•

" '
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FUNCTIONAL OTOSURGERY
Gregorio BABIGHIAN, MD, FRCS (Ed)
Chairman of the Department of ENT and Ear Surgery
Azienda Ospedaliera - Universita Padova, Italy
4 Functional Otosurgery

Functional Otosurgery
Gregorio BABIGHIAN, MD, FACS (Ed)
Michele CICCOLELLA, MO
Chairman of the Department of ENT and Ear Surgery
Azienda Ospedaliera - Universita Padova, Italy

Contact:
Gregorio Babighian, MO, FACS (Ed)
DirettOf'e di Otorinolaringoiatria.e Otochirurgia
Azienda Ospedaliera -'l.:Jniverslta Padova
Via Giustiniani, 1
1·35100, Padua, Italy
E-mail: otochlrurgia@sanita.padova.lt

C 2009 Endo: PressN, Tuttlingen, Germany

ISBN 978-3-89756-104-5, Printed in Germany
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Gregorio BABIGHIAN, MD, FRGS (Ed)
Phone: +49 (0)7461/14590
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 FuncliOllal Otosurgery 5

Table of Content

Introduction 6

Myringoplasty 6
1.1 Transcanal Approach (TCl ., :" ~............................................ 7
Autologous Fat Graft Myringoplasty with fat harvested from the ear lobe 8
1.2 Endaural Approach (EA) 8
Tympanomeatal Flap 9
1.3 Postauricular Approach (PAl.......................................................................................................... 10
1.4 Transplant or Implant Materials 11
The Use of Flaps in Myringoplasty....................................................................................................... 13
1.5 Underlay Technique....................................... 15
1.6 Overlay Technique........................................... 15
1.7 SHEEHY Technique (Overlay Grafting for Total Myringoplasty)................................................. 16

2.0 Repair and Reconstruction of the Ossicular Chain (Ossiculoplasty) 17

3.0 En-bloc Osteoplasty of the Posterior and Attic Wall according to BABIGHIAN (1992)
or Reversible Tympanoplasty according to McELVEEN and HULKA (1998).................................... 20

4.0 Stapedotomy
Incus-Stapedotomy................................................................................................................................ 22

5.0 Mal1eo·Stapedotomy 24
5.1 Surgical ProtocoL............................................................................................................................ 24
5.2 Alternative Techniques.................................................................................................................... 25

Suggested Readings 26

Recommended Set for Ear Surgery

and Otoneurosurgery
according to G. BABIGHIAN. M.D................................................................................................................. 28
6 Functional Otosurgery

Introduction
Selection of a microsurgical approach to the tympanic
caVity fO( eradicatlOO of lesionS and reconstruction of
the sound transmission system is determined by the
nature and extent of the pathology, regional anatomy,
nature and extent of the functional defect, type of
the procedure, and the individual preferences of the
surgeon.
In such a situation, availability of adequate surgical
instrumentation is a crucial prerequisite. While some
basic instruments can be easily adapted and afe found
more or less in all microsurgical sels, others (based on
the individual experiences of the surgeon) have been
designed for particular applications, and allow certain
steps of ear surgery to be performed more rapidly and!
or effectively, and more precisely.
The techniques described in this booklet include
basic otosurgicaJ procedures, such as myringoplasty,
ossiculoplasty, and stapedotomy which are practiced
on a regular basis at the Department of Otolaryngol-
ogy and Ear Surgery of the Padua General HQSpltal and
are taught in our Temporal Bone Dissection Courses.
The micro instrurneots comprising our set have been
designed and manufactured according to the stand-
ards of precision, technical accuracy, sturdiness,
and ergonomics that have traditionally distinguished
KARL STORZ products, and present this manufacturer
(known throughout the world for many years) as an
absolutely reliable partner for both the otolaryngologist
and ear surgeon.
The proficient surgeon will find in this set the quality of
design and structural precision essential for avoiding
awkward or rough contacts between the instrument
and tiny anatomic structures, while the junior surgeon
will quickly acquire the familiarity and dexterity required
to skillfully approach and treat extremely delicate
anatomical structures.
Gregorio Babighian

1.0 Myringoplasty
MICrosurgical access to the tympanic cavity for eradi-
cation of lesions and reconstruction of the sound trans-
mission system may be obtained via a transcanal (TC),
endoaural (EA), or a postauricular {PAl appl'"oach. The
decision finding process in the course of which the
most appropnate surgical pathway needs to be ascer-
tained, is determined by the nature and extent of the
pathology, regional anatomy, type of procedure, ana
the iooividual preferences of the surgeon (Table 1).
Fig. 1 and Table 1 demonstrate the preferred path-
ways chosen under different anatomical and surglca
conditions (TC, transcanal; EA, endaural; PA, post-
auricular)

Type of Lesion Preferred Access

Tympanic perforation 1/4 to 2/4,

retromallear
stapes fixation, TC,EA
incus erosion,
stapes with intact eardrum

Malleo-Stapedotomy, lateral fixation EA

Tympanic perforation '/4 to '1/4,

premaJlear. with or without fA. P
treatment of the attic

Tympanic perforation 3/4 to 4/4

without marginal erosion
Fig. 1
TymparMc membrane (TM) quadrants:
Tympanic perfOl'ation 3/4 to 4/4
nght: .: antero-supenor q., b: antero-l1fenor q.,
c: posteto-infenor q., d: postetO-supeoor q. PF, pars flaccida Table 1
(Shrapnell's membrane).
Functional Otosurgery 7

Figs. 2a, b
-ne l.8yIa sp8Cl1Iu'n hok* IS attad'led to the operatll'lg table (a~ Nole it¥ll the <ws of the.speculuri'i coriespoods to the opIlCalllX<S of
tne ITlICfOSCOP8 (b).

