Tragus perichondrium-cartilage island transplant in middle ear surgery. Method and results after 5 years

Temporalis fascia remains the most widespread material for reconstructing the tympanic membrane in tympanomastoid surgery. If total or partial ossicular replacement prostheses are needed or pathology of the eustachian tube causes ventilation impairment, a more rigid transplant material is required. Between 1989 and 1994 perichondrium-cartilage composite grafts were used in a series of 597 cases of tympanomastoid surgery performed at the University ENT Clinic of Würzburg. The graft was taken from the tragus and prepared as a cartilage island with perichondrium attached to one side, the perichondrium-cartilage island transplant (PCI). If reconstruction of the ossicular chain was necessary, glass ionomer cement protheses (IONOS) were used. Closure of the tympanic membrane could be achieved in 90% of all cases. In those cases where ossicular chain reconstruction was postponed to a second procedure, closure of the drum was achieved in 96%. The audiological results of the different type III procedures were evaluated. By using the PCI technique a favorable closure of the air-bone gap to 10-25 dB was achieved, even in cases with advanced ear pathology technique and results are presented in detail.     

Successful chemotherapy in a patient with recurrent carcinoma of the urachus

OBJECTIVE: Titanium in other parts of the body, well known for its biocompatibility, was examined in an animal model for its use as an ossicular replacement material. STUDY DESIGN: The biocompatibility of titanium was studied in the middle ear of rabbits using light and scanning electron microscopy. Titanium pins were placed as middle ear prostheses or as free implants and were examined after 28, 84, 168, and 336 days. RESULTS: After 28 days, the prostheses were covered by regular mucosa. The free implants took up to 336 days to be totally epithelialized. There were no inflammatory cells observed on the surface of the material nor were unusual amounts of fibrous tissue seen. In addition, the titanium material exhibited an affinity toward bone. CONCLUSIONS: The results of this animal experiment indicate that titanium is a useful material for ossicular replacement prostheses.     

Tissue reactions to glass ceramics in the middle ear

The bioactive glass ceramic "Ceravital" was used to fashion prostheses for the replacement of various ossicles in the middle ear. They were tested in 70 rabbit ears, where they were accepted in osseous areas without formation of surrounding fibrous tissue. Histological examinations regularly showed an osseous bond with the surrounding bony tissue. Mucous membrane covered these ossicular chain prostheses and showed no evidence of inflammatory reactions. Glass ceramic implants were also used to reconstruct the ossicular chain and the posterior wall of the outer ear canal in 100 patients. The functional results were satisfactory in all cases.     

Plasti-pore implants in middle ear surgery

Plasti-pore, a high-density polyethylene sponge, was one of the earliest biocompatible materials developed specifically for implantation in the middle ear. It is one of the most nonreactive materials known when tested in simulated biochemical exposure to pseudoextracellular fluid. The two basic prosthetic designs are the total ossicular replacement prosthesis and the partial ossicular replacement prosthesis. Plasti-pore implants have now been used for 20 years and are widely accepted by otologic surgeons. The basic properties of the material, implant design, and surgical techniques involved using these prostheses are reviewed in this article.     

Titanium as a biomaterial for ossicular replacement: results after implantation in the middle ear of the rabbit

The middle ear poses unique challenges when finding suitable materials for ossicular reconstruction, primarily because of its link to the external environment via the eustachian tube and, hence, its greater exposure to infectious agents. In this study, the biocompatability of titanium was examined in the middle ear of rabbits by using light and scanning electron microscopy. Implants were placed as middle ear prostheses or as free implants. These were inspected at 28 days, 84 days, 168 days, 336 days and 504 days following implantation for mucosal coverage, percent epithelization and any sign of foreign-body reaction. After 28 days, the prostheses were covered by regular mucosa. Although a majority of the free implants took up to 336 days for complete epithelialization, some of the free implants were not epithelialized even at day 504. There were no inflammatory cells observed on the surface of the material, nor were unusual amounts of fibrous tissue seen. In addition, the titanium material exhibited an affinity toward bone. The results of this animal experiment indicate that titanium is a favorable material for ossicular replacement prostheses.     

Replacement of ear ossicles with titanium prostheses

BACKGROUND: Titanium has been a well established implant material for many years. New material processing techniques now permit the manufacture of small implants for ossicular chain reconstruction. METHODS: Between November 1994 and September 1995, 100 titanium middle ear implants (55 PORP, 45 TORP) were used for reconstruction of the ossicular chain. A range of five different sizes for partial and total protheses suits all implantation needs. The shape of the implants can be altered by bending. Time consuming intraoperative shaping and trimming is avoided. RESULTS: At a follow-up time of three months (33 patients) and six months (17 patients), no adverse reactions or extrusions occurred. Biologic fixation between the foot of the partial prothesis and the head of the stapes was found eight months after implantation. A hearing result of 0-20 dB residual air-bone gap was achieved in 79%. CONCLUSION: Titanium middle ear implants show good bio-compatibility and are readily integrated into the ossicular chain. Although delicate in shape, they offer excellent mechanical properties in respect to sound conduction and implantation. Initial results show Titanium to be a perfect implant material for middle ear prostheses, although long-term results are not yet available.     

