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A wide variety of pistons are available for stapes surgery in otosclerosis. The objective of this work was to analyze the short-term and medium-term results of Soft-CliP® piston in prima­ry stapes surgery and to compare it with a conventional prosthesis. The study was prospective, monocentric, rando­mi­zed, based on efficiency of Soft-CliP® prosthesis (11 patients) versus Causse® Teflon prosthesis (9 patients) in otosclerosis surgery. Epidemiological data, treatment modalities, pure-tone audiometric results and outcome of patients were studied. Mean follow-up was 10 months. Soft-CliP® placement was statisti­cally longer. The mean postoperative air-bone gap was within 10 dB in 73% and 67% of cases at 2 months and in 82% and 89% of cases at medium-term in Soft-CliP® and Teflon groups respectively. A statistically significant decrease in mean air-bone gap and for all frequencies was observed at 2 months and at medium term, with no difference between the 2 groups. The main result was the demonstration of the reliability and safety of Soft-CliP® prosthesis. With a new design, Soft-CliP® place­ment was easy. The biomechanics of ossicular chain should be better preserved, and the risk of incus erosion and necrosis decreased. A study on a larger population in the long-term would validate these results.

Objectives: We report two surgical techniques devised to restore a disrupted incudostapedial joint., Material and Methods: Thirty patients underwent rebridging of distal portion of incus long process in the ENT Department of University of Grenoble and Saint-Etienne, between October 1998 and September 2002. Two types of ossicular prostheses were used: A titanium-gold angle prosthesis according to Plester Winkel Kurz (n = 16 patients), and a hydroxylapatite prosthesis as Martin Incudo Prosthesis (n = 14 patients)., Results: The average hearing gain in short term is of 8.30 dB for the Martin-Incudo group. It is of 5.23 dB in the Winkel group. Seven and three cases of failures (Residual Rinne > 20 dB) were noticed respectively in the groups Martin-Incudo and Winkel. Seven and four cases of labyrinthisation were observed respectively in the groups Martin-Incudo and Winkel. The average hearing gain in long term is 3.43 dB in the Martin-Incudo group; and 2.85 dB among patients with Winkel Kurz prosthesis. Average residual Rinne is higher than 20 dB in the Winkel group. The hearing gain is not statistically significant between the two groups (p > 0.05)., Conclusion: The titanium partial prosthesis did not give good functional results. In the case of a limited lysis (< 2 mm) of the distal portion of incus, we use the cement or cartilage interposition. When ossicular chain cannot be preserved entirely, we privilege incus transposition or a titanium PORP. The Martin-Incudo prosthesis seems interesting in the event of lysis of 2 mm of the long process of incus, nevertheless engineering changes are necessary in order to make rigid the incudostapedial joint.

Objective: To analyze the results obtained with hydroxyapatite bone cement (HABC)., Patients: A total of 73 ossiculoplasties with HABC were evaluated. Ears were divided into 4 groups: Group 1: Reinforcement of the incudo-stapedial joint with HABC; Group 2: Reconstruction of an incus long process defect with HABC; Group 3: Partial ossicular reconstruction between stapes and malleus handle with HABC; Group 4: Reconstruction of stapes with mobile or fixed footplate with moderate or extensive incus long process erosion using a titanium piston glued to the incus remnant using HABC., Results: The mean follow-up was 21 months. The percentage of postoperative average air-bone gap (ABG) < or = 20 dB for groups 1, 2, 3 and 4 were 100%, 95%, 83% and 91% respectively; for ABG < or = 10 dB: 90%, 71%, 50% and 50%. No complications related to HABC and extrusion occurred., Conclusion: Today, the use of HABC seems to help us improve our functional results and also to avoid extrusion. In our experience, ossiculoplastie with HABC seems to provide better and more stable functional results. HABC is safe and easy to use. The use of cement with or without biocompatible ossicular prostheses allows us to repair different types of ossicular defects whilst trying to conserve an anatomical and physiological ossicular chain. Reconstruction of the incus long process or incudo-stapedial joint defect with cement is preferable rather than using partial ossicular reconstruction with HABC.

