583
(incus-20dB, titanium-0dB).
• Five patients underwent intact canal wall with Tympanoplasty: Post
operative PTA was 35 ± 3 dB (incus-35dB, titanium-30dB) and hearing gain
was 23 ± 15.379 (incus-18.33dB, titanium-30dB).
• Thirteen patients underwent canal wall down procedure with
Tympanoplasty: Post operative PTA was 45.67 ± 5.228 dB (incus50.4dB,
titanium-41.8dB) and hearing gain was 9.33 ± 12.309 (incus-2.4dB, titanium-
14.285dB).
• Complications in the short period studied were nil in both groups.
• Conclusion:-
• Incus and titanium has equal postoperative hearing .In terms of hearing gain
Titanium prosthesis gave a better hearing gain than Ossicular transposition
STUDY 3
• AIM:-
Autologous reshaped Incus and Teflon partial ossicular replacement prosthesis (PORP) are
commonly used for ossicular chain reconstruction. The present study attempts to assess the post-
operative outcome with these two prostheses.

• STUDY DESIGN:-Randomized Prospective study

• SETTING:-tertiary care hospital of West Bengal between February 2017 and March
2018.
• MATERIALS & METHODS:-
• Patients presenting at OPD with the clinical diagnosis of COM with perforation or
retraction were selected.
• The study population consisted of a total of 50 patients. Ossiculoplasty with
reshaped Incus or PORP was performed after Canal Wall Up mastoidectomy.
Hearing results were measured by Air-Bone gap in PTA after 6 months of surgery.
• Results:-
• Selecting the criteria <20 dB ABG as success when Stapes superstructure is
present, Incus has 64.29% success rate, whereas PORP has 31.81% success.
• Extrusion rate of different prosthesis shows PORP has 18.18% extrusion whereas
autologous Incus has lower (7.14%) extrusion rate.
• Conclusion:-
• Among these two ossiculoplasty materials, autologous Incus gives better
postoperative hearing gain and lower extrusion rate.
STUDY 4

INDIAN JOURNAL OF OTOLOGY

• AIM:- 
• The objective was to determine which material, among autologous cartilage,
autologous incus and partial ossicular replacement prosthesis (PORP), gives
better postoperative hearing result in ossiculoplasty. 
• Study Design: Nonrandomized prospective cohort (longitudinal study)
• Settings: Tertiary referral center.Nil Ratan Sircar hospital MCH.
• Materials and Methods:
• Patients with clinical diagnosis of CSOM with cholesteatoma or granulation tissue were
selected.  Exclusion criteria were patients having complications , those patients who had
lost stapes superstructures or intact ossicular chain.
• Necessary preoperative investigations including pure tone audiometry (PTA).
• Total 50 patients were taken in the study group. 
•  Ossiculoplasty with cartilage, incus and PORP after modified radical mastoidectomy. 
• Hearing results were measured by PTA-air bone gap (PTA-ABG) after 6 months of
operation. 
• RESULTS :-
• Among the 50 patients in this study 15 underwent cartilage ossiculoplasty, 19 by
autologous incus and 16 by PORP.
• When incus is used as graft material, only 21.05% patients has ABG > 30 db.
Whereas cartilage has 40% and PORP has 43.75%.
• <20db postoperative ABG is considered as a success, incus - 73.68%, cartilage -
60% and PORP - 56.25% success rate.
• Extrusion rate of different prosthesis shows, PORP - 25%, cartilage - 20%
extrusion. Incus -5.26% (lowest). 

• Conclusion
Among the ossiculoplasty materials, autologous inucs gives best postop hearing
gain and lowest extrusion rate.
STUDY 5
• AIM:-
Study was aimed to prove the utility of the middle ear risk index score and its
predictive value in hearing outcome. Hearing results for different reconstruction
materials (autologous incus,cortex bone,plastipore PORP)was also evaluated.

• Study design:-Retrospective study

• Patients and methods:-
• A retrospective chart review of 189 patients who had ossiculoplasty with intact
stapes using autologous incus, cortex bone chips and plastipore partial ossicular
reconstruction prosthesis.
• Hearing outcomes and the average improvement in hearing with different
reconstruction materials were analysed by using middle ear risk index scores.
MIDDLE EAR RISK INDEX 2001
MIDDLE EAR RISK INDEX 2001
OTOLOGIC FACTORS MAXIMUM SCORE
Otorrhoea 3
Perforation 1
Cholesteatoma 2
Ossicular status 4
Middle ear granulation 2
Previous surgery 2
Smoking 2
• Results:-
• The average hearing improvements for incus, cortex and plastipore PORP
were 12.77±14.58 (p<0.001), 12.34±15.98 (p=0.005) and 14.10±13.87 dB
(p<0.001), respectively. The postop air-bone gap levels were 20.42±14.54 dB
in incus, 17.33±16.86 dB in cortex and 17.59±11.66 dB in PORP
• 304 patients who underwent ossiculoplasty with an intact canal wall. A 58%
success rate was seen in the group with autologous incus interposition, while
those with Plastipore PORPs resulted in 56% success rate. 9.3% of implants
were extruded in this study.
• Conclusions:-
•  In ossiculoplasty with intact stapes, using autologous incus, cortex bone chips
and plastipore PORP, improvement in hearing was nearly equal.
• In patients who had mild risk scores, the incus had better gain values
compared with patients who had severe scores.
 STUDY 6

