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Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 18-22

Comparison between autologous and artificial graft ossiculoplasty in canal wall down tympanomastoidectomy: A 10 year's personal experience

1 Department of Otolaryngology and Head and Neck Surgery, Jordan University Hospital, University of Jordan, Amman, Jordan
2 Department of Neurosurgery, Jordan University Hospital, University of Jordan, Amman, Jordan

Date of Submission05-Oct-2020
Date of Decision15-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Elnagi Ali
Department of Otolaryngology and Head and Neck Surgery, Jordan University Hospital, University of Jordan, Amman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_219_20

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Background: Ossiculoplasty is the reconstruction of ossicular chain: Malleus, incus, and stapes. This procedure attempts to reestablish the continuity between the tympanic membrane and the oval window. Different materials were used in ossiculoplasty; whether to use autologous grafts or synthetic prosthesis. Aims: This study aimed to evaluate hearing changes in patients' undergone ossiculoplasty as a part of Tympanomastoidectomy. Also, to appraise the autologous reconstruction materials used in ossiculoplasty at Jordan University Hospital (JUH) in comparison to other materials. Materials and Methods: A retrospective study done for a total of 100 patients underwent ossiculoplasty using autologous and artificial graft during canal wall down tympanomastoidectomy at JUH from 2009 to 2019. Results: Overall average mean of air-bone gap (ABG) closure (Hearing Gain) for Group A was 11.07 dB, while for Group B was 7.5 dB; this decrease was found to be highly significant (P = 0.002). In Group A, ABG mean was (34.44 dB) preoperative and reduced to 23.37 dB postoperative, while in Group B was (32.95 dB) preoperative and reduced to 25.45 dB postoperative. Conclusions: Autologous grafts can be used safely in reconstruction of middle ear with favorable outcome. Our study is one of the few reports that compare outcome between artificial and autologous graft in ossiculoplasty.

Keywords: Artificial graft, autologous graft, canal wall down tympanomastoidectomy, ossiculoplasty

How to cite this article:
Tawalbeh M, Khreesha L, Ali E, Al Nsour A, Shatnawi J, Al-Shudifat A. Comparison between autologous and artificial graft ossiculoplasty in canal wall down tympanomastoidectomy: A 10 year's personal experience. Indian J Otol 2022;28:18-22

How to cite this URL:
Tawalbeh M, Khreesha L, Ali E, Al Nsour A, Shatnawi J, Al-Shudifat A. Comparison between autologous and artificial graft ossiculoplasty in canal wall down tympanomastoidectomy: A 10 year's personal experience. Indian J Otol [serial online] 2022 [cited 2022 Aug 8];28:18-22. Available from: https://www.indianjotol.org/text.asp?2022/28/1/18/343759

  Introduction Top

Ossiculoplasty is the reconstruction of ossicular chain: Malleus, incus, and stapes. This procedure attempts to reestablish the continuity between the tympanic membrane and the oval window. It is needed when the ossicular chain is discontinued or fixed from variable causes such as middle ear cholesteatoma. Less common causes are penetrating trauma, congenital malformations, surgical iatrogenic causes, neoplasia, and inner ear causes like superior semicircular canal dehiscence. All these cause ossicular chain destruction which manifest as conductive hearing loss. More than 80% of cases are due to cholesteatoma or chronic supportive otitis media.[1]

Different materials were used in ossiculoplasty; synthetic prosthesis including hydroxyapatite and titanium and autogenous grafts such as; incus, malleus, cortical bone, and cartilage. In partial ossicular replacement, it was found that autogenous grafts were more beneficial for high frequency hearing gain, compared to the synthetic prosthesis, but without prioritizing any autogenous material. While in total replacement, incus was the most effective between autogenous materials.

Although the optimal material for ossiculoplasty is still controversial, the selection of the prosthesis should be individualized and modified to patients' middle ear anatomy.[2] In this study, we aimed to present our department experience in ossiculoplasty and comparing different materials used for ossiculoplasty.

  Materials and Methods Top

This is a retrospective study was conducted on medical files of patients affected by middle ear or mastoid cholesteatoma who undergone canal wall down (CWD) tympanomastoidectomy and ossiculoplasty at Jordan University Hospital (JUH) between 2009 and 2019, and had a follow-up examination. Patients, whom have craniofacial anomaly as well as revision and recurrent cases, were excluded.

Hearing results were assessed according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines of the committee on hearing and equilibrium, by calculating pure preoperative and postoperative air-bone gaps (ABG) and tone average pure tone audiometry (PTA), then postoperative hearing gain was calculated from the PTA before the ossiculoplasty and at last follow-up examination. The follow-up examination included PTA, and was done under the same conditions as for the preoperative work-up. Statistical analyses were performed using SPSS for Windows software (ver. 19.0; SPSS Inc., Chicago, IL, USA). The distribution of the data was determined by the Shapiro–Wilk test. The Chi-squared test was used to determine differences between groups for categorical variables. Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentage. Continuous variables were compared between the two groups with analysis of variance test. A P < 0.05 was considered to indicate statistical significance in all tests (95% confidence interval).

