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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4453_Библиотеки_им_академика_М_И_Перельмана
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G.-j. Wang et al.
A. Handle of the malleus
B. Chorda tympani
C. Shaped autogenous incus
D. Stapedius tendon
Fig. 3.14 Interposition of the shaped incus and reconstruction of the
ossicular chain (right)
Place the “joint fossa” end of the shaped incus onto the head of the
stapes using a suction tip and a hook; place the groove end on the superior one-third of the malleus handle. The chorda tympani can be used to
aid in the stabilization of the autogenous incus. Move the malleus han-
dle gently to assess the mobility of the reconstructed ossicular chain.
Tissue glue can be applied to the connections between the autogenous
incus and the malleus, as well as the stapes. To protect the inner ear,
avoid disturbing the stapes as much as possible
Instruments: suction cannulas, right-angle hook
A. Tympanomeatal flap
B. Tympanic membrane
Fig. 3.15 Replacement of the tympanomeatal ap (right)
Replace the tympanomeatal ap; check repeatedly to conrm that the
reconstructed ossicular chain is in a good position (not connected to
surrounding bone) and the tympanic membrane is in an appropriate
position
Instruments: middle ear elevator, alligator forceps
3 Transcanal Approach
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Hearing Reconstruction: PORP Implantation
withIncus Removal
FeiYu
When performing mastoidectomy, the main priority is to prevent the serious or fatal complications of otitis media. Since
the 1950s, surgeons have been performing hearing reconstruction during the same surgical procedure, following
resection and control of middle ear diseases, based on the
understanding of the mechanism and transmission of middle
ear diseases. Hearing reconstruction materials include autologous materials (autogenous ossicles, autogenous bone cortex, and autologous cartilage), allogenic materials (allogenic
ossicles and allogenic cartilage), and articial materials
(high-molecular-weight polymer materials, hydroxyapatite,
and titanium). The biocompatibility of autologous materials
is ideal, while the use of autologous materials may result in
reimplantation of residual disease. Allograft materials risk
the spread of conditions such as human immunodeciency
virus infection, Creutzfeldt–Jakob disease, and various forms
of hepatitis. The range of applications of the former two
kinds of materials has therefore been gradually reduced. The
compatibility, higher strength, and plasticity of titanium in
biological articial materials avoid the inherent disadvantages of autologous and allograft materials; these characteristics also reduce displacement and the need for removal
with improved surgical technique and product design. In
addition, titanium exhibits good compatibility for magnetic
resonance imaging. In particular, titanium ossicular prostheses do not exhibit any obvious migration or heating in the
high-intensity magnetic eld of 3.0-tesla machines and are
therefore promising middle ear implants.
With respect to form and purpose, titanium ossicular prostheses can be divided into partial ossicular replacement prostheses (PORPs), total ossicular replacement prostheses
(TORPs), and pistons (articial stapes). PORPs are used in
patients who exhibit intact stapes, but lack a part of the lateral
two ossicles; TORPs are used in patients who exhibit an intact
footplate of the stapes but lack other ossicles. Pistons are used
in patients with stapes xation. PORPs and TORPs are made
by different manufacturers and are available in different
forms; they largely consist of a disk (tympanic membrane
end), a stapes end, and a connecting rod. Articial ossicles
may exhibit adjustable or xed length connecting rods.
The current design of articial ossicles includes: (1) a
perforated disk, which can expand the surgeon’s eld of
view below the disk and reduce its weight as well; (2) an
adjustable connecting rod, which enables customization of
prosthesis height for each patient; (3) the medial frosted surface of the stapes end can improve the connection between
the prosthesis and the head of the stapes; and (4) gaps in the
stapes end, which can accommodate the tendon of the stapedius muscle and facilitate the installation.
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A. Chorda tympani
B. Right-angle hook
(90° Plester hook)
C. Long process of the incus
D. Lenticular process of the
incus
E. Head of the stapes
Fig. 3.16 Separation of the incudostapedial joint (left)
Elevate the tympanomeatal ap and enter the tympanic cavity; then,
identify the chorda tympani, remove some of the scutum and expose
part of the epitympanum; nally, explore the mobility of the ossicular
chain and gently separate the incudostapedial joint between the lenticular process of the incus and the head of the stapes
Instruments: middle ear elevator, right-angle hook
A. Chorda tympani
B. Free incus
C. Head of the stapes
Fig. 3.17 Separation of the incudomalleal joint and removal of the
incus (left)
The shape of the incus is irregular. It lies in both the epitympanum and
mesotympanum; the tympanic cavity is narrow, such that it can be difcult to remove. First, separate the incudostapedial joint using a rightangle hook, then displace the long process of the incus forward and
backward. Dislocate the incudomalleal joint using a right-angle hook in
the joint, then grasp the long process to remove the incus using ear
forceps. During extraction, protect the chorda tympani, facial nerve,
and stapes by using gentle dissection
Instruments: right-angle hook, ear forceps (serrated Hartmann ear
forceps)
3 Transcanal Approach
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A. Chorda tympani
B. Head of the stapes
C. Handle of the malleus
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Fig. 3.18 Tympanic cavity after removal of the incus (left)
The stapes, handle of the malleus, and anteriorly folded tympanic membrane are visible after removal of the incus; in addition, the stapes
A. Chorda tympani
B. PORP model (Kurz)
exhibits good movement. In accordance with the Fisch type 1 classication, a PORP implant is feasible for repair of the ossicular chain
Instruments: #9 Suction cannulas, straight microneedle (0° microneedle)
Fig. 3.19 Measurement of the distance between the handle of the malleus and the head of the stapes (left)
The distance between the head of the stapes and the tympanic membrane should be carefully assessed before PORP implantation. An
appropriate PORP length is important for a suitable hearing outcome: a
short PORP will cause disconnection of the ossicular chain, while a
long PORP will risk tympanic membrane penetration. The implanted
prosthesis should be slightly longer than the measurement taken to
avoid disconnection of the ossicular chain caused by postoperative outward migration of the tympanic membrane. Measuring tools differ
depending on the manufacturer. The image shown depicts a single-use
PORP model from the Kurz company in Germany
Instruments: suction cannulas, right-angle hook
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G.-j. Wang et al.
