Ossicular Reconstruction
David F. Austin, MD, Chicago
Methods of ossicular reconstruction are reviewed
from both evolutionary and pragmatic surgical
standpoints. The statistical basis of evaluating
hearing results was described and used in compar-
ing techniques of reconstruction of four basic os-
sicular defects. Autografting and homografting
with both ossicular bone and cartilage have been
evaluated to aid in surgical method selection.
From these experiences, principles of ossicular
repair have been induced and proposed as a guide
to this aspect of chronic ear surgery.
Hi .EARING restoration through ossicular
reconstruction is not universally successful.
Many failures, though of diverse origin, may
be avoided through recognition of the poten¬
tial pitfalls of tympanoplastic surgery. The
most frequent difficulties are retained active
disease and poor function of the eustachian
tube. Both are common to all tympanoplas¬
ty. This presentation will discuss specific
problems of ossicular reconstruction using
autografi and homograft techniques encoun¬
tered in the past five years.
The fundamental purpose and the initial
stages of tympanoplasty are control of the
disease. Persistent disease (or recurrence)
negates all attempts at hearing reconstruc¬
tion.
Types of Ossicular Defect
The methods of reconstruction to be de¬
scribed deal with four types of ossicular
defect. These types depend on the presence
or absence of the malleus handle and the
presence or absence of the stapes arch.
When these conditions are combined, four
possibilities exist. These may be designated
malleus present, stapes present; malleus
present, stapes absent; malleus absent,
stapes present; and malleus absent, stapes
absent (M + S+, M + S-, M-S + and , gram (malleus handle present, stapes arch
M S ). This is presented in chart for-
— —
Accepted for publication July 8, 1971.
From the Department of Otolaryngology, Abraham
Lincoln School of Medicine, University of Illinois
College of Medicine, Chicago.
Reprint requests to 55 E Washington St, Chicago
60602 (Dr. Austin).
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015
Malleus Handle
Present Absent
Present
Stapes Arch 59.2%(29.5%) 7.8% (3.8%)
Absent
23.2%(11.6%) .2%(4.1%)
Fig 1.—Chronic ear disease; anatomical descrip¬
tion of defects In ossicles, a, Malleus present, stapes
present; b, malleus absent, stapes present; c, malleus
present, stapes absent; and d. malleus absent, stapes
absent. Total (100%) based on 1,151 consecutive
ears. Unbracketed percentages indicate incidence of
defect in ears with an ossicular defect; bracketed per¬
centages indicate incidence in entire group with a
chronic ear disease.
Table 1.—Summary ot Results
Reconstruction Type No. of Cases Failures
Incus transposition 6(26%)
23
Malleus-stapes assembly 23 2 (8%)
Malleus-footplate assembly_33_7 (21%)
Tympanic strut 9 1 (14%)
Transplant columella_10_8 (80%)
"L"-shaped transplant_12_2 (17%)
Total ¡TO 26
mat in Fig 1. Defects such as loss of the
head of the malleus or loss of the body of
the incus are not included because they do
not influence the selection of type of recon¬
struction in the way the other factors do.
Isolated loss of the arch of the stapes is not
shown because of its rarity (1.7% of ossicu¬
lar defects). This defect is corrected with
application of a stapes replacement pros¬
thesis; further discussion of this problem is
not within the scope of this presentation.
In Fig 1, loss of the long process of the
incus corresponds to the box of the dia¬
present). The c box is that of combined loss
of the long process of the incus and the
stapes arch. Loss of the malleus handle, b,
may occur as an isolated defect (2%), but
most often occurs in the combination with
defects of the incus.
 The figures presented in Fig 1 are from an
analysis of 1,151 consecutive surgical pa¬
tients with chronic ear disease. Of these pa¬
tients, 574 (50%) had ossicular defects of the
type shown. The larger percent figure desig¬
nates the proportion of that defect in rela¬
tion to all ossicular defects; the parenthetical
figure designates the percentage occurrence
in the entire group of 1,151 patients with
surgically treated chronic ear disease.
The methods of ossicular reconstruction to
be discussed are based on the above classifi¬
cation of ossicular loss. Under study are
110 tympanoplastic procedures, sequentially
chosen, and observed continuously since
their original surgical procedure. The period
or observation is from one to five years.
However, the analysis of results is made
from the status at one year after surgery.
The cause of failure is of primary considera¬
tion. In the interval between the first and
fifth year cited, most failures have under¬
gone repeat surgery. This has permitted ver¬
ification of the cause of failure, and these
results are reported in Table 1.
Data Analysis
A search of the literature supports the
contention that no standard or reliable sta¬
tistical method for obtaining significant con¬
clusions regarding differences in operative
results has been evident. Simple statements
regarding "success rate," or "average hear¬
ing results," or "percentage of patients
reaching social adequacy" do not define the
data or permit drawing statistically valid
conclusions. The figures cannot and do not
speak for themselves, since, in the absence of
some statement regarding the possibility
that the figures represent a pure chance
50 -40 -30 -20
Change in Bone-Air Gap (dB)
(Therapeutic Efficiency)
Fig 2.—Comparison of "Therapeutic Efficiency"
curves for incus transposition (dotted line) and malleus-
stapes assembly (solid line). The curves are significant¬
ly different when the means are compared by t-test.
X= analysis of "success rate" failed to show this
difference.
occurrence, one can only guess if there is a
chance that the results are meaningful. The
problem is further compounded because pop¬
ulation distribution curves of hearing results
tend to be skewed; good results cluster
around zero hearing loss while the remain¬
der tail off toward a maximum loss. With
this non-normal distribution, the more po¬
tent methods of statistics employing mean
and variance (or scatter) may not be used,
limiting analysis to nonparametric methods.
One method of analysis, which seems par¬
ticularly applicable in dealing with hearing
results of groups of fewer than 100 cases, has
been described by McNemar.1 This analysis
is based on the change in the conductive
hearing loss resulting from the surgical tech¬
niques under study. If the distribution curve
of these individual changes falls into a nor¬
mal distribution curve, then the mean and
the variance can be used in analyzing differ-