A COMPARISION OF AUTOGRAFT INCUS AND TITANIUM

PROSTHESIS IN PRIMARY OSSICULOPLASTY IN MODIFIED
RADICAL MASTOIDECTOMY
SOURCE:-INDIAN JOURNAL OF OTOLOGY,APRIL 2016,Vol 22,Issue 2
• AUTHOR:Ankur Gupta, Ashok Kumar, Kanwar Sen, Isha Preet Tuli
• Department of Otorhinolaryngology, PGIMER Dr. Ram Manohar Lohia Hospital, New Delhi, India
• AIM:-
• This study aims to analyze and compare the outcome of primary
ossiculoplasty in terms of hearing gain using autograft incus and
titanium (Ti) prostheses in patients with active squamosal chronic otitis
media (COM) undergoing modified radical mastoidectomy (MRM). 
• Study Design: Randomized study. 
• Materials and Methods:-
• 60 patients with active squamosal COM with ossicular chain erosion
undergoing MRM were divided into two equal groups.
• First group(Gp A) underwent ossiculoplasty with autograft incus and the second
group(Gp B) received Ti prostheses.
• Follow-up was done over a period of 6 months and hearing thresholds were
evaluated postoperatively at 3rd and 6th month at the four frequency average of
0.5/1/2/4 KHz. 
• Results:-
• In Gp A , at 3months, 83.3% patients had hearing improvement with 73.3% experiencing a
gain between 5 and 20dB. No extrusion was noted. However, in Gp B, 60% patients had
hearing gain with 5 patients having AC gain of >20dB.3 patients developing extrusion of
prostheses.
• At 6 months in Gp A, 80% patients had AC gain. Majority of patients had gain between 5
and 20dB. In Gp B, 60% patients had hearing gain and 3 patients showed extrusion of
prostheses.
• There was no significant difference in hearing gain b/w two groups at the end of 6 months
however complication rate was less in autograft group.
• CONCLUSION:-
•  Autograft incus and Ti prostheses both give a comparable hearing gain in primary
ossiculoplasty in MRM however both grafts do have signifcant improvement in hearing
outcome. Incus transposition is well tolerated as it is more physiological and biocompatible
having lower extrusion rates. This technique requires time and skill to ensure appropriate
sculpting to minimize ankylosis of the fallopian canal, scutum, and posterior canal wall.
STUDY 7
• AIM:-
To compare the outcome using autologous ossicle and titanium prosthesis in
two groups of suitable patients presenting with chronic suppurative otitis
media for middle ear reconstructive surgeries.
• STUDY DESIGN:-Prospective study
• MATERIALS AND METHODS:-
• Study was done from July 2012 to December 2013. The Target group included
patients with Chronic Suppurative Otitis Media admitted and planned for
reconstructive middle ear surgery. The Study group patients among the target group
requiring certain ossicular reconstruction.
• The patients were divided in two groups:
• Group A Patients of CSOM with ossicular discontinuity/erosion in whom autologous incus was
used for ossiculoplasty.
• Group B Patients of CSOM with ossicular discontinuity/erosion in whom total/partial titanium
ossicular replacement prosthesis was used for ossiculoplasty.
• The Sample size: 88 pts were included in the study
• Randomization: Patients were assigned into group A and group B alternately.
 • Detailed history ,Examination and preop PTA was done. In all cases ossiculoplasty was
performed in one stage with tympanomastoidectomy.
•
If there was necrosis of the ossicles, ossiculoplasty according to assigned group using
either autologous incus/malleus/cortical bone/cartilage or titanium prosthesis was done.
• Follow up was done at 1 month, 6 weeks and 3 months. At each follow up the complaints
of the patients were noted, Microscopic examination was done .PTA was done at 6th
month of follow up.
• As per AAO-HNS guidelines, successful outcome is defined as closure of post-
operative AB gap by ≤20 dB so postoperative ABG < 20 dB as successful.
• RESULTS:-
• On comparison of pre-operative and post-operative hearing results there
was improvement in air conduction threshold and air bone gap in both the
groups
• On analysis of the A-B closure in group A and group B, found that the air-
bone closure in group A was 8.47 ± 4.17 and group B was 10.59 ± 4.9. The
difference between group A and group B was statistically significant
(P value = 0.032) suggesting better hearing outcomes after using titanium
ossicular replacement prosthesis.
• CONCLUSION:-
• To conclude titanium ossicular replacement prosthesis have better
outcome, and no significant difference found in audiological outcome for
TORP and PORP. Presence of the handle of malleus and absence of previous
surgery indicated a favorable outcome for ossiculoplasty.
CONCLUSION
• Autologous /Reshaped incus and titanium prosthesis gives almost
similar hearing outcome postoperatively.
• Post op Extrusion rates and complications are higher with Titanium
compared to incus.
• Hence Titanium prostheses are a good alternative in longstanding
cases of active squamous COM without any available ossicular
autograft for hearing reconstruction.