Approval from Local Institutional Review Board at JUH was given under reference 67/2019/7158. Our study is retrospective and the data is anonymous and not public so no personal data will be shown and consent from study participants not applicable and the guidelines outlined in the Declaration of Helsinki were followed.

  Results Top

The total of target group patients was 240 patients [Table 1], 100 patients fulfilled the criteria for the study and included in the study group. The age of the patients included in the study ranged from 18 to 55 years with mean age of presentation of 33.67 ± 9.50 years. Forty-five were male (45%) while 55 were female (55%). All patients were complaining of ear discharge 100% of the patients. While hearing impairment was the second common presenting complaint which was seen in 84% of patients.
Table 1: Epidemiology of the patient operated for chronic suppurative otitis media during the study period

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The study group divided into two groups; Group A and Group B. In Group “A” patients underwent ossicular reconstruction using autologous ossiculoplasty. While in Group 'B' patient's artificial prosthesis as total Ossicular Replacement Prosthesis (TORP) and partial Ossicular Replacement Prosthesis (PORP) were used for ossicular reconstruction. Out of total 100 patients, 50 patients included in Group A, while the rest of 50 patients included in Group B, in 24 patients from group B patients PORP was used, while TORP was used in the rest 24 patients.

Pre-operatively mean air conduction in group A was 46.65± 8.912 dB. Mean bone conduction was 12.21± 4.60 dB and mean air bone gap was 34.44± 4.31 dB Similarly, Pre-operatively mean air conduction in group B was 45.7± 7.33 dB. Mean bone conduction was 12.75± 4.627 dB and mean air bone gap was 32.95± 2.7 dB [Table 2] and [Table 3].
Table 2: Pre-operative hearing status

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Table 3: Comparison of pre- and post-operative hearing results

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In group 'A' post-operative mean air conduction was 36.32± 7.922 dB, mean bone conduction was 13.25± 4.98 dB and mean air–bone gap was 23.37± 2.942 dB. Similarly, in group 'B' the post-operative mean air conduction was 38.36±7.352 dB, mean bone conduction was 13.22 ±4.71 dB and mean air–bone gap was 25.45 ± 2.643 dB [Table 3] and [Table 4].
Table 4: Post-operative hearing status

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Comparison between both groups in hearing results preoperative and postoperatively showed improvement in ABG in both the groups [Table 5]. However, analysis for ABG closure in Group A was 11.7 ± 4.79 and Group B was 7.5 ± 4.41. On applying t–test, there was highly significant difference between the two groups (P value 0.002) this verifying the favorable hearing outcome of using autologous graft in ossiculoplasty in compared with using artificial graft [Figure 1].
Figure 1: Mean of pre and post op air–bone gap for autologous (Group A) and artificial graft (Group B)

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Table 5: Comparison between air-bone gaps pre- and post- operative and air-bone gaps closure in Group A and B

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  Discussion Top

Many ossiculoplasty techniques have been developed in the last decades. Newer surgical techniques and advances in the equipment and medicines available helped otologists to have a noticeable improvement over recent years, determination of the hearing success in ossiculoplasty is govern by technical ability and for large extent, case selection. In our department, we adopted standardized guidelines for ossiculoplasty over the past 10 years.

The targeted group of patients in this study was patients of chronic suppurative otitis media with or without cholesteatoma being treated surgically. All of them were treated with CWD. Autologous grafts were used for 50 patients while artificial grafts were used for the rest of patients. Cholesteatoma was present in 85% of the cases in this study, the long process of incus was the most susceptible part of the ossicular chain to be affected due to the disease process (n = 88) followed by the stapes (n = 27) patients, while the malleus was the most resistant by being affected in only 9 cases. This correlates with the precarious blood supply of the long process of incus that results in making it the most susceptible ossicle for erosion.[3],[4],[5]

The placement of cartilage between the prosthesis head and the tympanic membrane decreases the extrusion rates to <2%.[6],[7] Cartilage interposition between the prosthesis and the tympanic membrane is able to reduce but not eliminate extrusion in alloplastic materials.[6],[8] In the present study, all patients had cartilage interposition. We noted implant extrusion in four cases (3.4%) two in Group A and two in Group B but three of them had postoperative Pseudomonas infection.

There was no significant difference between using hydroxylapatite and autograft prosthesis in TORP.[3] Titanium prosthesis had better hearing results compared to other materials as both partial and total replacement prosthesis.[5] Another study done by truy et al showed no statically significant difference between using titanium and hydroxylapitie prostheses in ossicular chain reconstruction in terms of both functional results and stability. Same study showed a slight superiority of titanium in partial reconstruction and hydroxyleapatite in total reconstruction. In our practice, we have used different techniques and a variety of autografts and artificial prostheses for CWD tympanomastoidectomy including reshaped incus, universal titanium, dense hydroxylapatite. also in some cases when the malleus was not eroded we used the head of it as PORP after reshaping it.

