|Year : 2017 | Volume
| Issue : 3 | Page : 189-192
Comparison of myringostapediopexy and malleostapediopexy tympanoplasty with sculptured incus in case of hearing reconstruction in tubotympanic chronic otitis media: A case series
Virendra Pratap Singh, Neha Sharma, Chetan Bansal
Department of ENT, Shri Mahant Indiresh Hospital, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
|Date of Web Publication||31-Aug-2017|
Department of ENT, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
Introduction: Chronic suppurative otitis media (CSOM) is a burden on Indian population due to hearing loss due to deformation of the ossicular chain which needs reconstruction (ossiculoplasty). This study is an attempt to analyze the use of autogenous incus in ossiculoplasty for the same. Aim: The aim of this study is comparison of malleostapediopexy and myringostapediopexy in seventy cases of tubotympanic CSOM. Materials and Methods: Seventy patients with CSOM were operated and tympanoplasty was done. Ossiculoplasty was done using incus interposition as malleostapediopexy and myringostapediopexy and results analyzed. Results: In the present study, the pre- and post-operative air-bone gap values for myringostapediopexy cases were 38.00 ± 6.84 and 27.28 ± 5.12, respectively, and for type malleostapediopexy were 37.95 ± 7.51 and 18.08 ± 4.34, respectively. Statistical Test Used: Unpaired t-test. Conclusion: A better outcome was seen in malleostapediopexy than myringostapediopexy.
Keywords: Chronic suppurative otitis media, incus repositioning, ossiculoplasty, malleostapediopexy, myringostapediopexy
|How to cite this article:|
Singh VP, Sharma N, Bansal C. Comparison of myringostapediopexy and malleostapediopexy tympanoplasty with sculptured incus in case of hearing reconstruction in tubotympanic chronic otitis media: A case series. Indian J Otol 2017;23:189-92
|How to cite this URL:|
Singh VP, Sharma N, Bansal C. Comparison of myringostapediopexy and malleostapediopexy tympanoplasty with sculptured incus in case of hearing reconstruction in tubotympanic chronic otitis media: A case series. Indian J Otol [serial online] 2017 [cited 2021 Apr 13];23:189-92. Available from: https://www.indianjotol.org/text.asp?2017/23/3/189/213872
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a very common disease in developing countries affecting mainly the younger population. The disease is associated with various factors such as low socioeconomic condition, overcrowding, lack of concern about hygiene, and poverty. Patients suffering from CSOM of tubotympanic type with permanent perforation are handicapped because of an associated hearing loss. This hearing loss is often due to a concomitant ossicular chain defect, which needs to be corrected for hearing restoration.
The ideal prosthesis for ossicular reconstruction should be biocompatible, stable, safe, and capable of yielding optimal sound transmission. Autologous incus graft fulfills all these criteria and has been used by various surgeons over the years. A strut or crutch in the short process of the incus is created for malleus and with the cup made for the stapes physical integrity creating a malleostapediopexy and a comparative strut for myringostapediopexy. The closure of air-bone (AB) gap in pre- and post-operative audiometry is the best indicator of the success of specific ossicular reconstruction.
Aims and objectives
The aim of this study is comparison of malleostapediopexy and myringostapediopexy in seventy cases of tubotympanic CSOM.
| Materials and Methods|| |
This study was carried out in the Department of Otorhinolaryngology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun, Uttarakhand, India over a period of 2 years and 6 months.
All cases of safe CSOM with ossicular defects such as erosion of the lenticular process or long handle of malleus eroded:
- Age - 12 years or above
- Patient willing to undergo surgery
- For myringostapediopexy where the malleus handle was eroded or considered to be too far anteriorly to give a stable assembly.
- Unsafe CSOM
- Malignancy of middle ear
- Revision surgery.
