Outcome of Incus Interposition after Preservation in Soft Tissue

Document Type: Original


1 Otolaryngology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

2 Department of Otolaryngology, Shiraz University of Medical Sciences, Shiraz, Iran


The lenticular process of the incus succumbs to necrosis in chronic otitis media. Few researchers have addressed the issue of autograft incus preservation in the soft tissue of the tragus or mastoid cavity. Nonetheless, preservation of the incus in this method during the second stage of ossiculoplasty is a subject that is still up for debate. This study was carried out to demonstrate the hearing outcome after a modification of the incus interposition technique, which involved preserving it in the periauricular soft tissue.
Materials and Methods:
In the primary operations, tympanoplasty was performed with a postauricular incision. At the end of the surgery, a small pocket was created to preserve the incus beneath the temporalis fascia. The second stage of ossiculoplasty was performed 6 to 18 months after the primary operation. Post-operative pure tone audiometry was analyzed after at least 12 months and was considered successful after achieving an air-bone gap (ABG) within 20 dB.
In this paper, we analyzed 199 ears. The mean duration of follow up was 2.5 years. We achieved post-operative ABG within 20 dB in 157 patients (78.9% of patients).
This study indicates the efficacy and safety of incus interposition when it is preserved in the postauricular soft tissue.


Main Subjects

1. Mohanty S, Gopinath M, Subramanian M, Vijayan N. Relevance of Pure Tone Average (PTA) as a Predictor for Incus Erosion. Indian J Otolaryngol Head Neck Surg. 2012;64(4):374-6.

2. Varshney S, Nangia A, Bist SS, Singh RK, Gupta N, Bhagat S. Ossicular chain status in chronic suppurative otitis media in adults. Indian J Otolaryngol Head Neck Surg. 2010;62(4):421-6.

3. Brenski AC, Isaacson B. Reconstruction of the ossicular chain in children. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2009; 20(3): 187-96.

4. Albera R, Canale A, Piumetto E, Lacilla M, Dagna F. Ossicular chain lesions in cholesteatoma. Acta Otorhinolaryngol Ital. 2012;32(5):309-13.

5. Chien W, Northrop C, Levine S, et al. Anatomy of the distal incus in humans. J Assoc Res Otolaryngol. 2009;10(4):485-96.

6. Kim HH, Wiet RJ. Preferred technique in ossiculoplasty. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2003; 14(4): 243-6.

7. Hotz MA, Speirs AD, Oxland T, Muller M, Hammerle C, Hausler R. Radiologic and mechanical properties of inactivated ossicle homografts. Laryngoscope. 1999;109(1):65-9.

8. Gyo K, Hato N, Shinomori Y, Hakuba N. Storage of the incus in the mastoid bowl for use as a columella in staged tympanoplasty. Auris nasus larynx. 2007;34(1):5-8.

9. Fritsch MH, Moberly AC. Tragal storage of autograft middle-ear ossicles. Otolaryngol Head Neck Surg. 2010;143(1):161-2.

10. Pyle GM. Ossicular sculpting for conductive hearing loss. Operative Techniques inOtolaryngology- Head and Neck Surgery. 2003;14(4):237-42.

11. O'Reilly RC, Cass SP, Hirsch BE, Kamerer DB, Bernat RA, Poznanovic SP. Ossiculoplasty using incus interposition: hearing results and analysis of the middle ear risk index. Otol Neurotol. 2005;26(5):853-8.

12. Somers T, Van Rompaey V, Claes G, et al. Ossicular reconstruction: hydroxyapatite bone cement versus incus remodelling: how to manage incudostapedial discontinuity. Eur Arch Otorhinolaryngol. 2012;269(4):1095-101.

13. Felek SA, Celik H, Islam A, Elhan AH, Demirci M, Samim E. Type 2 ossiculoplasty: prognostic determination of hearing results by middle ear risk index. Am J Otolaryngol. 2010;31(5):325-31.

14. Chaudhary N, Anand N, Taperwal A, Rai AK. Role of autografts in the reconstruction of ossicular chain in intact canal wall procedures. Indian J Otolaryngol Head Neck Surg. 2003;55(3):157-9.

15. Neudert M, Zahnert T, Lasurashvili N, Bornitz M, Lavcheva Z, Offergeld C. Partial ossicular reconstruction: comparison of three different prostheses in clinical and experimental studies. Otol Neurotol. 2009;30(3):332-8.