1.1 Transcanal Approach (TC)

An ear speculum, 0.0. 6-7 mm (use the largest possible
size) IS introduced and positioned in the auditory canal
USing a flexible speculum holder (Schuknecht or Leyla
speculum holder) enabling the surgeon 10 use both
hands during surgery.
The speculum should be oriented to allow panoramic
VISion of the tympanic region and adjacent areas (annu-
lUS and pf'Oximal portion of the auditory canal, about 8
mm from the annulus). Optimal vision may be obtained
t:I'f lining up the mallear profile with the superior edge of
the speculum opening.
USing a longitudinal knife (straight or sickle-shaped, Fig.3a
Sickle knife. (No. 233403). The rounded CUlling tiP allows the
F'9s. 3a, 3b) a first incision is made on the floor of the incision to be made without stretching the adjacent tissue.
au<litory canal, beginning at 6 o'clock and extending
""\8 cut for about 8 mm toward the external meatus.

Fig.3b
Round knife, (No. 233401). The blunted llfltenor edge 01 the blade
prevents the tympillllC ,11l!l,bane from iatroget'HC orlfU'"Y on inad-
vertent contact Wllh II
8 Functional Otosurgery

A similar incision is made with the same knife from the

lateral process of the malleus (Of slightly anteriorly)
continuing for &-, 0 mm consistently in the direction of
the external meatus (Fig. 4).
At this point a third incision is made with the round
knife, approximately 7-8 mm from the annulus linking
the two previous incisions (Fig. 5).
Another advantageous option is to use a Bellucci
scissors, starting from the superior end of the circular
incision and cutting toward the lateral process of the
malleus while keeping the flap stretched with a small·
diameter Sl.X:OOn lube.
F"I{I. 4
Round kllde (No. 233401) or SlCkIe knrle (No 233403). " '

Autologous Fat Graft Myringoplasty

with fat harvested from the ear lobe
This is accomplished by using an extremely simple
transcanal technique, intended for small central per-
forations that are completely visible and accessible.
The brief. office-based procedure requires local anes-
thesia by infiltratioo of the canal, refreshment of the
perforation margins, harvestIng of fat from the ear lobe
(starting with a small cutaneous incisiorJ in the posterior
surface of the ear lobe), and insertion of the fat graft
into the perforation in a plug-like fashion. Secure with
gelfoam, and remove remnants after 3 weeks.

Fig. 5
Klllfe. round 45· (No 233408).

1.2 Endaural Approach (EA)

An intertragal-helical incision is made along the roof
of the canal, starting from the annulus and proceeding
externally, The incision is enlarged with a strong blunt
elevator. The concha and helix are retracted posteriorly
and the tragus is retracted anteriorly using two small
self-retaining retractors with twin prong arms placed
perpendicular to each other over the entrance of the
external auditory canal (EAC) (Fig. 6).

Fig. 6
Retractors (No 2202131_
 Functional Otosurgery 9

A flap of temporalis fascia may be created by working in

the intertragal-helical notch without additional incisions
(Fig. 7).
Bleeding from the meatal subcutaneous tissue and the
temporozygomatic area is controlled by using a delicate
bayonet-shaped bipolar coagulating fOfCeps.
Under certain conditions of small vessel bleeding (both
veins and arteries) use of a FREER irrigation e1evatOf"
(KARL STORZ 212005) may prove beneficial since it not
only permrts the surgICal field to be kept free of blood
but also allows Simultaneous detachment of deliCate
structures. This is an instrument WIth great potential in
otoneurosurgery.
Fig. 7
BopoIa< eoag. 'CaWlO Fo-CllPS (No 84431 g\

Tympanomeatal Flap
USing a round knrfe like an elevatOf". the tympanomeataJ
flap is gradually elevated with the help of a small suction
tube which is simultaneously held with the knife handle.
The knife IS positlOOed close to the bone and advanced
as far as the fibrocartilagInous amulus in the tympanic
sulcus (Fig. 8).
Next, use a sharp elevator (KARL STORZ 233410),
possibly alternating it with the sickle knife, to excise the
mesothelium Of" its remnants, penetrate the cavity, and
elevate the flap anteriorty. The safe course runs via the
notch between the fibrocartilaginous annulus and the
tympanic sulcus (Figs. 9a, b).
Fig. 8
Knife. round 45° (No. 233408)