Objectives: To report the functional results of ossicular reconstruction achieved with a specific partial prosthesis in tympanoplasty for cholesteatoma., Materials and Methods: Forty-four patients presenting cholesteatoma of the middle ear were involved in a retrospective study. Tympanoplasties were performed by the same surgeon over a 30-month period. The patients underwent ossiculoplasty with the shortest nondivisible partial titanium Spiggle & Theis prosthesis. Twenty-eight procedures were canal wall-up tympanoplasties and 17 were canal wall-down procedures; 27 were primary tympanoplasties and 18 were revisions. Audiometric data were evaluated before and after surgery, with a mean follow-up of 13.4 months., Results: Improvement of the air-bone gap was 6+/-12.2dB. The overall success rate was 56% and 67% using the Glasgow Benefit Plot and a postoperative air-bone gap lower than 20dB, respectively. There was no significant functional difference between canal wall-up and canal wall-down procedures. Hearing results were better in primary tympanoplasties than in revisions (p=0.004). The extrusion rate was 2.2%., Conclusion: The functional results observed in this study confirm that this partial titanium Spiggle & Theis prosthesis is a valuable biomaterial for ossicular reconstruction in primary tympanoplasty for cholesteatoma.

Unlabelled: The measurement of the piston is always described as a significant stage of the surgery but its length is never clearly defined., Objective: The goal of this work is to determine the length of the prosthesis., Materials and Methods: From May 2003 to May 2005, 128 patients with otosclerosis, diagnosed on the basis of their clinical history and their audiogram, were included in this prospective study. Some of them were revision surgeries. The prosthesis generally used was the Portmann piston clip (Medtronic Xomed Inc Portmann Piston Clip Stainless Steel/Fluoroplastic). In stapedectomies, a Teflon piston of 0.6 mm of diameter was used (Pouret Company Fluoroplastic Stapes Prosthesis). These prostheses must be trimmed before their installation. The measurement technique is described. The length of the prosthesis was increased by 0.5 mm to include the thickness of the footplate., Results: The Portmann piston clip was used 116 times (100 initial surgeries and 16 revisions surgeries) and the Teflon prosthesis of 0.6 mm of diameter only 13 times (6 primary stapedectomies and 7 revisions stapedectomies). The length of the prosthesis was between 3,5 mm and 5 mm. In the majority of cases, the length of the prosthesis was 4.75 mm (62 patients, 48.1%), followed by 4.5 mm (29 patients, 22.5%) and 5 mm (27 patients, 20.9%). In eleven cases (8.5%) the prosthesis measured less than 4,5 mm. None of the patients in this study experienced a postoperative sensorineural hearing loss., Conclusion: The measurement of the length of the piston is very significant, and in our study the majority of the pistons were cut at 4.75 mm which indicates an incus-footplate measurement of 4.25 mm.

Objectives: Report the functional and anatomic results of ossicular reconstruction by titanium prosthesis., Materials and Methods: Retrospective chart reviews were performed for 111 patients who had undergone titanium ossicular implants between November 1998 and 2002 (61 PORP, 50 TORP). The anatomical and audiometric data were analyzed on average at 3 and 20 months., Results: At 20 months, the improvement of air-bone-gap mean was 12.7 dB with better results at low frequencies. The global success rate was 66% (PORP 77%, TORP 52%). It decreased significantly in the open techniques. Extrusion rate was low (2/111) and the labyrinthization rate was 3.6%. Twenty patients required a surgical revision (18%). In 9 patients, the prosthesis was too short. At long-term follow-up, the gains were stable in 60 patients, improved in 32 patients and worsened in 19 patients., Conclusion: The success rate is higher in the group of the PORP with the closed technique. The stability of the TORP in open technique still remains problematic. In all cases, the risk of extrusion requires a large cartilage graft recovering the plate of the prosthesis. The high rate of luxation (9/111 prosthesis too short) has led us to increase slightly the length of the prosthesis (+1.22 mm mean).

