Ossicular Malformation / Ossiculoplasty

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Ossicular Malformation / Ossiculoplasty

Otology/Audiology
Author Credentials 

Robert J. Yawn, MD
Alejandro Rivas, MD
Otology Group of Vanderbilt
Vanderbilt University Medical Center
Nashville, TN

Module Summary

Ossiculoplasty is the surgical restoration/rehabilitation of patients with conductive hearing loss secondary to ossicular dysfunction. This dysfunction manifests as conductive hearing loss and can be the result of congenital causes, or result secondarily as the result of cholesteatoma, tympanosclerosis, or otosclerosis. This module focuses on anatomic and embryologic considerations in ossiculoplasty and ossicular malformations as well as surgical considerations. Otosclerosis and stapedotomy are discussed in detail in another module.

Module Learning Objectives 
  1. Explain relevant anatomy as it pertains to the ossicular chain.
  2. Review embryology as it relates to the formation of the ossicles.
  3. Describe common ossicular malformations.
  4. Describe surgical considerations for ossiculoplasty.

Embryology

Learning Objectives 

Describe the embryologic origins of the malleus, incus, and stapes and their derivation from the pharyngeal arches.

References 
  1. Whyte J, Cisneros A, Yus C, Fraile J, Obon J, Vera A. Tympanic ossicles and pharyngeal arches. Anatomia, histologia, embryologia. 2009; 38:31-33.

Anatomy

Learning Objectives 
  1. Describe the anatomic position of the ossicles as they relate to the ear canal, facial nerve, chorda tympani nerve, jugular bulb, and carotid canal.
  2. Describe normal variants of the ossicular chain, and which ossicles have more variability in their appearance and shape and which ossicles are more consistent from patient to patient.
References 
  1. Saha R, Srimani P, Mazumdar A, Mazumdar S. Morphological Variations of Middle Ear Ossicles and its Clinical Implications. J Clin Diagn Res. 2017 Jan;11(1):AC01-AC04.
  2. Luers JC, Huttenbrink KB. Surgical anatomy and pathology of the middle ear. J Anat. 2016 Feb;228(2):338-53.
  3. Kamrava B, Roehm PC. Systematic Review of Ossicular Chain Anatomy: Strategic Planning for Development of Novel Middle Ear Prostheses. Otolaryngol Head Neck Surg. 2017 Aug;157(2):190-200. 2017; 157:190-200.

Pathogenesis

Learning Objectives 

Describe common pathologies of ossicular malformations, including stapes ankylosis, stapes ankylosis with additional ossicular malformation, ossicular malformation without stapes fixation, and other aplasias.

References 
  1. Teunissen EB, Cremers WR. Classification of congenital middle ear anomalies. Report on 144 ears. Ann Otol Rhinol Laryngol. 1993 Aug;102(8 Pt 1):606-12.

Genetics

Learning Objectives 

Describe common genetic syndromes that can lead to conductive hearing loss.

References 
  1. Jecmenica J, Bajec-Opancina A, Jecmenica D. Genetic hearing impairment. Childs Nerv Syst. 2015 Apr;31(4):515-9.

Patient Evaluation

Learning Objectives 
  1. Describe prognostic factors in ossiculoplasty.
  2. Describe evaluation of children with conductive hearing loss.
References 
  1. De Vos C, Gersdorff M, Gerard JM. Prognostic factors in ossiculoplasty. Otol Neurotol. 2007 Jan;28(1):61-7.
  2. Dougherty W, Kesser BW. Management of Conductive Hearing Loss in Children. Otolaryngologic clinics of North America 2015; 48:955-974.

Imaging

Learning Objectives 

 

  1. Describe the role of computed tomography in evaluating ossicular malformations.
  2. Describe the imaging findings related to ossicular malformations in patients with grade 1 microtia or mild external auditory canal stenosis.
References 
  1. Nakasato T, Nakayama T, Nakayama M, Ehara S, Ohtsuka H, Sato H. Minor ossicular anomalies in the middle ear: role of submillimeter multislice computed tomography. J Comput Assist Tomogr. 2014 Sep-Oct;38(5):655-61.
  2. Jacob R, Gupta S, Isaacson Bet al. High-resolution CT findings in children with a normal pinna or grade I microtia and unilateral mild stenosis of the external auditory canal. AJNR Am J Neuroradiol. 2015 Jan;36(1):176-80.

Pathology

Learning Objectives 
  1. Describe the pathologic evidence for use of autografts in ossiculoplasty.
  2. Describe the influence cholesteatoma and chronic otitis media have on ossicular chain status and hearing.
References 
  1. Attanasio G, Gaudio E, Mammola CLet al. Autograft ossiculoplasty in cholesteatoma surgery: a histological study. Acta Otolaryngol. 2014 Oct;134(10):1029-33.
  2. Blom EF, Gunning MN, Kleinrensink NJet al. Influence of Ossicular Chain Damage on Hearing After Chronic Otitis Media and Cholesteatoma Surgery: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):974-82.

