Autograft Ossiculoplasty in Cholesteatoma Surgery: Is It Feasible?

Auris Nasus Larynx, 2002

Objecti6e: The choice of the graft in ossicular chain reconstruction during middle ear surgery for cholesteatoma is a subject still discussed on. In order to clarify the discussion of reuse of the autologous ossicles obtained during middle ear surgery for cholesteatoma, we evaluated the probability of residual disease histologically and the safety of the ossicles after autoclavization, the most promoting alternative method to eradicate residual cholesteatoma and infection on them. Methods: The specimens used in this study were eroded twenty-seven ossicles (22 incuses, 5 malleoli) which were removed from the 27 consecutive patients operated because of cholesteatomatous middle ear disease. They were grouped as follows: Group 1, Fifteen ossicles examined histopathologically directly. Group 2, Five ossicles autoclaved for 20 min at 134°C and then examined histopathologically. Group 3, Five ossicles autoclaved for 20 min at 134°C after mechanical surface cleaning by a fine diamond drill, examined histopathologically. Group 4, Two ossicles removed from two different patients were placed in their mastoid cavities in order to be examined after access in the second-look operation. While one ossicle was only autoclaved, the other was mechanically cleaned by a drill before autoclavization (for 20 min at 134°C). The ossicles were examined histopathologically after the removal at the second stage operation performed 12 months later. Results: In Group 1, all ossicles showed evidence of periosteal thickening. Additional findings were surface cholesteatoma or epithelia in 13 ossicles, surface inflammation in 12 ossicles, granulation tissue in 10 ossicles, osteitis in six ossicles. In Group 2, all five ossicles had preserved their lamellar structure but, no vital cells were seen. The lacunes that had the osteocytes was almost completely empty. The inflammatory cells were eliminated from the ossicles. In Group 3, ossicles were found well preserved with their lamellar structures and contours, with empty lacunes and eliminated inflammatory cells. In Group 4, in two ossicles of this group the lacunes were replaced by the new migrated viable osteocytes with evidence of new bone formation and neovascularisation. No new inflammatory focus or epithelia were found on the surfaces of the ossicles. The shape and the contour of the ossicles remained unchanged. Conclusion: In cholesteatoma surgery, ossicles with minimal erosion and adequate thickness can be used after autoclavization. In this study, it was observed histopathologically that the autoclaving autologous ossicles before ossiculoplasty in cholesteatomatous middle ear is a safe and reliable method.

Bengal Journal of Otolaryngology and Head Neck Surgery

Introduction: Chronic otitis media is a long standing infection of part or whole of middle ear cleft. Its active squamosal variant (cholesteatoma) is most dangerous due to its bone eroding property. Aims & Objective: Background knowledge of ossicular status in cholesteatoma will help us in determining the type of reconstruction needed during the surgery. Material & methods: 60 cases of cholesteama, irrespective of age and sex [diagnosed on the basis of clinical examination , audiological and radiological evaluation] were selected during the study period of two years and their ossicular status were recorded intra-operatively. Results & analysis: Ossicles and their parts getting involved in cholesteatoma cases , in decreasing order are : Lenticular process (in total 50 cases)>Long process of incus (in total 49 cases) > stapes super-structure(in total 29 cases) > body of incus(in total 26 cases)> head of malleus(in total 23 cases)> handle of malleus(in total 10 cases)...

2015

Introduction Chronic otitis media is a long standing infection of part or whole of middle ear cleft. Its active squamosal variant (cholesteatoma) is most dangerous due to its bone eroding property. Aims & Objectives Background knowledge of ossicular status in cholesteatoma will help us in determining the type of reconstruction needed during the surgery. Materials And Methods 60 cases of cholesteama, irrespective of age and sex [diagnosed on the basis of clinical examination , audiological and radiological evaluation] were selected during the study period of two years and their ossicular status were recorded intraoperatively. Result Ossicles and their parts getting involved in cholesteatoma cases , in decreasing order are : Lenticular process (in total 50 cases)>Long process of incus (in total 49 cases) > stapes super-structure(in total 29 cases) > body of incus(in total 26 cases)> head of malleus(in total 23 cases)> handle of malleus(in total 10 cases). Ossicular chai...

