This document provides an overview of the anatomy, physiology, types, clinical evaluation, and management of ossicular disorders of the middle ear. It discusses the anatomy of the middle ear and ossicles, types of ossicular dysfunction including discontinuity and fixation. Evaluation involves history, examination, audiometry, and imaging. Management options are discussed, including surgical procedures like stapedotomy and stapedectomy as well as alternatives like hearing aids. Post-operative care and potential complications are also outlined.

1. By: Dr. Wudie.M (ORL-HNS R3)
Clinical evaluation and
management of ossicular disorder
12/5/20201

2. outlines
 Middle ear anatomy & physiology
 Types of ossicular dysfunction
 Discontinuity
 Fixation
 Clinical evaluation of ossicular function
 Management
 refferences
12/5/20202

3. Anatomy and physiology of middle
ear
 Middle is air filled space
 Divided into hypotympanum,
mesotympanum, and
epitympanum
 The epitympanum, lies above
the level of the malleolar folds.
 The hypotympanum lie below
inferior tympanic sulcus- this
space may contain a
 dehiscent, high-riding jugular
bulb or an aberrant carotid
artery
 The mesotympanum is the
space just medial to the
tympanic membrane,
 Extends from the eustachian
tube opening anteriorly to the
facial nerve posteriorly
12/5/20203

4. Ossicles
 Malleus
 composed of head
manubrium, neck ,
ant. and lateral
processes
 The anterior process
is attached to the
anterior tympanic
spine by the anterior
mallelar ligament.
 Tensor tympani
muscle attaches to
medial aspect of the
neck and manubrium.
12/5/20204

5.  The incus is the
largest of the ossicles,
 composed of a body
and three processes
 The short process of
the incus occupies the
incudal fossa,
attached by the
posterior incudal
ligament.
 Body rest to
epitympanuem &
articute with head of
mallues 12/5/20205

6.  The stapes is the most
medial and smallest of
the ossicles,
 composed of a head
(capitulum), anterior
and posterior crura, and
the footplate.
 The footplate is
encircled by the annular
ligament, which serves
as a “joint,” sealing the
footplate in OW
 Stapedius tendon attach
to the superior aspect of
the posterior crus, just
inferior to the head.
12/5/20206

7. Blood supply and innervation
 Middle ear is supplied by two arteries are the
main,
 (i) Anterior tympanic branch of maxillary artery
which supplies tympanic membrane.
 (ii) Stylomastoid branch of posterior auricular artery
which supplies middle ear and mastoid air cells
 The main innervation of ME is from the tympanic
plexus and Jacobson’s nerve, which receives a
major contribution from the glossopharyngeal
nerve through the inferior tympanic canaliculus
12/5/20207

8. 12/5/20208

9. Physiological gain
12/5/20209
 There are two basic pathways by which sound is able
to stimulate the inner ear
1. Ossicular coupling -transmission of sound
pressure through the tympanic membrane and
ossicular chain via the oval window.
hydraulic lever effect -difference between the
surface area of the tympanic membrane relative to
that of the oval window (usually a ratio of nearly 21:1).
 Gain of 26 dB
malleoincudal lever effect – results from length
defference b/n handle of malleus and long process of
incus along its angle of rotation. 1.3:1 … it has gain of
2 dB
2. Acoustic coupling

10. 12/5/202010
 - transmision of sound directley to OW and RW with
out involvement of TM and ossicular chain.
 In the presence of intact ossicular chain and TM , it has
less importance.
 Phase- A sound stimulus to the inner ear is detected
as the net difference in sound pressures applied to
the round and oval windows that results in movement
of intracochlear fluids.
 If these sound pressures are simultaneously applied
to the round and oval windows with equal amplitude
and phase, they will counteract each other and no
resultant intracochlear fluid displacement will occur

11. Otosclerosis
 Otosclerosis is a disease of bone that is unique to
the otic capsule.
 It may cause a conductive hearing loss, a mixed
conductive-sensorineural hearing loss, or
occasionally a purely sensorineural hearing loss
 It has 2 phase of the disease
 Active phase (cxzed by bone resorption )-
spongiosis
 Remisssion phase – characterized by bone
deposition (sclerosis)
12/5/202011

