Ossiculoplasty

Otolaryngologists sometimes encounter cases of hearing impairments in which there are difficulties in conducting sound vibrations to the sound-receiving mechanism. In such a situation, they talk about conductive hearing loss - a multifactorial pathology caused by damage to one or more links in the chain "outer ear - eardrum - auditory ossicles - inner ear". Ossiculoplasty often helps in the treatment of the disease - this is a specific reconstructive intervention for prosthetics of the auditory ossicles, which allows improving or restoring the hearing of patients.

Restoring hearing in some patients is only possible through surgical intervention ossiculoplasty. If the doctor believes that such an operation is necessary, then you should agree with his opinion, as this will help to avoid complications - such as persistent hearing loss or absolute hearing loss.

Oscillatory plastic surgery is the reconstruction of the middle ear ossicular chain that has been disrupted or destroyed by using certain devices that help restore the original mechanics of the ossicular chain to transmit sound energy to the inner ear. Ossicular disruptions can range from loss of bone continuity due to trauma, surgical manipulation or middle ear pathology such as cholesteatoma or ossicular fixation in cases of otosclerosis and myringostapediopexy, or they can be a combination of both.[ 1 ]

Indications for the procedure

The goal of bone chain reconstruction is to improve hearing, usually for spoken language. The goal of ossiculoplasty is not to close the air-bone gap per se, but to improve the patient's overall hearing (i.e., improve the air conduction index). The patient's perceived hearing improvement is best when the hearing level in the poor-hearing ear is improved to a level close to that of the better-hearing ear. Smaller hearing improvements are more commonly appreciated by patients with bilateral hearing loss. [ 2 ]

Ossiculoplasty is performed when the following indications are present:

• chronic form of purulent otitis media;
• adhesive form of otitis media, which is accompanied by the formation of adhesions and connective tissue ulcers;
• chronic otitis media with cholesteatoma.

In general, ossiculoplasty is prescribed for deterioration of hearing function caused by impaired mobility of the auditory ossicles - for example, with proliferation of connective tissue due to a prolonged inflammatory reaction.

The indications are determined by the doctor based on the data of microscopic otoscopy and audiography.

The type of intervention depends on the degree of damage to the structures of the inner ear, which can be determined during an external examination, X-ray examination and audiometry.

Preparation

Modern ossiculoplasty techniques have generally been developed empirically through trial and error. With the development of newer surgical techniques and advances in instrumentation available to the otologist, the auditory outcome of ossiculoplasty has shown marked improvement in recent years. Success in ossiculoplasty is determined by technical capabilities and, to a large extent, case selection. [ 3 ] Unfortunately, the multitude of reconstructive techniques suggests that none of the currently available methods is ideal. [ 4 ]

In advance, the doctor performs the necessary diagnostic measures, carefully assesses the general health of the person, determines the individual characteristics of the disease, and identifies possible contraindications to ossiculoplasty. Conducting a full examination makes it possible to obtain the necessary positive effect from the intervention.

A patient undergoing ossiculoplasty is recommended to:

• get advice from a general practitioner, anesthesiologist, resuscitator, and, if necessary, doctors of other specialties;
• do a CT scan of the temporal bones;
• perform an endoscopic examination of the nasal cavity and nasopharynx;
• check hearing acuity and auditory sensitivity to sound vibrations of different frequencies using audiometry;
• do an electrocardiogram and an overview X-ray;
• assess the functionality of the respiratory organs;
• take laboratory tests (extended clinical blood test, blood biochemistry, determination of blood type and Rh factor, assessment of blood clotting quality, determination of antibodies to human immunodeficiency virus, syphilis, hepatitis C and B).

Technique ossiculoplasty

Ossiculoplasty is performed according to the method of hearing restoration, using deep endotracheal anesthesia. The surgeon, using a microscope and the necessary microsurgical instruments, removes damaged auditory ossicles, cicatricial growths and tumor formations (cholesteatomas). Then the surgeon forms a renewed eardrum, adhering to a special myringoplastic technique, after which he models the auditory ossicles. It is optimal to use identical prostheses made by German or French specialists for this purpose.