Table 2.—Summary ot Preoperative Populations.

No. of Mean
Ossicular Defect Cases Hearing Loss SD r-Value
Malleus present, stapes present 46 27.3 10.91 „
«ce*
Malleus present, stapes absent 33 33.6 11.31

jl.925
Malleus absent, stapes present 9 39.7 ^"^li 07a
Malleus absent, stapes absent 22 37.6 11.8/
*
Significant at = .05.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 enees surgical results. In fact, such an
in
analysis now to the point and might be
is
termed a "therapeutic efficiency curve." Fol¬
lowing McNemar's description, we have a
situation in which the only requirement nec¬
essary is that the preoperative hearing loss
for the group follow a normal distribution.
This has been found to be true in all studies
in this series.
The basic data needed for each patient
are the preoperative bone and air conduc¬
tion and the postoperative air conduction for
the period under study, ie, one year follow¬
ing initial surgery. (This use of preoperative
bone conduction and postoperative air con¬
duction to compute the postoperative bone-
air gap is standard as recommended by the
Committee on Nomenclature in Chronic Ear
Disease and the Otosclerosis Study Club.)
Analysis of the data is based on three
measurements: the preoperative bone-air
gap, the preoperative bone-postoperative air
gap, and the difference between these two
values. These data are then analyzed by
computing mean and variance (or scatter
from the mean) for the preoperative and
difference values so that i-tests can be used
to determine statistical significance. The
postoperative hearing loss (bone-air gap)
may be shown in histogram or other form to
visually demonstrate the end result of sur¬
gery, but is not used for statistical evalua¬
tion.
This method obviates the need for arbi¬
trary success or failure criteria placed on the
continuum of postoperative hearing results.
Rather, differences in the "therapeutic
efficiency" curves are analyzed statistically
to determine if significant differences in the
operative techniques under study do exist,
and are not the result of pure chance.
Since the preoperative population is also
defined, valid comparisons with the tech¬
niques and results of others are also possible.
As an example, Fig 2 shows the "therapeutic
efficiency" curves for the first two surgical
techniques discussed. Analysis by f-test,
which is a derived confidence ratio, shows a
significant difference (P < .025). By con¬
trast, analyzing the difference in "success
rates" based on postoperative bone-air gap
of less than 20 dB results in a 2 (a
measure of probability of hypothesis vs null
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015
hypothesis in relation to chance) of 1.36.
This is not a significant value (P > .25).
The data in this study are presented and
analyzed by the methods described above.
Table 2 summarizes the parameters of the
four preoperative populations under study.
All postoperative hearing results are taken
from the one-year examination.
Malleus Present—Stapes Present
In this series (box a of Fig 1), two
methods have been used to correct this ossic¬
ular defect. Failures were associated with
the first technique, incus transposition.
These failures led to the development of the
second technique, malleus-stapes assembly.
Surgical Technique.—Incus Transposition
is diagrammed in Fig 3. Replacing the incus
body on the head of the stapes was the
original method of ossicular autografting.2·3
This method was used for 23 of the reported
patients. In some reconstructions, a small
cup was drilled into the body of the incus to
receive the stapes head to stabilize its posi¬
tion. In other instances this was not neces¬