Objective: The goal of this study was to compare the anatomical and functional results of two groups of patients having an ossiculoplasty type II, either with the incus, or with a PORP Bell Vario prosthesis (Kurz)., Materials and Methods: Retrospective study concerning 98 patients having had an ossiculoplasty type II with the incus (Incus group) and 50 patients having received a PORP titanium prosthesis Bell Vario from Kurz (Titanium group)., Results: The rate of extrusion was small (1% Incus group and 4% Titanium group). Average preoperative air bone gap of patients who received the Titanium prosthesis was 21.2 dB and 42.8 dB for the incus group. The average postoperative air bone gap was 16.9 dB Titanium group and 25.5 dB Incus group (p < 0.05). The gain was 18.7dB in the Incus group and 4.3 dB in Titanium group (p < 0.05). The difference between pre and post air conduction thresholds in both groups was statistically significant (p < 0.05). The post-op airbone gap was less on 20 dB in 62% of cases (Incus group) and 61% (Titanium group). There was no significant loss of the bone conduction thresholds in each group., Conclusion: Audiometric results obtained among patients with an incus transposition are better than those obtained with a PORP Titanium prosthesis. These results are to be appreciated by taking account of the greatest proportion of cholesteatoma and of reoperation in the Titanium group. The PORP titanium Bell Vario prosthesis (Kurz) is a material well tolerated by the middle ear as shown by the low rate extrusion. Its qualities (easy and precise measurement, easy positioning) make a material of choice of it when the patient's incus is not usable.

Objective: The prostheses known as biocompatible are usually proposed for columellar repair in absence of stapes but at which cost and which long-term tolerance? It appeared useful to study the possibilities of autograft ossicular reconstruction (incus and cortical bone) in absence of suprastructure of the stapes., Material and Methods: Retrospective study for 82 operated patients for cholesteatoma with lysis of the cruras of the stapes. Columellar repair was obtained by prosthesis, columella of cortical mastoid bone, and more often autograft of incus (54 cases). The technique of Autogreffe Tympanum-Cartilage-Os-Platinum (ATCOP) (Autograft Tympanum-Cartilage-Bone-Footplate is described: tympanic repair by fascia and cartilage from the concha is made at the first surgical step. Type III ossiculoplasty is performed at the second look. The distance tympanum-footplate is then lower than 6 mm and the body of the incus, preserved as a spare ossicle in the mastoid, has a sufficient length to be interposed in between new drum and footplate., Results: 78% of the patients have final air bone gap less or equal than 30 decibels. The average post op air bone gap is 23 decibels with incus while it was 42 decibels before surgery. Average gain is 19 decibels. The cost of autograft is null and tolerance is excellent., Conclusion: Patient's incus is usable in type III ossiculoplasty thanks to a cartilage graft of the tympanic membrane. Patient's ossicle is a material of choice for columellar repair even in absence of the suprastructure of the stapes. Prostheses in biomaterial appear justified in case of absent or destroyed incus.

Objective: To report the case of a 52 year-old-woman presenting with a left mixed hearing loss. Surgical exploration revealed an attical fixation of the malleus head associated with obliteration of the round window by a high jugular bulb., Method: Surgical exploration revealed this rare association. Attical fixation of the malleus head was treated by a partial prosthesis. The mobility of the chain was normal at the end of the surgical exploration but it was not possible to search for the round window sign because the niche of the round window was obliterated by an high Jugular bulb., Results: Audiogram was unchanged even if CT-scan confirm the good position of the partial prosthesis., Conclusion: Surgical treatment of an attical fixation of the malleus head do not seem to be necessary if it is associated with a simultaneous obliteration of the round window. Indeed, obstruction of the round window by a high Jugular bulb can caused a conductive hearing loss.