12. Types of otosclerosis
1. Clinical otosclerosis – the lesion that affects the
stapdius, stapidiovestibular joint or round wind and
causing CHL
2. Cochlear otosclerosis –the lesion involving cochlear
endostium with out affecting stapidius or
stapidiovestibuar joint, causing pure SNHL
3. Histologic –histopathology of temporal bone shows
otosclerosis but clinically asymptomatic
4. Obliterative -involvement of both oval and round
window and most of bony labyrinthine.
 Results mixed hearing loss
5. Far adevanced otosclerosis- Air or bone
conduction , or at best Ac not better than 95 dB and
bone conduction at 55-60 dB at 1 frequency only.
12/5/202012

13. Epidemiology
 Most common among Caucasians
 Although occurring in all age groups, usually
presentation is b/n 2nd to 5th decades of age
 F:M 2:1
 In 70 % of cases , it’s bilateral
12/5/202013

14. Etiology
 Genetic – autosomal dominant
 Infection such as measles viral infection
 Endocrine
 Onset of hearing loss in otosclerosis may
associate pregnancy
12/5/202014

15. Clinical presentation
History
 Typically, with otosclerosis, hearing loss is
gradual onset and progresses slowly over several
years.
 Disease become apparent in late 10s to 20s of
age
 Most of pts will have CHL with paracusis of
Willis phenomena.
 Unilateral hearing loss may be unoticeble & may
have difficulty with direction of sound.
 Tinnitus is 2nd most common symptoms
12/5/202015

16.  Positive family hx with negative history for infections
or trauma.
Physical examination
 Otoscopic and microscopic examination – to rule out
other possible causes of CHL
 Schwartze sign - a red blush over the promontory or
the area anterior to the oval window.
 Tuning fork test- with 512 Hz
 Weber's test lateralize to ear which have more CHL
 Rehn’s test BC> AC in the presence of 15 to 20 dB CHL
with 512 Hz fork
12/5/202016

17. Investigations
 PTA- low frequency CHL with a dip at 2 kHz
known as Carhart’s notch. BC at 2kHZ is 15dB if
it is greater than 15 dB , there may be cochlear
OS.
 Tympanometry-either normal or depressed (As)
 Stapiediul reflex- normal in early stage , and can’t
be elicited in late stage
 Speech reception and perception test are often
normal unless there is choclear involvement.
12/5/202017

18. CT Scan and MRI
 Not routine workups
 CT scan is more usefull than MRI in OS evalation
 CT scan is indicated in the following cases
 CHL but absent carhart notch
 Equal ABG all over the frequencies
 Mixed hearing loss
 All cases of revision stapes surgery
 Appears as hypodense area, on CT. it has 90%
sensitivity.
12/5/202018

19. Management
 Surgical- indication is CHL with ABG >20 dB
 stapedioplasty
 Stapedotomy
 Stapedectomy – total vs partial
 Medical
 Hearing aid
12/5/202019

20. Stapes Mobilization (stapedioplasty)
 performed selected cases who has small point of
fixation of stapes from OS.
 using an endoscope and the argon laser
 potentially avoid the placement of a prosthesis
 Long term follow up show re fixation of stapes.
12/5/202020

21. Anterior crurotomy with partial
stapedectomy
 removal of only the anterior footplate and crus.
 Done in case of only anterior foot plate fixation
 helpful in a patient with isolated anterior fixation
at the fissula ante fenestram.
 The footplate is fractured in its mid portion, and
only the anterior half is removed
 A connective tissue graft placed over the exposed
area
 The IS join will remain intact and the stapidial
tendon will not cut,
 It has especial benefit for pts who workin noise
env’t. 12/5/202021

22. Fenestral stapidotomy
 after adequate exposure is established, the
malleus, incus, and stapes are palpated to
ascertain mobility.
 The distance from the incus to the stapes
footplate is measured . The usual distance from
the lateral surface of the incus to the footplate is
4.5 mm.
 Because the piston prosthesis is usually
measured from the medial surface of the incus,
0.25 mm is subtracted to allow for this distance
(incus = 0.5 mm + extension into vestibule of
0.25) .
 The most common piston size is 4.25 mm.
12/5/202022