sary. There were 20 autografie and three
homografts used.
Malleus-Stapes Assembly is diagrammed
in Fig 4. Rotation of the malleus to the
stapes has been repeatedly described.4-6 It
appears more desirable to leave the malleus
handle in the tympanic membrane to insure
efficient energy transfer to the ossicular
chain. In this alternate technique, either the
malleus head or incus body is shaped to fit
between the stapes head and the malleus
handle. A cup-shaped depression is drilled
into the bone prosthesis to receive the stapes
head and it is carved to fit snugly against
the malleus handle. Normally, the malleus
head fits best as the bone prosthesis; but if
there is a longer than normal distance be¬
tween the malleus and stapes, an incus is
used as the assembly prosthesis. This tech¬
nique is especially suitable in case of attic
ossicular fixation. Here, the malleus head is
amputated and used as the autografi mal¬
leus-stapes assembly. The incus in such an
ear is removed for later use as a homograft.
This technique has been used in 23 patients.
A malleus graft was used 16 times, an incus
graft was used seven times. There were 11
autografts and 12 homografts used.
 Table 3.—Summary of Reconstructive Techniques
Mean Change Mean
Hearing
Technique (TE)* (PO)t TE/SD t(TE)
Malleus Present, Stapes Present
Incus transposition 12.8 14.5 14.6 4.205Î 1.742S
Malleus-stapes assembly 20.0 7.3 13.4 7.158Î
Malleus Present, Stapes Absent
Malleus-footplate assembly 22.9 10.7 15.8 8.326Î
Malleus Absent, Stapes Present
Tympanic strut 28.7 11.0 12.7 6.780t
Malleus Absent, Stapes Absent
Natural columella 7.8 29.8 12.1 2.0385
2.359S
"L"-shaped prosthesis 20.3 17.3 12.7 5.537t
*
TE, "therapeutic efficiency curve."
t PO, postoperative.
t Highly significant.
§ Significant.

Malleus Stapes Assembly

-

Fig 3.—Incus transposition. Diagrammatic lateral Fig 4.—Malleus-stapes assembly. Diagrammatic lat¬
and cross-sectional views. eral and cross-sectional views.

Results.—Figures 5 and 6 illustrate the

results of the two techniques used to correct
loss of the long process of the incus. Each
graph indicates the preoperative conductive
loss as a frequency polygon, the postopera¬
tive conductive loss as a histogram, and the
Therapeutic Efficiency curve in half scale in
the insert.
Table 3 summarizes the statistical analy¬
sis of these results. Both incus transposition
and malleus-stapes assembly resulted in a
significant improvement over the preopera¬
tive hearing status of the patients. The 7.8-
dB difference in the means of the Thera¬
peutic Efficiency curves gives a statistically Fig 5.—Results of incus transposition. The preopera¬
tive bone-air gap is indicated by the bar histogram,
significant (P < .025) advantage to the the postoperative bone-air gap by the frequency poly¬
malleus-stapes assembly technique. At pres¬ gon, and the change in the bone-air gap measured one
ent, malleus-stapes assembly will continue year postoperatively ("Therapeutic Efficiency" curve)
is shown in half-scale in the inset.
to be my method of choice when confronted
by a defect of the incus.
Causes of Failure.—With incus transposi¬ Ossicular gap occurs during the healing
tion there were six hearing failures. One process due to shrinkage of the tympanic
failure was due to recurrent disease in the membrane graft. There is consequent later-
form of otitis media. All of the other failures alizing of the transposed incus from its at¬
were secondary to the problems resultant tachment to the stapes. This problem was
from incus transposition, namely, ossicular identified in two of the reconstruction fail¬
gap or obstruction to attic aeration. ures. In both revision operations a wedge of

