Ossiculoplasty
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ossiculoplasty, types of ossiculoplasty
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Ossiculoplasty
- 1. OSSICULOPLAST Y DR. AJAY MANICKAM JUNIOR RESIDENT MS ENT RG KAR MEDICAL COLLEGE
- 2. THE OSSICULOPLASTY ο Reconstruction of the ossicular chain β aims to surgically optimize the middle ear transformer mechanism. ο Sound from the environment is conducted to inner ear fluid with minimal loss
- 3. History ο 1957 β ossicular repositioning was described ο Plastic prosthesis β high extrusion, stapes footplate fistula ο Homografts β convenient β but viral or prion disease risk ο Wire prosthesis - stainless steel wires, platinum better tolerated but displaced over time
- 4. An Ideal prosthesis ο Durable ο Biocompatible ο Easy to manipulate material
- 5. Plastipore ο Alloplast made from High Density Polyethylene sponge (HDPS) ο TORP, PORP ο Thermal fused HDPS β Polycel ο However its necessary to cover plastipore with cartilage to minimize extrusion
- 6. Ceramic Implants ο 1979 ο Bio inert and bio active ο Unfortunately higher extrusion
- 7. Hydroxylapatite ο Bioactive implant with ca2+ and phosphorous to human bone ο Osseointegeration ο Can come into direct contact with tympanic membrane
- 8. Hybrid prosthesis ο Tolerance of tympanic membrane contact ο Flexibility of plastipore ο Hybrid prosthesis with hydroxyl apatite head shafts made of teflon, platinum or stainless steel ο Bone cements β limited erosions
- 9. Pre operative assesment ο Otoscopy, HRCT, audiometry ο Intraoperative decisions more important
- 10. The planning ο Healthy ears or chronic diseased ears ο If active disease β priority to make middle ear mastoid disease free
- 11. Factors resulting in success ο S β Surgery (open or closed mastoid) ο P β Prosthesis type ο I β Infection +/- ο T β Tissue health ο E β Eustachian tube function
- 12. AUSTINβS CLASSIFICATION Malleus handle (M+, M-) Stapes superstructure (S+, S-) ο Type A (M+, S+) ο Type B (M+, S-) ο Type C (M-, S+) ο Type D (M-, S-)
- 13. Wullstein classification ο Type 1 β no need for reconstruction ο Type 2 β graft placed over remaining malleus/long pro incus ο Type 3 (1) minor columella ο Type 3 (2) major columella ο Type 4 β graft over stapes footplate ο Type 5 β graft over an open oval window sound transmission to pass to fenestrated LSCC
- 14. Principles of ossiculoplasty ο T β Tension with which implant placed ο R β Round window protection ο A β Angle (45 β 90) ο C β Centred (prosthesis to TM) ο S β Space (>0.3ml, N= 1ml)
- 15. Type A ο Favourable relationship ο Unfavourable relationship
- 16. Favourable relationship ο Lenticular process of incus is eroded and the manudrium is in close proximity ο Interpositioning graft ο Drilled with 0.5 mm diamond burr ο Sculpted incus must exceed the size of gap ο Malleus must be pushed anterolaterally
- 18. Unfavourable relationship ο Manubrium positioned far anterior to stapes superstructure ο PORP is suggested in such conditions ο Smaller defect β hydroxylapetite bone cement
- 19. Type B & Type D ο TORP ο Long term results unsatisfactory as the medial slurt can be displaced ο Cartilage shoe is helpful β size of oval window niche, hole in center to accommodate TORP
- 20. Type B & D TORP
- 21. Type B & D
- 22. Type C ο PORP ο Cartilage graft placed medial to TM effective in reducing the extrusion rates of Titanium and Hydroxylapatite
- 23. Type C PORP
- 24. Factors to be coordinated ο Anterior mesotympanum to be packed with gelfoam and TM positioned ο Graft gently elevated ο Prosthesis placement ο Cartilage interposition ο Graft to final position
- 25. Malleus fixation syndrome ο Difficult to diagnose preoperatively ο Tympanosclerosis ο Chr. Infection ο Trauma ο Pagetβs disease ο Ligament ossification ο Otosclerosis ο Congenital & Idiopathic disorders
- 26. Approach ο Atticotomy ο Absorbable esterified hyaluronate is interposed and left in place
- 27. Revision surgery ο Long term success results are good ο Control of chronic disease and ET dysfn ο CT scan β defines better ο LASER to lyse adhesions ο Lots of adhesion β silastic sheeting over promontory ο Failed TORP β inspect fistula - repair with graft
- 29. Myringostapediopexy ο Short columella ossiculoplasty β allogenic septal spur cartilage or autogenic/allogenic incus graft ο Steps of surgery
- 30. Shaping of cartilage graft ο Allograft septal spur cartilage ο Superior contact surface should be sloping ο Margins should be smooth ο Inferior drilled and socket created for stapes head
- 31. Myringoplatinopexy ο Absence of stapes superstructure, with or without malleus difficult for reconstruction ο Malleus transposition ο Long columella technique
- 32. Long columella ο Shaping of malleus β handle removed and reshaped ο Cartilage graft β superior surface enough contact with margins blunted, inferior part is blunted to fit to footplate area without touching facial promontory
- 33. Placement ο Mobility of footplate is confirmed, rectangular temporalis fascia kept over footplate and spread partly on facial canal and promontory ο Shaped ossicle placed between footplate and neotympanum β supported by gelfoam
- 35. Cartilage graft Cartilage graft ο Biocompatible ο Inexpensive ο Easy to handle ο Disadvantages β challenging, prion disease, HIV transmission, extrusion rates, necrosis of cartilage
- 36. Conclusion ο Factors of success β SPITE ο Principles of ossiculoplasty β TRACS ο AUSTIN & WULLSTEIN ο Careful attention must be played to principles of ossiculoplasty so that there is assurance of better hearing outcome for the patient
- 37. THANK YOU