Figs. 9a, b
-Baby 1" elevator, sharp (No. 2334101: 0wII'Ig to it5 sharp edges
t combines the lea1ur8$ 01 an elevator and euttoog Instrument.
 '0
Fig_ lOa
Use of the I'TWI'Ol' (No. 2236001 for nspec:bon 01 the n-ddIe ea-.
A useful tip to facilitate the procedure is to use an
alligator forceps mounted with a cotton pledget soaked
with adrenaline.
If the flap seems somewhat stretched at the superior
and inferior margins, these should be mobilized with
relieving incisions.
The length and width of the tympanomeatal flap can be
increased by continuing the incision in the canal another
7-8 mm from the annulus. This may be an advantage,
for example in Bondy tympanoplasty when the altic-
aditus region has 10 be covered with a skin graft.
Fig. 11
M II"ICtSOOO IS made ., the postauriCular sulcus. the auncle IS
everted antenorly and secured WIth se/f-reta,nmg retractOfS or
elastIC hooks.
Functional Otosurgery
fig. lOb
:!he flWr9r (No. 223600; ~ 01 stair1IeSs SleeI. WIth ~
rel1ectlYe fnsh) IS Yf!Jry uselullor nspectlOtl of otherwise poor1y
accessi';lle areas of the I'l1IddIe ear
1.3 Postauricular Approach (PA)
An incision is made in the postauricular sulcus, the auri-
cle is everted anteriof1y and secured with self-retaining
retractors or elastIC hooks (Fig. 11).
We perform the skin incision with a # 1001" #15 knife
blade. The incision is deepened with a needle electrode
that is coonected to a high frequency electrosurgery
unit pre-adjusted to coagulation mode.
This approach is adopted in the case of wide total
or subtotal perforations r/4, 4/4), especially when the
anterior margin of the perforatioo or anterior annulus is
scarcely visible, and/or when significant treatment 01 the
mastoid or the posterior wall 01 the canal is planned.
In general, a muscle flap with a pedunculated anterior
portion (Paiva flap) is prepared in advance. This can
make the approach to the mastoid cortex more rapid,
practically free of blood, and may be used to obliterate
the mastoidotomy cavity. After it as been repositioned
and sutured over the bony breach at the end of the
intervention, it prevents or minimizes the formation of
pits in the postauricular skin.
Once McEwen's triangle (suprameatal pit) and spine of
Henle have been identified (which, if very pronounced,
may be removed with a diamond burr or bone punch),
begin gradual elevation 01 the skin from the bony surface
of the canal, continuing toward the fibrocartilaginous
annulus.
 Functional Olosurgery 11

There are two options once the annulus is reached: •

1. Transversal incision, 7-8 mm from the annulus, Fig. 12
made with a sickle knife or BeUuci forceps - see a Floe. anterior·based
"Paiva" flap, sutured
the description of the tympanomeatal flap on p. 9.
at the tiP to the sub-
2. Preparation of a vascular strip. Using the cutting cutaneous tissue 10
COflstllUle a muscle
edge of a sharp elevator (KARL STORZ 233410) or layer adjacent 10 the
a sickle knife (KARL STORZ 233403) two incisions sutuce hoe on the
are made that start at the transition between the
cartilaginous and the bony canal and are continued
"'"
b V;r;o.a' Slnp. cre-
aled by eutlng the
medially toward the tympanic annulus. One incision slun of the canal
- superiorly - follows the tympanosquamous on lop along the
~
suture. The other incision - inferiorly - travels aJong sutuce and. on the
the tympanomastoid suture. The result is a rect- bottom, along the
angular flap, pedunculated on top, and capaPle ""-"""'''''''
fsic~ krtrfe.
sullie
of vascularizing the tympanic graft (e.g. fascial No. 2334(3)
graft) that is stretched freely over the Ix>ny surface
(Fig. 12).

1.4 Transplant or Implant Materials

Repair or Reconstruction of the Tympanic Membrnne
(Myringoplasty or Type I Tympanoplasty)

• Temporalis fascia
• Perichondrium (tragal or conchaJ)
• Cartilage (tragal or conchaQ
• Pefiosteum
• Autologous lobular fat
• Vein
• Dura mater
• Pericardium
• Fascia lata

Tab. 2
Materials for mynngoplasty.

Currently, we almost exclusively prefer the temporalis

fascia and the tragal or conchal perichondrium. A com-
posite graft may be used to prevent an atelectatic TM by
covering all or part of the tympanic area. (HEERMANN
palisade technique and AIACH chondromyringoplasty)
(Fig. 13).
The fascial flap, carefully stretched on a glass or
plastic plate. is cleaned of residual muscle fibers with
the back and the tip of a #11 knife blade.
Prior to transplant, the flap is appropriately trimmed to
Fig. 13
shape and size. Colldlomlr1fl9OPlaStlCa.

J
12 Functional OtosurgEll)'

The tragal perichondrium (and also the related car·

tilage if needed) is obtained via a skin incision, prefer-
ably pertormed on the internal surface of the tragus to
avoid visibile scars. The conchal perichondrium (and
possibly a wide cartilaginous flap) is obtained via a post+
auricular incisioo.
Once it has been stretched on a plastic frame and
covered with gauze soaked in normal saline solutIon,
the graft is ready to be modeled to shape and size at
the appropriate time.

There are two types of myringoplasty:

Fig. 14
Onlay technique: nole lhe position of Ihe malleus handle lateral
to the gratt. The elevators no. 233414 - 233422 or micro-
elev'llors 233420 and 233415 should be used.
1. Medial or internal or underlay myringoplasty:
the. flap graft is.p'ositione.d beneath the lamina
propria of the tympanic remnants (Fig. 17)
2. Lateral or onlay, or overlay myringoplasty: the
graft is stretched over the tympanic remnants
(lamina propria), but always medially to the malleus
handle, if present.