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 Malleus
-
^
Footplate, Incus

Fig 6.—Results of malleus-stapes assembly. The

preoperative bone-air gap is indicated by the bar Malleus Footplate. Cartilage Strut
histogram, the postoperative bone-air gap by the -

frequency polygon, and the change in the bone-air Fig 7.—Methods of reconstructing stapes loss with
gap measured one year postoperatively ("Therapeutic malleus present in diagrammatic lateral and cross-
Efficiency" curve) is shown in half-scale in the inset. sectional views. Top, Malleus-footplate, incus and
bottom, malleus-footplate, cartilage strut.
ossicular bone was placed in the gap be¬
tween stapes and incus. The outcome of this
method of correction was only partially suc¬
cessful in closing bone-air gap.
Obstruction to aeration occurred in three
instances. This problem is more severe and
leads to mucus accumulation and the risk of
continued infection. The cause of this prob¬
lem lies in the fact that the only aeration
route to the attic and mastoid is posterior to
the tensor tympani tendon. The bulk of the
transposed incus body, when enlarged by
mucosal edema, is sometimes sufficient to
block this route. Lack of aeration leads to
continued chronic otitis media and interferes
with hearing.
Fig 8.—Results of malleus-footplate assembly. The
With malleus-stapes assembly there have preoperative bone-air gap is indicated by the bar
been two failures. Neither of these patients histogram, the postoperative bone-air gap by the
have been reopera ted upon. In each in¬ frequency polygon, and the change in the bone-air gap
measured one year postoperatively ("Therapeutic Effi¬
stance, immobility of the tympanic mem¬ ciency" curve) is shown in half-scale in the inset.
brane was associated with the inability to
inflate the ear. The presumptive cause of 1. A single technique has been used; that of
failure in these patients (one postmastoidec- malleus-footplate assembly (Fig 7).
tomy, the other with chronic otitis media Surgical Technique.—A strut between the
without cholesteatoma) was eustachian tube malleus handle and the stapes footplate
dysfunction. preserves both normal tympanic membrane
action and ossicular lever action.7 An incus
Malleus Present—Stapes Absent (autograft or homograft) is most often used.
After padding the stapes footplate with a
Less common than defects of the incus thin layer of connective tissue, the short
alone, this problem is usually associated process of the incus is placed in the oval
with primary or secondary acquired choles¬ window and the articular surface under the
teatoma. These are presented in box c in Fig malleus handle. The long process is cut off.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 Occasionally, dimensional problems are en¬
countered, such as a narrow oval window or
excessive distance between the malleus and
footplate. When such a situation exists, a
strut of homograft nasal cartilage with wire
reinforcement is fashioned to fit between
malleus and footplate.8 In this group of re¬
W
ó\

