Ossiculoplasty Using Preserved Septal Cartilage

Ossicular chain reconstruction is the primary method of restoring conductive hearing deficit seen in chronic middle ear disease. Many factors affect outcomes in this procedure including the middle ear environment, status of the Eustachian tube, surgical technique, type of prosthesis and status of residual ossicular remnants. Many materials have been used for Ossiculoplasty including both biologic and alloplastic materials, with varying degrees of success. This study was done to evaluate the efficacy of preserved septal cartilage as ossicular reconstruction prosthesis in patients with mucosal type of COM (chronic otitis media) with ossicular discontinuity. Objective: To evaluate the efficacy of preserved septal cartilage as ossicular reconstruction prosthesis in patients with mucosal type of COM with ossicular discontinuity. Methods: A prospective study of with mucosal type of COM, Ossiculoplasty tertiary Results: A total 20 patients (13 males and 7 females) between the age group of 18-60 years with mucosal type of COM with ossicular discontinuity were included in the study. Out of 20 patients 18 patients (90%) had improvement in A-B gap (air bone gap) after surgery and 2 patients had no improvement in A-B gap after 3 months of follow up. The mean hearing gain was 12.25±7.23 dB which was statistically significant (p value 0.001). Conclusion: Preserved septal cartilage is a good material for ossicular reconstruction in terms of postoperative hearing improvement and closure of A-B gap. By giving careful attention to the principles of ossicular construction and understanding basic principles and applying them in clinical practice, it is possible to give more desirable hearing results for the patients.


Introduction
Chronic otitis media (COM) is the presence of irreversible inflammatory disease in the middle ear cleft. It also affects the ossicular chain leading to conductive hearing loss. Erosion of the ossicular chain is seen in about 80% of patients who present with chronic otitis media with cholesteatoma whereas it is present in approximately 20% COM cases without cholesteatoma. Incus is the most frequently affected ossicle, followed by the stapes and malleus [1]. Ossicular chain reconstruction is the primary method of restoring conductive hearing deficit seen in chronic middle ear disease [2,3].Many factors affect outcomes in this procedure ossicular remnants [4,5]. Austin classified ossicular chain disruption into 4 groups (ABC&D) based on the presence or absence of the malleus handle and the stapes arch. Kartush added three more categories to this classification: intact ossicular chain (0), fixation of the malleus head (E) and fixation of the stapes (F) [6]. Many materials have been used for Ossiculoplasty including both biologic and alloplastic materials, with varying degrees of success. Ideally, the reconstruction material should be biocompatible, safe, easy to fit and handle, and capable of efficient sound transmission. Biologic materials like autograft or homograft ossicles, cortical bone, teeth, and cartilage have been used. Body of Incus often reshaped, is the most common auto graft used as ossicular prosthesis [7]. This study was done to evaluate the efficacy of preserved septal cartilage as ossicular reconstruction prosthesis in patients with mucosal type of COM with ossicular discontinuity.

Material and Methods
A prospective study of 20 patients with mucosal type of COM, undergoing Ossiculoplasty was conducted at a teaching tertiary care hospital from January 2019 to July 2020.

Discussion
The objective of the tympanoplasty is to provide a dry ear, ensure the function of Eustachian tube, and restore the soundconducting system of the middle ear. Ossicular chain reconstruction is a challenging procedure even for experienced otologists and the success is achieved with good and long-lasting audiometric outcome, represented by closure of postoperative A-B gap less or equal do 20 dB [4,8]. We observed an improvement of a mean  [11,12]. Out of these, the presence of a malleus handle, the presence of a stapes superstructure and the status of the middle ear mucosa, have been found to be most important [11][12][13]. Mills in his study reported that the loss of the stapes arch was a significant factor causing worse outcome, handle was the only significant factor [11]. In our patient series, middle ear mucosa was healthy and the stapes suprastructure was present in all the patients explaining a good success rate (90%) and hence proved to be the most significant prognostic factors for successful ossiculoplasties.

Conclusion
Ossicular reconstruction still remains a challenging procedure.
The outcome of surgery depends on many prognostic factors. In our study we obtained surgical success in 90% of surgeries.
The presence of the stapes superstructure and normal middle ear mucosa were significant predictive factors for successful results after ossiculoplasty. With the continuing advances in the understanding of middle ear mechanics, the outcome of ossiculoplasty is improving. By giving careful attention to the principles of ossicular construction and understanding basic principles and applying them in clinical practice, it is possible to give more desirable hearing results for the patients.