Myringo-malleolabyrinthopexy ABDUL AHAD, S. K. KACKER

Myringo-mal leo labyr inthopexy w a s done in 25 patients . A majo- rity o f the pat ients were rev is ion s tapedectomy cases and the others were cases o f chronic supp- urative otit is media. Teflon p i s ton was the c o m m o n l y used prosthe- s is (15 cases). In the others wire prosthes is , oss ic les and carti lage strut were used. There was signi- f icant hearing i m p r o v e m e n t in 64 per cent o f the patients. Sen- sori -neural hearing loss develop- ed in 12 per cent o f the cases.

One is left with an exposed oval window medially and the malleus and tympanic membrane or only the tympanic membrane laterally with the intervening ossicles already destroyed or non-serviceable, during the reconstruction of the middle ear in certain situations. In these situa- tions the malleus can be directly connected to the oval window and the hearing improved. Harrison et al (1959) believe that in such situa- tions patients will have only a conductive loss of 2.5 db if there is a good communication between the tympanic membrane and the oval window because this ear is only deprived ofa 3 to 2 lever effect which is due to the difference in the length between the handle of malleus and long process of incus but still possesses 17 to 1 hydraulic effect of the large tympanic membrane connected to a small oval window. This paper is an analysis of data to see if this ideal can be achieved.

Indicat ions

Initially this technique was used to improve hearing in fenestrated ears connecting the head of the malleus to the horizontal semi-cir- cular canal. Harrison et al (1959) used a polyethylene tube as the connection while Ruedi (quoted by Harrison et al 1959) used the incus. In this way the residual air bone gap of 25 dB remaining after fenes- tration operation was eliminated.

Abdul Ahad, Assistant Professor, Depart- ment of E.N.T., Medical College, Srinagar, Kashmir.

S. K. Kacker, Professor and Helad of the Department of Otorhinolaryngology, All India Institute of Medical Sciences, New Delhi- 110 016.

In cases of fenestration failures when stapedectomy was done, the incus was absent so the oval window had to be connected directly to the malleus.

Gradually the scope of this pro- cedure widened. Sheehy (1966) had to use this procedure in otosclerosis in the following situations:--

(i) Incus abnormalities--necrosis, fixation, dislocation of incus, short incus and absence of incus.

(ii) Malleus fixation in the attic.

(iii) Oval window exposure prob- l e m s - w h e n incus is in a posi- tion which prevents satisfactory use of a drill in a thick solid foot plate. Incus can be removed, a hole drilled and the malleus connected to oval window.

(iv) Following a successful stape- dectomy two of his cases (Sheehy, 1966) developed sub- jective distortion, vibration or rattling with low sounds. Both these were relieved by connect- ing the prosthesis from malleus to oval window. Similarly this procedure was used in revision

stapedectomy, tympanoplasties and congenital abnormalities wherever situations warranted. Tabb (1976) found this method more reliable and predictable even when the foot plate was mobile and the incus and stapes crura were absent during tym- panoplasty procedures. He re- moved the foot plate and did malleolabyrinthopexy rather than connect the malleus to the foot plate.

Materials used

A large variety of materials have been used to connect the malleus to the oval window. Initially prosthetic materials were used but now-a-days, the trend is to use either ossicles (homograft or autograft) or cartilage (Table No. 1).

Foreign bodies placed in direct contact with the tympanic membrane will usually perforate the drum and be rejected (Gunderson 1971 and Sheehy 1972). In such situations ossicles or cartilage are best as the tympanic membrane tolerates these materials without perforation. Car- tilage has another advantage and that is it does not get fixed to the bone.

Various materials

Author

Harrison et al (I959)

Ruedi (quoted by Harrison et aI, 1959)

Sheehy (1963)

Shea (quoted by Sheehy, 1963)

Sheehy (1965)

Sheehy (1966)

Sheehy (1972)

Tabb (1976)

Moon (1976)

Shea (1976)

Hicks et al (1978)

TABLE I

used for MyringomaUeolabyrinthopexy.

