Ossiculoplasty

Otolaryngologists sometimes encounter cases of auditory disorders in which there are difficulties with conducting sound vibrations to the sound-receiving mechanism. In such a situation, they speak of conductive hearing loss - a multifactorial pathology caused by the defeat of one or more parts of the chain “outer ear - membrane - 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 can improve or restore the hearing of patients.

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

Osiculoplasty is a reconstruction of the auditory ossicle chain of the middle ear that has been broken or destroyed by using some devices that help restore the original mechanics of the auditory ossicle chain to transfer sound energy to the inner ear. Disorders of bone tissue can vary from loss of bone continuity due to trauma, surgical procedures or middle ear pathology, such as cholesteatoma or bone 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 speaking. The purpose of ossiculoplasty is not to close the air-bone gap as such, but to improve the patient’s overall hearing (that is, to improve air conduction). The patient’s perceived improvement in hearing is best when the hearing level of the hearing impaired is elevated to a level close to the hearing level with better hearing. Minor hearing improvements are more often evaluated by patients with bilateral hearing loss. [2]

Ossiculoplasty is performed in the presence of such indications:

• 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 auditory function, provoked by impaired mobility of the auditory ossicles - for example, during proliferation of connective tissue due to a prolonged inflammatory reaction.

Indications are determined by the doctor, based on data from 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, during an x-ray examination and audiometry.

Preparation

Modern methods of ossiculoplasty, as a rule, have been developed empirically as a result of trial and error. With the development of the latest surgical methods and advances in instrumental armamentation available to the otologist, the auditory result of ossiculoplasty has shown a noticeable improvement in recent years. Success in ossiculoplasty is determined by technical capabilities and, to a large extent, by choice of case. [3] Unfortunately, many reconstructive methods indicate that none of the currently available methods is ideal. [4]

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

A patient who is undergoing ossiculoplasty is recommended:

• get advice from a general practitioner, anesthesiologist, resuscitator, if necessary - doctors of other specialties;
• make a computed tomography of the temporal bones;
• perform an endoscopic examination of the nasal cavity and nasopharynx;
• check hearing acuity and auditory sensitivity to sound vibrations of various frequencies using audiometry;
• make an electrocardiogram and a survey radiograph;
• evaluate respiratory function;
• take laboratory tests (extended clinical blood test, blood biochemistry, determination of blood group and Rh factor, assessment of blood coagulation quality, determination of antibodies to human immunodeficiency virus, syphilis, hepatitis C and B).

Technique of the ossiculoplasty

Ossiculoplasty is performed according to the method of hearing restoration, using deep endotracheal anesthesia. A surgeon uses a microscope and necessary microsurgical instruments to remove damaged auditory ossicles, cicatricial growths and tumor formations (cholesteatomas). Next, the surgeon forms an updated 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.

The 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 since the extrusion rate is within acceptable limits. [5],  [6] Despite advances in biosynthetic materials, many authors believe that the reconstruction of a inklyuzionnoy insert remains the gold standard for ossikuloplastiki whenever possible. 

Osikuloplasty using a titanium prosthesis is a safe and effective procedure both anatomically and functionally. This study suggests that using PORP gives better hearing outcomes than TORP.[7]

Intervention - ossiculoplasty - is performed through the auditory canal, or by ear access. In general, the operation can last from one to two hours, which depends on the complexity of the disease.

Contraindications to the procedure

Active infection in the ear is the only true contraindication, but relative contraindications include persistent disease of the mucous membrane of the middle ear 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 media);
• impaired functionality of the auditory tube;
• impossibility of nasal breathing.

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

If there are no serious contraindications, then postpone the operation is not worth it. Timely surgical care can prevent adverse complications and restore lost auditory function.

Consequences after the procedure

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

• allergic reactions associated with anesthesia or parenteral administration of drugs;
• impaired auditory 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, with insufficient debridement during the operation.

Intraoperative complications of ossiculoplasty can be a fracture of the brackets, a dislocation of the brackets, a rupture of the annular ligament with a perilymphatic fistula, severe or complete SNHL with a prosthesis and a bone fracture with an incus-stapes prosthesis. Other complications may vary from dizziness, erosion, or extrusion of the prosthesis.

In order not to cause any complications after the procedure, patients are advised to undergo ossiculoplasty at well-known treatment centers, whose specialists have extensive experience in performing such interventions.

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

Care after the procedure

The patient after surgery, ossiculoplasty is placed in a hospital for about a week (the minimum hospitalization period is two days). After discharge, after just 2-3 days, the patient completely restores disability and can go to work.

Hearing improvement is observed approximately on the tenth day after surgery: depending on individual characteristics, auditory function continues to recover for the next three months after surgery.

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

Four weeks after removal of the tampon, the audiometry test procedure is performed.

Any specific care in the postoperative period is not required. It is important to exclude significant physical activity, not to visit a bathhouse and not to take hot baths or showers for four weeks after ossiculoplasty.

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

Ossiculoplasty procedure reviews

Surgical ossiculoplasty in recent years has become quite a popular procedure. Many patients with conductive hearing loss have already managed to assess the benefits of this operation as the only cardinal way to improve and restore hearing. Numerous surveys have made it clear that surgical intervention solves many problems associated with impaired auditory function:

• the patient begins to clearly understand speech and perceive sounds in accordance with his expectations;
• communication comfort 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, without practically any risk of unpleasant consequences.

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