ossiculoplasty chain evaluation and strategy€¦ · ossiculoplasty employing a titanium partial...
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OSSICULOPLASTY
Chain Evaluation and Strategy
© Bruce Black MD
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OSSICULOPLASTY Case Evaluation
Ossicular chain Other ear aspects Patient general condition
© Bruce Black MD
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CHAIN CLASSIFICATION Applications
Describe Pathology Evaluate Technique /
Prosthesis / Surgeon Compare Series Plan Surgery Prognostication Patient Counselling
© Bruce Black MD
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OSSICULAR CLASSIFICATION Prior techniques
Austin 1972 Kartush 1994 Black 1995 Dornhoffer 2001
© Bruce Black MD
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AUSTIN 1972
A : Malleus + C : Malleus – Stapes SS + Stapes SS-
B : Malleus + D : Malleus – Stapes SS - Stapes SS -
Austin ossicular classification. This recognised that in COM cases the incus was absent or removed in the great majority of cases, but did not clarify the © Bruce Black MD time of classification or the status of the stapes footplate.
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Austin ossicular classification. Diagrammatic illustration of the common ossicular pathology groups, but omitting the
difficult compromised stapes group © Bruce Black MD
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KARTUSH 1994 Middle Ear Risk Index
AUSTIN ABCD + Normal Chain Attic Fixation Stapes Fixation
Kartush ossicular classification. Initial surgical findings. The need for an attic fixation category is uncertain. These, the normal chain, and other cases will be subject to change during surgery. © Bruce Black MD
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DORNHOFFER 2001
Normal Malleus + Malleus –
Fixed stapes cases are excluded
Dornhoffer Ossicular classification, initial surgical findings. Note that normal chain cases will be substantially changed if chain repair is necessary, or excluded from
a series if not. Stapes fixation cases are a signifcant and substantially compromised group, difficult to manage successfully. © Bruce Black MD
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Compromised Stapes: a. SSS fibrosed
b. SSS tympanosclerosis c. SSS ossified
d. SSS displaced e. Ossified tendon
f. Otosclerosis g SFP tympanosclerosis
h. SFP ossified i. SFP fractured j. SFP subluxed
k. SFP penetrated l. Post-stapedectomy
m. Residual cholesteatoma n VII overhang
o. Stapedial artery © Bruce Black MD
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BLACK 1995
AUSTIN ABCD +
E : Compromised Stapes
© Bruce Black MD
Black ossicular classification: The threat of the compromised Stapes was recognised; The classification stipulates the status of the chain at the moment of repair; the malleus +/- status indicates a present/absent functionally useful handle. The classification may be used pre-operatively by visualising the status at repair, but is intended to provide a basis for more accurate ossiculoplasty research by indicating the prognositc threats.
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CHAIN STATUS CHANGES Initial Visit → Pre-Ossicular
N=753 (unpublished data)
Austin % Pre-Ossiculoplasty (Malleus – Stapes > 45º = M-) A C A C 76 4 45 24 → 12 8 10 13 B D B D
E 8
© Bruce Black MD
Ossicular status: Distribution of the ossicle pathology comparing the Austin and Black methods. Greater numbers of poorer prognoses in the latter.
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CHAIN RECLASSIFICATION Effect on Outcomes, ABG < 20 db
N=753
Austin % Black Pre-Ossicular (Malleus – Stapes > 45º = M-) A C A C 70 33 78 67 → 52 51 80 48 B D B D
E 22
© Bruce Black MD Outcomes of Austin and Black groupings. The shift of poorer pathology To groups C and D has improved A and B case outcomes,
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OSSICULOPLASTY Technical Options
Columella Drum-stapes Drum-footplate Assembly Malleus-stapes Malleus-footplate Niche Methods Incus supplements Stapedial replacement Other
© Bruce Black MD
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Austin groupings with suggested reconstruction methods. Note that PORP and TORP prostheses are applicable to
groups A and B respectively. MSA/MFA: malleus-stapes/footplate assembly © Bruce Black MD
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Application of prosthetic models to the Austin group situations. PORPs and TORPs may replace the illustrated
Spanner models in groups A and B © Bruce Black MD
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Malleus-stapes relationship. The situation varies according to the respective xyz dimensions, and, especially, the
malleus-stapes angulation A0 © Bruce Black MD
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The effect of malleus-stapes angulation. Assemblies are effective in cases of lesser angulation, but columellas are
preferable when greater angulation dissipates vector forces. © Bruce Black MD
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Malleus stapes assembly: ideal direct angulation situation.