Patients diagnosed with CSOM and posted for middle ear surgery were included in this study. Preoperative audiometry was done. The incus was removed in cases where an ossicular defect such as erosion of the long process of incus, lenticular process of incus, and handle of malleus among others was found. The incus was then removed. The distance between the head of the stapes and malleus handle was measured using a long hook and depending on the distance, the decision was made whether the malleus and stapes assembly will be stable and the incus was sculpted accordingly. Incus sculpted and repositioned between the tympanic membrane and the stapes capitulum or interposed between the malleus and the stapes capitulum. These cases were then included in the study. A total of seventy cases were done in the study. Out of these, 35 cases underwent myringostapediopexy and 35 underwent malleostapediopexy. The age distribution of the cases is as per [Table 1]. There was no obvious gender bias between the two groups. Postoperative audiometry was done at 1 month and then at 3 months. A comparison was then carried out of the audiometric data.
| Results|| |
The comparison of mean air conduction (AC), bone conduction, and A-B gap was done between malleostapediopexy and myringostapediopexy tympanoplasty using the unpaired t-test.
There was a uniform distribution of the patients across the age groups in both the groups. The comparison of mean A-B gap preoperatively at 1 month and 3 months was done between malleostapediopexy and myringostapediopexy using the unpaired t-test [Table 2]. There was no significant difference in the mean A-B gap preoperatively between malleostapediopexy and myringostapediopexy. The mean difference in A-B gap from baseline to 1 month and from baseline to 3 months was done between malleostapediopexy and myringostapediopexy using the unpaired t-test. The mean difference in A-B gap from baseline to 1 month and from baseline to 3 months was significantly more among malleostapediopexy.
|Table 2: Comparison of mean air-bone gap preoperatively, at 1 month and at 3 months between malleostapediopexy and myringostapediopexy|
Click here to view
| Discussion|| |
Tympanoplasty is the procedure of choice for the management of CSOM of tubotympanic type. Tympanoplasty is defined as “a procedure to eradicate disease in the middle ear and to reconstruct hearing mechanism with or without tympanic membrane grafting.”
According to modified Wullestein tympanoplasty [Table 3] is classified as:
Patient's perceived hearing improvement is best when the hearing level of the poorer hearing ear is raised to a level close to that of better hearing ear. Small improvements in hearing are more likely to be appreciated by patients with bilateral hearing loss. Austin stated that the two important ossicles for sound transmission were the malleus and the stapes suprastructure. The incus, therefore, could be safely removed and repositioned.
Austin classification is as [Table 4].
The expected range of postoperative A-B gap is defined by the 10 db range in which the hearing of the majority of the patients was found postoperatively.
The ideal prosthesis for ossicular reconstruction should be biocompatible, stable, safe, and capable of yielding optimal sound transmission. Autologous incus graft [Figure 1] fulfills all these criteria and has been used for some time. It is biocompatible and can be repositioned to exactly fit into the defect between the head of the stapes and the malleus handle/neotympanum. Reshaping is mostly required because of anatomical variations encountered. The distance between the head of the stapes and the malleus handle/neotympanum is measured using a straight needle and it corresponds to the length of the remodeled autogenous incus. The incus is held in an ossicular holding forceps and examined under microscope to rule out any disease [Figure 2] and [Figure 3]. A hole is made in the long process of the incus which will incorporate the head of the stapes [Figure 4]. A groove is made in the head of the incus for incorporating the malleus handle/neotympanum [Figure 5]. The length of this remodeled incus is as per the requirement.
