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Current Topics in Otolaryngology - Head and Neck Surgery Middle Ear Surgery: Recent Advances and Future Directions by Klaus Jahnke () on.
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Regarding the compensation of atmospheric pressure changes, the eardrum, the ligaments and the joints of the ossicles, and the annular ligament play a decisive role. After prosthetic middle ear reconstruction, those elements partly do no longer exist. Because of favorable properties of the material, titanium prevailed among the alloplastic materials during the last years. Beside the excellent acoustic transmission characteristics and a very good biocompatibility, the possibility to develop particularly filigree design, is of major significance.

This property allows integrating functional elements in the middle ear prostheses. The aim of such functional elements is the compensation of pressure variations [ 96 ]. Generally, functional elements may be integrated at the prosthesis plate, the prosthesis strut, and the prosthesis foot. The extraordinary significance of the malleus handle manubrium for the postoperative hearing results was already mentioned in chapter 2.

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Efforts have been undertaken to reconstruct a completely destroyed manubrium. Several approaches to replace the manubrium, have been described [ 97 ], [ 98 ], [ 99 ], [ ]. This procedure minimizes the risk of extrusion of the implant or dislocation. The integration of the neo-malleus has the advantage of better PORP or TORP coupling at the tympanic membrane and thus to minimize the risk of dislocation. Furthermore, the reception of sound pressure and the transmission to the reconstructed chain with a neo-malleus is clearly superior to the reconstruction of the eardrum alone Austin-Kartush type C.

In the clinical setting, even a better result with the malleus prosthesis was achieved due to the additional influence factors. While the postoperative ABG amounted to Due to the material properties, the neo-malleus anchored in the bone can be easily adjusted to the projection axis of the footplate so that extreme angular TORP deviations are avoided. An additional stabilization of total prostheses is possible with corresponding centering device on the footplate.

The titanium neo-malleus can also be used as alternative coupling point for a malleo-vestibulopexy [ ].

Research in Head and Neck Oncology

In order to avoid prosthesis head plate dislocation from the tympanic membrane or to achieve long-term stability in this area without negative effects on the acoustic transmission properties, modifications of the rigid connection between the prosthesis strut and the head plate or the head plate itself are useful. A modification of the head plate to which 0. Under experimental and clinical conditions, a protection could be achieved with regard to lateral dislocation of the prosthesis plate during reconstruction of the tympanic membrane. Another advantage of such an anchoring of the head plate in the reconstructed eardrum is observed especially in the early phase during or directly after surgery and wound healing.

After complete wound healing, the head plate is generally fixed with connective tissue so that sufficient stability is assured. The eardrum-implant interface also requires an optimized middle ear prosthesis because of the anatomical and dynamical circumstances. Positioning of the head plate with joints to the prosthesis stem may allow an adjustment to the uneven position of the reconstructed eardrum that varies according to the angle [ 96 ], [ ].

In this way, the head plate passively follows the forces that postoperatively and in the context of wound healing lead to a changed position of the eardrum. Furthermore, this has a positive effect on short-term variations of the air pressure as well as longer-lasting pressure changes that occur in chronically sick ears due to changes of the middle ear mucosa.

Especially in cases of chronic ventilation disorders, the position of the head plate at variable angles contributes to avoiding migrations of the prosthesis plate. Without increasing the pre-tension, an acoustically favorable coupling to the manubrium can be performed. Experimental trials with titanium prostheses with prostheses heads installed in ball-joints could show that under physiological conditions no material abrasions occur in the area of the titanium ball-joint and the transmission properties are comparable to those of the intact ossicular chain [ ].

Also for total prostheses, the integration of a ball-joint is described with similar transmission characteristics [ ].


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The experimentally identified properties could be confirmed in first clinical studies in 60 patients [ ], in 18 patients [ ] for partial prostheses, and in 12 patients [ ] for total prostheses. Regarding the use of total prostheses, the mobile head plate represents an additional surgical challenge that must not be underestimated because the angular variability makes a stable intraoperative positioning very difficult.

Long-term results for both types of prostheses must still be evaluated.

Dana White Ear Surgery at House Ear clinic January 2013

In summary, the integration of a titanium ball-joint between the head plate and the prosthesis strut are a promising innovation for compensating short-term pressure fluctuations and long-lasting pressure differences without having a negative effect on the acoustic transmission properties of the prostheses. The integration of a joint in the prosthesis strut is another possibility to avoid the rigid coupling between the eardrum and the footplate for compensation of atmospheric pressure variations and thus protection of the inner ear and of dislocations [ 96 ], [ ].

The static prosthesis stem, following the biological example of the joint-like columella of birds, is replaced by a resilient joint. In cases of atmospheric pressure changes, the extra-columella is shifted to the inside with the eardrum and thus protects the inner ear from pressure-related damage Figure 8 Fig. Experimental investigations with titanium total prostheses with a silicone-enhanced micro-joint that was integrated in the prosthesis stem, the feasibility of this approach could be confirmed.

The integration of a joint in a silicone mantle provides the desired reset effect so that a decrease of the pressure leads to a restoration of the original position. In this way, compared to the articulated connections in the area of the prosthesis plate that have a ball-joint with friction, there is a significant advantage: resilient joint with reset effect. There is no difference in transmission properties of the bended prosthesis in the dynamic range of sound transmission compared to rigid TORP. Under increased pressure negative pressure in the middle ear the transmission can be compared to the one of the intact middle ear.

