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| EDITORIAL |
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| Year : 2015 | Volume
: 21
| Issue : 4 | Page : 231-232 |
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Ossiculoplasty: A historical perspective
Narmaya Thapa
Department of ENT-HNS, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| Date of Web Publication | 16-Oct-2015 |
Correspondence Address:
Narmaya Thapa
Department of ENT.HNS, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu
Nepal
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-7749.167395
How to cite this article:
Thapa N. Ossiculoplasty: A historical perspective. Indian J Otol 2015;21:231-2 |
Ossiculoplasty is defined as the reconstruction of the ossicular chain. Its historical aspect is worth reviewing. The earliest recorded ossiculoplasty was attempted by Matte in 1901 to re-establish a connection between the tympanic membrane and the oval window in the case of missing ossicles. After a long time, Wullstein in 1951 utilized a vinyl acrylic as an ossicular prosthesis. Since then, numerous materials including both biologic (autograft and homograft) and alloplastic have been used to re-create the middle ear sound-conducting mechanism.[1],[2],[3],[4]
Hall and Rytzner (1957) performed the first ossicular reconstruction using autologous incus which has been the most common autograft material and is often reshaped to fit between the manubrium of the malleus and the stapes head. They also interposed autologous malleus between neotympanic membrane and stapes footplate. Malleus transposition techniques have also been described by Bell (1958), Farrior (1960), Portmann (1963), Chandler (1965), Guilford (1965), Sheehy (1965), Szpunar (1967), and Wright (1967). In 1971, Austin described the classification of ossicular defect and also described interposition techniques. Similar techniques were described by Hildyard (1967) and Hough (1970). Later, Pennington (1973) and Wehrs (1974) improved Austin's malleus/stapes assembly. Lee and Schuknecht (1971), MacGee (1979), Smyth (1980), and Goodman (1980) also recommended the various types of interposition techniques.[3],[4],[5]
Sculptured autologous cortical bone from outer mastoid cortex, bony external auditory canal, and spine of Henle were used by Hough (1958), Zollner (1960, 1969), Farrior (1960, 1966), Kley and Draf (1965), Bauer (1966), Guilford (1966), Wright (1967), and Tos (1974). Similarly, Utech (1960) introduced sculptured auricular cartilage for interposition. Jansen (1963) found autologous tragal cartilage and septal cartilage suitable for tympanic membrane to stapes head and tympanic membrane to footplate assembly, respectively.[3],[4]
Autograft materials are not always available, or as in patients with cholesteatoma ossicle may have microscopic squamous epithelium infiltration that precludes their use. Because of this, alcohol preserved or irradiated homograft ossicles and cartilage were first introduced in the 1960s. House, Patterson, and Linthicum (1966) introduced the incus allograft. Many other surgeons started using allograft ossicular bone preserved in alcohol (Pulec, 1966; Wehrs, 1967; Smyth and Kerr, 1967) or by autoclaving (Hildyard, 1967; English et al., 1971) for ossiculoplasty when healthy ossicular autografts were not available. Wehrs (1974) introduced the notched incus autograft or allograft technique. Sculpturing techniques for malleus/stapes and malleus/footplate assemblies using allograft or autograft incus or malleus with minor modifications were used by most surgeons (Smyth {1972}, Goodhill, Westerbergh, and Davis {1974}, Marquet {1976}, Ironside {1979}, Smith {1980}, Hough {1982}, Smith and McElveen {1982}).[3],[4] House, Glasscock, and Sheehy (1969) then conceived the idea of alcohol preserved composite allografts, consisting of en bloc tympanic membrane with ossicles attached (tympano-ossicular monoblock grafts) for use in ears without a tympanic membrane, malleus, and incus, with or without a stapes superstructure. Homograft ear banks were also established in the USA. However, since 1986, homograft materials are rarely used because of the risk of disease transmission, e.g., HIV, Creutzfeldt-Jakob disease, etc. There is also a high chance of resorption of cartilage and bone.[3],[5],[6],[7]
Because of the disadvantages of autograft materials and the potential risk of infection from homograft implants, combined efforts between biomaterial scientists and surgeons led to manufacture different types of alloplastic materials for implantation. As a result of these efforts, three porous plastic materials, namely Proplast, Plastipore, and Polycel, together with a vast range of ceramic materials have been developed for ossiculoplasty. These materials can be classified as biocompatible, bioinert, or bioactive. In the late 1950s and the 1960s, biocompatible materials, such as polyethylene, Teflon, and Proplast, were used. Ossicular reconstruction with these materials often resulted in migration, extrusion, penetration into the inner ear, or significant middle ear reactivity. For these reasons, use of these solid polymeric substances was eventually abandoned.[2],[3],[4],[8]
In the late 1970s, a high-density polyethylene sponge (HDPS) that had nonreactive properties was developed. The original form was a machined-tooled prosthesis (Plastipore); a more versatile manufactured thermal-fused HDPS (Polycel) arrived later. This latter form permitted coupling with other materials, such as stainless steel, thus lending itself to a wide variety of prosthetic designs. A high incidence of extrusion occurred when either Plastipore or Polycel was placed in contact with the tympanic membrane. This defect was reduced considerably when cartilage was placed between a Plastipore or Polycel prosthesis and the tympanic membrane.[2],[9],[10],[11],[12]
The prototype bioinert material, dense aluminum oxide ceramic was popular in Germany and Japan in the 1970s.[13] Bioactive implants were also introduced in the 1970s. The first bioactive implants were Bioglass and Ceravital. These materials have limited use today because of the difficulty in trimming and their instability in infected environments.[2]
Bone cement has also been used to join defects between ossicles.[14] Hydroxylapatite is currently one of the most common alloplastic materials used for ossicular reconstruction.[15],[16],[17],[18] It forms a direct bond with bone at the hydroxylapatite/tissue interface. Silastic, stainless steel, titanium, and gold are other examples of biocompatible materials used for ossicular reconstruction. Titanium, which is lighter than other materials and compatible for magnetic resonance imaging, has shown significant biostability in the middle ear and has gained popularity for the past decade.[19],[20],[21],[22],[23] Researches are going on to find out more suitable material such as tissue-engineered which is biocompatible, stable, safe, easily insertable, and capable of yielding optimal sound transmission.[24]
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