Ossiculoplasty is the reconstruction of the disrupted middle ear ossicular chain using prosthetic devices or grafts to restore hearing mechanics. The document discusses the history, relevant anatomy, materials used, and types of ossiculoplasty procedures. Key points include that ossiculoplasty aims to regain sound transfer through the ossicular chain to the inner ear. A variety of autografts, allografts and prosthetics can be used depending on the ossicular defect. The success of ossiculoplasty depends on factors like the graft/prosthesis used and extent of ossicular disruption.

1. Ossiculoplasty
PRESENTED BY:
Dr. Taba Nitin
PGT,Dept of ENT
SMCH
Moderator:
Dr (prof) Shams Uddin
HOD, Dept of ENT
SMCH

2. • INTRODUCTION.
• HISTORY OF OSSICULOPLASTY.
• RELEVANT ANATOMY AND MECHANISM OF HEARING.
• INDICATIONS.
• CONTRAINDICATIONS.
• MATERIALS USED IN OSSICULAR RECONSTRUCTION.
• TYPES OF OSSICULOPLASTY.
• OSSICULAR CHAIN DEFECTS AND OSSICULOPLATY TECHNIQUES.
• COMPLICATIONS
• DEFINING SUCCESS
• FACTORS AFFECTING THE RESULT OF OSSICULOPLASTY.
Contents :

3. Introduction
• Ossiculoplasty is the reconstruction of the middle ear ossicular chain which has been disrupted or
destroyed, by the use of some interpositioned devices which helps in regaining the original mechanics of
the ossicular chain to transfer the sound energy to the inner ear.
• Ossicular abnormalities can range from loss of ossicular continuity due to trauma, surgical manipulation
or middle ear pathology such as cholesteatoma or fixation of the ossicles in cases of otosclerosis.

4. History of Ossiculoplasty
The first recorded ossiculoplasty : Matte in 1901 for a missing ossicle. (myringostapediopexy)
1950 - 1970
1952 vinyl acryl : wullstein
1957 Autologous incus : Hall
1958 Polyethylene : shea
1960s Cortical bone,EAC, Spine of henle :
Hough, Zollner, Farrior
1960 -1963 Autologous cartilage : Utech, Jensen
1962 Polytetrafluoroethylene : Austin
1966 Homologous incus : House
1969 Stainless steel : Palva
1971-1990
1974 proplast : Shea
1976 Plastipore : Shea
1979 Aluminium oxide ceramic : Jahnke
and Plester
1981 Hydroxyl apatite : Grote
1983 Ceravital : Reck
1986 Bioglass : Merwin

5. 1991 - till date
1993 Titanium : Dalchow
Improvised form of titanium partial
ossicular replacement prosthesis :
Spiggle and Theis

6. Relevant anatomy and the mechanism of
hearing :
Malleus (hammer)
• 9 mm in length.
• weighs about 20 – 25 mg.
malleus head :
• lies in attic.
• 2.5 x 2 mm in size.
Clinical relevance :
• Malleus head fixation can either exist as a
congenital anomaly or as an acquired anomaly
with fixation of body of incus.
• 15 – 25 db hearing loss.

7. THE NECK :
• Narrowest part.
• Tendon of tensor tympani muscle inserts on its medial
surface.
• Chorda tympani crosses the medial surface above the
insertion of TT.
• its lateral surface forms the medial wall of Prussak’s
space.
C R: if anterior malleolar ligament needs to be cut, make
sure the tensor tympani tendon is holding malleus neck
tightly.

8. THE MANUBRIUM (THE HANDLE) :
• Directed downwards, medially and backwards
• Between mucous and fibrous layer of TM.
• Periosteum of the handle of malleus at umbo
continues directly with the fibrous layer of the TM.
• so it becomes difficult to separate the TM from the
malleus at umbo.
• Handle loosely connected to TM midway between
the lateral process and the umbo.
• Prosthesis can be easily clamped at this location.

9. SUPPORT OF MALLEUS :
• 3 suspensory ligaments : anterior, lateral
and superior.
• Do not play any role in stabilizing the malleus.
• Anterior Malleal Ligament : most important
ligament for support of malleus.
• Extends from : angular spine of the sphenoid
bone, passes through the petrotympanic fissure,
accompanied by anterior tympanic artery.
•Insertion : neck of malleus.
• Posterior malleal ligament.
• tympanic membrane.
• tensor tympani tendon.

10. INCUS :
• Measures about 5 x 7 mm.
• Weighs about 30 mg.
• Trapezoid shaped.
• Circular cross sectional shape (long process)
• Long process along with the lenticular process first
gets eroded.
• Supplied by end vessels, prone to asceptic
necrosis.
• Important : during surgery tight crimping of clip of
piston around long process can lead to its necrosis.
lenticular process :
• Forms the IS joint by forming a joint capsule
surrounded by thick fibres.
• Mean diameter of distal plate = 0.7mm
• mean diameter of long process = 0.6mm
• Incus is thinnest at its lenticular process
(bony pedicle 0.2mm).