constructive procedures, 26 autografts and Incus Transplant

seven homografts were employed.
Results.—Figure 8 displays the results of
malleus-footplate assembly. The summary
Table 3 shows that the average 22.9 dB
improvement is a significant change in the
conductive hearing loss. The preoperative
hearing loss associated with loss of both the
incus and stapes is significantly worse than Malleus Transplant
that occurring with loss of the incus alone.
Causes of Failure.—Seven of these pa¬ Fig 9.—Methods of reconstructing loss of malleus
tients had a postoperative bone-air gap with stapes present in diagrammatic lateral and cross-
sectional views. Top, Incus transplant and bottom, mal¬
greater than 20 dB. Three were due to con¬ leus transplant.
tinued middle ear disease and four (12%)
due to a failure of the reconstruction. Fig 10.—Results of tympanic strut reconstruction.
The major cause of failure has been fixa¬ The preoperative bone-air gap is indicated by the bar
tion of the incus to a wall of the oval histogram, the postoperative bone-air gap by the fre¬
quency polygon, and the change In the bone-air gap
window. This occurred in two of the four measured one year postoperatively ("Therapeutic Ef¬
failures. In one ear, there was a poor fit of ficiency curve) is shown in half-scale in the inset.
the incus, resulting in a gap between the
graft and the footplate. In the one remaining
failure, erosion of the graft, a homograft
incus, occurred. It is anticipated that more
frequent use of cartilage should prevent
most failures in future reconstructions of
this type. -40 -20 0 20
Change in Bone-Air Gap (dB)
(Therapeutic Efficiency)
Malleus Absent:—Stapes Present
Postoperative
Loss of the malleus handle with preserva¬
tion of the stapes was the least common
ossicular defect noted in patients with
chronic ear disease. This is box b in Fig 1. 0 10 20 30 40 50 60
Bone-Air Gap (dB)
Loss of the malleus handle may occur as
an isolated defect in rare instances (2% of
ears with ossicular defects). It is more fre¬ grafts are used to restore efficient sound
quently associated with loss of the incus. transfer to the conductive system. In order
This problem is most frequently encountered to achieve good energy transfer, a strut
in mastoidectomy revision. Myringostape- should be incorporated into the tympanic
diopexy in such an ear often fails. Either membrane graft. To accomplish this and to
graft contraction pulls the tympanic mem¬ maintain the normal tympanic dimensions, a
brane from the stapes head, or narrowing of homograft malleus or incus is used (Fig 9).
the tympanum results in its scarring and The graft is placed with head (malleus) or
obliteration. The following technique avoids body (incus) against the stapes head, and
these problems by allowing the tympanic the handle or processes extending across the
membrane to assume its normal position. middle ear under the tympanic membrane
Surgical Technique.—Ossicular homo- graft. It is supported on absorbable gelatin

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 40 -20 0 20
Change ¡ Bone-Air Gap
Postoperative (dB)
Incus "L"

10
tfi^
0 10 20 30
Bone-Air Gap (dB)
40 50
Preoperative

60
^

Fig 12.—Results of "L"-shaped prosthesis. The pre¬

operative bone-air gap is indicated by the bar histo¬
gram, the postoperative bone-air gap by the frequency
Cartilage "L"
polygon, and the change in the bone-air gap measured
one year postoperatively ("Therapeutic Efficiency"

