Middle ear reconstruction techniques

1. Dr. Muhammad Mozammal Haqure

2. Historical Background
 Berthold (1878):
Myringoplastik
Full thickness skin graft
 Nylen (1921): Monocular operating
microscope.
 Holmgren, teacher of Nylen (1922):
Binocular operating microscope
 In 1953, the Zeiss operating microscope:
Commercially available

3. Historical Background…..
Moritz (1952)
Zollner (1953, 1955) German,
Wullstein (1953,1956) Onlay skin graft
To restore or conserve hearing and promote
healing, after excision of disease from the middle
ear and mastoid.

4. Middle Ear Reconstruction
Not only the restoration of the anatomical or
mechanical components but also of the
physiology or function of the ear.
Tympanoplasty
Ossiculoplasty
Mastoidectomy:
 Open or canal wall-down procedures
 Closed or canal wall-up procedures

5. Tympanoplasty
Definition: Repair of the tympanic membrane
(TM) with inspection of middle ear & possible
ossicular chain reconstruction.
 This is different than a myringoplasty
Aims:
 Prevent recurrent disease
 Improve hearing
 Provide a dry ear canal
 Enable patient to bathe & swim freely

6. Tympanoplasty………..
 Appropriate
candidates:
 Perforation of TM
 Cholesteatoma / other
lesion involving TM or
tympanic cavity
 Resolved otorrhea
 Preferably no
Eustachian tube
dysfunction

7. Tympanoplasty………..
Poor Candidates:
 Multiple failed attempts at closure
 Poor Eustachian tube function
 Smoker
 Systemic disease
 DM
 Steroid use
 Actively draining

8. Tympanoplasty………..
 Commonly used materials:
 Temporalis fascia
 Perichondrium/cartilage
 Periosteum
 Fat
 Vein
 Duramater
 Techniques
 Overlay
 Underlay

9. Tympanoplasty………..
Approaches
 Transcanal
 Post auricular
 Endaural

10. Tympanoplasty………..
Wullstein (1956)
 Type I
 Type II
 Type III
 Type IV
 Type V

11. Types of tympanoplasty
Type I—
intact ossicular chain
 simple
tympanoplasty
(Myringoplasty)

12. Types of tympanoplasty
Type II—
intact incus and
stapes with erosion
of malleus
 Graft onto incus
= incudopexy
 Graft onto malleus
remnant

13. Types of tympanoplasty
Type III—
intact mobile stapes
superstructure
 Graft onto head of
stapes
 Columella
tympanoplasty

14. Types of tympanoplasty
Type IV—
intact stapes footplate
with absent or
eroded stapes
superstructure
 Footplate MOBILE
 Graft covers RW
(round window baffle)
 Footplate exteriorized

15. Types of tympanoplasty
Type V- fenestration of horizontal
semicircular canal
Immobile
footplate

16. Underlay v. Overlay
Underlay= medial Overlay= lateral

17. Underlay technique—
selection of patients
 Posterior central perforations
 “Smaller” perforations
 Any perforation with intact annulus

18. Underlay technique—procedure

19. Overlay technique—
selection of patients
 Marginal perforations
 Total perforations/“larger perforations”
 Need for canalplasty
 Previously failed tympanoplasties

20. Overlay technique—procedure

21. Tympanoplasty--complications
 Persistent / recurrent perforation
 Cholesteatoma (ME, drum, EAC)
 Dysguesia
 Blunting
 Lateralization
 SNHL / vertigo
 Facial nerve injury

22. Ossicular disorders
 Types
 Ossicular
discontinuity
 Ossicular fixation
 Causes
 Chronic otitis media
 Trauma
 Congenital
 Tympanosclerosis
 Otosclerosis

23. Common ossicular disorders
 Long process of Incus
 Stapes superstructure
 Handle of the Malleus

24. Ossiculoplasty (OCR)
 Appropriate candidates:
 Resolved otorrhea with no middle ear disease
 Conductive or mixed hearing loss
 No Eustachian tube dysfunction (ideal)
 Need enough middle ear space and aeration to allow for
prosthesis and function
 Previous CWU for second-look

25. Ossicular grafts and implants
 Autologous :
Ossicle grafts: Incus/ Head of the malleus
Cortical bone grafts: Mastoid cortex
Cartilage
 Homologous human ossicles
 Synthetic ossicular implants:
Porous high-density polyethylene (Plastipore) -
FBGCR
Plastic material -microdegradation
Bioactive glasses, aluminum oxide ceramic, carbon,
hydroxylapatite-polyethylene (Hapex)

27. Ossicular chain defect
Austin’s classification
4 Common types: Incus absent in all cases and TM reconstruction
required in all cases.
 Type A: M+, S+
Loss of part of incus or total loss of incus.
 Type B: M+, S-
Loss of incus & stapes superstructure but the malleus handle still
present.
 Type C: M-, S+
Loss of incus & malleus but the stapes superstructure still present.
 Type D: M-, S-
Loss of incus, malleus & superstructure of stapes, but mobile
footplate still present.