Material used

Tantallum wire and polyethylene tube

Incus

Wire fat plug

Teflon piston

Polyethylene

Wire loop prosthesis

Ossicles and cartilage

Malleus homograft

Autograft or homograft incus

Autograft or homograft incus, malleus or cartilage.

Plastipore total ossicular replacement prosthesis (TORP).

Indian Journal of Otolaryngology, Volume 31, No. 4, December, 1979 97

M Y R I N G O M A L L E O L A B Y R I N T H O P E X Y - - A H A D & K A C K E R

Material and Methods

Twenty-five patients varying in age from 15 years to 55 years under- went Myringomalleolabyrinthopexy at the All India Institute of Medical Sciences, New Delhi from 1970 to 1978. The distribution of these patients according to their primary disease is given in table No. II .

(A) Revision Stapedectomy Group: There were thirteen of these cases. Out of these seven had necrosis of the long process of the incus, in four cases the incus was absent and in two eases the incus was dislocated. There was regrowth of focus in three of these eases.

(B) Chronic otitis media: Out of eight of these patients two had absence of all the ossieles, only incus was abnormal in five patients; in three incus being absent and in two its long process was necrosed. In one patient the long process of the incus and stapes superstructure were necrosed. All of these had fixed foot plates. Adhesive process was found in five eases.

(C) Congenital ossicular chain defects: There were four such cases. In one all the three ossicles were fixed. Stapedectomy was done and incus and malleus removed. Then incus was placed between tympanic mem- brane and oval window. In another patient stapes and incus were replaced by a single bony ossicle fixed at the attic and other end at foot plate. Stapedius tendon was absent. Both were removed and wire gelfoam prosthesis used. In one patient there was absence of super- structure of stapes and incus, foot plate was fixed, wire fat prosthesis was used in this case following stape- dectomy. In another patient incus was absent and foot plate of stapes was fixed. Some of these cases were reported by Dasgupta and Kacker (1974). Results of surgery are shown in Fig. No. 1.

Technique os S u r g e r y

Tympanotomy is done under local anaesthesia. An incision is made in mucoperiosteum of malleus handle at its upper end. This is elevated to create an opening between tympanic membrane and handle to recexve the prosthesis. This procedure was used in twenty-one patients (Table No. I I I ) . In four pataents incus or

98

TABLE II

Indications of surgery

15--30 yrs. 31--45 yrs. Primary disease

M F M F

Revision stapedectomy 2 3 4 1

Chronic otitis media 4 - - 3 1

Congenital ossicular chain defects

above 45 yrs. Tota l

M F

2 1 13

- - - - 8

4 . . . . . 4

I0 3 7 2 2 1 25

TABLE m TABLE IV

Materials used Results of surgery No. of Cases

Teflon piston 15 Bone air gap No. of dosed within cases Percentage

Wire gelfoam 3

Wire fat 3 10 db 5 20

Incus (autograft) 2

Homograft cartilage 2 15 db I 1 44

Total: 25 20 db 15 60

"1-

6

o z

to o <[ n. ,,J >.

0

I 0

4 0

5 0

6 0

7 0

CHART SHOWING PRE AND POST OPERATIVE I..~.ARING IN CASI~.,.

x - -PRE OPERATIVE AIR CONDUCTION O - - P O S T OPERATIVE AIR CONDUCTION

] - PRE OPERATIVE BONE CONEXX~TION r" - POST OPERATIVE BONE CONDUCTION

:It ' 3r" " . : l

- 3C~ 2r 2" = " = - 27. .. - D D" D r - 7.

C ~,"

~ j - , , i t-

8 0

9 0

I 0 0 I 2 3 4 5 6 7 8 9 I011 ~. 13 14 15 16 17 18 19 2 0 2 1 22 23 24. 2 5

NO, OF CASES

Fig. I. Showing results of surgery

Indian Journal of Otolaryngology, Volume 31, No. 4, December, 1979

MYRINGOMALLEOLABYRINTHOPEXY~AHAD & KACKER

cartilage was. directly put from the tympanic membrane and malleus to the oval window. Till 1974 wire prosthesis with either fat or a gel- foam piece were used. After this teflon piston is more commonly used. In three cases, where malleus handle was also absent, either homograft cartilage (2 cases) or incus (one case) was used.