Fig. 15
Onley myringoplasty USing !he BABIGHlAN tlllCro elevator
(No. 233420}.

rig. 16 Fig_ 17
Onlaymyr.~ usrog the 15" ~Ied seeker (No, 233415). Medial or ..,temal or t.nOerlay mymgopIasty: the gmt! IS SlNlld1ed
0YfM the Iamana propna of the tympanIC membiane remnants.
Shown above IS the use of the BABIGHIAN ITlIaO elevator.
(No. 233420).
Functional Otosurgery 13

The onlay technique may also be performed in the

absence of tympanic rerTVlaI1ts, and especially in total,
•
sublotal, and anterior perforatIons. In contrast, the
underlay lechnlQue requires a tympanic remnant or at
least the presence of an anterior annulus.
The basic surgical protocols are:
- Cleaning the operative field
-Anesthesia (usually loca~
_Refreshment of the perforation margins with a
micro sickle knife and I Of a small hook, and alliga-
tor forceps. This procedure is intended to eliminate
scar or fibrous tissue from the perforation margins,
thereby facilitating graft attachment (Fig. 18).

The Use of Flaps in Myringoplasty

Fig. 18
Among the numerous flaps described in the literature, Sickle knife (No. 233405) and needle No. 233430).
there are three that are important for the purposes of
myringoplasty:
1. Tympanomeatal flap (described above)
2. Swing door flap (two "wings; (any approach)
3. Spiral flap (endaural approach)

The swing door flap (PALVA, 1963) has a posterior

incision between 6 and 12 o'clock and a second incision
in lhe middle at 9 o'clock (Figs. 18a--g).
The two swing door flaps, superior and inferior,
are elevated along with the corresponding annulus seg-
"""'I.
In tolal perforations, this technique improves visualiza-
tion of Ihe anterior tympanum.
Once the fascial or perichondrial flap is in place the two
"wings" are folded back onto the flap itself and regain
their original position.
For the Fisch spiral flap, the meatal skin is incised on an
ascending spiral path (blade #15), elevated. and excised
2 mm laterally from the annulus. An inferiorly based flap
is obtained and this is kept at a safe distance from the
operative field using a flexible strip of aluminum (the
sleeve cut from a suture wire will be appropriate).

F"19. 188
BevabOr'l of the tymp<wlomeatall!ap, nghl ear
Rou'ld knife, 45" (No. 233408).
sharp elevalrn {No. 233410 and 2334121
14 Functional Otosurgery

FIg.l8b Fig. 18c _ _

The postenor poruon 01 the swong door flap is dissected as f(W" In ttws wltf the two "'Wngs: of the swmg door are created
as the perf0f3lJOn. HOUSE-BELlIJCCl SosSOB (No. 222602) and then elevated upw<W'd lWId anlencwty. Micro elevator
(No. 233420).

Fig. 18d Fig.18e

The tympanic graft is ~aced liS an underlay. The procedure is Elevation of the graft is $$Cured with two gelloam plugs.
rac;ilitated by the position of the "WIngS',

Fig. 181 Fig. lag

The "wings" of the sWIl'lg door are reposrtJoned. The tympamc graft protrudes somewhat from the repaored
MICI'O elevator (No. 233420).
""'""""'"
FunctionalOtosurgery 15

-, -

Fig. 193 F".g. 19b

BABIGHlAN elevator, sharp rBaby 1". No. 233410) BABIGHLAN elevator, blunt rBaby r. No. 233412)

1.5 Underlay Technique 1.6 Overlay Technique

The tympanomeatal flap is evened anteriorly, possibly All of the epithelium circumscribing the perforation
exposing the perloration margins below (Fig. 19a). margins is elevated and removed, possibly utilizing
Once the flap graft has been introduced and advanced the abrasive properties of a wetted colton swab. and
into the cavity - if possible in contact with the meso- the tympanic area is scraped using an alligator fOf'ceps
thelial surface of the eardrum and the inferior surface of (Fig. 20).
the malleus - it is then stretched between the fibrocar-
tilaginous annulus and the bony sulcus using a micro
elevatOf' (so-called uvaginator") (Fig. 19b).
The flap is evened to its original position and, if the per~
foration was well circumscribed, the graft is clearly vis-
ible to the surgeon and protrudes slightly (Fig. 18g).

Stabilization of the graft may be performed as

follows:
1. Create a small pocket between the lateral surface
of the malleus handle and the tympanic remnants,
and insert the flap graft some distance there; or
2. Pull the implanted flap graft through 1-2 openings
created in the tympanic remnant, at a distance
from the perlOf'ation margins, using a small hool<.

