Bone-Cement Usage for Ossicular Reconstruction.
Istanbul Medeniyet University, Faculty of Medicine, Department of Otorhinolaryngology, Goztepe Training and Research Hospital, Istanbul, Turkey
- *Corresponding Author:
- M. Tayyar Kalcioglu
Istanbul Medeniyet University
Faculty of Medicine
Department of Otorhinolaryngology
Goztepe Training and Research Hospital
E-mail: [email protected]
Ossicular chain erosions may cause a hearing loss in many chronic otitis media cases. It may be possible to solve this problem by using incus interposition, autograft bone or cartilage or ossicular replacement prostheses. Bone-cement is recently used material for reconstruction of ossicular chain defects. In this commentary, we discussed to use Bone-cement for some ossicular chain problems.
Ossicular chain defect, Bone-cement, Bridging
Chronic otitis media is a commonly seen Otorhinolaryngology disorder which may affect ossicular chain, especially the long process of the incus. Defective ossicular chain causes conductive hearing loss as a result . To solve these ossicular chain problems, it is possible to use interposed incus, autograft bone or cartilage, ossicular replacement prostheses, or bone-cement. The ideal graft material should be biocompatible, stable and easy to insert.
All these options have their own advantages and disadvantages; autograft incus interposition has advantages such as no foreign body reaction due to the use of patient’s own tissue and easy to access. On the other hand, it may be affected because of the infection, may dislocate after interposition. These are the main disadvantages of this procedure. Incus interposition can be performed between stapes and malleus if the case has stapes suprastructure. If not, it can be performed between footplate and malleus or footplate and tympanic membrane. In all these procedures, especially if stapes suprastructure is absent, interposed incus may be dislocated and cause hearing loss [1,2]. It is also has been discussed the necessity of being autoclaved of ossicules before the operation to have safe ossicule to use for interposition in the cases who has cholesteatoma .
Due to the similar pathologies, to solve ossicular chain problems, various prostheses may be used. These prostheses were specially designed for acoustic transmission . Various prostheses have been produced for various pathologies. Angular clip prosthesis which is applied between stapes and malleus when incus long process is defective . Partial Ossicular Replacement Prosthesis (PORP) that is placed on the stapes suprastructure, Total Ossicular Replacement Prosthesis (TORP) that is placed on the stapes footplate, and Vincent malleus prosthesis which is used when malleus is absent are some of the options that can be used to ensure the integrity of ossicular chain [6,7]. Although these prostheses have good biocompatibility with the tissue, they also have extrusion risk. Because of this, some authors recommend putting some autograft materials on the prosthesis such as cartilage to decrease extrusion risk . Another question about this prosthesis is their high cost. Furthermore, especially TORP can be easily dislocated from used area, cause hearing loss and functional results of surgery may be failure
Bone-cement was developed in the 1970s and started to use in dental practice . It has good biocompatibility and presences new bone formation on applied ossicule. It has been started to use for otologic and neurotologic surgeries since 1992 [1,9-12]. In addition to being well tissue biocompatibility, the usage of bone cement is very easy and much more economical than the prostheses. Those are some of the reasons why the bone cement becomes popular recently. Bone cement is prepared and shaped easily and after getting hard and it doesn’t get affected by any fluids like blood .
The majority of used area of bone-cement is the defect of incus long process . Most preferred pathology to use bone-cement is incus long process defect and it is used between incus and stapes for incudostapedial re-bridging. This usage gives a natural sound transmission way (Figure 1). In this way, the energy of the sound transmits to use malleus, incus, stapes, and oval window way as the natural pathway. Thanks to that, the natural pathway of the sound transmission is continued. According to us, the natural pathway is very important for the middle ear mechanics.
When incus long process is defective, according to the size of the defect, bone-cement may be applied directly (Figure 1), after putting a cortical bone (Figure 2) or a wire between incus and stapes [1,13].
There are many studies in the literature about incudostapedial re-bridging with bone-cement. In our previous study, results of the 29 patients which bonecement was used for incus long process defect was reported . In these patients, the preoperative mean Air- Bone Gap (ABG) was 32.8 dB. After postoperative 35 months follow-up period, mean ABG was found 15.3 dB . In the study performed by Dere et al. 23 patients who had incudostapedial re-bridging with bone-cement, had 27 dB ABG preoperatively and 20.7 dB ABG postoperatively after at least one-year follow-up . All these and similar studies have shown that, when incudostapedial re-bridging perform for incus long process defects, the functional results are quite successfully. When incus is absent or not useful for incudostapedial re-bridging, to make a bridge between malleus and stapes is another way for sound transmission to the inner ear (Figure 3). Both our personal experiences and results of the literature show that patients who had a malleostapedial bridge by using bone-cement have successful hearing results [10,14,15]. Sennaroglu et al. reported 30.2 dB hearing improvement in 5 patients whom they used bone cement between manubrium mallei and stapes . Edizer et al. reported their results of bone cement usage between malleus and stapes in 32 patients when incus is absent . According to their results, postoperative ABG was 28 dB after at least one-year follow-up while preoperative ABG was 42.4 dB. Bayazıt et al. reported their results of 42 patients who have malleostapedial bone-cement bridge with preoperatively 22.7 dB ABG and postoperatively 6.2 dB hearing level . All these results and our personal experience point that when there is no useful incus, performing bone cement between manubrium mallei and stapes may show quite successfully results.