Objectives: To analyze outcome after otosclerosis surgery with stamedeotomy with blood clot sealing., Patients and Methods: Otosclerosis surgery was performed in 150 adult patients between 1997 and 1999 by five surgical teams (70% of the procedures were performed by senior surgeons) and followed for 18 months. Stapedotomy was carried out under general anesthesia with an intrameatal approach in 96% of the cases. Stapedotomy (n=120, 80%) was performed with a drill in 141 cases and by laser in 9 (6%). Ninety percent of the Teflon prostheses had a 0.4 mm diameter and a 4.5 mm length. The footplate opening was sealed with blood clots. Venous interposition (n=30, 20%) was performed in the event of partial or total stapedectomy which occurred in spite of an initial stapedotomy attempt., Results: The preoperative air-bone gap (ABG) was 32 +/- 10.3 dB. The gain in air conduction was 25 +/- 11.7 dB with 75% of the patients having more than 15 dB gain. The ABG was 10 +/- 5.4 dB with 73% of the patients having less than 5 dB gain. The interaural difference was 0.5 +/- 14.1 dB and the bone conduction (BC) variation was 1 +/- 7.5 dB. Functional failures were related to significant intralabyrinthine bleeding and revision procedure. The following factors had not effect on outcome: i) stapedotomy versus partial or total stapedectomy, footplate opening sealed by clots or vein, ii) diameter of the stapedotomy and/or the prosthesis, iii) surgical procedure performed by a junior surgeon., Conclusion: Sealing the stapedotomy opening with blood clots appears to provide reliable and reproducible functional outcome that remains stable over time. In this study, changing from partial to total stapedectomy with vein interposition did not modify the functional outcome.

Objective: To define factors predictive of outcome after ossiculoplasty in adults., Material and Methods: From 1992 to 1998, 220 ossiculoplasties were performed for chronic otitis media in 200 patients (100 men and 90 women), average age 53 years, age range 17 - 82 years. Ninety-four patients (47%) had not undergone prior surgery (99 ossiculoplasties) and 106 (53%) underwent revision procedures (121 ossiculoplasties). Average follow-up was 20 months. All patients were reexamined at consultations 3 and 12 months after surgery and 100 patients (50%) were reexamined at two years. The operations were classified in type II tympanoplasty when the patient presented a normal stapes (n=120), and a type III tympanoplasty when the stapes arch was absent (n=100). Perforations (n=200) were repaired by temporal aponeurosis in 160 cases (80%) and a tragal perichondrium in 40 cases (20%). The materials used included 23 incus autografts (10%), 105 hydroxyapatite composite Goldenberg prosthesis (48%), 55 all-hydroxyapatite Xomed prosthesis (25%) including 20 covered with a thinned tragal cartilage, 19 teflon Klein prosthesis (9%), 12 Ionos prosthesis (5%) and 6 Malleus prosthesis (3%). The results were analyzed from the microscopic aspect and audiometric data for frequencies 0,5 to 3 KHz., Results: Twenty prosthesis luxed or extruded (9%) within an average of 6 months, 15 (12.4%) after a revision procedure and 5 (5%, p<0,05) after an initial procedure. Fifteen perforations (15/200, 7.5%) occurred, 9 with temporal aponeurosis grafts (9/160, 5.6%) and 6 with perichondrium grafts (6/40, 15%, NS). The residual air-bone gap (ABG) was equal to 23 +/- 12,5 dB with 57% of ABG<20 dB at 12 months follow-up. The gain in air conduction was 14 +/- 16,5 dB and the change in air-bone gap 13 +/- 12,3 dB. Some factors could significantly improve functional results: presence of the stapes arch (n=120, p<0,05), first-intention procedure (n=99, p<0,05), and use of all-hydroxyapatite prosthesis in type II (p<0,05) or type III tympanoplasties., Conclusion: Ossiculoplasty with all-hydroxyapatite prosthesis produced satisfactory results in type II or III tympaonoplasties.