16. Farrior JB, Nichols SW. Long-term results using ossicular grafts. Am J Otol. 1996;17(3):386-92.

17. Nikolaou A, Bourikas Z, Maltas V, Aidonis A. Ossiculoplasty with the use of autografts and synthetic prosthetic materials: a comparison of results in 165 cases. J Laryngol Otol. 1992; 106(8): 692-4.

18. Martins O, Victor J, Selesnick S. The relationship between individual ossicular status and conductive hearing loss in cholesteatoma. Otol Neurotol. 2012;33(3):387-92.

19. Schmerber S, Troussier J, Dumas G, Lavieille JP, Nguyen DQ. Hearing results with the titanium ossicular replacement prostheses. Eur Arch Otorhinolaryngol. 2006;263(4):347-54.

20. Mardassi A, Deveze A, Sanjuan M, et al. Titanium ossicular chain replacement prostheses: prognostic factors and preliminary functional results. Eur Ann Otorhinolaryngol Head Neck Dis. 2011; 128(2):53-8.

21. Michael P, Fong J, Raut V. Kurz titanium prostheses in paediatric ossiculoplasty--short term results. Int J Pediatr Otorhinolaryngol. 2008;72(9): 1329-33.

22. Eleftheriadou A, Chalastras T, Georgopoulos S, et al. Long-term results of plastipore prostheses in reconstruction of the middle ear ossicular chain. ORL J Otorhinolaryngol Relat Spec. 2009;71(5): 284-8.

23. Alaani A, Raut VV. Kurz titanium prosthesis ossiculoplasty--follow-up statistical analysis of factors affecting one year hearing results. Auris nasus larynx. 2010;37(2):150-4.

24. Ho SY, Battista RA, Wiet RJ. Early results with titanium ossicular implants. Otol Neurotol. 2003; 24(2):149-52.

25. Gardner EK, Jackson CG, Kaylie DM. Results with titanium ossicular reconstruction prostheses. Laryngoscope. Jan 2004;114(1):65-70.

26. Vassbotn FS, Moller P, Silvola J. Short-term results using Kurz titanium ossicular implants. Eur Arch Otorhinolaryngol. 2007;264(1):21-5.

27. Fong JC, Michael P, Raut V. Titanium versus autograft ossiculoplasty. Acta oto-laryngologica. May 2010;130(5):554-8.

28. Woods O, Fata FE, Saliba I. Ossicular reconstruction: incus versus universal titanium prosthesis. Auris nasus larynx. 2009;36(4):387-92.

29. Goldenberg RA, Emmet JR. Current use of implants in middle ear surgery. Otol Neurotol. 2001;22(2):145-52.

30. Dhanasekar G, Khan HK, Malik N, Wilson F, Raut VV. Ossiculoplasty: a UK survey. J Laryngol Otol.  2006;120(11):903-7.

31. Wake M, Robinson JM, Sheehan AL, Bazerbachi S, Codling BW. The histology of 'stored' autologous ossicles. J Laryngol Otol. 1992;106(1): 17-20.

32. Merchant SN, Nadol JB, Jr. Histopathology of ossicular implants. Otolaryngol Clin North Am. 1994;27(4):813-33.

33. Schuknecht HF, Shi SR. Surgical pathology of middle ear implants. Laryngoscope. 1985;95(3):

34. Bahmad F, Jr., Merchant SN. Histopathology of ossicular grafts and implants in chronic otitis media. Ann Otol Rhinol Laryngol. 2007;116(3):181-91.

35. Pennington CL. Incus interposition. A 15-year report. Ann Otol Rhinol Laryngol. 1983;92(6 Pt 1): 568-70.

36. Ferekidis E, Nikolopoulos TP, Yiotakis J, et al. Should we use ossicular remnants in ossicular reconstruction following cholesteatoma removal? ORL J Otorhinolaryngol Relat Spec. 2006; 68(4): 243-6.

37. Stankovic M. Applicability of autologous incus: the influence of age and localization of cholesteatoma. Eur Arch Otorhinolaryngol. 2007; 264(9):995-8.

38. Mahadevaiah A, Parikh B. Use of autogenic and allogenic malleus in tympanic membrane to footplate assembly - long-term results. Indian J Otolaryngol Head Neck Surg. 2009;61(1):9-13.