Bone-cement may be also used to avoid dislocation of interposed incus . If there is a useful malleus, interposed incus can be fixed by bone-cement to the malleus, if it uses between stapes suprastructure and malleus (Figure 4) or stapes footplate and malleus (Figure 5). Hearing loss due to dislocation can be prevented with these methods. Hearing results as ABG in our previous study were preoperatively 34,3 dB and postoperatively 18,5 dB in the group which incus interposition performed between stapes suprastructure and malleus while preoperatively 43dB and postoperatively 20,8 dB in the group which incus interposition performed between stapes footplate and malleus and fixed with bone-cement, after 36 and 39 months follow-up period, respectively . There were 25 and 13 patients and the net gain was 15,8 dB and 22,2 dB in both group, respectively.
Since bone-cement becomes popular to use in otologic and neurotologic surgeries, some discussions started on it. One of them is medium and long term results of bone-cement used cases and its shear bond strength on ossicules. Also, its separability from the ossicules was begun to be questioned. Experiences developed over time showed that when it is needed to separate bone-cement from the ossicules, it can be done easily with an instrument such as a peak. It was reported as a result of a recent study to evaluate the shear bond strength of different hydroxyl apatite and glass ionomer cements that water-based cements such as Aqua Meron (Voco, Germany) and Aqua Cem (Dentsply, USA) are held on to the ossicules strongly than the others . There is a need for new studies on this topic.
According to results of our personal practice and some literature, bone-cement usage for some type of ossicular chain problems as an economic application, may have successfully functional results. Longer term follow-up results may help to understand long-term efficiency of bone-cement.
- Kalcioglu MT, Tan M, Fleerakkers J. The use of bonecement for ossicular chain defects. Eur Arch Otorhinolaryngol 2013; 270: 2849-2855.
- Pennington CL. Incus interposition. A 15 year report. Ann Otol Rhinol Laryngol 1983; 92: 568-570.
- Miman MC, Aydin NE, Oncel S, et al. Autoclaving the ossicles provides safe autografts in cholesteatoma. Auris Nasus Larynx 2002; 29: 133-139.
- Colletti V, Fiorino F. Malleus-to-footplate prosthetic interposition: Experience with 265 patients. Otolaryngol Head Neck Surg 1999; 120: 437-444.
- Huttenbrink KB, Luers JC, Beutner D. Titanium angular clip: A new prosthesis for reconstruction of the long process of the incus. Otol Neurotol 2009; 30: 1186-1190.
- Chole RA, Skarada DJ. Middle ear reconstruction techniques. Otolaryngol Clin North Am 1999; 32: 489–503.
- Vincent R, Bittermann AJ, Wenzel G, et al. Ossiculoplasty in missing malleus and stapes patients: experimental and preliminary clinical results with a new malleus replacement prosthesis with the otology-neurotology database. Otol Neurotol 2013; 34: 83-90.
- Saraceno CA, Gray WC, Blanchard CL. Use of tragal cartilage with the total ossicular replacement prosthesis. Arch Otolaryngol 1978; 104: 213.
- Dere H, Ozdogan F, Ozcan KM, et al. Comparison of glass ionomer cement and incus interposition in reconstruction of incus long process defects. Eur Arch Otorhinolaryngol 2011; 268: 1565-1568.
- Bayazit YA, Ozer E, Kanlikama M, et al. Bonecement ossiculoplasty: Incus to stapes versus malleus to stapes cement bridge. Otol Neurotol 2005; 26: 364-367.
- Atan D, Dere H, Yamur AR, et al. Results of ossicular chain reconstruction with glass ionomer cement in pediatric patients. Int J Pediatr Otorhinolaryngol 2016; 85: 103-106.
- Righini-Grunder F, Häusler R, Chongvisal S, et al. Glass ionomer cement in otological microsurgery: experience over 16 years. Eur Arch Otorhinolaryngol 2015; 272: 2749-2754.
- Hafiz G. A more reliable method for incudostapedial rebridging ossiculoplasty: Bone-cement and wire. Adv Ther 2005; 22: 56-62.
- Sennaroglu L, Gungor V, Atay G, et al. Manubrio-stapedioplasty: New surgical technique for malleus and incus fixation due to tympanosclerosis. J Laryngol Otol 2015; 129: 587-590.
- Edizer DT, Durna YM, Hamit B, et al. Malleus to stapes bonecement rebridging ossiculoplasty: Why don't we perform frequently? Ann Otol Rhinol Laryngol 2016; 125: 445-451.
- Kalcıoğlu MT, Uzun İH, Yalçın M, et al. Evaluation on shear bond strength of different glass ionomer and hydroxy apatite cements used in ossiculoplasty. Balkan Med J 2015; 32: 23-29.