Fig 11.—Methods of reconstructing loss of malleus curve) is shown In half-scale in the inset.
and stapes in diagrammatic lateral and cross-sectional
views. Top, Incus "L" and bottom, cartilage "L." Fig 13.—Results of natural columella. The preopera¬
tive bone-air gap is indicated by the bar histogram, the
sponge (Gelfoam) blood packing, and may postoperative bone-air by the frequency polygon, and
the change in the bone-air gap measured one year
be cup-drilled when necessary to insure sta¬ postoperatively ("Therapeutic Efficiency" curve) Is
bility. Silicone-rubber (Silastic) sheeting shown in half-scale in the inset.
over the promentory to prevent adhesions
has not been used in this study.
Results.—The hearing results for the tym¬
panic strut technique are shown in Fig 10.
The statistical parameters are summarized
in Table 3. The hearing change demonstrat¬ 40 -20 0 20
ed by the "therapeutic efficiency" curve for Change in Bone-Air Gap (dB)
(Therapeutic Efficiency)
these nine patients is highly significant
(P< .001).
Cause of Failure.—Of the five malleus
homografts and four incus homografts used, Preoperative
one patient failed to better a 20-dB postop¬
erative bone-air gap. This failure was due to
0 10 20 30
lateralization of the incus homograft from Bone-Air Gap (dB)
the stapes head. It has been corrected by
revisionai procedures in which an ossicular
bone wedge was placed in the gap between residual problems. This series includes two
the incus and stapes. methods of approach; the grafted columella
and the "L"-shaped prosthesis (Fig 11).
Malleus Absent—Stapes Absent
Surgical Technique.—In this series, ten
Total loss of the ossicular system is a procedures employed either the malleus or
long-familiar problem and a difficult one to incus as a natural columella. The method
overcome. Long-term study of results with requires placement of the neck of a malleus
columellas (both artificial and natural) or the short process of an incus on the
have been disappointing.9 Artificial columel¬ tissue-protected stapes footplate. The head
las extrude and scarring and atelectasis com¬ of the malleus or articular surface of the
plicate both types of prosthesis. Staging of incus contacts the undersurface of the tym¬
the reconstruction10 improves the results panic membrane graft. These were one-stage
with natural columellas, but this, too, has procedures.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 The "U'-shaped prosthesis, introduced by
Jansen8·11 uses a strut, with one arm placed
on the stapes footplate, while the other ex¬
tends at right angles across the middle ear
to be incorporated in the tympanic mem¬
brane graft. This latter arm serves a double
function. First it gives efficient coupling to
the tympanic membrane for transfer of
sound energy; second, by virtue of support
of the drumhead, it prevents collapse of the
tympanum. Either incus homografts or carti¬
lage reinforced with wire may be used.8 The
incus is used in those cases with a sufficient¬
ly shallow oval window to contain the short
process without risk of postoperative fixa¬
tion. The long process then extends across
the middle ear. Cartilage homografts are
carved as an "L" after measurement, then
reinforced with 4-0 stainless steel wire and
positioned in the manner described.
Results.—As previously stated, this study
reports the one-year postoperative findings.
However, as a point of information, in the
past 24 months the use of this type of recon¬
struction has eliminated two-operation stag¬
ing. The results reported are those in which
a single operation was performed. This se¬
ries includes six in which incus homografts
were used and six with cartilage. Figure 12
summarizes the results of the "L"-shaped
transplant. The 29.3-dB mean hearing im¬
provement is a significant change for those
patients with a severely damaged ear as
shown in the summary Table 3. Other than
the tympanic strut method used when the
stapes is present, no other technique has
been as impressive in results for severely
damaged ear. The postoperative conductive
deficit has averaged 16 dB. Until the practi¬
cal concept of total tympanic homografts
has been established, this technique will of¬
fer as good a surgical solution to this prob¬
lem as I have experienced and evaluated.
Natural columella results are shown in
Fig 13. The 7.8-dB change from the preop¬
erative status is marginally significant. The
marked superiority of the "L"-shaped trans¬
plant can be seen by comparing the two
"therapeutic efficiency" curves. Numerical¬
ly, this difference is significant with
< .01.
Causes of Failure.—The natural columel¬
las failed in eight of the ten patients. Four
failed because of inadequate sound energy
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015
transfer. (The tympanum and columella
were normal and well positioned). Two
failed because of scarring and atelectasis of
the tympanum. Of the remaining two fail¬
ures, one patient had fixation of the graft to
the walls of the oval window and the other
had extrusion of the columella. This was the
only extrusion of a graft in the entire series.
Two of the 12 "L"-shaped transplants
were hearing failures. In both instances,
scarring of the tympanum occurred second¬
ary to continued infection of the middle ear.
Autografi or Homograft
In this series of 110 surgical problems, 44
homografts and 66 autografts have been
used. Autografts, being easily available,
were more frequently used early in the
study. With short interval examination and
testing of hearing offering constant feedback
of results, an occasional instance of absorp¬
tion of the graft was observed. This was
consistent with predictable effects because of
the anticipated course of the disease in these
bones. A growing practice developed of auto-
claving any autograft that had evidence of
erosion, even when the eroded portion was
trimmed prior to use for grafting.
Homografts have since become more plen¬
tiful, and now are preferred. Histologie
study has supported and strengthened this
choice. Microscopic examination of one ossi¬
cle (Fig 14) with only the short process
grossly eroded and which formerly would
have been selected as suitable for autograft-
ing, reveals involvement of the entire bone
with vasculitis. Not all autograft material
shows such extensive subnormality (Fig
15), but care must be taken in using auto¬
grafts. Any bone with more than minimal
erosion must be discarded. All bones with
adherent squamous epithelium should be
discarded in favor of a homograft. Though
autoclaving would control the infection and
clinical experience does not suggest that ab¬
sorption is common, it has seemed to be a
better choice to use healthy homograft mate¬
rial.
Microscopic examination of a removed
homograft ossicle (Fig 16) after one to two
years shows areas of new bone formation
with both osteoblastic and osteoclastic activ¬
ity. New living osteocytes are present. Com-
 Fig 14.—Incus shows widespread necrosis of inter¬
nal structure. This ossicle appeared healthy externally Fig 15.—Incus removed from diabetic with severe
other than being partially covered with squamous epi¬ otitis media shows relatively normal structure and
thelium which was removed prior to processing. could have been used for autograft.

