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G. Tanyeri Toker et al.
Table 24.8 Reconstruction
options for malleus xation
Table 24.9 Reconstruction
options for isolated
stapes defect
Fig. 24.3 Reconstruction
of incus lenticular process
defect with bone cement
Malleus head xation (Austin/Kartush E)
Shaped ossicular transposition
PORP
M+I+ S- (Austin/Kartush F)
Stapes base intact and mobile Stapes base absent/
xed
TORP Piston (Fig.24.11)
Shaped ossicle or cortical
bone transposition
M+I+S- Malleus, present; incus, present; stapes, none
Fig. 24.4 Incus
interposition
24 Ossiculoplasty
Fig. 24.5 Reconstruction
of incus defect with partial
oscicular replacement
prosthesis
Fig. 24.6 Reconstruction
of the incus defect by
malleostapediopexy with
bone cement
493
Fig. 24.7 Reconstruction
of incus and stapes defect
with total ossicular
replacement prosthesis
494
Fig. 24.8 Reconstruction
of incus and stapes defect
with piston. The hook of
the prosthesis is attached to
the malleus
Fig. 24.9 Reconstruction
of malleus and incus defect
with partial oscicular
replacement prosthesis
G. Tanyeri Toker et al.
examination of the tympanic cavity before being repositioned securely. Gel
foam pieces are placed lateral to the tympanic membrane within the external ear
canal. In this context, we prefer to position the gel foam pieces after applying a
thin silastic cover on the lateral side of the graft and tympanic membrane remnant. This cover type offers two advantages. It facilitates the graft’s approach to
the tympanic membrane remnant, especially when tympanic membrane reconstruction is performed simultaneously with ossiculoplasty and prevents the gel
foam pieces from adhering to the tympanic membrane (graft). During the postoperative period, no bleeding or complications are observed during the aspiration of the gel foam pieces.
In the transcanal approach, only the graft donor area is sutured; in the retroauricular approach, the periosteum, muscle, subcutaneous tissue, and skin are closed
with appropriate sutures.
24 Ossiculoplasty
Fig. 24.10 Reconstruction
of malleus, incus, and
stapes defect with total
ossicular replacement
prosthesis
Fig. 24.11 Reconstruction
with piston prosthesis in
stapes xation
495
Finally, a Merocell tampon is placed in the external ear canal to seal the surgical area and secure the ap. Improper placement may disrupt contact with the
remnant by pushing the graft medially. This may result in irregularities in the
canal, compromise the nutrition and positioning of the ap, and potentially displace the prosthesis by exerting pressure on the reconstruction material/prosthesis. The base of the stapes may break as the prosthesis pushes the stapes, and the
shaft may enter the saccule.
24.9 Ossiculoplasty Results
Numerous factors inuence the outcomes of ossiculoplasty. The most important
factor is the preoperative status of the ossicular chain, that is, the nature, localization, and size of the defect. These factors, along with other positive and negative
considerations, are listed in Table 24.10 [40]. The determinants of success and
496
Table 24.10 Factors that have a positive and negative effect on ossiculoplasty results
Positive factors Negative factors
Small ossicular chain defect Large ossicular chain defect
Presence of stapes suprastructure Absence of stapes suprastructure
Presence of malleus Absence of malleus
Absence of xation Ossicular head xation in the epitympanum
Functional Eustachian tube Non-functional Eustachian tube
Good middle ear mucosa Presence of pathological tissue in the middle ear
mucosa
Perioperative dry ear Perioperative discharge from ear
Primary operation Revision operation
No need for simultaneous
mastoidectomy
Mastoidectomy being a closed cavity Mastoidectomy being an open cavity
Low middle ear risk index High middle ear risk index
Table 24.11 Reasons for success and failure in ossiculoplasty
Success Failure
Right reconstruction material selection Wrong reconstruction material selection
Correct size adjustment of the
reconstruction material
Proper placement of reconstruction
material
Correct patient selection Connection weakness in the reconstructed
Suitable conditions in the middle ear Presence of recurrent/residual disease
Need for simultaneous mastoidectomy
Inability to adjust the size of the reconstruction
material well
Failure to perform appropriate reconstruction
ossicular chain
Fixation of reconstruction material
Dislocation of reconstruction material
Resorption of reconstruction material
G. Tanyeri Toker et al.
failure are succinctly outlined in Table 24.11 [40]. Notably, indices such as the
middle ear risk index [49] and ossiculoplasty outcome parameter staging [50] have
been proposed to aid in the prediction of surgical success [51].