Ossicular coupling of an implantable hearing aid transducer using an Er:YAG laser

Special coupling devices made of pure gold or titanium have been developed to connect a new implantable hearing aid transducer (Tübingen implant) to the ossicular chain. They allow piezotransducer probe-tip connection to the long process of the incus or the stapedial head. Similar to the design of conventional PORPs (partial ossicular replacement prostheses), the coupling devices can be fixed at the ossicular chain, e.g., with the eye loop of stapedial piston prostheses or the bell element of golden wire PORPs. A crimp technique allows connection between coupling device and transducer probe tip [5]. The main disadvantage in connecting the long process of the incus or the stapes having is to drill a dorsal tympanotomy in the posterior wall of the ear canal during surgery. The short distance between tympanotomy and N. facialis contains serious surgical risks. To avoid the risk of facial paralysis, Fredrickson's alternative coupling technique for the body of the incus is investigated in this paper [2]. In this case, the transducer probe tip will be positioned to the incus body and placed on its surface with controlled elastic displacement of the ossicular chain. The simple direct attachment of the probe-tip end on the surface of the incus, however, will not guarantee a stable long-term connection. Thus, by creating a conical, 0.5-to 0.7-mm-deep hole in the incus, the probe tip will be fitted much better. With a novel surgical Erbium-YAG laser this can be done in a contactless procedure. In this paper, first results of microsurgical laser applications with human temporal bones will be shown.     

Proplast implants used in otology and in facial reconstructive surgery

Proplast, a self-stabilising alloplastic material, was evaluated in ear surgery and in facial reconstructive surgery. Proplast implants were used on 33 patients to reconstruct the ossicular chain (total or partial ossicular replacement prosthesis), or to rebuild the mastoid cavity. The lack of extrusion over a 24-month period is encouraging. In facial reconstructive surgery 11 patients received Proplast implants to augment and restore facial contours. Contamination with saliva remains a problem, owing to the high porosity of Proplast, which could harbour infection. When Proplast was sterile when implanted, no extrusion appeared over a 12-month period. Although the patients presented here were followed up for a relatively short time, they provide reason for some optimism that the vexed question of alloplastics applied in the field of ear, nose and throat surgery may be solved.     

The action of perchlorate on malignant-hyperthermia-susceptible muscle

We developed two types of implantable hearing aids, a totally implantable hearing aid (TIHA) and a partially implantable hearing aid (PIHA) in 1983. In both types a piezoelectric ceramic bimorph was used as an ossicular vibrator which was coupled to the stapes to transmit sound signals to the inner ear efficiently. Due to technological immaturities, clinical application of the TIHA has not yet been realized. But the PIHA is available for clinical use at present. In the PIHA only the ossicular vibrator is implanted with inner link coil. The rest of components such as microphone, amplifier, battery, and outer link coil remain in their usual location behind the auricle. Since 1984, we have applied the PIHA to 37 patients with mixed deafness. Careful follow-up studies have been conducted on all of them to assess clinical and audiological results. We have confirmed that the device could function safely for more than 10 years affording natural quality of hearing without howling and wearing discomforts. Our studies suggest that the PIHA can be a choice of rehabilitation for mixed deafness due to middle ear diseases which cannot be rehabilitated satisfactorily by either surgical means or a conventional hearing aid. Functional principle of device, indications and surgical methods of implantation were described. Failures and delayed problems we experienced were also presented together with the preventive measures. We believe that an implantable hearing aid of this type will be an otologic breakthrough if substantial technological difficulties are cleared.     

Immunodiffusion and immunohistochemical investigations on the reactivity of oxide ceramic middle-ear implants

Oxide ceramic materials (partial and total ossicular replacement prostheses) have been implants of preference for the reconstruction of the ossicular chain because of their excellent biocompatibility. The reaction on the surface of the implants takes place at three biodynamic levels according to the model of Stern's bilayer. We investigated the adsorption of proteins, which is determined by the cellular reaction and degradation to the surface using radial immunodiffusion and immunohistochemical methods. First, ceramic implants of aluminum oxide, hydroxyapatite, glass ceramic and zirconium oxide have individual actual (i.e. biological) surfaces. With a perthometer and the contact-free laser Focodyn method we determined each actual (i.e. biological) surface of the various ceramic implants mentioned above. Using radial immunodiffusion, the adsorption of albumin, glycoprotein, plasminogen, fibronectin, IgA, IgG and IgM shows characteristic rates of adsorption to the respective ceramic surfaces in correlating to the actual surface. A cross-check with fluorescent antibodies confirmed the protein adsorption. The individual surface adsorption of the proteins remains characteristic and is the basis for the recording of cellular reactions after implantation.     