Fig. 20
16
Fig. 21
In all 0Wlf1ay gaftll1g PiocediM'es lor total Of sob!otaI pel1ol'atl(lllS.
the anIenol' CQfM!lUty 01 the bony e.w IS usuaty ~ away
WIth the dIamolld boo' to filly YJSUalile the tynlpalliC area.
MIClomo!or (No 20 7110 32). The tyrnpar.c floor is protected by
means of a slall.Ul sleel plale.
DeepithelializatlOl'l is contlnued attemptIng to preserve
the continuity of the eptdermis as far as the peri-annular
skin of the canal. Finally, the graft is positioned ooto the
lamina propria and secured by restoring and folding the
skin or its remnants over the tympanic surface.
The cavity is partly filled with a couple of pellets of
absorbable sponge to support the flap from below. The
posterior margin of the flap must overlap the bony pos-
terior wall of the canal to the minimum extent. Here too,
the use of a micro elevator ("vaginalor'") - either spatula
or ball type - is beneficial since the curve of the instru-
ment can be used to advance the pellets as far as the
hypotympanum and protympanum.
1.7 SHEEHY Technique (Overlay Grafting
for Total Myringoplasty)
A vascular strip is created (see above), which is folded
outward and kept in situ with the same self-retaining
retractor used to stabilize the auricle and the PaIva flap.
A circular incision is made on the external two-thirds
of the canal and the skin Is elevated toward the annu~
Ius in continuity with the epithelial layer of the tympanic
remnants. The annulus is left intact. The anterior skin
is removed, placed on glass and covered with wetted
gauze; the orientation of the flap is marked.
Functional Otosurgery
'~- .......
Ftg.22 •
Elevator. 15~(No. 233414 and BAelGHlAN MlCfO Elevator.
curved. bUlt (No, 2334201
In all overlay grafting procedures for total or subta--
tal perforations the anterior convexIty of the bony
canal is usually drilled away with the diamond burr to
fUlly visualize the tympanic area. The eardrum or its
remnants are carefully shielded against the burr with a
fine aluminum disk (Fig. 21).
In addition, enlarging the antenor tympanomeatal angle
effectively averts anteriOf postoperative blunting.
The graft is shaped to a disk with a diameter of about
2-3 mm greater than that of the eardrum. A radial slit is
incised from the periphery 10 the disk center. The disk
is stretched over the tympanic area with the malleus
handle emerging from the slit (Fig. 22).
The disk margin is carefUlly stretched lar enough over
the bony margins of the tympanic annulus to leave an
overlap of1 mm. The two ~Ieaflets~ of the slit are gently
pulled upward to allow the malleus neck to emerge at
the center of the slit. The anterior ~Ieaflet~ of the flap is
folded back down to cover the malleus handle.
Before closing, first elevate the postero-inferior portion
of the flap graft and then insert 1-2 pellets of gelfoam
into the caVity to secure the new eardrum.
Functional Otosurgery
2.0 Repair and Reconstruction of the Ossicular Chain
(Ossiculoplasty)
The AUSTIN classification (Table 4) provides a simple
method for describing the altered anatomy of the ossic-
ular chain.
It is a pre·reconstructive classification, meaning that it
defines the status 01 the MreslduaJ chain after eradica-
M
tion of the pathology and prior to surgical reconstruc-
tion.
Class Status Legend
I M+S+ M: Malleus haod!e
"'"
IV
M+S-
M-S+
M-S-
S: Stapedial arch
+ pl"esent, - absent
Tab. 4
PnHeconstruetlOr'l ose....... status tAUSTIN dass/fiCatJOtL 1972)
Whenever possible, repair of the OSSIcular chain is per-
formed with autologous material. This involves that
adequate areas of contact are available: a mobile mal-
leus handle or the stapes head.
In other cases It may be appropriate to use small allo-
plastic columellas, deSigned to couple the malleus or
new eardrum to the stapes (stapes head or footplate).
These usually require a fragment (disk) of cartilage to
be interposed on the prosthesis platform while avoiding
that a wide area of the new tympanic surface still comes
into direct contact with the platform itself. Such interpo-
sition seems less necessary when the eardrum is intact
or if contact is to be made with the malleus alone.
17
Although indispensable in many cases of ossictJloplasty.
pl'"ostheses still have limitations (Table 5). specifically:
a. Usually very high costs
b. Structural stability may be compromised in the
long term (degradability of a pl'"osthesis of bioaetJVe
ceramics).
c. Exessive stiffness of the prosthesis due to the mate-
rial pl'"operties (e.g. ceramic pl'"ostheses).
d. A very fine shaft (Ill total prostheses) IS required to be
able to vil:¥:ate fr~. .
e. Vertical alignment with the vestibulum is required.
f. Stable interlaces.
Key Factors in Ossicular Chain
Reconstructions by Use of Prostheses
• Free vibration of the pl"osthesis
• TORP with very fine shaft to avoid contact
• Vertical alignment, not oblique, between M and
S, (HOTIENBRINK. 1994, VLAMING & FEENSTRA,
1986).
• Solid coupling between prosthesis and ossicle,
(more secure allachment at the stapes head)
Table 5
Table 6 lists the materials used in our institution in
2,060 cases treated between 1988 and 1998.
OssiculoplasUes 1988 - 98: n. 2060
Follow·up: minimum 5 yrs, n. 1187
Materials
• Autologous ossicle
• Sinterized HA
• Homologous ossicle, chemically dehydrated
.Ionos
• Polycel
• Ceravital
• Frialit
• Mixed
Table 6
18 Functional OIosorgery

FIg.23a
Incus body modeled lor
int8f1)OlSll1Ol'l between
malleus and head of
stapes
Flg.23b
for incus placemerJt, the use of 11'90" angled hook (No. 233440)
and II curved ~ (Ro$en type, No. 233430) has prcMII'I helpful.

They are particularly useful when an autologous incus

Titanium and Ossicular Prostheses or a titanium strut (FISCH), measuring between 3 and
• Biocompatibility (minimum tissue reaction) 5 mm, are not available (Fig. 25a). The laller are posi.
tioned with a 45° pick inserted into the appropriate
• Very low weight (8 times lighter than gold)
opening (Fig. 25b).
• Malleable
• May be modelled by use of a diamond burr The author designed combined-material prostheses of
hydroxylapatite and titanium of variable length that may
• No osseointegration
be adapted to the patient'S individual anatomy by a
• Magnetically inert spring inserted in a titanium sleeve interposed between
Table 1 the footplate and prosthesis shaft.