11. LIGAMENTS OF INCUS :
• Only 2 ligaments.
• Susceptible to traumatic dislocation.
1. Posterior incudal ligament
2. Superior incudal ligament

12. STAPES (STIRRUP)
• smallest ossicle.
• height = 3.2 mm
• weight = 3-4 mg
• width = 1.4 mm
surgical importance :
HEAD :
• The width of stapes head is about 1 – 1.5 mm.
• Important for developing right size of the prosthesis.
THE CRURA :
• posterior crus is longer, thicker and more curved than anterior crus.
• presence of stapes suprastructure in ossicular chain pathology is important factor for
success of ossiculoplasty.
• Most of the times bony pedicle gets necrosed but head remains attached to the head of
stapes. It should be removed for accurate graft assembly.
for stapedotomy :
• Stapes suprastructure should be removed before placing the piston.
• Posterior crus removal is difficult. High risk of avulsion. Partially drilled with skeeter drill
or cauterized and cut with a carbon dioxide laser before removal.
•Anterior crus can be fractured and removed with a downward pull.

13. FOOTPLATE :
• very thin
• oval shaped
• width = 1.5 mm
• thichness = 0.25 – 0.3 mm
• Lateral tympanic surface is lined by mucoperiosteum of
middle ear.
• Distance from long process of incus to the tympanic surface
of footplate = 4mm
• Medial(vestibular) surface of footplate is flat and is covered
by endosteum of the ottic capsule.
• Saccule is 1 mm deep from anterior part of medial surface
of footplate
• Utricle is 1.5 mm deep from the posterior part of footplate.

14. SURGICAL IMPORTANCE :
• When stapes suprastructure is necrosed the footplate is used
as a base for an interposition graft as well as columella graft
placement.
• In case of TORP the position of the prosthesis should be
accurately placed on the footplate.
• The anterior footplate is preferable because the annular
ligament is thinner and footplate is wider ant thus more mobile.
• in stepedotomy the fenestra is drilled between the middle and
posterior third of the footplate as both utricle and saccule are
farthest from footplate in this location.

15. ANNULAR LIGAMENT :
• Ring of elastic fibres that attaches the cartilaginous margin
of the footplate to the border of the oval window.
• Fibres of the annular ligament fuse with the periosteal and
endosteal layer all around the oval window.
• ligament thinner anteriorly.
• Hinge attachment of the stapes into the oval window.
Movement of footplate in two planes :
• Piston like and rocking movement
• Upto 1 khz – piston like movement.
• Higher frequencies – complex, with rotatory/rocking motion
along both the long and short axis of the footplate.
CLINICAL RELEVANCE :
• In otosclerosis of anterior aspect of annular ligament –
piston- like movement of the stapes is restricted rather than
the rocking movement. This explains why in early stage of
otosclerosis, there is only low frequency conductive hearing
loss.

16. SURGICAL IMPORTANCE :
• Undue pressure during removal of cholesteatoma matrix,granulation or
hypertrophied mucosa from the surface of the footplate can lead to snhl.
• To avoid this work parallel to the plane of the stapedial tendon from posterior to
anterior.
• Tendon prevents luxation of the stapes.

17. MUSCLES OF THE MIDDLE EAR :
1. Tensor tympani muscle :
• 20 mm long ( 2.5 to 3 mm intra tympanic part )
• From cartilaginous part of eustachian tube, the bony canal
around the tube and greater wing of sphenoid to the medial
surface of the neck of malleus.
• Action : draws manubrium of malleus medially and
dampens the movement of ossicular chain.
2. Stapedial muscle :
• smallest muscle
• only 1mm in size.
• action : stretching of annular ligament thus fixing the
footplate and dumping its movement.

18. MECHANISM OF HEARING :
• Middle ear transmits sound from the low impedence energy
field in the EAC to high impedence energy field of fluid within
cochlea by 3 lever mechanisms :
• Catenary lever
• Ossicular lever
• Hydraulic lever
1. CATENARY LEVER(EAR DRUM) :
• Buckling mechanism of TM.
• Force is transmitted from the centre of TM.
• TM doesn’t move as a plate.
• This causes high pressure with low displacement.

19. 2. OSSICULAR LEVER(LEVER RATIO):
• Length of the handle of Malleus 1.3 times
longer Than long process of Incus.
• total gain = 1.3 times
3. HYDRAULIC LEVER (AREA RATIO )
• Area of TM = 45 mm2
• Area of stapes footplate = 3.2 mm2
• MAGNIFIES 17 TIMES.