24.10 Complications
Complications are generally related to the perioperative condition of the ear, reconstruction technique, type of reconstruction material, and the skill and attention of
the surgeon.
Facial Nerve Damage Facial paralysis is the most important complication of ear
surgery. Nerve damage occurs most commonly around the second elbow of an oval
window. To avert facial nerve paralysis, adherence to the following three fundamental principles is imperative:
24 Ossiculoplasty
497
1. A comprehensive understanding of anatomy is imperative: Surgeons must possess a thorough knowledge of anatomy and prociently identify and illustrate the
surgical landmarks.
2. The precise dissection of the facial nerve is crucial, the facial nerve needs to be
distinguished from pathological tissues, and the dehiscence of the Fallopian
canal should be assessed. One should not hesitate to use nerve-monitoring methods. When working close to the nerve, bone cooling should be employed through
irrigation.
3. Experience is crucial: one should work under the supervision of a master’s surgeon until sufcient experience is gained. During surgery, the fallopian canal can
be approached at any time; however, the nerve may exhibit abnormal progress.
Some surgeons prefer using diamond drill tips when working close to the nerve,
generating more heat compared with cutting drill tips. In such cases, washing the
bone with warm physiological serum is necessary. It is better to employ a cutting
drill tip until it approaches very close to the nerve and then switch to a diamond
drill bit if necessary. The drill should be operated at high speed without applying
pressure on the bone tissue. Additionally, it is more suitable to drill parallel to the
nerve trace. Generally, a drilling tip that is either large or slightly larger than the
nerve’s diameter is used during the procedure.
To avoid this very important complication:
1. Surgical technique should be modied, if necessary, to take less risk. For example, endoscopy-assisted surgery should be used when necessary.
2. Attention should be paid to intraoperative ndings, anatomical relationships,
and landmarks.
3. If possible, intra-operative nerve monitoring should be used.
4. The facial nerve should not be touched unless it is necessary.
5. It is necessary to work very carefully to avoid complications. It is benecial to
comply with the general precautions and basic otological surgical principles
stated above to refrain from nerve paralysis. If an ossicle fracture or dislocation
occurs, its repair is performed as described above in the OCR surgical technique.
Perilymphatic Fistula This may develop secondary to stapes dislocation. It is
important to recognize and close intraoperatively. It is usually sufcient to lay the
fascia or perichondrium over the window opening in the labyrinth. It is useful to lay
a thin silastic cover over the fascia or perichondrium until the surgery is completed,
ensuring that the cover stays in place, remains undamaged, and does not stick to the
bone chips. At the end of the surgery, the silastic dressing is removed prior to closure. In the early postoperative period, patients should rest in bed with their heads
elevated, and vestibular suppressants may be recommended.
Dural Damage When using a drill in a mastoidectomy, the bone layer above the
dura may be accidentally opened. Occasionally, the dura may be exposed due to
bone resorption. Therefore, it is not important to determine whether the dura is vis-
498
Table 24.12 Ossiculoplasty complications
Intraoperative
Facial nerve damage Vertigo Perilymphatic stula
Perilymphatic stula Vertigo + SNHL Tympanic membrane reperforation
Ossicular fracture Bleeding CHL
Annular ligament
damage
Ossicular luxation Facial paralysis Bone external ear canal erosion
High-frequency SNHL Graft slipping out of its
Anacusis Flap necrosis/dislocation Extrusion of the prosthesis
Dural damage CHL Tympanosclerosis
SNHL sensorineural hearing loss, CHL conductive hearing loss
Early postoperative
Infection Ossicular necrosis secondary to
place
Late postoperative
prosthesis
External ear canal stenosis
G. Tanyeri Toker et al.
ible. If there is a defect in the dural plate but the dura is not traumatized, treatment
is not required. Nonetheless, in cases where the dura is not punctured but is slightly
traumatized by the drill, herniation may occur into the mastoidectomy cavity during
the postoperative period. In such situations, the dura should be covered with a perichondrium cartilage layer.