An Arabic language version of the health promotion lifestyle profile

BACKGROUND: Characteristic features of cholesteatoma of the middle ear are destruction of the bone and a high tendency for recurrent disease. The choice of surgical procedure is determined by audiological results and the rate of recurrent cholesteatoma. PATIENTS: One hundred fifty patients who underwent primary cholesteatoma surgery were investigated 3-5 years postoperatively. Preoperative and postoperative audiological results and rate of revision surgery were compared for the respective surgical procedures. All cholesteatomas were treated with an open surgical technique. The lateral attic walls and cholesteatomas were removed. RESULTS: Cholesteotoma recurred in 15 patients (10%). Primary reconstruction of the ossicular chain with a tympanoplasty (type III) was performed in 98 patients in the first operation. Approximately 80% of patients treated with a type III tympanoplasty had a maximum postoperative air-bone gap of 20 dB in the main speech range, depending on the frequency. In about 50% of patients, this value was 10 dB or less. Comparison of preoperative and postoperative conductive hearing loss between 250 Hz and 8000 Hz revealed an improvement (p < 0.05) of 10 dB (500 Hz, 3000 Hz, 4000 Hz) and 15 dB (250 Hz, 1500 Hz, 2000 Hz, 8000 Hz). CONCLUSIONS: In our opinion, a second look operation should be performed in cases where a large cholesteatoma cannot be removed with sufficient reliability. This applies especially to a cholesteatoma in the oval window. Here, we suggest second-look surgery after one year.     

Hypnotic susceptibility order effects in waking analgesia

OBJECTIVE: To develop a measuring apparatus that has the ability to sweep both frequency and external auditory meatus static pressure and can display measurement results in a three-dimensional expression. To measure the middle ear dynamic characteristics of normal-hearing subjects and of patients with this apparatus. DESIGN: Investigate 275 ears of 153 normal-hearing subjects and 72 ears with middle ear diseases. RESULTS: The measurement results show fairly distinctive patterns depending on the middle ear conditions, i.e., normal, ossicular chain separation, ossicular chain fixation, secretory otitis media, tympanic membrane perforation, and tympanic membrane atelectasis. The evaluation of patients with ossicular diseases revealed that the rate of correct diagnosis of ossicular chain separation is 84% and that of ossicular chain fixation is 74%. These diagnoses were confirmed by surgery. CONCLUSION: Displaying the measurement results in a three-dimensional expression is helpful to make correct diagnosis in clinical practice. It is especially easy to make a distinction between the ossicular chain separation and ossicular chain fixation. Therefore, it is concluded that this apparatus has a high degree of clinical applicability to the diagnosis of these diseases.     

Toynbee Memorial Lecture 1997. Middle ear mechanics in normal, diseased and reconstructed ears

A review of the structure-function relationships in normal, diseased and reconstructed middle ears is presented. Variables used to describe the system are sound pressure, volume velocity and acoustic impedance. We discuss the following: (1) Sound can be transmitted from the ear canal to the cochlea via two mechanisms: the tympanoossicular system (ossicular coupling) and direct acoustic stimulation of the oval and round windows (acoustic coupling). In the normal ear, middle-ear pressure gain, which is the result of ossicular coupling, is frequency-dependent and smaller than generally believed. Acoustic coupling is negligibly small in normal ears, but can play a significant role in some diseased and reconstructed ears. (2) The severity of conductive hearing loss due to middle-ear disease or after tympanoplasty surgery can be predicted by the degree to which ossicular coupling, acoustic coupling, and stapes-cochlear input impedance are compromised. Such analyses are used to explain the air-bone gaps associated with lesions such as ossicular interruption, ossicular fixation and tympanic membrane perforation. (3) With type IV and V tympanoplasty, hearing is determined solely by acoustic coupling. A quantitative analysis of structure-function relationships can both explain the wide range of observed post-operative hearing results and suggest surgical guidelines in order to optimize the post-operative results. (4) In tympanoplasty types I, II and III, the hearing result depends on the efficacy of the reconstructed tympanic membrane, the efficacy of the reconstructed ossicular chain and adequacy of middle-ear aeration. Currently, our knowledge of the mechanics of these three factors is incomplete. The mechanics of mastoidectomy and stapedectomy are also discussed.     