20. NEWER MODIFICATIONS TO THE OLD
THEORY HAVE BEEN PROPOSED :
1. OSSICULAR COUPLING
2. ACOUSTIC COUPLING

21. INDICATIONS FOR OSSCICULOPLASTY
DISCONTINUITY OF OSSICULAR CHAIN :
• Trauma
• Erosion by chronic otitis media/ cholesteatoma (most Common)
• Eroded incudostapedial joint (80% of patients)
• Eroded or absent incus
• Partially or fully eroded stapes
FIXATION :
• Malleus head ankylosis (idiopathic)
• Ossicular tympanosclerosis
• Scar bands due to inflammatory middle ear disease

22. CONTRAINDICATIONS
• Acute infection of the ear is the only true contraindication. (Poor healing,
prosthesis extrusion)
Relative contraindications :
• Persistent middle ear mucosal disease.
• Tympanic membrane perforation.
• Repeated unsuccessful use of the same or similar prostheses.

23. GRAFT MATERIALS USED AT
PRESENT
1. BIOLOGICAL GRAFT
Auto graft ( tissue harvested from patients own
body)
• Incus
• Head of malleus
• Floor, tragal, and conchal cartilage
• Cortical bone, external canal wall bone, and spine
of henle.
Homografts/allogenic grafts ( derived from
human donor tissue, screened and treated
to avoid transmission of disease and
preserved for later use )
• Incus
• Tooth
• Septal cartilage.
2. ALLOGRAFTS ( SYNTHETIC,
BIOCOMPATIBLE IMPLANTS
THAT CAN BE SAFELY USED IN
MIDDLE EAR ).
• Plastipore
• Hydroxyl apatite
• Teflon
• Gold
• Titanium

24. IDEAL PROSTHESIS
• Biocompatible
• Stable
• Safe
• Facilitate easy insertion
• Yield optimal sound transmission
Surgical importance :
• Weight of more than 5 mg can affect sound transmission above 1 khz.

25. USABLE AUTOGRAFTS :
1. INCUS PARTIALLY NECROSED :
• Necrosed part drilled away.
• Gives stable results when used as interposition graft between handle of malleus and the stapes head/footplate.
Autograft incus
remodelled into different
shapes
Incus when placed
between stapes and
handle of malleus.
Incus when placed
between footplate and
handle of malleus.

26. 2. Incus necrosed and unusable :
Autologous head of malleus over head of stapes
(columella graft)
3. Autologous cartilage graft :
Tragal/conchal/floor cartilage
Trimmed into cartilage strip with perichondrium at least on
one side.

27. ADVANTAGES
• Biocompatible, no possibility of rejection
• Ideal consistency
• No added cost
• No risk of transmitting disease
• Can be done in single stage.
DISADVANTAGES
• Needs sculpting, requires good surgical acumen.
• May harbor microscopic cholesteatoma
• Can be displaced easily if not interposed
correctly.
• Adhesion/ bony ankylosis may develop between
grafted incus and surrounding bone leading to
failure of ossiculoplasty.

28. TITANIUM PORP/ TORP/ ANGULAR PROSTHESIS / PISTON
Titanium PORP Titanium angular prosthesis Titanium TORP
TITANIUM CLIP PISTON
Titanium malleovestibulopexy piston

29. ADVANTAGES
• Most biocompatible alloplastic material
available at present.
• It has low specific density i.e less than
57% of stainless steel.
• Extremely rigid, non magnetic
• Extremely light, fine yet strong.
• Does not need sculpting.
• No risk of residual disease.
• No risk of transmitting disease.
• Results comparable to autologous grafts
DISADVANTAGES
• Expensive.
• Possibilty of adhesion with surrounding tissue.
• Equally time consuming to trim the length of the
shaft according to height of middle ear in every
cases.
• Though regarded as biocompatible, it can get
extruded if it comes in direct contact with the tm.
So partial thickness cartilage graft with
perichondrium need to be placed between tm
and prosthesis.

30. UNIVERSAL TITANIUM PROSTHESIS WITH FLEX HYDROXL APATITE
SHAFT AND TITANIUM SHOE
Universal titanium prosthesis
with titanium head and shaft
which fits into flex hydroxyl
apatite shaft with titanium
shoes.
Hydroxyl apatite shaft
with titanium shoe.
Titanium head with shaft
which can be trimmed.

31. HYDROXYL APATITE PORP/ TORP
• Same chemical composition as bone.
• Bioactive, integrates with surrounding
bone and tissue.
• Within two weeks it gets covered with
an epithelial layer.
Hydoxyl apatite PORP.
Hydoxyl apatite TORP.