Surgical Therapies

Learning Objectives 
  1. Describe common surgical issues in treating patients with conductive hearing loss.
  2. Describe the role of hydroxyapatite cement in ossiculoplasty.
  3. Describe titanium versus non-titanium prosthesis use in ossiculoplasty.
  4. Describe the role of endoscopic approaches in ossiculoplasty.
References 
  1. Raz Y, Lustig L. Surgical management of conductive hearing loss in children. Otolaryngol Clin North Am. 2002 Aug;35(4):853-75.
  2. Zhang LC, Zhang TY, Dai PD, Luo JF. Titanium versus non-titanium prostheses in ossiculoplasty: a meta-analysis. Acta Otolaryngol. 2011 Jul;131(7):708-15.
  3. Cushing SL, Papsin BC. The top 10 considerations in pediatric ossiculoplasty. Otolaryngol Head Neck Surg. 2011 Apr;144(4):486-90.
  4. Yawn RJ, Hunter JB, O'Connell BPet al. Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction. Otol Neurotol. 2017 Oct;38(9):1296-1300.
  5. Galy-Bernadoy C, Akkari M, Mathiolon C, Mondain M, Uziel A, Venail F. Comparison of early hearing outcomes of type 2 ossiculoplasty using hydroxyapatite bone cement versus other materials. Eur Ann Otorhinolaryngol Head Neck Dis. 2014 Nov;131(5):289-92.
  6. Philippon D, Laflamme N, Leboulanger Net al. Hearing outcomes in functional surgery for middle ear malformations. Otol Neurotol. 2013 Oct;34(8) 1417-1420.

Complications

Learning Objectives 
  1. Describe common reasons for long-term failure and complications from ossiculoplasty.
  2. Describe the impact that tobacco use has on ossiculoplasty complications.
References 
  1. Cox MD, Page JC, Trinidade A, Dornhoffer JL. Long-term Complications and Surgical Failures After Ossiculoplasty. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2017; 38:1450-1455.
  2. Cox MD, Anderson SR, Russell JS, Dornhoffer JL. The Impact of Smoking on Ossiculoplasty Outcomes. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2016; 37:721-727.
     

Review

Review Questions 
  1. What are the embryologic origins of the malleus, incus, and stapes?
  2. What is the relationship of the chorda tympani nerve, facial nerve, and ear canal to the ossicles?
  3. What is the difference between titanium and non-titanium prostheses in ossiculoplasty?
  4. How does smoking impact complications in ossiculoplasty?
References 
  1. Whyte J, Cisneros A, Yus C, Fraile J, Obon J, Vera A. Tympanic ossicles and pharyngeal arches. Anatomia, histologia, embryologia 2009; 38:31-33.
  2. Saha R, Srimani P, Mazumdar A, Mazumdar S. Morphological Variations of Middle Ear Ossicles and its Clinical Implications. Journal of clinical and diagnostic research : JCDR 2017; 11:AC01-AC04.
  3. Luers JC, Huttenbrink KB. Surgical anatomy and pathology of the middle ear. Journal of anatomy 2016; 228:338-353.
  4. Kamrava B, Roehm PC. Systematic Review of Ossicular Chain Anatomy: Strategic Planning for Development of Novel Middle Ear Prostheses. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2017; 157:190-200.
  5. Teunissen EB, Cremers WR. Classification of congenital middle ear anomalies. Report on 144 ears. The Annals of otology, rhinology, and laryngology 1993; 102:606-612.
  6. Jecmenica J, Bajec-Opancina A, Jecmenica D. Genetic hearing impairment. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2015; 31:515-519.
  7. De Vos C, Gersdorff M, Gerard JM. Prognostic factors in ossiculoplasty. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2007; 28:61-67.
  8. Dougherty W, Kesser BW. Management of Conductive Hearing Loss in Children. Otolaryngologic clinics of North America 2015; 48:955-974.
  9. Nakasato T, Nakayama T, Nakayama M, Ehara S, Ohtsuka H, Sato H. Minor ossicular anomalies in the middle ear: role of submillimeter multislice computed tomography. Journal of computer assisted tomography 2014; 38:655-661.
  10. Jacob R, Gupta S, Isaacson Bet al. High-resolution CT findings in children with a normal pinna or grade I microtia and unilateral mild stenosis of the external auditory canal. AJNR American journal of neuroradiology 2015; 36:176-180.
  11. Attanasio G, Gaudio E, Mammola CLet al. Autograft ossiculoplasty in cholesteatoma surgery: a histological study. Acta oto-laryngologica 2014; 134:1029-1033.
  12. Blom EF, Gunning MN, Kleinrensink NJet al. Influence of Ossicular Chain Damage on Hearing After Chronic Otitis Media and Cholesteatoma Surgery: A Systematic Review and Meta-analysis. JAMA otolaryngology-- head & neck surgery 2015; 141:974-982.
  13. Raz Y, Lustig L. Surgical management of conductive hearing loss in children. Otolaryngologic clinics of North America 2002; 35:853-875.
  14. Zhang LC, Zhang TY, Dai PD, Luo JF. Titanium versus non-titanium prostheses in ossiculoplasty: a meta-analysis. Acta oto-laryngologica 2011; 131:708-715.
  15. Cushing SL, Papsin BC. The top 10 considerations in pediatric ossiculoplasty. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2011; 144:486-490.
  16. Yawn RJ, Hunter JB, O'Connell BPet al. Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2017; 38:1296-1300.
  17. Galy-Bernadoy C, Akkari M, Mathiolon C, Mondain M, Uziel A, Venail F. Comparison of early hearing outcomes of type 2 ossiculoplasty using hydroxyapatite bone cement versus other materials. European annals of otorhinolaryngology, head and neck diseases 2014; 131:289-292.
  18. Philippon D, Laflamme N, Leboulanger Net al. Hearing outcomes in functional surgery for middle ear malformations. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2013; 34:1417-1420.
  19. Cox MD, Page JC, Trinidade A, Dornhoffer JL. Long-term Complications and Surgical Failures After Ossiculoplasty. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2017; 38:1450-1455.
  20. Cox MD, Anderson SR, Russell JS, Dornhoffer JL. The Impact of Smoking on Ossiculoplasty Outcomes. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2016; 37:721-727.
Resources 

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