|Figure 2: Drilling the socket for stapes head in the incus with 0.6 mm burr|
Click here to view
|Figure 3: Drilling the socket for stapes head in the incus with 0.8 mm burr|
Click here to view
|Figure 5: The groove for malleus head on one side and also making socket for stapes head for malleostapediopexy|
Click here to view
Adhikari et al. did a study in which the mean postoperative A-B gap with classical myringostapediopexy was 36.3 dB which was more than the present study. Our functional results are comparable with those of other authors. Berenholz et al. from a series of staged canal wall down tympanoplasty with ossiculoplasty procedures, reported an average postoperative A-B gap of 17.8 dB. Babighian (2002) reported that following single-stage canal wall down tympanoplasty with ossiculoplasty for cholesteatoma, the average postoperative A-B gap was 25.4 dB. Similar results were obtained by Cook et al. for single-stage canal wall down tympanoplasty with ossiculoplasty. In the study by De Corso et al (2007), a gain of 11.46 dB (±12.55) in the TORP (total ossicular replacement prosthesis) group and 15.22 dB (±15.61) in the PORP (¼ partial ossicular replacement prosthesis) group was observed. This was quite similar to the present study in which there was a mean gain of 10.73 dB.
The preoperative and 3 months' postoperative A-B gap values in the present study were 38.09 ± 6.91 and 11.92 ± 6.78, respectively, with a significant change. The improvement in the A-B gap was significantly more among malleostapediopexy in comparison to myringostapediopexy at 1 month and 3 months in the present study. In the present study, the pre- and post-operative A-B gap values for myringostapediopexy cases were 38.00 ± 6.84 and 27.28 ± 5.12, respectively, and for type malleostapediopexy were 37.95 ± 7.51 and 18.08 ± 4.34, respectively, with a significant change in both the groups.
It is difficult to compare these studies because of different age groups and subgroups, the definition of success; as many studies did not look at hearing outcome, the technique used, and the level of the surgeon's experience.
Functional success after tympanoplasty is only partly determined by a surgeon's technical skill. Other factors are some biological and pathological factors. A number of pathological changes including deposition of fibrous tissue, the formation of adhesions, and neo-osteogenesis. These tissue responses can compromise middle ear sound transmission in a variety of ways: fixation of the stapes footplate, ankylosis or displacement of an ossicle strut, immobilization of the Tympanic Memberane, as well as more subtle interference with the mechanics of the Tympanic Memberane or ossicles Balasubramaniam et al.
Thus, it was observed that both the procedure achieved significant improvement in bone conduction, AC threshold, and A-B gap. However, clinical trials, like this study, are less available in the literature which compared both the anatomical and functional outcome of malleostapediopexy and myringostapediopexy.
| Conclusion|| |
This study reveals significant hearing improvement with both the procedures in chronic otitis media. It was also noted that hearing restoration was better in cases with lesser A-B gap preoperatively irrespective of the procedures performed.
There was a statistical difference in the hearing outcome with a better outcome among malleostapediopexy than myringostapediopexy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tos M. Manual of Middle Ear Surgery. Approaches, Myringoplasty, Ossiculoplasty, Tympanoplasty. Vol. 1. Georg Thieme Verlag; 1993. p. 265-70.
Adhikari B, Ghosh AK, Pal S, Haque F. Clinico-audiological comparison between classical type-III tympanoplasty and ossiculoplasty using autograft ossicles in patients with Austin type a defect. Int J Contemp Med Res 2016;3:2422-5.
Berenholz LP, Rizer FM, Burkey JM, Schuring AG, Lippy WH. Ossiculoplasty in canal wall down mastoidectomy. Otolaryngol Head Neck Surg 2000;123:30-3.
Babighian G. Posterior and attic wall osteoplasty: Hearing results and recurrence rates in cholesteatoma. Otol Neurotol 2002;23:14-7.
Cook JA, Krishnan S, Fagan PA. Hearing results following modified radical versus canal-up mastoidectomy. Ann Otol Rhinol Laryngol 1996;105:379-83.
De Corso E, Marchese MR, Sergi B, Rigante M, Paludetti G. Role of ossiculoplasty in canal wall down tympanoplasty for middle-ear cholesteatoma: Hearing results. J Laryngol Otol 2007;121:324-8.
Balasubramaniam GK, Thirunavukkarasu R, Kalyanasundaram RB, Palaniappan H, Shanmugam PR. Hearing benefits in various types of tympanoplasties: A prospective study. Indian J Otolaryngol 2015;21:129-33.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]