The Egyptian Journal of Otolaryngology, 2018

Objective This study aims at comparing cartilage ossiculoplasty by lever method with ossiculoplasty by partial ossicular replacement prosthesis during cholesteatoma surgery. Patients and methods This is a prospective study that was conducted on 36 cases having cholesteatoma; they were randomly divided into two groups of 18 in each group. In the first group (cartilage group), ossiculoplasty was performed with cartilage. In the second group (prosthetic group), ossiculoplasty was performed by partial ossicular replacement prosthesis. In both groups, eradication of the cholesteatoma was performed first at the same sitting of the ossiculoplasty by canal wall down tympanomastoidectomy with reconstruction of the posterior meatal wall at the same sitting. Results Within the follow-up period (1 year at least), the total rate of reported complications was relatively, but not significant, higher in the prosthesis group (50%) in comparison with the cartilage group (27.7%). There was a significa...

European Archives of Oto-Rhino-Laryngology, 2013

We describe the surgical technique of temporary removal of the posterior auditory canal wall with reconstruction and report the outcome of using this technique as a treatment method for cholesteatoma in a case series. In 32 cases of cholesteatoma surgery a technique of temporary removal of the posterior bony wall was applied. During primary surgery the posterior auditory canal wall was removed using an oscillating saw. For the purpose of reconstruction, the canal wall was repositioned and fixed using two titanium microplates (n = 26). In case the canal wall could not be reconstructed with osteosynthesis, either glass-ionomeric cement (BioCem TM ) was used for fixation (n = 4) or fibrin glue (Tissucol TM ) (n = 2) to support the posterior wall. The outcome includes the healing process in the first postoperative month, the absence of residual or recurrent disease and the successful reconstruction of the posterior auditory canal wall as evaluated during secondlook surgery. When microplates where used, we saw healing problems of the canal skin in about 4 % of patients. Recurrent cholesteatoma was found in 4 cases (14 %), residual cholesteatoma in 8 ears (25 %). In the osteosynthesis group, successful reconstruction was achieved in 25 patients (96 %). In 3 out of 4 patients of the glassionomeric cement group (75 %) excessive granulation tissue developed with extensive bony lysis. Temporary removal of the posterior auditory canal wall offers potential for the control of cholesteatoma. Our first results suggest that osteosynthesis allows for a good anatomical and functional reconstruction.

PubMed, 2003

Objectives: We evaluated the factors that have considerable significance on the outcome of open cavity procedures in the treatment of cholesteatoma. Patients and methods: The study included 66 patients (43 males, 23 females; mean age 47 years; range 21 to 69 years) who underwent surgery for cholesteatoma. Of these, 56 patients completed at least a five-year follow-up. Results: Mucosal infections and granulation tissue formation occurred in seven patients (10%) in the early postoperative period. Retraction pockets developed in three patients (4%); of these, only one patient required excision because of deep localization. Drum perforations that occurred in two patients (3%) were repaired by myringoplasty. Revision surgery was performed in four patients (7.1%) due to residual cholesteatoma within a five-year follow-up. Conclusion: The height of the facial ridge was found as the most important factor related to a successful outcome of open-technique procedures. Other factors included the creation of a smooth mastoid cavity with round edges, removal of all diseased mastoid cells, and an extensive conchameatoplasty.

Annals of Otology, Rhinology & Laryngology

Objective: Determine the effect of complete malleus removal during canal wall up tympanomastoidectomy for cholesteatoma on ossiculoplasty success and rate of residual cholesteatoma. Methods: We reviewed the operative, audiogram, and clinical reports of patients who underwent canal wall up tympanomastoidectomy for cholesteatoma between 2009 and 2016 at a tertiary academic medical center with at least 8 months of follow-up after surgery. To control for extent of disease, we independently catalogued the subsites of the middle ear and mastoid that cholesteatoma involved from each operation. We performed multivariate logistic regression to determine the independent effect of complete removal of the malleus on the rate of residual disease and success of ossiculoplasty. Results: One hundred eighty surgeries were included in the analysis. For ossiculoplasty success, the adjusted odds ratio of complete malleus removal was 1.7 (95% CI, 0.43-7.0, P = .43), which was not statistically significant. For residual disease, the adjusted odds ratio of complete malleus removal versus not was 0.29 (95% CI, 0.074-1.1, P = .076), which approached but did not meet statistical significance. Conclusion: Though complete malleus removal does not independently decrease the rate of residual cholesteatoma, it may be a safe technique as it did not compromise ossiculoplasty success.