The autologous ossicle (if available) offers the best cost-

benefit ratio and meets the structural requirements of
an ossicular reconstruction material (Figs. 23a, b).
It is a different slory for the geometric reqUIrements: in
the absence of the malleus and stapedIal arch, the use
of partial ossicular reconstruction prostheses (POAPs)
or total ossicular reconstruction prostheses (TORPs)
is mandatory. Preferably, these are made of titanium,
a material widely used today because of its good bie-
compatibihty (Table 7).
At the tiP 01 the shaft. PORPs (short columellas,
S+ cases) have an acetabulum or asmaJi baskel~ that
receives the stapes head and may easily be grasped
with an alligator forceps.
The length is vanable, usually between 2.0 mm and
2.75 RVn.
lOAPs Qong columellas, S- but also S+ cases) have
a variable length ranging between 4.0 and 6.0 mm
(Fig. 24). Fig. 24
Sample of II TORP prostheSIS. the FISCH Tilarllum Total Prosthe-
sis, w~h foot, 10.0 x diameter 0.6 mm
Functional Otosurgery
Fig. 258, b
FISCH strut (InCUS). made n btanun
The length should be carefurty measured: in Canal Wall
Up, or closed tympanoplasty (CWU), from the stapes
head or from the foot plate to the posterosuperior annu-
lar margin of the tympanic scutum, making sure that the
prosthesis platfonTl does not come to rest beneath the
scutum itself.
At this point It is always appropriate to confirm the
absence of pathology in the tympanic sinus, which is
easily accomplished using a tele-otoscope 00, 4 mm.
diameter (No. 1215 AA) or micro mirrors (No. 223600,
223602), that ensure a very clear and precise reflected
image because of their special surface finish.
If it proves necessary to dissect and remove diseased
tissue or structures, even if very small in size, the micro
Fig. 26<1, b
A sleeve of autologous C81til&ge may be used 10 secure a rORP
(In thIS case. a FISCH TllalllUl'll Prosthesasl·
"
' ..
elevators may be very useful (cuved right or left) Since
they are very adaptable also to otoneurosurgery (No.
233418,233419).
In Canal Wall Down or open tympanoplasty (CWO).
the length should instead be measured from the stapes
head or footplate to the superior edge of the facial
ridge.
It may be benefICial to interpose a small flap of fibrous
tissue onto the mobile footplate to protect it from foot-
plate fractures or luxation into the vestibule.
In addition, a sleeve of autologous cartilage may be
used to secure the prosthesis when given a fork-like
shape and inserted at the shaft or base of the prosthe-
sis (Figs 26a, b).
20 Functional OtOSUfQ6fY

3.0 En-bloc Osteoplasty of the Postefior and Attic Wall

according to BABIGHIAN (1992) or Reversible Tympanoplasty
according to McELVEEN and HULKA (1998)
The procedure combines the advantages of the open
technique (exposure of anatomic structures and pathol-
ogy) and those of the closed tympanoplasty (preserva-
tion of the anatomic structures and auditory properties
of the middle ear).

Fig.27a Objectives of the procedure:

Mocro compass saw (No. 254300) WIth a set of 5 blades. Thls
Instrument remoo.teS a precase ultrafine sectJOn of bone and thus
1. Osteoplasty with temporary en-bloc removal of the
&Ids 11'1 reduclng the healing penod of the bone gap WIthout callus posterior and attic wall to enlarge the access to the
-~. attic, protympanum, sinus. and hypotympanum;
2. Repositioning of the bony wall after eradication of
any disease, and tympanic.-ossicular reconstruc·
tioo, if required.

The surgical protocols listed in the following require the

availability of a compass micro saw with an ample set
of blades (Fig. 27a, b).

254312 Saw Blade, blade thickness 0.25 mm,

working lenght 11 mm, package of 12,
for use with 254300
254313 Same, working length 14 mm

254314 Same, wof1<ing length 18 mm

254315 Same, wor1(ing length 22 mm

254316 Same, working length 26 mm

Fig_ 27b
set of Saw Blades (No. 254312-16) for use with the MICro
Compass Saw (No. 254300)
Functional Otosurgery 2'

Fig. 28
..
Fig. 29
...
There are several indications:
1. Postauricular or endaural approach
• Pars tensa cholesteatoma and sinus cholesteatoma.
2. Closed (Canal Wall Up) technique (CWU) with
• Tympanosclerosis.
deep posterior tympanotomy (Fig. 28).
• Glomus tympanum.
3. Superior and inferior cuts are made using the
• Facial nerve neurinoma.
micro compass saw. The target sites are marked
with a skin marker pen (Fig. 29). • Cochlear implant revision.
• Cochlear ossification in implant surgery.
4. En-bloc rerooval of the bony wall and its preserva-
tion in normaJ saline solution.
5. Eradication of pathology, ossiculoplasty, and
myringoplasty, if required (Fig. 30).
6. Cleaning, repositioning, and fixation of the bony
wall at its original Site {using bone cement or OOne
paste, or accurate cutting templates of the bony
margin (Fig. 31).

