Üniversal titanyum protez ile ossiküler rekonstrüksiyonda erken dönem sonuçlarımız / Our early results of ossicular reconstruction by universal titanium prostheses
Our aim is to evaluate effects of operation procedures, scheduling, ossicular chain damages, presence of cholesteatoma and preoperative Middle Ear Risk Index (MERI) scores on postoperative hearing results. This paper is based on twenty-two patients, all of whom had ossiculoplasty at Vakif Gureba Training and Research Hospital Department of Otorhinolaryngology between September 2008 and October 2010. Three patients were excluded from the study, due to prosthesis extrusion and cholesteatoma recurrence. As a result, the evaluations were performed on the remaining nineteen patients. The time interval of patients follow-up was between six to twenty-five months with a mean of 16.26. The mean age of the patients was 32,21±8,75 years, ages varying from 17 to 51 years. Seven of the patients had cholesteatoma. Canal wall down (CWD) technique was performed to three patients, while canal wall up (CWU) technique was performed to sixteen. Eleven patients had CWU with mastoidectomy; remaining five patients had CWU without mastoidectomy. Total ossicular reconstruction was performed to 13 patients and partial ossicular reconstruction was performed to six patients. Universal titanium total ossicular reconstruction prosthesis (TORP) and partial ossicular reconstruction prosthesis (PORP) were used as ossiculoplasty materials. The mean air-bone gap of the patients were calculated at 0.5., 1., 2., and 4. kHz frequencies. Postoperative air-bone gap (ABG) of 20 dB or below was used as functional success criteria. Also in the study, hearing gains and ABG gains were calculated. In statistical analysis; variance was used in evaluating continuous variables. Kruskal Wallis and Mann Whitney U tests were used in evaluating the differences between variables among non-normal groups. On the other hand, the chi-square test was used in categorical comparisons. In addition, a P value of less than 0.05 was considered significant. In this study, ABG ≤20 dB was found in four (21.1%) cases, ABG 21-30 dB in seven (36.8%) cases and ABG ≥ 31 dB in eight (47.1%) cases in the postoperative sixth month. In the PORP group, ABG ≤20 dB was found in one (16.7%) cases, and ABG ≤30 dB in six (100%) cases. In the TORP group, ABG ≤20 dB was found in three (23.1%) cases, ABG ≤30 dB in five (38.5%) cases, and ABG ≥31 dB in eight (61.5%) cases. ABG gains and hearing gains were significant high in the patients, who had PORP as compared to TORP in the postoperative sixth month. On the other hand, ABG values did not have significant differences between the prosthesis. ABG gains were significant high in the patients, who had CWU with and without mastoidectomy when compared to the patients, who had CWD mastoidectomy in the postoperative sixth month. Also, the patients who had malleus handle had better ABG, ABG gain and hearing gain results. The postoperative sixth and twelve month ABG gains were significantly higher in stapes suprastructure group than the stapes suprastructure-missing group. In addition, postoperative ABG had better results in revision surgery than in the staged surgery. Statistically significant difference was not found between the operation scheduling groups, due to small number of the patients. However; the results were close to the level of significance. In the the postoperative sixth month ABG and air-conduction results were better in chronic otitis with cholesteatoma group as compared to chronic otitis without cholesteatoma group. ABG<30 dB ratio was 100% in the patients with mild MERI scores (1-3), 87.5% in the patients with moderate MERI scores (4-6) and 12.5% in the patients with severe MERI scores (7-12). It was found a correlation between postoperative sixth month ABG and the grade of preoperative MERI. Postoperative ABG values marked a rise with increasing of the MERI scores. Two patients had an extrusion of the prostheses (9%) because of recurrent middle ear disease. Cholesteatoma recurrence was observed in one patient (4.5%), as a result open cavity procedure was performed and the prosthesis was taken out. Revision surgery was performed for four (%18) cases, because of prosthesis dislocation. Retraction was determined in three (13.5%) cases. Eight cases with severe MERI risk scores had complications. Two cases with moderate MERI risk scores developed retraction. None of the cases had sensorineural hearing loss. When compared to the preoperative evaluations, significant decreases was observed in bone conduction response at 1., 2., and 4. kHz. in the postoperative 12th months of the study. As a result, it was seen that according to the success rates in ossiculoplasty interventions; CWU technique was more successful than CWD technique and so was partial ossicular reconstruction than total ossicular reconstruction. The postoperative hearing success rates were affected by; preoperative MERI scores, presence of cholesteatoma, malleus handle and stapes suprastructure. The results between the operations scheduling were close to the level of significance. Success of hearing reconstruction is affected by preoperative middle ear factors. Preoperative MERI scores may lead surgery and may lead to case-specific strategy for each patient. In conclusion; persistent and recurrent abnormalities within the middle ear should be considered as the most important reason for failure. In addition, staged surgery should be preferred, and ossicular chain reconstruction should be planned after decreasing MERI risk scores.