Journal of Laryngology and Otology, 2010

Objective: To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery. Methods: We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females). Results: At the first post-operative assessment, a median air-bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air-bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome. Conclusions: In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

Egyptian Journal of Ear, Nose, Throat and Allied Sciences

Introduction: Residual cholesteatoma occurs due to incomplete removal after primary surgery by microscope and is frequently caused by inaccessible locations such as the sinus tympani. The use of the surgical endoscope brought advances in the surgical management of cholesteatoma. Aim: This work aims to assess microscope-assisted otoendoscopy in cholesteatoma surgical management. Patients and Methods: Forty patients underwent ear surgery for a cholesteatoma using different canal wall up or canal wall down mastoidectomy techniques. Surgery was initially performed using a surgical microscope. After complete disease excision microscopically, the middle ear and mastoid cavities were examined by otovideoendoscopy, especially sinus tympani, facial recess, anterior epitympanic recess, Eustachian tube, and hypotympanum. Residual cholesteatoma was identified, and its location was reported. Results: Residual cholesteatoma was found by endoscope in 10 sites; 6, 3, and 1 in sinus tympani, anterior epitympanic recess, and facial recess, respectively. These ten sites were divided into 4 in modified radical mastoidectomy and 6 in conservative approaches. Conclusion: Endoscopic-assisted ear surgery had much-increased benefits in cholesteatoma surgery. Endoscope had become a crucial complement to the operating microscope through visualizing the middle ear cleft hidden areas and discovering any residual disease in such areas as the sinus tympani..

European Archives of Oto-Rhino-Laryngology, 2016

To investigate the effects of surgery type [intact canal wall (ICW) or canal wall down (CWD) mastoidectomy] and different ossiculoplasty materials on hearing outcome in single-staged cholesteatoma surgery. A retrospective case-control study. A total of 116 cases (97 adults, 29 children) underwent surgery, including ossiculoplasty, between 2012 and 2015 for cholesteatoma. Patients who had undergone surgery for the first time, and whose grafts were successful, were included in the study. Patients with adhesive otitis media, unsuccessful grafts, revision and recurrent cases, radical mastoidectomy, and craniofacial anomalies were excluded. Audiogram examinations of the enrolled patients were performed 3-6 months after surgery, and the audiometric results were analyzed according to the criteria of the American Academy of Otolaryngology, Head and Neck Surgery. All ossiculoplasties were performed during the first operation. The preoperative average air-bone gap (ABG) of the patients was decreased from 31.37 ± 10.1 to 27.42 ± 10.4 dB; this decrease was found to be highly significant (p = 0.0001). Concerning the ICW technique, statistical evaluation of the hearing gain at frequencies of 500, 1000, and 2000 Hz, as well as the mean frequency, showed a high level of significance. Improvement at 4000 Hz was not found to be statistically significant. When the ABGs at 500, 1000, 2000, and 4000 Hz, and the mean frequency in patients with an hydroxyapatitepartial ossicular replacement prosthesis (HA-PORP) or autograft-partial ossicular replacement prosthesis (APORP), were evaluated, it was found that, at 4000 Hz, the APORP significantly reduced the ABG (p = 0.02). No significant difference was determined between patients with the hydroxyapatite-total ossicular replacement prosthesis (HA-TORP) and those with the autograft-total ossicular replacement prosthesis (ATORP) (p = 0.565). Although the use of the malleus as an APORP was found to be less effective than other autografts, the degree of advantage of using the incus, malleus, cortical bone, and cartilage did not significantly differ between materials (p = 0.152). Despite the effects of the incus, malleus, and cortical bone not differing in terms of the postoperative ABG (p = 0.160), incus usage was highly beneficial for hearing gain (p = 0.009). Despite CWD tympanoplasty affecting all frequencies, it has a particularly negative effect on the hearing threshold at 1000 Hz. In patients with partial ossicular replacement, autogenous grafts are more successful in restoring hearing at high frequencies, particularly at 4000 Hz. Although autogenous materials do not differ in terms of partial replacement effectiveness, the incus has been shown to be most effective for total replacement.