28. Type A1: Bone pate-glue/ prosthesis

29. Type A2: Autograft or homograft bone (Incus
interposition) / Prosthesis

30. Type B: Autograft or homograft bone/ Prosthesis

31. Type C: PORP/ Autograft or homograft bone
 Partial Ossicular Replacement
Prosthesis
 Intact superstructure
 Stapes superstructure TM

32. PORP - Types

33. Type D: TORP/ Autograft or homograft bone
Total Ossicular
Reconstruction Prosthesis
Footplate TM
Oval window (with graft)
TM

34. TORP
All OCRs are held in place by tension. When
placing a TORP, Gantz will frequently put a second
piece of cartilage to support the prosthesis.

36. Ossicular chain defect…….
Rare ossicular chain defects
1)Isolated loss of the malleus handle: 2%
2) Isolated loss of the stapes superstructure: 1.7%

37. Continue….
Fixed stapes
1) Malleus handle presnt stapes fixed
2) Malleus handle absent stapes fixed

38. Defining Success
 1995 guidelines of the AAO
 Pre and postoperative air-conduction and bone-
conduction thresholds are measured at 4 designated
frequencies (0.5, 1, 2, and 3 kHz), then averaged
 Success is defined as a mean postoperative air-
bone gap of less than 20 dB and is the main
outcome considered for this talk

39. Prognostic Factors
 It is clear that optimal results depend not only on
the qualities of the prosthesis, but also on the
environment in which it is placed and the
surgical techniques used.

40. Prognostic Factors
 Austin (1972) defined four groups in which the incus
had been partially or completely eroded:
 Type A, malleus handle present, stapes
superstructure present (60% occurrence)
 Type B, malleus handle present, stapes
superstructure absent (23%)
 Type C, malleus handle absent, stapes
superstructure present (8%)
 Type D, malleus handle absent, stapes
superstructure absent (8%)

41. Prognostic Factors
 Kartush (1994) proposed a scoring system called
the middle ear risk index (MERI) to form an index
score to determine the probability of success in
hearing restoration surgery.
 MERI is used to describe the preoperative middle
ear environment at the time of ossiculoplasty

43. Prognostic Factors

44.  All studies of prognostic factors identify middle ear
mucosal status and presence of malleus handle
as important predictors of successful hearing
restoration

45. Result of ossicular reconstruction
 Incus/stapes assembly - air-bone gap closure with 10 dB
in 50% cases & under 20 dB in 70-80% cases.
 Malleus/stapes assembly –
0-10 dB 50% cases
0-20 dB in 80% cases
 Malleus/footplate assembly-
20 dB in 35- 60% cases.
 Use of PORP – air-bone gap closure < 20 dB in 77%
cases.
 Use of TORP – air-bone gap closure < 20dB in 52%
cases.
expert surgeon

46. Complications
 Persistent CHL
 Recurrent CHL
• Displaced ORP
• Extruded ORP
 SNHL
 Vertigo
 Facial nerve injury

47. Mastoid surgery
 Canal wall down/open cavity mastoidectomy
 Canal wall up/intact canal wall/closed cavity
mastoidectomy:

48. Mastoid Surgery…….
Aims:
1) Eradication of disease
2) An epithelialized, self cleaning ear.
3) Hearing improvement.

49. Canal wall down/open cavity
mastoidectomy
 A. Obliteration techniques
 B. Posterior canal wall and outer attic wall
reconstruction.

50. A. Obliteration techniques
To line & reduce the size of the mastoid cavity
or
Obliterate it completely

51. Obliteration techniques…………..
 Autologous cancellous iliac crest bone graft
(Schiller & Singer, 1960)
 Allogenic femoral cortical bone chips
(Shea, Gardner and Simpson, 1972)
 Bone chips/ dust
 Autogenous cartilage (chondral part of pinna)
 Hydroxylapatite ceramic powders &
particles.