Currently, the silicone enclosure of the joint represents a manufacturer-related obstacle. With regard to the acoustic and static performance, however, this approach is very promising [ ].

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The medial interface between the implant and the residual ossicles plays a particular role in many regards. On the one hand, a stable anchoring is desirable to avoid a dislocation of the total prosthesis. On the other hand, anchoring at variable angles are useful that allow positioning of the total prosthesis to the eardrum without increasing the pre-tension of the reconstruction.

Furthermore, because of the punctual load of the stapes footplate after implantation of a total prosthesis, a possible fracture must be expected after intensive pressure increase [ ]. Additionally, the central joint-ball represents a coupling point at variable angles for total prostheses. This approach takes up a strategy described in suggesting a modular prosthesis concept with a surgical procedure in two sessions.

A stable anchor point should be established on the footplate by incorporating bioactive ceramic on the footplate without prosthesis-related relative movements , in a second step the proper prosthetic reconstruction of the sound conduction apparatus should be performed with a total prosthesis [ ]. The use of the omega connector represents the realization of the modular prosthesis concept, however it does not resolve the problem of a bone-like coupling point on the footplate. Even if the larger surface of the omega connector provides a higher stability on the footplate and thus the risk of dislocation is lower, relative movements may lift the footplate prosthesis.

‘Unparalleled visualization’

So also this dislocation protection is rather a centering device. The remaining risk of dislocation might only be completely avoided by a bone-stable anchoring in the sense of osseo-integration of prosthetic material on the stapes footplate [ ]. According to biomechanical calculations, this could be possible [ ]. Even experimentally, a growth-factor mediated osseo-integration on the footplate could be realized in mammalian organisms, for the clinical application, however, this concept is currently not available, also because of economic reasons [ ].


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All before-mentioned functional elements are used for reconstructing the function of pressure balance of the ossicular chain. The acoustic rehabilitation alone can be well implemented with a stable and firm connection between the eardrum and the stapes under conditions of pressure balance.

In order to minimize the risk of prosthesis dislocation, especially of TORP, the use of prostheses is recommended that are longer than required by the anatomical circumstances. A slightly too high prosthesis construction leads to a tight embracing and to prosthesis fixation between the stapes and reconstructed eardrum. This dynamic bracing intends to counteract the risks and forces of dislocation occurring immediately after surgery as well as in the context of wound healing [ 3 ].

In this way, outward movements of the tympanic membrane may be compensated by the fixation of the reconstruction. The footplate displacement in direction of the vestibulum leads to tension of the annular ligament and its resulting stiffening leads to reduced vibration and thus to a reduced middle ear transmission. This relationship between desired dynamic fixation of a prosthesis in the ossicular chain on the one hand and on the other hand the resulting reduction of sound transmission through the middle ear has already been investigated experimentally.

Trials performed with temporal bones at which reconstructions were performed with prostheses of different lengths, could reveal differences in the middle ear transfer function [ 44 ], [ 45 ], [ ], [ ]. With increasing prosthesis length and higher fixation, first a minimal increase of the transfer function in high frequencies was observed that was associated with a decrease of the lower frequencies. With further increasing tension, a general decline of the transmission was noted. Those basic results were mainly measured with conventional differences of the length of 0.

For a long time it remained unclear to what extent the pretension caused by too long prosthesis led to the stiffening of the eardrum or the annular ligament. So it was not possible to quantify the transmission loss that is generated by the fixation of the annular ligament alone. This is due to the fact that the visco-elastic properties of the eardrum show a linear behavior with a constantly low stiffness.

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So if the distance between the eardrum and the footplate is longer, the tympanic membrane yields with constantly low stiffness over longer distances Figure 9 Fig. In contrast, the annular ligament does not behave linearly [ ], [ ] which leads to a significantly increased stiffness already in cases of minimal displacements of the footplate Figure 10 Fig. The pretension of the annular ligament has also an impact on the transmission properties when the stapes is tilted of the vertical axis of the footplate Figure 11 Fig.

This mechanism may also be responsible for poorer transmission properties of partial prostheses. If they are firmly fixed on the stapes, the forces that affect the head plate are transmitted on the annular ligament. In cases of total prosthesis, only a low moment of force, if at all, is generated at the contact point between the prosthesis foot and the stapes footplate. However, because of the missing anchoring in this area, this is not transmitted to the footplate. Even the use of centering devices does not change this situation so that tilting of the footplate with resulting pretension of the annular ligament does not occur [ ].

It must be taken into account that the before-mentioned investigations were performed in human cadaver specimens. So biological remodeling processes as they are observed in vivo, cannot be displayed. Furthermore, often the eardrum is reconstructed in the context of ossiculoplasty or the prosthesis head plate is covered with cartilage. This procedure modifies the elastic properties and the stiffness of the lateral components in comparison to the natural tympanic membrane with the manubrium. In summary, for ear surgeons this means that from a biomechanical point of view any pretension should be avoided in order not to cause transmission losses already at the beginning that could be enhanced by further, biological factors.

Undoubtedly, the surgical reality requires positioning and coupling of prostheses as stable as possible, so that under certain circumstances in the operation room the generation of pretension cannot be completely avoided. Nonetheless, the surgeon should know about those correlations and apply methods of dislocation protection for stabilization of the prostheses in favor of a reduction of the pretension [ 97 ], [ ], [ ], [ ]. The authors declare that they were supported by Heinz Kurz Medical Technique Company during the last 3 years in the context of travelling grants and performed contract research.

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