Ossicular graft is usually considered as the reference for surgical substitution in ossiculoplasties. Nevertheless, according to the infectious risks, nothing but autografts or synthetic prosthetic substitutes should be used nowadays. Authors compare hearing results for 100 patients after ossiculoplasty with either ossicular autograft or calcium-phospathe chain reconstruction. Audiometric results were retreived using both Glasgow Benefit Plot study and post-operative air-bone gap thresholds closure. Significant hearing improvement was statistically demonstrated in both conditions, and 60% of the patients had a post-operative hearing gain. Autograft ossicular reconstructions did not show to provide higher results. Biocompatibility and functionnal properties of calcium-phosphate materials retreived in this study, indicate that those ceramic substitutes should be considered as the best alternative to autografts.

Objectives: In order to evaluate the results of tympanoplasty in one stage middle ear cholesteatoma surgery, a retrospective study of 180 consecutive cholesteatomas operated on was undertaken., Methods: 150 single procedures and 30 revision surgeries realized between 1992 and 1997 were analysed by studying anatomical and functional results with a mean follow-up of 24 months., Results: Among the 150 adult patients, 85 (57%) were previously operated on in other centres and presented a recurrence of cholesteatoma. Closed technique was performed in 110 cases (61%) and opened one in the remaining cases (41%). Ossiculoplasty was made in 101 cases (56%) with different materials (15 incus autografts, 14 teflon prosthesis, 35 hydroxyapatite (HA) composite prosthesis and 37 all in HA prosthesis): 91 cases in a one-stage procedure but 10 worse functional results required a closed revision procedure. Twenty cases were also revised after one year of follow up at least: six recurrences of cholesteatoma were operated on by using canal down mastoidectomy (4%), 14 limited residual cholesteatomas (9.3%) had a revision closed technique procedure. CT Scan followed up all the patients operated on by a closed technique. Postoperative air-bone gap (ABG) was 20 +/- 11.3 dB and 27 +/- 10.1 dB in closed and opened techniques, respectively (p < 0.05). ABG was 20 +/- 9.2 dB and 26 +/- 13 dB in type II and type III tympanoplasty, respectively (p < 0.05)., Conclusion: If the tympanic and posterior cavities are reasonably safe, middle ear cholesteatoma in adults can be well cured by a one-stage procedure including ossicular chain reconstruction with hydroxylapatite prosthesis covered with cartilage graft who achieved a valuable hearing restoration.

There are various prostheses used for ossiculoplasty in chronic middle ear disease. Plastipores are one of the most commonly used prostheses. We performed ossiculoplasty with plastipores in 237 ear operations in a five years period. The results of the operations were summarized and causes of prosthesis failure were discussed. In 55 (23.2%) patients, tympanic membrane perforation recurred. Cholesteatoma recurrence was encountered in 16 (6.8%) cases. The extrusion of prosthesis was observed in 10 (4.2%) cases. The underlying ear disease was cleaned in 156 (65.8%) patients. An air-bone gap to within 20 dB was achieved in 87 (55.8%) ou of 156 patients. In 69 (44.2%) the gap closure was more than 20 dB. The experience of the surgeon in otologic surgery, severity of the chronic ear disease, status of the eustachian tube, extention of the ossicular chain disruption, type of surgery and characteristics of the prosthesis are critical for ossiculoplasty.

Using the guinea pig middle ear model, we assessed decalcified, lyophylized, sterile heterotopic porcine ossicular xeno-implants based on a histology (optic and electron scan microscope) and immunologic (immunofluorscence) methods. Implants were placed in the middle ear and others in the dorsal subcutaneous area. Allo-implants were compared as controls. Implants were placed in the middle ear in 54 animals and skin implants in 14. Under the influence of BMP, the implant ossified in all cases in the middle ear. Intense immune recruitment was not observed. Inversely, there was a mononuclear infiltration reaction to the skin implants with formation of a fibrous capsule, immunoglobulin and complement influx and consequently sequestration. The allo-implants were partially reossified. These findings confirm the value of decalcification with hydrochloric acid for BMP induction, independent of species and the failure of attempted immune despecification. Implant outcome is not dependent on its antigen load, which is high compared with its weight, but on the site of implantation. The middle ear appears to be a privileged site of implantation.