Fig. 30
The postenor bony waD has been temporarily removed and the
ossicular challl t8COl>StrUeted wrth 1IlI000000tlOfl ol. Fisch 1lIa-
mum StlU! ~ M.. and S... Note the amputatlOl'l ol the mal-
leus head by use 01 a small pICk (No. 225408 and/or 225415)
Fig. 31
USIng IOI'IOITleOC cemeol (SereooCem . Connthian Medoe.aJ LtO
UK) the osseous segmenl 01 the wallIS reposItlONd and staO<'
liled In srtu by use ol a BABIGHIAN mlCtO eleVator -'0 233J20
22
Fig. 32
Various types of stapes prostheses, made of teflon, steel, Ie/lon-
steel. teflon-platinum. (Left to right) Cawthorne, Shea. McGee.
RobinSOll. Schuknecht, and De La Cruz prostheses.
4.0 Stapedotomy (Incus-Stapedotomy)
The procedure is intended 10 restore mobility to the
OSSICUlar chain by eliminating the source of ankylosis I
fixation (total or partiaQ that has terminated or reduced
the mobility of the stapes or the ossicular chain.
The disease involved in the first case is otosclerosis, in
the second pseudotosderosis.
Stapedotomy (lncus-Stapedotomy)
Transcanal or endaural approach (the lalter is almost
mandatory in malleo-stapedotomiesj. The tympana-
meatal flap IS safely elevated when the elevator fol-
lows the cleavage plane between the fibrocartilaginous
annulus and the tympanic sulcus.
A variety of stapes replacement prostheses is availabie
(Fig. 32), one of which - the teflon-nitinol (titanium-
nickel alloy) Smart Piston - is highly interesting. Once
it is placed in position around the long process of the
incus, it is sufficient to touch the prosthesis hook with a
heat source of 60° (laser tip or bipolar microforceps at
minimal intensity) or. more appropliately, with a special
instrument (Thermal Tip) to obtain a complete and
uniform closure of the ring around the ossicle.
The pure titanium FISCH piston IS one of the best
suitable prostheses (Fig. 33).
The stapes prosthesis is grasped with a large. straight,
atraumatlc alligator forceps from the conIng block and
carefully inserted into the stapedotomy opening (with a
1.0 mm, 45° pick) as far as the vestibulum. It is measured
with a special distance measuring rod (Fig. 34) and
trimmed to the appropriate length 00 a special titanium
block equipped with a guillotine-like blade.
Functional Otosurgery
Fig. 33
Set of FISCH TrtllQlum Stapes Pistons, available in three differ-
ent lengths. (No. 22751l>-12) with a diameter of 0.'1 mm: 10 mm,
appropriate-sited fOf malleo-slapedolomy, diam. 6.5 mm and
diam. 7 mm.
To provide better stability to the prothesis, the block is
wetted with a few drops of saline solution. A central pla-
tinotomy (diameter 0.6 mm) is prepared prior to remov-
ing the arch using a low-speed micro drill (0.6 or 0.7
diamond burr) or laser. Manual perloratOfS (very conve-
nient - they offer a peculiar tactile sensation) should be
used ooly by experts (No. 233428).
Next, the loop is crimped over the incus USIng a straight,
smooth, alligator forceps. This manoeuver is facilitated
when the stapes arch has been left intact (Fig. 36a).
To remove the arch, Ihediamond burr (size 0.6-0.7 mm)
should be used at low speed in the posterior crus con-
cavity (the anteriol' crus often fractures spontaneously).
Remedial measure in the case of a floating footplate:
• Creation of a "pothole" or laser application.
• Measure the prosthesis and calculate an additional
0.25mm.
Fig. 34
Uswlg the BA8lGHIAN distaoce rneasuvog rod (No. 233450.
available., 3 different SWlS 4. 4.5. 5 nYl'I! detem'llOaloon of the
exact length of the prosthesis. measured betweel'I the n::us
rmlerior marg.nl and the stapes footplate.
Functional Otosurgery 23

Once the platinotomy is completed the teflon-platinum

or titanium pistoo (usual length 4.25-4.5 mm. diameter
0.4 or 0.5 mm) is placed and secured before removing
the arch. This is a reverse protocol technique which we
have called the FISCH-2 technique (Fig. 36b).
The surgical protocol for "fine·tuning~ the stapedial
prosthesis (or an ossicle or ossicular prosthesis in the
case of ossicuJoplasty) involves the use of a series of 45°
and 900 hooks/picks. straight or angled. curved upward
or downward. right or left. which allow the surgeon
very precise dexterity that respects the structural and
geometnc integrity of the prosthesis itself (see section
"Recommended Set for Ear Surgery and Otoneuro*
surgery according to G. BABIGHIAN. pp. 28). Fig. 35
The FISCH SlaRl\S Trtardn PiSlon p1ll<*1lfl the preformed
The piston and even ossicular prostheSIS may be 0.4 mm diam. hole d the eutlA'lg block Lnlil fuftlw use.
adequately positioned using a small or large micro fork
(No. 233425, 233448).
Following confinnation of ossicular mobility, the pros-
thesis/platinotomy margin interface is sealed using
small pledgets of absorbable sponge, or fibrous tissue
harvested from the intertragus-helix incision, or small
autologous blood clots harvested at the beginning of
the intervention. For packing the extemal auditory canaJ
absorbable sponge or a medicated (antibiotic ointment
or solution) orion gauze may be used.