32. PLASTIPORE PORP/TORP
• First alloplastic material to be used
worldwide.
• Semisoft white sponge of high density
polyethylene.
• Can be easily trimmed with a knife
• Nonreactive properties with sufficient
porosity to allow ingrowth of tissues.
• Short term results good but
unacceptable long term extrution rate.
(15 – 30 %)

33. TEFLON PORP / TORP
• Biocompatible alloplastic material.
• Use substantially reduced after titanium porp
and torp came into existance.
• It is affordable

34. HOMOLOGOUS INCUS :
OLD METHOD OF PRESERVATION
• Grafts preserved in bottles either in 70 %
alcohol (smyth) or Cialit 1 in 5000(marquet) at
+/- 3 degree celcius.
• It should be removed within 24 hours of
death.
NEW METHOD OF PRESERVATION
• After removal from donor site it is
thoroughly examined under microscope for
any microinvasion after harvesting.
• Thoroughly washed with saline and kept in
4 % formaldehyde for 48 hrs for fixation
and then kept in 70 % ethanol for minimum
of 2 months before usage.

35. BONE CEMENT (Latest addition as an ossiculoplasty material )
• Used in dentistry as filling material.
• Used in cases of IS joint necrosis with a gap between stapes and incus less than 3 mm and
minimal necrosis of long process of incus.
•

36. GLUES AND ADHESIVES
Tissue glues
• Mecrylate(COAPT-1)
• Bucrylate(COAPT)
• Eubucrylate(Histo-Acryl)
Fibrin glues
• Tissucol/Tisseel (human fibrinogen & factor XIII with thrombin ca
cl2/aprontinin sol.)

37. TYPES OF OSSCICULOPLASTY
PRIMARY :
• Ossiculoplasty and mastoidectomy done simultaneously.
SECONDARY:
• Staging ossiculoplasty: first eradication of the disease by mastoidectmy and
ossciculoplasty done after 6 months or one year.
SURGICAL APPROACHES
• Post auricular
• Permeatal
• Endaural

38. OSSICULAR CHAIN DEFECTS :
AUSTIN’S CLASSIFICATION
Incus absent or necrosed in all cases and TM reconstruction required in all cases.
1. Type A: m+, s+ loss of part of incus or total loss of incus.
2. Type B: m+, s- loss of incus & stapes superstructure but the malleus handle still present.
3. Type C: m-, s+ loss of incus & malleus but the stapes superstructure still present.
4. Type D: m-, s- loss of incus, malleus & superstructure of stapes, but mobile footplate still
present.
KARTUSH ADDED TWO MORE CLASSES TO THE AUSTIN CLASSIFICATION :
• E for ossicular head fixation with intact ossicles.
• F for stapes fixation with presence of all ossicles.

39. Type A : m+, s+
loss of part of incus or total loss of incus.

40. Dornhoffer interpositional
Prosthesis
WEHRS
OTHER METHODS

41. Type b: m+, s- loss of incus & stapes superstructure but the malleus
handle still present.
Autograft or homograft bone/ Prosthesis

42. PORP/ AUTOGRAFT OR
HOMOGRAFT BONE
Type c: m-, s+
PORP  Intact superstructure
Stapes superstructure  TM

43. TORP/ AUTOGRAFT OR HOMOGRAFT
BONE
Footplate  TM
Type d: m-, s- loss of incus, malleus & superstructure of
stapes, but mobile footplate still present.
Oval window (with graft)  TM

46. Fixed footplate and mobile malleus
and incus :
A standard stapedectomy or stapedotomy is
performed.

47. • Tear of the annular ligament with a perilymphatic fistula.
• Sensorineural hearing loss.
• Nerve injury : facial / chorda tympani
• Vertigo
• Recurrent cholesteatoma.
• Infection
• Graft extrusion
Complications

48. FACTORS AFFECTING THE RESULT
OF OSSICULOPLASTY :
• MIDDLE EAR RISK INDEX
(MERI)1994 BY KARTUSH

49. IMPORTANT FACTORS AFFECTING THE OUTCOME OF
OSSICULOPLASTY :
1. EUSTACHIAN TUBE FUNCTIONING
2. AERATION OF MIDDLE EAR VIA VENTILATION PATHWAYS.
3. DIMENSION OF OSSICULOPLASTY GRAFT
4. STATUS OF THE MUCOSA OF THE MIDDLE EAR.
5. STATUS OF RESIDUAL OSSICLES.
6. POSTEROSUPERIOR CANAL WALL CONSTRUCTION.
7. CANAL WALL UP/DOWN MASTOIDECTOMY.
8. CULTURE SENSITIVITY OF THE EAR DISCHARGE BEFORE
SURGERY.

50. 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 airbone gap of less
than 20 db
• Bringing the operative ear to within 15 db of the contralateral ear.

51. REFERENCES:
1. ATLAS OF OSSICULOPLASTY : MADHURI MEHTA.
2. SCOT BROWN 4TH EDITION.

52. Thank you for
your attention..