parable specimens of cartilage also have during submucous resections of the nasal
shown the presence of new living chondro- septum; they could also be obtained at au¬
cytes. topsy. It is preserved in the manner de¬
Two specimens showed breakdown and scribed.
absorption of tissue. One was an autograft Ossicular or Cartilage Graft
cartilage (Fig 17) (tragal) used in a nonin-
fected congenital ear reconstruction. The Commitment to the continued use of a
other specimen was a homograft incus, and specific technique is often made by a sur¬
showed massive absorptive erosion (again geon and followed long after superior
without infection) after five months (Fig methods are available. Experience and profi¬
18). Whether these examples represent re¬ ciency do, however, overcome many original
jection phenomenon is not known. disadvantages when using one technique ex¬
These few examples demonstrate that in¬ clusively. The varied dimensions and several
sufficient time and data collection has oc¬ forms of pathologic damage found in the ear
curred to permit conclusions for the advan¬ do require of the surgeon some ingenuity in
tages or disadvantages of either graft type. ossicular reconstruction. There is no "best"
Analysis of only the hearing results with material or method at this time. The experi¬
autografts and homografts shows no signif¬ ences related in this presentation would sup¬
icant differences in favor of either of them. port the thought that certain techniques are
Nasal cartilage offers a distinct supe¬ more suitable than others for a specific ossic¬
riority over tragal cartilage because of the ular lesion. These are presented below only
difference in consistency. Tragal cartilage as a summary of personal experience to
(autograft) has a fragile, almost soft, con¬ date. It is not presented, to borrow a Zen
sistency; it tends to break apart when it is concept, as "the way."
being cut to shape. Nasal septal cartilage Fixation of Malleus Head or Incus.—The
(homograft) is much stronger and may be malleus head is amputated, the incus is re¬
sliced to obtain thinner sheets. This reason moved and either of these is used in a malleus-
alone makes homograft nasal cartilage the stapes assembly as an autograft while the other
better material in most instances. is saved in the homograft bank.
The only disadvantage of homografting is Loss of Long Process of Incus.—A homo-
graft malleus head (or incus body) is used in
the need for a bank of these materials. Once
the malleus-stapes assembly.
instituted, this is no real inconvenience. Os¬ Loss of Long Proess of Incus and Stapes
sicular homografts are obtained by the pa¬ Arch.—The malleus-footplate assembly is used.
thologist during selected head autopsies. The problem of fixation of the incus in the oval
The tegmen is opened with a gouge and the window will lead to greater use of wire rein¬
ossicles removed from above. These are re¬ forced cartilage placed in a similar manner.
frigerated while immersed in 70% ethyl al¬ Loss of Malleus, Stapes Present.—Here, mal¬
cohol. The homograft cartilage is removed leus or incus homografts, placed as a tympanic