A. PORP stapes end
B. PORP connecting rod
C. PORP disk
D. Cartilage disk
Fig. 3.20 Assembly of the PORP and formation of the cartilage disk
A xed-length PORP with suitable height or an adjustable PORP cut to
the appropriate height should be selected in accordance with the measured distance between the head of the stapes and the tympanic membrane. A cartilage disk should be made in accordance with the size of
the PORP disk end. The image shown depicts an adjustable titanium
ossicle from Kurz. The stapes end is claw-shaped with the inner side
surface dull polished, the disk is at and perforated, and the length of
the connecting rod is adjustable
Instruments: PORP assembly kit, scalpel
A. Chorda tympani
B. PORP stapes end
C. PORP disk
Fig. 3.21 Implantation of the PORP (left, Kurz)
Insert the selected PORP between the head of the stapes and the tympanic membrane. The deep part of the tympanic cavity can be observed
through the perforated disk of the PORP
Instruments: right-angle hook, #9 suction cannulas
3 Transcanal Approach
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A. Chorda tympani
B. PORP disk
C. Cartilage disk
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Fig. 3.22 Placement of the cartilage disk between the outer surface of
the PORP and the tympanic membrane (left)
In all cases using metal ossicular replacement prostheses, a cartilage
disk should be placed between the titanium surface of the PORP disk
A. Chorda tympani
B. PORP stapes end
C. Cartilage disk
D. Tympanic membrane
and the tympanic membrane. This avoids perforation of the tympanic
membrane and extrusion of the articial ossicle
Instruments: ear forceps, right-angle hook, #9 suction cannulas
Fig. 3.23 Adjustment of the cartilage disk (left)
The trimmed cartilage disk should be inserted and adjusted to the right
position. The disk covers the whole PORP disk and should make sufcient contact with the effective vibration area of the tympanic mem-
brane. If necessary, the chorda tympani can be placed lateral to the
cartilage disk to ensure it remains in place
Instruments: right-angle hook, #9 suction cannulas
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A. Tympanomeatal flap
B. Tympanic membrane
covering the cartilage disk
Fig. 3.24 Reset of tympanomeatal ap (left)
Reset the tympanic membrane and tympanomeatal ap, conrm the
length of the implanted PORP and the location of the cartilage disk, and
ensure the absence of residual perforation of the tympanic membrane.
Any abnormal nding should be corrected at this time
Instruments: middle ear elevator, eardrum attening device (45° Rosen
rounded knife)
A. Chorda tympani
B. PORP stapes end
C. PORP disk
D. PORP malleus notch
Fig. 3.25 PORP (right, Kurz)
The malleus notch prosthesis (MNP, Kurz) exhibits a notched tail at the
edge of the disk. The notch connects with the handle of the malleus to
reinforce the reconstruction of the ossicular chain, reduce PORP compression on the tympanic membrane, and reduce the possibility of
PORP extrusion. In addition, gaps in the stapes end of the PORP can be
positioned over the tendon of the stapedius muscle, thereby allowing
better connection between the PORP stapes end and the head of the
stapes
Instruments: right-angle hook, #9 suction cannulas
3 Transcanal Approach
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A. Chorda tympani
B. PORP disk
C. PORP stapes end
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Fig. 3.26 PORP (right, Spiggle & Theis)
Based on the specic ndings at surgery, PORPs of different shapes
from different manufacturers can be used. The image depicts the alltitanium PORP disk with perforations (Spiggle & Theis), which can aid
A. Chorda tympani
B. PORP stapes end
C. PORP disk
D. Round window niche
E. Tympanic membrane
in the visualization of the deep cavity. The inside surface of the bellshaped stapes end is already frosted to improve the connection between
the prosthesis and the head of the stapes
Instruments: right-angle hook, #9 suction cannulas
Fig. 3.27 PORP (right, Medtronic)
PORP from Medtronic, with xed length, exhibits holes in the disk and
a claw-shaped stapes end
Instruments: right-angle hook, #9 suction cannulas
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G.-j. Wang et al.
A. Chorda tympani
B. PORP
C. Handle of the malleus
D. Tympanomeatal flap
Fig. 3.28 PORP (right, Medtronic)
PORP from Medtronic, with adjustable length, exhibits holes in the
disk and a claw-shaped stapes end
Instruments: right-angle hook, #9 suction cannulas
A. Cartilage disk
B. Chorda tympani
C. PORP
Fig. 3.29 Positioning of the cartilage disk (right)
To avoid perforation of the membrane and PORP extrusion, a cartilage
disk must be placed over all types of metal PORPs under the tympanic
membrane
Instruments: ear forceps, right-angle hook, #9 suction cannulas
3 Transcanal Approach
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A. Umbo
B. Malleal stria
C. Lateral process of the
malleus
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Fig. 3.30 Reset of tympanomeatal ap (right)
Reset the tympanic membrane and tympanomeatal ap, then inspect
repeatedly to ensure the ossicular chain and cartilage disk are stable and
the tympanic membrane remains intact
Instruments: middle ear elevator, eardrum attening device (45° Rosen
rounded knife)
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