52. Obliteration techniques…………..
 The muscle obliteration techniques:
(more popular)
Local random pattern muscle periosteal transposition
& rotation flaps of sternomastoid muscle( Meurman
and Ojala, 1949)
Temporalis muscle (Rambo, 1958)
Postauricular muscle periosteal flaps based on the
SCM muscle (Hilger and Hohmann, 1963)
Anteriorly based postauricular muscle-periosteal
transposition flaps together with bone pate (Palva,
1963,1982,1993)

53. Obliteration techniques…………..
 Local axial pattern flaps:
Temporoparietal fascia flap, based on the
superficial temporal vessels (Byrd, 1980; East,
Brough and Grant, 1991)
The temporalis fascia flap; ‘Hong Kong flap’ ,
(van Hasselt, 1994)
 Free grafts: Fascia (temporalis), fascia lata,
abdominal fat, local muscle and periosteal grafts

56. B: Posterior canal wall and outer attic
reconstruction-
Alternative to cavity obliteration.
 Autologous material
> Bone dust & chips
> Cortical bone graft
> Tragal cartilage/Scaphod cartilage
 Allogenic
> Bone graft
> Tragal cartilage
 Hydroxylapatite

59. Tympanoplasty with mastoidectomy
1) Closed cavity mastoidectomy with tympanoplasty.
2) Open cavity mastoidectomy with tympanoplasty.
3) Obliteration of open mastoid cavity with
tympanoplasty.
4) Reconsturction of the outer atlic wall or posterior
canal wall of open mastoid cavity with
tympanoplasty.

60. Ossicular chain reconstruction
1) When incus is eroded but malleus handle & stapes
is present.
Malleus/stapes assembly by –
> Autologous & allogenic malleus head or incus body
to fit between the malleus handle & stapes head.
> Artifical prostheses are also available to perform
the same task.

61. Continue…
2) When loss of incus & stapes superstructure but
handle of the malleus present.
Malleus/footplate assembly by-
> Autologous or homologous bone can be used.
> Artifical prostheses are also available.
3) When loss of incus & malleus but stapes
superstructure present.
TM/ stapes head assembly by-
> Autograft or homograft bone can be used .
> Artfical prostheses are also available.

62. Continue….
4) When loss of incus, malleus & stpaes
superstructure
but mobile footplate.
TM/ footplate assembly by-
> Autograft or homograft bone can be used.
> Artifical prostheses are also available.

63. SURGICAL APPROACHES
A. Post Aural (William Wilde) Incision: A cured incision is wade in the natural Post aural
gulcus. Starting nt the 12 o’ clock Position sumperorly and terminatiog at the 6 o’clock
position just behing the ear lobule
Used
 Myringoplasty & Tympano Pasty ( Comsined At)
 Masteidectomy (All)
 Cochler Implant
 Exposove of CN VII in vertical sac.
B. End aural inusion: i) incision in the canal and icisuratermials
 Lempert I: It is semicircular incision made from 12 ‘o clock to 6 o’ clock Position in the
posteromeatul wall at the bony Cartilaginous function.
 Lempert II: Starts from the 1st incision at 12 o clock and them pome upwords in a cuvilinear
fashion btween tragus and crus of helix. It pases though the incisura terminals and them
doen not cut hte cartilage. Both masterd and external canal surgery can be done
Indication:
 Lage tympanic membrane perforations.
 Attic cholesleatonas with limited extension into the andrum.
 Excesion of osteona or exostosis of earcanal.
 Modified radical mastordectomy where disane is limited to attic, antrum and part of
masted.

64. C. Permeatal approacho ( tramcanal) (Endomeatal)/
Rosen incision ( Lateral Tympanotomy)
Resn’s incisim in the most commonly used for stapectechomy It comnts of two
parts
a) A Small vertical inlision at 12’ o Clock Position near the annulus and
Acarvilinear incirion storting at 6 o’ clock Position to meet the 1st incision in the
poster superior region of the canals, 5mm-7mm away from the annulus.
Indication:
 Stepes surgery
 Myrugplasty
 Omicnler chain reconstruction
 Exporatory tumpanotomy Examination of omcular chain in congenital conductive
defames.
Success rate in achieving tympanoplasty?
Ans: In expert hand armed -95%
Trainee – 74%
Most out patiant methods have a success rate of between 30 and 80 percent
depending on pathology technique and operator Patience Minor surgery for small
defects can be successful in 80% or More Myringoplasty can be expected to
close 90% of Perforndim with a follow up of 12 months in experiorud hands.