Ossicular Chain Damage When working in the tympanic cavity or fossa incudis
and epitympanum in the mastoid antrum, fractures or dislocations in the ossicles
and sensorineural hearing loss, which are particularly related to high frequencies,
may develop. When working close to the ossicles, they should not be touched while
removing the pathological tissues. Care should be taken when checking the ossicular chain mobility. When a prosthesis is used for ossicular chain reconstruction,
fractures in the stapes superstructure, stapes dislocation, annular ligament damage,
stapes base fracture, sensorineural hearing loss, total hearing loss, and vertigo may
occur, depending on the length of the prosthesis or its placement using rough movements. The ossiculoplasty complications that may occur intraoperatively and postoperatively are summarized in Table24.12 [40].
24.11 Postoperative Care
Postoperative care varies depending on the surgery performed and the presence of
complications. After surgery, sterile gauze is applied over the ear. On the rst day,
the gauze is replaced due to dampness and blood leakage. Occasionally, a large
amount of blood and serohemorrhagic uid may leak from the external ear canal. In
such cases, the leakage from the Merocell can be aspirated using a sterile aspirator.
Aspiration is deemed unnecessary if there is minimal leakage.
The incision line is wiped with polyvinylpyrrolidone iodine (Batticon®) and subsequently re-covered with sterile gauze. This dressing is repeated once daily, as needed.
In cases where an endaural or retroauricular approach is used, the stitches are removed
in the rst week. The Merocell tampon placed in the external ear canal is removed in
24 Ossiculoplasty
499
the second week. Leaks and melted gel foam pieces in the outer ear canal are cleaned
using a ne aspirator. This process is facilitated when a silastic cover is used.
Topical antibiotics are recommended if an infection occurred. Topical steroid
drops are recommended if there is edema in the granulation tissue or canal skin. The
dressings are applied at intervals until a dry external ear canal is achieved. During
this period, care should be taken not to allow water to leak into the external ear canal.
Postoperative prophylactic antibiotics are not required. Prophylactic measures
against infection involve the administration of intravenous ceftriaxone at 1000mg in
adult patients and 500mg in pediatric patients during anesthesia induction. Patients
are advised to avoid contact with individuals with acute viral upper respiratory tract
infections, particularly 2–3 weeks after surgery. An initial audiometric evaluation
should be performed 6weeks after surgery. The evaluation is repeated over time.
24.12 Follow-Up
There are no specic follow-up protocols currently available. After early postoperative dressing and follow-up are completed, it is useful to follow patients in the rst
month, third month, rst year, and once a year thereafter for at least 5years. The
hearing gain achieved with ossiculoplasty decreases over time [52–54]. If synthetic
material is used in reconstruction, long-term follow-up should be performed, considering the potential for expulsion. In cases where cartilage is utilized, monitoring
should also consider the possibility of resorption [55, 56].
24.13 Conclusion
1. The success of surgical treatment is inversely proportional to the severity of the
existing disease and the extent of the resulting damage.
2. In particular, the presence of the stapes superstructure and malleus is critical for
ossiculoplasty results.
3. Successful results can be achieved by a careful and relatively experienced sur-
geon who schedules the surgery well, carefully examines the condition of the
ossicular chain, complies with basic surgical principles, and chooses the reconstruction material correctly.
4. Postoperative hearing results are not satisfactory in ears with large ossicular
chain defects and poorly ventilated ears.
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