Results

These twenty-five patients were operated upon between July, 1970 and September, 1978. The follow up varied from six months to more than eight years. The closure of bone air gap to within 20 dB or better in speech frequencies of 500, 1000 and 2000 Hz is considered a good result. Hearing improved in 16 patients (64 per cent). Sixty per cent of the ears closed the bone air gap to within 20 dB (Table No. IV.). Hearing remained unchanged m 5 cases (20 per cent) and worsened in 4 cases (16 per cent). Out of the four ears whose hearing deteriorated, 3 (12 per cent) developed sensori neural hearing loss, one (4 per cent) of these getting a dead ear.

There was not much difference in the results according to the primary pathology of the patients (Table No. V). In view of small groups no significance can be attached.

Duration o f Improvement

Five patients showed significant initial gain in hearing only to show a decrease with passage of time. In these cases the average initial gain was 24dB ranging from 18 dB to 31 dB. On detailed analysis no distinguishing features could be dis- cerned in this group as compared to general group. Subsequently average gain decreased to 13 dB over a period of time v~rying from 6 months to 5 years post-operatively (Table No. VI). In none of the patients pros- thesis got extruded.

Discussion

incus. Foot plate of the stapes may either have already been removed as in stapedectomy or may be fixed due to otosclerosis, congenital fixation, or as a result of chronic middle ear infection. Shea (1 976) found fixation of stapes in 7.5 per cent cases out of a series of 1502 consecu- tive tympanoplasty procedures. Abnormalities of the incus could be its necrosis (due to infection or pressure from the prosthesis), fixity, absence, dislocation (could be due to stapes surgery, mastoidectomy or skull fracture) or shortness of its long process so that prosthesis cannot be attached to it. Tabb (1976) even used the procedure in tym- panoplasty when foot plate was mobile but incus and stapes crura were absent. He removed stapes in these cases. He found this procedure more reliable and predictable than attaching the process to the mobile foot plate. However, it would carry a higher risk of cochlear damage. Whenever this procedure has to be done in cases with drum perforation, it should be done in two stages; closing the perforation at first stage and removing the stapes and re- constructing the link at second stage

as doing the procedure at same stage carries risk of infection to inner ear.

Initially prosthetic materials like wire, polyethylene tubes and teflon pistons were used but now-a-days more and more surgeons have started using cartilage and ossicles. Foreign bodies placed in direct contact with the tympanic membrane will usually perforate the drum and be rejected (Gundersen 1971 and Sheehy, 1972). Sheehy (1963) developed tears in the tympanic membrane in 13 per- cent of his cases when he used wire prosthesis.

Good results have been reported by doing myringomalleolabyrinthopexy in various conditions. Shea (quoted by Sheehy 1962) using polyethylene strut in 34 cases of fenestration failures (on whom stapedectomy was done) obtained 58 percent successful results. Kos (quoted by Sheehy 1962) obtained very good result in 60 percent of a small number of cases. Sheehy (1966) obtained bone air gap closure to within 20 dB in speech frequencies in 87 per cent cases of stapedectomy (non-fenes- trated), 74 per cent in stapedectomies

TABLE V

Successful results according to the type of disease

Myringo Malleo labyrinthopexy in Closure of bone air gap to within

10 dbs 15 dbs 20 dbs

Stapedectomy 15.7% 57% 61.5%

Tympanoplasty 25% 37.5% 62.5%

Congenital ossicular chain problems 25%

Prosthesis

Wire fat

Teflon piston

Myringomalleolabyrinthopexy is Wire fat indicated whereever there is an abnormality of the stapes foot plate Teflon piston combined with pathology of the Teflon piston