© Bruce Black MD
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The common group A situation: Malleus handle present with a direct angulation, Stapes superstructure present.
© Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Management of a group A case with a direct malleus-stapes assembly strut.
© Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Group A case of minor incudal necrosis resulting in the loss of the lenticular process and part of the long process,
common in Stage III adhesive otitis drum collapse cases. © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Niche ossiculoplasty. Replacement of the incus tip with an Applebaum hydroxylapatite prosthesis. Useful only in minor
necrosis. The latter may continue and compromise the outcome. © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Malleus-stapes angulation. Dissipation of forces and “wobble” effect. Instability on the head of the stapes.
© Bruce Black MD
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Indirect/inverted-L malleus-stapes assembly. Stable with good transmission of forces in direct angulation situations. May achieve an additional columellar effect in flat drums. © Bruce Black MD
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EFFECT OF MALLEUS ANGULATION
Spanner MSA Cases Angulation ABG db
0 – 10 11-20 < 45º 48% 31% > 45º 28% 36%
© Bruce Black MD
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Angulation of an indirect/L-strut malleus-stapes assembly producing pressure under the drum and resultant extrusion
risk. Less stability on the stapes. © Bruce Black MD
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Malleus footplate angulation causing a “footplate skid” effect. This may be partly overcome using an L-strut prosthesis, but this may incur drum reaction risks. © Bruce Black MD
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“Wobble” effect of greater angulation in assembly cases. The vector forces dissipate, and the prostheses become
unstable. Columellas adapt better in these cases. © Bruce Black MD
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Complications of columellar prostheses: extrusion, displacement, fixation to the scutum.
© Bruce Black MD
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PORP columellar complication: toppled prosthesis under an intact drum.
© Bruce Black MD
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Complications of columellas: early extrusion of a polyethylene PORP.
© Bruce Black MD
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Columella complications: total extrusion of a hydroylapatite columella
© Bruce Black MD
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Group C ossicular situation. The handle of the malleus is lost or unsuitable for reconstruction (angulation, necrosed
or displaced). © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Ossiculoplasty employing a titanium partial ossicular replacement prosthesis (PORP) with a cartilage composite
graft covering the head flange to avoid extrusion. © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Group D ossicular situation. The malleus handle is lost or unusable. The stapes superstructure has necrosed, but the
footplate is mobile and free of disease. © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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Repair of a group D case. A titanium total ossicular replacement prosthesis is sited on the stapes footplate, with
the head flange protected form extrusion by a cartilage-perichondrium composite graft. © Bruce Black MD
Illustration by courtesy Robt Jackler MD
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The group E ossiculoplasty problem. In infected ears, a stapedectomy is unwise, risking labyrinthitis, and should be
left to a second stage surgery. © Bruce Black MD
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Group E ossiculoplasty. Removal of the stapes footplate requires grafting to seal the site, but the graft may not
support a columella adequately, necessitating 3rd stage repairs. © Bruce Black MD
Unstable
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Group E ossiculoplasty. Columellar complications on an unstable oval window graft. If the prosthesis is to short,
displacement may occur. © Bruce Black MD
Too short
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Columellar ossiculoplasty in a group E case with an unstable footplate graft. Excessive prosthetic length may
cause vestibular penetration. © Bruce Black MD
Too long
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Group E ossiculoplasty cases. A malleus-stapes piston provides a stable reconstruction, provided the handle is suitably positioned for optimal transmission of forces.
© Bruce Black MD
Illustration by courtesy Robt Jackler MD