Adjusting the geometry of implantable hearing aid components to human temporal bone. II: Microphone

Prerequisite to implantation of a piezoelectrical transducer of an implantable hearing aid is a shape allowing its implantation into human mastoid and middle ear. To approach this problem, a consecutive series of six transducer prototypes was created in an iterative process. Their functional geometry was evaluated in 50 human temporal bones. A shape for a functioning transducer was found which will enable implantation in 78% of the cases examined (confidence interval: 61.5%-89.2%). It will allow simultaneous implantation of the transducer into the mastoid and microphone, which is situated transmastoidal in the posterior wall of the ear canal. Furthermore, the transducer may be coupled to the ossicular chain or the perilymph.     

Bladder cancer in a patient on long-term haemodialysis

OBJECTIVE: The results of the first cohort of 60 cavity reconstructions with hydroxyapatite with a minimum follow-up period of 15 years were studied. STUDY DESIGN: The study design was a retrospective study. PATIENTS: A total of 60 patients had a follow-up period of >15 years. In four patients, not all data were available. Therefore, 56 patients were included in the study. They had a combination of cavity problems and hearing loss. INTERVENTION: The ear canal was reconstructed with a canal wall prosthesis of porous hydroxyapatite. The ossicular chain was reconstructed with an incus or incus-stapes prosthesis of dense hydroxyapatite. RESULTS: After 15 years, 42 patients (75%) had an intact reconstructed ear canal. The main problem for failure was the recurrent purulent middle ear infection and not cholesteatoma. The histology of the retrieved canal wall showed a good remodeling in living bone tissue. After 15 years, 34 patients had a normal ear canal and an ossicular chain. Of these patients, 7.05% had an air-bone gap closure within 20 dB. CONCLUSIONS: Long-term results of cavity reconstruction with hydroxyapatite are possible. The main problem is recurrent mucosal disease of the new middle ear-mastoid cleft.     

Results of knee replacement with the Walldius and geometric prostheses. A comparative study

Sixty-two knees that were replaced with Walldius prostheses and twenty-five knees with geometric replacements were studied prospectively. The follow-up ranged from twenty-four to 162 months (average, seventy-four months) for the knees with the Walldius prostheses and from twenty-four to seventy-five months (average, forty-seven months) for those with the geometric prostheses. Using a 100-point clinical rating scale, the knees of patients who underwent Walldius replacement improved from their preoperative status by an average of 33 points (from 44 to 77 points) and those with geometric prostheses, an average of 24 points (from 54 to 78 points). Twelve patients with twenty Walldius prostheses were followed for more than 100 months (average, 127 months). The greater average improvement (36 points) in this group was due primarily to the absence of any major complications. Six patients underwent replacement of one knee with a Walldius prosthesis and one knee with a geometric implant. Although the ratings for the two knees were similar in each patient, four patients preferred the Walldius implant; one, the geometric replacement; and one had no preference. Significant technical errors or complications (defined as those affecting the end result) occurred in 8 per cent of the knees with Walldius implants and in 12 per cent of the knees in the geometric group. There were two late infections in each group. One Walldius prosthesis was removed and the knee was fused. The other three prostheses (one Walldius and two geometric) associated with infection were salvaged.     

Multifrequency tympanometry in chinchillas

Multifrequency tympanometry (MFT), using probe frequencies ranging from 226-2,000 Hz, was performed on normal chinchillas to obtain normative data against which to compare results from animals with middle ear pathology. A series of validating experiments was conducted to determine the effects of anatomical alterations of the middle ear on MFT. These included artificially extending the ear canal, opening the bulla, injecting saline into the middle ear, and disrupting the ossicular chain. The results indicate that MFT characteristics of chinchilla ears are qualitatively similar to those observed in normal humans and patients with middle ear disease, and MFT provides information that is not available from the 226-Hz tympanogram.     

Ossicular discontinuity

Because of the numerous and varied surgical approaches to ear pathology devised and expanded in the past two decades, we are destined to be confronted with increasingly frequent cases of ossicular defects behind an intact eardrum. Using a technique which is the converse of the established "patch" test a simple office procedure is described which may help establish the diagnosis of ossicular discontinuity in the adult with an intact eardrum. An audiogram is obtained and then a myringotomy performed with insertion of a large ventilation tube. A second audiogram is then done. A rise in the air conduction level, in the absence of fluid, is suggestive of ossicular discontinuity.     

Do GPs have the techniques for 'watchful waiting' in glue ear?

'Watchful waiting' for glue ear in children within primary care as a precursor or alternative to surgery is one of the increasing pressures on general practitioners (GPs) to limit outpatient referrals. An equipment survey questions whether primary care is properly equipped to 'watch', given the limited access to audiological equipment that might objectively underpin a decision on when 'waiting' should end.     

Charge shift electrophoresis of synaptosomal membrane antigens

Four patients who developed deep infection of six hips, on average three and a half years after total replacement by McKee-Farrar prostheses, are described. In each case there was strong evidence that the source of the infection was a distant focus.