Middle Ear Bone Surgery - Ossicular Reconstruction

Reconstructive surgery of the middle ear bones can be performed in a variety of ways dependent upon the anatomy and clinical circumstances.  In some instances it can be performed at the primary operation and other times it is best to delay the reconstruction as a second stage, particularly in cases of intact canal wall cholesteatoma when a 'second look” procedure is planned to ensure the lack of recurrence.  The two videos below demonstrate both situations and also utilize different materials.  In cases of cholesteatoma when there has been erosion or encasement of the damaged middle ear bones, it may be preferable to use artificial titanium prosthestic systems as there is less chance of recurrence and seeding of disease from the involved bones.  Many systems are currently available.  I show an example below of one of my preferred systems and techniques.  For more information of Cholesteatoma, Tympanoplasty and Mastoidectomy, please check the Specific Clinical Interests section of the website to find more information on these related topics.

Here is a video of a primary reconstruction with the natural incus.  There is no cholesteatoma so the eroded ossicle does not have the potential to seed a recurrence and can safely be used.  In selected cases of cholesteatoma, as well as in many parts of the world where the cost of synthetics is prohibitively high, the incus can even be stored in alcohol solution and then used during a staged reconstruction.  In the United States with the ready availability of highly biocompatible synthetics, we typically defer to their use for cholesteatoma or in cases of revision and/or when there is no adequate incus mass available.  It is a judgement call by the operating surgeon whether or not a primary or secondary reconstruction should be performed.  

Here is a video of a second look ossicular reconstruction with a synthetic partial ossiculoplasty reconstruction prosthesis PORP.  The technique is very similar to the one shown above at the top of the page.  However, the initial pathology was extensive and involved much of the lower and anterior middle ear as well as the attic (upper portion of the middle ear).  In these cases, it is sometimes useful to use an angled endoscope to properly inspect the middle ear cavity for lack of recurrence.  The endoscope can also be used as an adjunt to placement and positioning of the prosthesis.  It is a judgement call by the operating surgeon to when utilize these additional resources.