23.  A 0.7-mm diamond microdrill is used to create the
fenestra.
 Usually there is adequate room between the
facial nerve and the crus of the stapes to use the
drill on the footplate.
 Despite this, part of the posterior crura is drilled to
warn the patient of the drill noise,
 Weaken the crura for easy fracture, and, at times,
allow better access to the footplate .
 The laser can be employed to begin the fenestra.
 If the footplate is thin, the drill may not be needed
to complete the opening. 12/5/202023

24.  The fenestra is created with a light touch of the drill .
 The diamond is allowed to create the fenestra without
applying pressure.
 Excess pressure may fracture the footplate.
 When the drill is felt to drop into the vestibule, a
perfect 0.7-mm fenestra is completed.
 The 4.25-mm length, 0.6-mm diameter platinum
Teflon (polytetrafluoroethylene) prosthesis is placed
from the incus to the fenestra .
 It is crimped firmly on the incus .
 The incudostapedial joint is separated, and the
stapedial tendon is sectioned.
12/5/202024

25. 12/5/202025

26. 12/5/202026

27.  Superstructure of
stapes fractured and
removed
 Test to prostesis
performed to check
position
 Medial lateral
excuresion checked
with light manuplation
 If pt feels vertigo, the
prostesis may be too
long
 If pt does not feel,
check for anterior
posterior excursion & no
 Blood is placed around
the prosthesis as a seal
in the oval window, and
the tympanomeatal flap
is returned to its normal
position.
 Minimal packing is
required on the flap, a
cotton ball is placed in
the meatus,
 and a bandage is
applied to the ear
12/5/202027

28. stapidectomy
 Total stapedectomy – is
surgical removal of total
foot plate of stapes with
pick and hook
 replace it with a vein
graft and polyethylene
strut.
 partial stapedectomy,
removing only the
posterior half of the
footplate.
 The footplate is opened
with either picks or a
microdril
 The most common
tissue types used for
grafting are the dorsal
hand vein, tragal
perichondrium, or
fascia.
12/5/202028

29. Post operative care
 Immediately after surgary the pt head should be
elvated to 30 degree for an Hr.
 In the immediate postoperative period, the patient
is asked to avoid lifting and straining for about 1
month.
 Nose blowing should be discouraged.
 The patient should also cough or sneeze with the
mouth open, to reduce the risk of increased
middle ear pressure and displacement of the TM .
 The patient is kept on dry ear precautions until
the TM flap has completely healed.
12/5/202029

30.  A postoperative audiogram is obtained 2 to 3
months after surgery.
 In 90 % of cases there will be closure of ABG
within 10 dB of the preoperative bone-conduction.
 About 10% of patients experience either
worsening hearing or no improvement
 About 2% of patients suffer persistent and
profound SNHL.
12/5/202030

31. Out come
 small fenestra
techniques argue that
limited opening of the
vestibule
 lower risk of damage
to the inner ear and
resultant
sensorineural hearing
loss
 The most common
cause for failure of
stapedectomy has
been prosthesis
displacement, with or
without incus erosion.
 Other causes of
failure are
 footplate refixation,
 perilymph fistula.
 otosclerotic regrowth,
and lateralization of
the OW membrane
12/5/202031

32.  Persistent or progressive CHL can follow
stapedectomy.
 Loosening or displacement of the prosthesis,
 resorption of the incus long process,
 adhesions around the prosthesis, and further OS
lesions can produce postoperative CHL
12/5/202032

33. complication
Immediate complication
 Complication occurs
intra op
 Facial nerve injury
 Vertigo- usually
resolves with in short
period of time
 Hearing loss
 Persistant perilymphatic
leakage from OW
 Change in taste- in 9 %
of cases , improve with
in 3 to 4 mnths
 Labrynitis
 Tympanic menbrane
perforation- use paper
patch
Delayed complications
 Fistula formation – most
common cause is
poststapedectomy ( 3 %
to 9%),rare in
stapedotomy
 Granuloma
 Prosthesis dislocation-
needs revision surgary
12/5/202033

34. Alternative treatment
 Hearing aid- CHL caused by OS may use hearing
aid as alternative for surgical mgt
 Pts who have mixed HL may need Hearing aid after
surgical mngt.
 Fluoride therapy- NaF
 Pt with progressive hearing loss may benefit
 It changes active otospongiotic lesion to more
otosclerotic lesion
 Reduce the progression of hearing loss
 8mg po TID until the hearing loss stablized
12/5/202034