25% 50%

TABLE

Patients with initial hearing gain and subsequent deterioration

Initial hearing gain in db Time interval

22 1 yr. 8 months

31 6 months

27 5 years

18 10 months

23 9 months

Present gain db

10

15

22

5

12

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M Y R I N G O M A L L E O L A B Y R I N T H O P E X Y - - A I - I A D & K A C K E R

(in fenestration cases) and 73 per cent in tympanoplasty cases. Tabb (1976) obtained successful hearing results in 79 per cent of his cases of tympanoplasty. Our 64% of successful results are comparable to these results of other authors. Sheehy (1963) made a comparison of the results at 3 weeks, 4 months, and one year and noted an improvement between 3 weeks and 4 months and a tendency for a slight regression between 4 months and one year. Hick's et al (1978) believe that failure of hearing improvement immediately after surgery is probably due to inadequate prosthetic length and/or graft lateralization of the

prosthesis or pulling out of the prosthesis from the oval window. The latter two situations probably account for late hearing loss in these cases. Since in our five cases the regression showed conductive loss this explanation seemed more satisfactory.

Because of the exposure of the labyrinth these patients will carry a definite risk of sensori-neural hearing loss. In our series 12 per cent developed sensori-neural deafness with one (4 per cent) getting a dead ear. In the literature 4-8 per cent incidence of cochlear damage has been reported in these cases

(Shea, 1962; Sheehy 1963; 1966 and Tabb, 1976). Out of three of our patients who developed post-opera- tive sensori-neural loss two were revision stapedectomies, one of these undergoing revision a second time. The other case was that of chronic otitis media having a lot of adhesions. In all these three cases teflon piston was used.

Our experience is that if two attempts at ossiculoplasty are not successful a hearing aid should be advised without hesitation. Further attempts at surgery carry more risk of sensorineural hearing loss with less chances of success.

R e f e r e n c e s

1. Dasgupta, G. and Kacker, S. K. (1974.): Congenital abnormalities of ossicular chain in routine tympanoplasty opera- tions. Eye, Ear, Nose and Throat Monthly. 53: 362:

2. Gundersen, T. (1971): The construction of prostheses for the incus and for the incus and stapes arch--Prostheses in the ossicular chain, page 78.

3. Harrison, Wiley, H., Shambaugh, George, E., Kaplan Jules and Derlacki Eugene, L. (1959): Prosthetics in the Middle ear: Archives of Otolaryngology 69:661

4. Hicks, George, W., Wright, J. William Jr. and Wright J . William I I I (1978):

Use of plastipore for ossicular c h a i n . - Reconstruction: An Evaluation. The Laryngoscope 88: 1024.

5. Kos quoted by SheehyJames L., (1962). 6. Moon, Cary N. (1976): Ossicalar re-

construction in tympanoplasty Mobile Stapes without crural arches, fixed stapes with and without erural arches--The Laryngoscope. 86: 233.

7. Reudi--quoted by Harrison et al (1959) : 8. Shea, J . - -quoted by Sheehy James L.

(1962). 9. Shea, M. Cyle (1976): Stapes fixation

in chronic middle ear disease: The Laryngoscope 86: 230.

10. Sheehy, James L. (1962): Stapedectomy in the fenestrated ear. Annals of otology, rhinology and laryngology, 71: 1027.

I 1. Sheehy, James, L. (1963) : Stapedectomy in the fenestrated 6ar. Archives ofotolaryn- gology 78: 574.

12. Sheehy, James L. (1965): Ossicular problems in tympanoplasty. Archives of Otolaryngology 81 : 115.

13. Sheehy:James L. (1966) : Stapedectomy with incus replacement prosthesis. Laryngoscope. 76:1165.

14. Sheehy, James, L. (1972): Surgery of chronic otitis media. Otolaryngology, vol. II, Chapter 10, page 1.

15. Tabb, Harold G. (1976): A method of restoration of hearing in tympanoplasty with absence of the incus and stapes crura. Laryngoscope 86: 237.

100 Indian Journal of Otolaryngology, Volume 31, No. 4, December, 1979