A wide range of prosthesis designs and materials has been used for ossicular reconstruction in middle-ear surgery. To optimize postoperative functional results, ossicular grafts, and prostheses must be coupled well at their ends to bone or soft tissue, but must remain suspended in air elsewhere to transmit sound effectively.[4] The displacement of the prosthesis or the underlying cartilage, because of being too short, was implicated as the prime cause of functional failure in various studies.[10] Insufficient length of the prosthesis explained the poorer functional results and secondary displacement. Şevik Eliçora et al.[3] The size of cartilage cover is one of the few variables that the surgeon can control it during the ossiculoplasty. In our experience, we found that using of autologous giving better hearing gain in comparison with artificial prosthesis graft, also there are several studies include results of both partial (PORP) and total (TORP) ossicular reconstruction without making a distinction between these two subgroups.[11],[12],[13],[14] We found that there is no significant difference between these two subgroups. Finally, we found that the placement of cartilage between TORP and tympanic membrane prevents extrusion of graft prosthesis and giving better results.

We have encountered certain limitations in this study: retrospective design, the sample size (as each middle ear is different and there are so many different situations that sufficient representation in each group cannot be ensured), and the middle ear findings unfolds while progressing the surgery so the situation and conditions changes. Another concern is about the duration of the follow-up, which is variable.

  Conclusions Top

Autologous grafts are better and more cost-effective alternatives to artificial grafts according to our study. Long-term results, prospective studies, and analysis of different implants and situations are necessary to improve our knowledge and understanding of the stability and the durability of ossiculoplasty and all types of ear surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mudhol RS, Naragund AI, Shruthi VS. Ossiculoplasty: Revisited. Indian J Otolaryngol Head Neck Surg 2013;65:451-4.  Back to cited text no. 1
Kamrava B, Roehm PC. Systematic review of ossicular chain anatomy: Strategic planning for development of novel middle ear prostheses. Otolaryngol Head Neck Surg 2017;157:190-200.  Back to cited text no. 2
Şevik Eliçora S, Erdem D, Dinç AE, Damar M, Bişkin S. The effects of surgery type and different ossiculoplasty materials on the hearing results in cholesteatoma surgery. Eur Arch Otorhinolaryngol 2017;274:773-80.  Back to cited text no. 3
Goldenberg RA, Emmet JR. Current use of implants in middle ear surgery. Otol Neurotol 2001;22:145-52.  Back to cited text no. 4
Kumar S, Yadav K, Ojha T, Sharma A, Singhal A, Gakhar S. To evaluate and compare the result of ossiculoplasty using different types of graft materials and prosthesis in cases of ossicular discontinuity in chronic suppurative otitis media cases. Indian J Otolaryngol Head Neck Surg 2018;70:15-21.  Back to cited text no. 5
Maeng JW, Kim HJ. Effects of middle ear lesions on pre and postoperative hearing outcomes in patients with chronic otitis media. Korean J Audiol 2012;16:18-26.  Back to cited text no. 6
Mishiro Y, Sakagami M, Kitahara T, Kondoh K, Kubo T. Long-term hearing outcomes after ossiculoplasty in comparison to short-term outcomes. Otol Neurotol 2008;29:326-9.  Back to cited text no. 7
Martin TP, Weller MD, Kim DS, Smith MC. Results of primary ossiculoplasty in ears with an intact stapes superstructure and malleus handle: Inflammation in the middle ear at the time of surgery does not affect hearing outcomes. Clin Otolaryngol 2009;34:218-24.  Back to cited text no. 8
Truy E, Naiman AN, Pavillon C, Abedipour D, Lina-Granade G, Rabilloud M. Hydroxyapatite versus titanium ossiculoplasty. Otol Neurotol 2007;28:492-8.  Back to cited text no. 9
Iseri M, Ustundag E, Ulubil A, Ozturk M, Bircan O. Synchronous ossiculoplasty with titanium prosthesis during canal wall down surgery for advanced cholesteatoma: Anatomical and hearing outcomes. J Laryngol Otol 2012;126:131-5.  Back to cited text no. 10
Dalchow CV, Grün D, Stupp HF. Reconstruction of the ossicular chain with titanium implants. Otolaryngol Head Neck Surg 2001;125:628-30.  Back to cited text no. 11
Quaranta N, Zizzi S, Quaranta A. Hearing results using titanium ossicular replacement prosthesis in intact canal wall tympanoplasty for cholesteatoma. Acta Otolaryngol 2011;131:36-40.  Back to cited text no. 12
Vassbotn FS, Møller P, Silvola J. Short-term results using Kurz titanium ossicular implants. Eur Arch Otorhinolaryngol 2007;264:21-5.  Back to cited text no. 13
Schmerber S, Troussier J, Dumas G, Lavieille JP, Nguyen DQ. Hearing results with the titanium ossicular replacement prostheses. Eur Arch Otorhinolaryngol 2006;263:347-54.  Back to cited text no. 14


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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