35. Tympanosclerosis
 It is a deposition of calcium and accellular hyaline
to TM and middle ear cleft.
 Tympanosclerosis most commonly involves the
TM- myringosclerosis.
 If it has extension to middle ear cleft , it may
cause ossicular fixation
 Fixes stapes in the oval window region, and the
incus and malleus in the attic, or fixes both
simultaneously
12/5/202035

36.  Pathogenesis. Tympanosclerosis results as a
consequence of recurrent AOM, COM, or
tympanostomy-tube placement.
 The exact pathogenesis of tympanosclerosis
remains unclear.
 One possible mechanism is degeneration of
fibroblasts which are known to accumulate in
these plaques progressively
12/5/202036

37.  cytosolic matrix vesicles rich in calcium,
phosphate, and alkaline phosphatase that
eventually merge with the cell membrane and are
released extracellularly upon fibroblast-cell death
 Another possible mechanism is that of dystrophic
calcification of degenerated collagen fibers after
an infectious or inflammatory insult
12/5/202037

38. Diagnosis
 Usually it’s asymptomatic and incidental finding
 horseshoe-shaped white plaque over TM
 If there is ossicular chain involvement, will have
significant CHL
 Management
 Tympanoplasty with ossiculoplasty
12/5/202038

39. 12/5/202039

40. Ossicular chain discontinuity
disorder
12/5/202040

41. Ossicular trauma
 Most ossicular injuries are dislocation
 Dislocation of incuse being the most frequent
dislocation
 Incudo stapidial joint dislocation with minimal
incus displacement or complete separation may
occur.
 Ossicular fracture are much less frequent. If it
occurs the long process of ossicle is commonest
part.
 Isolated fructure of stapial foot plate is very rare
and almost always associated with penetrating
trauma. 12/5/202041

42.  Mechanism of injury –
 Skull trauma with or without # of the temporal bone
is the main cause
 About 60% occur with out concomitant TB #
 Barotrauma to middle ear
 Surgical trauma
 Drill-induced trauma to the incus during tympanomastoid
surgery usually causes incudostapedial joint dislocation
12/5/202042

43.  Evaluation
 PTA
 Initial audiometric evaluation should be done as
soon as after the injury.
 If there is CHL at initial evaluation, , Repeat PTA
after 3 months
 CHL in the presence of intact or healed TM and
with out any sign of hemotympanum ossicular
chain disruption
 Ossicular-chain disruption
 without perforation may result ABG up to 60 dB
 With perforated TM ABG 40 to 50 dB
12/5/202043

44.  Tympanometry- helps to identify cases of
complete ossicular disruption
 Discontinuous ossicular chain allows a wide
excursion of the tympanic membrane in response to
changing ear canal pressure, AD
 CT scan-
12/5/202044

45. Management of ossicular trauma
Conservative management
 surprisingly good hearing recovery may take
place with fibrous healing when the
incudostapedial joint is disrupted, even if the
incus is entirely displaced, a 3-month period is
recommended prior to surgical exploration
12/5/202045

46. Surgical management
 Indication for ossicular reconstruction is
conductive hearing loss of more than 30 dB that
persists for more than 2 months after injury.
 The most conducive injury for ossicular
reconstruction is a dislocation of the
incudostapedial joint.
 In this situation, an Applebaum hydroxyapatite
prosthesis is inserted between the long process
of the incus and the capitulum of the stapes .
 Dislocation of the entire incus requires bridging
the gap between the stapes suprastructure and
the manubrium of the malleus. A sculpted incus
interposition graft is preferred.
12/5/202046

47.  when the stapes suprastructure is fractured but
the incus remains connected to the malleus;
these patients are good candidates for a laser
stapedotomy.
12/5/202047

48. Ossicular erosion
 Chronic otitis media in almost any form can result in
the disruption of the integrity of the ossicular chain.
 Chronic eustachian tube insufficiency and tympanic
membrane retraction that results in prolonged contact
of the tympanic membrane with the tip of the incus
can cause this type of erosion, even without active
infection.
 Cholesteatoma is the most common cause of erosion
of the ossicles.
12/5/202048

