A CT scan is a form of X-Ray imaging which allows us to see the body in much clearer detail than plain X-Rays. The CT scan splits the image into thin layers, sliced like a salami, so that we can see much greater detail and pinpoint what is happening at any given point. It is only in recent years that scanners have been able to produce slices thin enough to give us useful information on the state of the middle ear. Some ear surgeons always require a CT scan before operating. In the days before CT scans, some ear surgeons always wanted mastoid X-rays before operating. I have never found them all that useful. Even with the best scanners, we don’t get anywhere near as good a view as we get with the operating microscope during surgery – full colour, three dimensional and up to 40 times magnification. It is impossible to tell with a scan whether some part of the ossicular chain is fixed – this can only be determined by trying to move it during surgery. Many of the patients referred to me for ear surgery have already had scans. They rarely make any difference to what I plan on doing. I do not need a scan as a matter of routine. A CT scan is needed if we suspect complications, especially if we suspect there may be spread of disease into the brain.
Simple chronic otitis media is characterized by having relatively little damaging effect on the ossicles. Greater damage is observed in the cases of cholesteatoma or granulation tissue in the middle ear. As compared to the group of patients with cholesteatoma, the patients with a predominance of granulomatous lesions did not have their hearing improved to a statistically significant degree after their ossicular chains were reconstructed using the same method. This observation coincides with reports in the literature that hearing improvement in patients with simple chronic otitis media reaches 80%, while in the course of granulomatous lesions it is about 50%. In the cases of cholesteatoma, the hearing level is maintained or improved after the surgery in about 90% of the patients. The above information regarding chronic granulomatous otitis media point to the necessity of non-invasive treatment in the period preceding the surgery, which would be aimed at obtaining “dry ear”. The elimination of otorrhea and an improvement of the condition of the mucous lining the ear have a significant effect on achieving better results of the surgical treatment [–].
Ossiculoplasty (oss-SICK-you-low-plas-tea) is an attempt to rebuild the damaged chain of tiny bones that conduct sound from the eardrum to the inner ear. The surgeon is faced with a three dimensional, microscopic jigsaw puzzle, where the pieces don’t interlock, and some are missing. The aim is to achieve a stable but mobile mechanical linkage, reconnecting the reconstructed eardrum to the inner ear. There are many techniques for ossiculoplasty, depending on the exact situation found at surgery.
Tympanoplasty (TIM-pan-o-plas-tea) is surgery to rebuild the damaged structures of the middle ear, including the eardrum and . There are limits to what can be achieved. A rebuilt middle ear seldom works as well as the original. Repairing the eardrum is myringoplasty (mi-RING-o-plas-tea). Rebuilding or replacing the ossicles is ossiculoplasty (oss-SICK-you-low-plas-tea). Tympanoplasty is the general term that covers both. Often, we don’t know how much reconstruction will be needed, or possible, until we are part way through the operation. Sometimes, tympanoplasty is done together with mastoidectomy, as part of the same operation. Other times it is done at a later stage, as a second operation, once we are satisfied that the cholesteatoma has been removed and any infection has settled.
The differences observed after 6 and 12 months reflect the impact of the reconstruction on the functional improvement of the middle ear. These differences expose the limitations of tympanoplasty in terms of restoring normal functionality of the ossicular chain. The obtained degree of ABG closure verifies the earlier hearing improvement prognoses based on the advancement of the pathological process in the middle ear.
The significant discrepancies between the average values of ABG for the particular groups are closely linked to the advancement of the pathological process in the middle ear and the possibility of the subsequent reconstruction of the sound-conducting apparatus. In the majority of cases the degree of hearing impairment observed before treatment has a statistically significant link with the condition of the tympanic membrane and the ossicular chain. Judging from the degree of damage to the conductive apparatus in the middle ear, preliminary prognoses are made as to the improvement of hearing after the surgery [–].
According to data in the literature, confirmation that the suprastructure of the stapes is normal after the cholesteatoma lesions have been eliminated, and the subsequent reconstruction of the ossicular chain by placing the patient’s own modelled ossicle on the head of the stapes, results in hearing improvement in nearly a half of the patients [–]. Among the analyzed patients, the improvement was significantly greater in the group with cholesteatoma than in the cases where the ossicular chain was damaged to a comparable degree, but the damage co-occurred with other pathological changes to the middle ear mucous. The same conclusions were reported by other authors, especially in the context of the unfavorable effect of granulomatous lesions in the middle ear on hearing improvement [,,,,].
After both 6 and 12 months, significant hearing improvement was also noted in the group of patients where the reconstruction was based on a ventilation tube placed on the head of the stapes. This original method of restoring the continuity of the ossicular chain applied at the Otolaryngological Teaching Hospital of the Collegium Medicum at the Jagiellonian University of Cracow turned out to be a good alternative for the patients whose own modelled ossicles cannot be used due to the scope of damage done to the ossicular chain by the pathological process. The use of this generally available and relatively inexpensive material as a PORP is competitive with other solutions. The ABG closure obtained in this group is comparable to the results obtained by other authors using PORP [–]. The use of the ventilation tube as a PORP is an innovative method of reconstructing the ossicular chain.
In the cases of patients with cholesteatoma classified into group 1, their own modelled ossicles were placed on the stapes after eliminating the pathological process. When performed at a relatively early stage, the treatment stopped the pathological process that damaged the ossicular chain and was followed by ossiculoplasty, resulting in significant hearing improvement in the patients with chronic cholesteatoma otitis media.
The use of a ventilation tube (group 3) to reconstruct the continuity of the ossicular chain resulted in a statistically significant change of the average value of ABG (p=0.046) as early as after 6 months following otosurgery, proving it justifiable to use this material as a PORP in selected cases. The comparison of the results obtained after 6 and 12 months following otosurgery did not reveal significant discrepancies, showing that the improved hearing effect was maintained during the successive checks ().
In group 2 significant changes (the closure of the average value of ABG) were not observed over time. The group consisted of patients with damaged ossicular chain and granulation within the middle ear. Although the performed reconstruction was similar to that in the patients with cholesteatoma (group 1), significant hearing improvement was not observed.
Statistically significant changes pointing to the effectiveness of treatment were observed in group 1. The average value of ABG after 12 months was smaller than the average value of ABG at the beginning of treatment and statistically equal to the average value of ABG after 6 months, while the average value of ABG after 6 months was significantly smaller than the average value of ABG at the beginning of treatment. In accordance with the philosophy behind ossiculoplasty, the elimination of cholesteatoma lesions and the successive type 2 tympanoplasty achieved satisfactory results in the form of hearing improvement.