Fig.36a

Fig.36b
"Fisch II" technIQUe (reverse pn;lIoco1 stapedotomy) USIng a
FISCH Stapes T.w..m Piston (No. 227511).
Ftg.36e
In the case of obl,terattve otosclerosos, In whoch the stapes Ioot-
p1atll is partly obscured by the otosderolJC Ioeus, ot IS possible 10
use an extra small angled double c~ene (No. 2240051
to strlllghten and expancllhe mar"," of the otosclerotIC atea
24 Functional Otosurgery

5.0 Malleo-Stapedotomy

In addition to stapes ankylosis and otosclerosis,

fIXation of the ossicles may be due to
1. previous inflammatory QOOditions (tympanoscle-
rolic pseudotosc/eros;s, lateral fixation of the
greater ossicles)
2. a congenital anomaly (ossification) of the (anterior
ligament) of the malleus.

5.1 Surgical Protocol

Fig. 37 .In malleo-sta,pedotomy, 'a single superior incision is
made sagittally with a scalpel and the anterior tympano-
malleal ligament removed with an angled microcurette
(No. 224005). With an ultra-micro knife (No. 233405) Of
a small hook and micro elevator (BABIGHIAN vaginalor)
a pocket is created between the malleus handle and the
mesothelial surface of the tympanic membrane about
half-way along the handle, between the lateral and
spadelike processes. Another option (easier to do) is 10
create a hinged flap below, as described by Fisch, cut·
ting the tympanic membrane for 2-3 mm at the level of
the lateral malleal process and then stripping the handle
for a short distance. The prosthesis ring is positioned
and pressed on here.
In malleotomy, to adapt the prosthesis to the anterior
position and to the individual inclination of the malleus
handle, the shaft may be bent at different levels on the
cutting block. To do this, the prosthesis is inserted
into the perforated slot of the cutting block and the
hook is delicately fashioned to the desired shape with
Fig. 38 a jeweler'S forceps. It is possible to do likewise in the
lateral direction if this proves necessary for sloping the
malleus toward the promontory (Fig. 37).
The prosthesis hook is attached to the malleus handle
on the distal side of the lateral malleal process. Fixation
of the prosthesis to the malleus is performed with the
same straight, atraumatic alligator forceps used for the
stapedotomy (larger tympanomeatal flap). Hold the for·
ceps with both hands. Following fixation, the prosthesis
hook should no longer be able to move freely (Fig. 38).
In malleo-stapedotomy, the prosthesis should be
inserted into the prepared pocket, holding the hook
horizontally or positioning it above the stnpped portion
of the mallear handle; such rnanoelMe is accomplished
with the extra·fine sickle knife (No. 233405) (Fig. 39).
Once the hook is closed, it may be necessary in some
Fig. 39
Malleo-stapedotomy wrth a FISCH stapes trtarVI.m PIston cases to adapt the shape of the shaft Itself to match dif-
ferent spatial conditions.
Functional Otosurgery
Figs. 4Oa, b
Single pulse CO2 Jaser applcatlOll.
a target Me of exactly the diameter defined by the surgeon-
(e,g. 0.5 mm).
b platlootomy performed with a single pI,llse of the laser unit.
The titanium pistoo needs to penetrate the platinotomy
as vertically as possible to ensure that it moves along
an orthogonal axis relative to the foot plate surface.
Close the ring with an alligator forceps.
Place autologous coonective tissue or blood clots
(collected from the patient prior to surgery and stored
in a small metal bowl for coagulation under sterile
condltl()(lS) at the Plstoo-pIatlnotomy interface.
Fill. 41a, b
Erbtum I8:ser appicatoon.
a postenor crurotomy
b plalmotomy 0.4 mm
25
" ,
5.2 Alternative Techniques
Laser stapedotomy with Erbium:YAG laser or Ultra-
Pulse CO2 laser (Figs. 40-41).
A stapedotomy with an Erbium:YAG laser presents
several advantages. SpeaficaDy, it does not induce skin
lesions (JAMAU et ar. 1998), it has no thermal effects
(SHAH et al. 1996), there is a significant improvement
in revision surgery (WIEr et at 1997). and it is more
effective than Argon, Holmium, or Excimer lasers for
bone ablation. On the other hand, it can generate a
short-term Temporary Threshold Shift (ITS) through a
noise-induced trauma, which in some procedures may
be successfully treated with a corticosteroid.
26 Functional Otosurg6fY

Suggested Reading

1. AUSTIN OF: Ossicular Reconstruction.

Otolatyngol. elin North Am.• 5: 145 - 160, 1972.

2. OORNHOFFER JL: Heanng results With the Oom-

hoffer ossicular replacement prosthesls.
Laryngoscope. 106: 531 - 536, 1998.
3. FISCH U: Tympanoplasty, Mastoidectomy and Sta-
pes Surgery. N. Y. Thteme, 1994.

4. GEYER, G: Matenals for reconstruction of the

middle ear. HNO, 47: 77.- 91,1999.
-
5. GOLDENBERG RA, EMMET JR: Current use of
implants in middle ear surgery.
Otol Neurotol 22: 145 - 152, 2001.

6. SHEEHY JL: Surgery of Chronic Otitis Media

In: English G, ed. Otolar'yngology.
Philadelphia: JB Uppincott, 1984, 1: 1 - 84.

7. TOS M: Manual of Middle Ear Surgery.

N.Y., G.Thieme, 1993.