49.  It can result
 Loss of lenticular process with preservation of soft
tissue connection
 Erosion of long process of incuse with stapes
suprastructure
 Incudostapidial erosion with partial or total malleus
fixation
12/5/202049

50. Ossiculoplasty
MATERIALS FOR RECONSTRUCTION
 The ideal material for ossicular reconstruction
should be biologically stable (resistant to resorption
and non-reactive),
 correct mass and stiffness,
 be easy to handle, and
 ideally low cost
 can be broadly divided into autografts,
homografts and alloplastic materials
12/5/202050

51.  Autografts are tissues that are harvested from the
same patient on which they are to be used, and
can include ossicles, cortical bone and cartilage.
 Homograft material is derived from human donor
tissue. A wide choice of pre-prepared graft
material is available with options including cortical
bone, cartilage, ossicles, and en bloc ossicular
chain with tympanic membrane attached
12/5/202051

52.  Alloplastic material
 solid plastics: polytetrafluoroethylene, polyethylene
 solid metals: stainless steel, gold, titanium
 porous sponge-like plastics: ProplastR, Plasti-Pore
 ceramics: aluminium oxide, hydroxyapatite.
 PORP = partial ossicular replacement prosthesis.
Generally used to mean a prosthesis that is
designed for situations with an intact stapes
superstructure.
 TORP = total ossicular replacement prosthesis.
For use in situations where there is no stapes
superstructure and the prosthesis restores a
connection with the stapes footplate.
12/5/202052

53.  A major decision to be made during surgery for
chronic otitis media (especially for cholesteatoma) is
whether to perform ossiculoplasty at the time of the
cholesteatoma excision or to perform ossiculoplasty
as a planned procedure some months later.
 Important factors relevant to this decision include the
following:
1. Status of the middle ear mucosa,
2. Amount of bleeding,
3. Advisability of reoperation for possible cholesteatoma
recurrence, and
 Middle ear mucosa that is thickened, infected,
traumatized, or partially missing is likely to heal with
fibrous tissue formation that may displace a
perfectly placed prosthesis 12/5/202053

54. SURGICAL OPTIONS TO
CORRECT SPECIFIC DEFECTS
Incus Erosion
 Erosion of long process of incus is the most
frequent ossicular defect
 There are 2 option to reconstruct incus erosion
1. Reconstruct the incudostapidial joint with type II
tympanoplasty
 If the defect between the incus and stapes is very
small, this can be accomplished by wedging a piece
of cartilage or bone between the incus and malleus
12/5/202054

55.  If the defect is large, we can use various prosthesis
engaged b/n stapes capitulum and the eroded
lentirular process
2. removal of the incus remnant and reconstruction
between the stapes and malleus (or tympanic
membrane),
 a type Ill minor columella tympanoplasty.
 Incus interposition
 PORP- stapes to malleus
12/5/202055

56. 12/5/202056

57. Malleus present, stapes absent
12/5/202057
 When both the incus and stapes superstructure
are absent, common options for reconstruction
include a type III major columella mechanism or a
type IV tympanoplasty,
 TORP
 Stapes foot plate to malleus
 Stapes foot plate to TM

58. Malleus absent, stapes present
12/5/202058
 Absence of the malleus handle to be a major
independent prognostic factor resulting in
poorer hearing outcomes following
reconstruction.
 Reconstructed by using
Either by stapes columella or
recreate the malleus handle, either with
autologous material or with a prosthesis
Homograft tympanic membrane with
attached malleus handles

59. Malleus and stapes absent
12/5/202059
 The most challenging ossicular defect and lead to
the poorest outcomes
 reconstruction may be footplate-totympanic
membrane, or alternatively a neo–malleus or
malleus replacement prosthesis may be used to
improve stability

60. Reference
12/5/202060
 Cummings otolaryngology–head and neck
surgery, 5th edition
 Scott-brown’s otorhinolaryngology head and neck
surgery,8th edition
 Ballenger’s otorhinolaryngology , head and neck
surgery 18th edition
 Bailey otorhinolaryngology head and neck
surgery, 5th edition
 Otosclerosis Diagnosis, Evaluation, Pathology,
Surgical Techniques, and Outcomes

61. 12/5/202061