We report our functional results about 81 ossiculoplastys during tympanoplasty with closed technique in chronic cholesteatomatous otitis. We discuss our functional results and the post-operative assessment of the audiometric gain. Patients presented either cholesteatomatous otitis sequelea or any preliminary status (retraction pockets) with attical impairment.

Between 1988 and 1993, 94 children from 3 to 15 years of age underwent one or more surgical procedures for cholesteatoma or epithelization of the middle ear space. Ten children had bilateral disease. 94 ears were operated for the first time and 10 ears had had previous surgery at other institutions. A total of 204 procedures were performed: 190 for cholesteatoma and 14 for epithelization of the middle ear space. Preoperative audiometry showed a mean air-bone gap of 30 decibels. 69% of the ears had ossicular osteolysis. The surgical technique was decided at the time of surgery. This was most often a canal-wall-up procedure which was almost routinely followed by surgical revision (92%). Pearl-like masses or recurrent cholesteatoma were frequently found at the second or third operation (73%) but most could ultimately be controlled with a canal-wall-up procedure. A canal-wall-up down procedure was necessary in 20% of the ears at either the second or third operation because of important residual or recurrent cholesteatoma. Post-operative audiometry showed a mean air-bone gap of 30 decibels.

Post-operative air conduction and bone conduction thresholds at 3 months, 1 year and 5 years after stapedectomy or stapedotomy in 67 patients were studied. Bone conduction thresholds improved in the first year postoperatively, then decreased progressively, less than in the non-operated ear but more than in a normal population. The air-bone gap was closed in 75% of the patients. The air-bone gap stayed at the same level during the studied period. Air conduction and bone conduction thresholds are better in the stapedotomy group than in the stapedectomy group only in the 4000 Hz frequency, and are similar for both groups in the 500-2000 Hz range.

Middle ear implants are a new type of hearing aid. Their principle is direct stimulation of the inner ear fluids, by a vibrator implanted in the middle ear. Two technologies are developed by different teams: electromagnetic vibrators, and piezoelectric vibrators. Middle ear implants should be partially implantable (P-MEI), or totally implantable (T-MEI). Authors develop, concurrently with animal experimentation an in vitro method to measure the performance date of the vibrators. The specifications of a future P-MEI have been defined, and vibrators tested with this method. First results encourage to develop this project.

Total and subtotal perforations of the tympanic membrane cause problems. Adhesions and poor hearing results are the outcome when just the stapes or the footplate remain intact. Reinforcement of the transplant using cartilage and plastic sheeting were not successful in the long run. The tympano-wire prosthesis with its concave form prevents the above mentioned disadvantages. Short interpositioning is to prefer in order to prevent impedance.

The authors present there experience with bone allografts and costal cartilage allografts in middle ear microsurgery. A drastic selection of the doners and a careful preparation of the grafts avoid the risk of viral transmission to the receiver. The easy available materials can be used for reconstructing the ear drum, the ossicular chain and the tympanic bony wall. With good anatomical and functional results, even at long-term (3 and 4 years).

A study was carried out to evaluate the value of high-frequency audiometry in stapes surgery in cases of otosclerosis. The hearing function was measured pre- and postoperatively by means of conventional and high-frequency audiometry (Demlar 20k). The operative findings of the gradation of otosclerosis were compared with the pre and postoperative audiometrical measurements. The results of this study point out that a clear relation exists between the preoperative high tone audiogram and the gradation of otosclerosis. In conclusion, we state that high-frequency audiometry can predict the state of stapes fixation in otosclerosis and that can be important in stapes surgery.

Biomaterial may be biological or non-biological in origin. Only the latter will be considered here. Their possible use in otology is threefold: ossiculoplasty: the author recalls the different materials used during the past 30 years. Today, it seems that only certain ceramics are able to compete with auto and homografts. Hydroxylapatite ossicles are a perfectly good alternative; canal wall reconstruction in radical operations: in this context their role appears to be less satisfactory than that of autografts; cavity obliteration: very useful and effective when performed in the correct situation and under certain well-defined technical conditions. After outlining the different materials used in the past 30 years, the author draws upon the experience of his own school to give his personal opinion.