Materials used in ossiculoplasty can be autografts or homografts or synthetic materials. Alloplastic materials include metals (titanium and gold), plastics (Plastipor, Proplast, Polyethylenes, Polytetrafluoroethylene or Teflon) and biomaterials (Ceramics and hydroxyapatite). Bioinert materials such as gold and titanium are well tolerated as the extrusion rate is within acceptable limits.[ 5 ],[ 6 ] Despite advances in biosynthetic materials, many authors believe that inclusion-insert reconstruction remains the gold standard for ossiculoplasty when possible.

Osciculoplasty using a titanium prosthesis is a safe and effective procedure both anatomically and functionally. This study suggests that the use of PORP provides better hearing outcomes compared to TORP.[ 7 ]

The intervention – ossiculoplasty – is performed through the ear canal or via a behind-the-ear approach. In general, the operation can last from one to two hours, depending on the complexity of the disease.

Contraindications to the procedure

Active ear infection is the only true contraindication, but relative contraindications include persistent disease of the middle ear mucosa and repeated unsuccessful use of the same or similar prostheses.

Ossiculoplasty cannot be performed if the patient has contraindications to the procedure:

• acute period of the inflammatory process (otitis);
• impaired functionality of the auditory tube;
• inability to breathe through the nose.

In addition, ossiculoplasty is contraindicated if the patient has severe, life-threatening pathologies, such as decompensated conditions.

If there are no serious contraindications, then there is no point in postponing the operation. Timely surgical care allows preventing adverse complications and restoring the lost hearing function.

Consequences after the procedure

Ossiculoplasty can be called an effective and at the same time harmless procedure. After the operation, the patient can return to his usual way of life in just a few days. Only in isolated cases can unpleasant consequences occur:

• allergic reactions associated with anesthesia or parenteral administration of drugs;
• impairment of hearing function if other structures of the inner ear were damaged during the operation;
• ear bleeding if the intervention was accompanied by damage to local blood vessels;
• relapse of the inflammatory process due to insufficient sanitation during surgery.

Intraoperative complications of ossiculoplasty may include staple fracture, staple dislocation, annular ligament rupture with perilymphatic fistula, severe or complete SNHL with prosthesis, and bone fracture with incus-stapes prosthesis. Other complications may range from vertigo, erosion, or extrusion of the prosthesis.

To avoid any complications after the procedure, patients are advised to undergo ossiculoplasty in well-known medical centers whose specialists have extensive experience in performing such interventions.

Long-term complications are an important consideration for all patients undergoing ossiculoplasty. Our data show that tobacco smoking, Eustachian tube dysfunction, and unexpectedly poor hearing on the first postoperative audiogram are important risk factors for the development of significant complications. [ 8 ]

Care after the procedure

After the ossiculoplasty operation, the patient is hospitalized for about a week (the minimum hospitalization period is two days). After discharge, in 2-3 days the patient fully recovers his ability to work and can go to work.

Improvement in hearing is noted approximately on the tenth day after surgery: depending on individual characteristics, hearing function continues to recover over the next three months after surgery.

On the seventh day after ossiculoplasty, the ear canal is freed from the protective tampon. For a month, the organ of hearing must be protected, preventing water from entering the canal (at least for 3 weeks).

Four weeks after the tampon is removed, a control audiometry procedure is performed.

No specific care is required in the postoperative period. It is important to avoid significant physical activity, not to visit a sauna or take hot baths or showers for four weeks after ossiculoplasty.

Traveling by plane is permitted no earlier than three months later.

Reviews of the Ossiculoplasty Procedure

Surgical ossiculoplasty has become quite a popular procedure in recent years. Many patients suffering from conductive hearing loss have already appreciated the advantages of this operation as the only radical way to improve and restore hearing. Numerous surveys have shown that surgical intervention solves many problems associated with the deterioration of hearing function:

• the patient begins to clearly understand speech and perceive sounds in accordance with his expectations;
• the comfort of communication returns, complexes and problems associated with social aspects disappear;
• the rehabilitation period is relatively short and comfortable;
• The operation itself is well tolerated by patients of any age, carrying virtually no risk of unpleasant consequences.

Most patients who participated in the survey expressed their complete satisfaction with the result: ossiculoplasty received mostly positive assessments, which indicates a high rating of the technique. The main thing is to choose the right clinic and treating specialist: doctors must have both fundamental theoretical training and extensive practical and clinical experience, combined with a scrupulous individual approach to each patient.