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 Fig 16.—Homograft ossicle removed after two years.
Both osteoclastlc and osteoblastic activity can be seen
on the external surface. Vascularlzatlon has taken place.
Fig 17.—Autograft cartilage (tragal) removed after
six months. Extensive necrosis without Infection has
strut, have proven of great value. The choice taken place.
between these two depends entirely on the di¬
mensions of the tympanum.
Loss of Malleus and Stapes.—In this prob¬ Fig 18.—Homograft Incus (alcohol-preserved) re¬
moved after six months. Complete absorption of short
lem, either incus or cartilage homograft may process (external surface) has taken place. No Infection
be used. At present it seems that wire rein¬ was present.
forced cartilage will be more universally applica¬
ble due to its adaptability to the various di¬
mensional problems that are encountered.
Principles of Ossicular Repair
The physics of sound transmission
through the human ear has long been
studied as has the pathology of the middle
ear. It is optimistic to say that universal
understanding or complete definition has
taken place. Experience and feedback from
problems has taught, however, that certain
guidelines will result in a smaller conductive
handicap for a larger percentage of patients.
These guidelines are as follows: former (areal ratio) will be utilized. The
1. Avoid artificial prostheses. Chronically tympanic strut also serves as an anchor point
diseased ears have a marked intolerance to so that as tympanic membrane graft shrink¬
foreign materials. Inertness is relative, and age takes place, the ossicular grafts will not
long-term follow-up has shown an intoler¬ be displaced laterally, leaving a gap between
ance to foreign materials by scarring or ex¬ portions of the system and consequent trans¬
trusion with consequent poorer hearing year mission loss.
by year in these patients. 3. Construct an ossicular lever system.
2. Maintain or reconstruct an energy-cou¬ The stapes is limited in excursion by its
pler within the tympanic membrane. Nor¬ annular ligament. Transformer action re¬
mal anatomy has given this clue in the quires a reduction in amplitude of motion
imbedding of the malleus handle within the with consequent increase in sound pressure
fibrous structure of the tympanic membrane. at the footplate. A columellar system is not
Preserving this structure or fashioning a new only poorly coupled to the tympanic mem¬
tympanic strut will avoid two problems. Ade¬ brane, but also permits only limited excur¬
quate energy transfer from the vibrating tym¬ sion from the areal sound wave. This cre¬

panic membrane to the ossicular system will ates much higher impedence, especially for
take place and the entire hydraulic trans- low frequency sound. Reflection of the sound

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015

 wave is increased and the energy transfer to
the cochlear fluids is reduced.
A lever system lowers impedence by al¬
lowing high amplitude vibration of the tym¬
panic membrane to be reduced in amplitude
and increased in pressure level at the foot¬
plate, thus increasing the transmission of
sound energy. All of the types of ossicular
reconstruction recommended in this paper,
including the "L"-shaped graft, provide the
type of lever transformation described.
Conclusion
Three years ago, in a paper on staging in
References
1. McNemar Q: Psychological Statistics, ed 4.
New York, John Wiley & Sons Inc, 1969, chap 7.
2. Richtner NG: On tympanoplasty. J Laryng 72:
66-77, 1958.
3. Farrior JB: Ossicular repositioning and ossicu-
larprosthesis in tympanoplasty. Arch Otolaryng 71:
443-449, 1960.
4. Bell HL: A technique of tympanoplasty. Trans
Amer Laryng Rhinol Otol Soc 1958, pp 572-576.
5. Hall A, Rytzner C: Malleus-stapes transposi-
tion. Pract Otorhinolaryng 21:316-321, 1959.
6. Sheehy JL: Ossicular problems in tympano-
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/24/2015
tympanoplasty,10 I stated that "the patient
will be pleased if a single operation will
provide this result (restoration of structure
and function). We must continue to struggle
to make possible this ideal." The overall
failure rate to that time was 23.4 percent.
With staging, the failure rate decreased to
22.5% (a nonsignificant change). With cur¬
rent methods, planned as a single-stage op¬
eration, the failure rate is 15.6%—a signif¬
icant change. Looking to the future, it is
hoped that someday the same results may be
reported, but using closure of the bone-air
gap to 10 dB or less as the success criteria.
plasty. Otolaryng 81:115-122, 1965.
Arch
7. Hall A, Rytzner C: Autotransplantation of
ossicles. Arch Otolaryng 74:22-26, 1961.
8. Jansen C: Combined approach for tympano-
plasty. Laryng 82:779-793, 1968.
9. Seidentop KH, Brown RC: Type III, polyeth-
ylene columella tympanoplasty. Arch Otolaryng 83:
560-565, 1966.
10. Austin DF: Types and indications of staging.
Arch Otolaryng 89:235-242, 1969.
11. Jansen C: Cartilage tympanoplasty. Laryngo-
scope 73:1288-1302, 1963.