Clinical Research Of Pure Tone Audiology Characteristic And Surgery Technique In Different Type Of Tympanosclerosis Patients

BackgroundTympanosclerosis is a scarring process with a remarkable variability in its localization within the middle ear, It can lead to conductive hearing loss in many cases and occur in any part of the tympanic cavity. It is usually caused by recurrent chronic inflammation of the middle ear. It is generally accepted that functionally relevant tympanosclerotic findings of the middle ear structures should be treated by surgery. Depending on the extent of the surgical resection, the tympanic membrane and the ossicular chain must be reconstructed individually. In cases of isolated myringosclerosis with no hearing loss, no surgery is required. When the ossicular chain is affected by the sclerosis, sound conduction can often be restored only by interposition of grafts. Stapes footplate fixation can be treated by a stapesplasty. Tympanosclerosis of the oval window combined with other chronic inflammation usually requires two-stage surgery. Tympanosclerotic findings without any clinical symptoms should not be removed. The fitting of conventional or implantable hearing aids is the only treatment if chain reconstruction fails or is impossible. The word of "sclerosis"was first proposed by Von Troltsch in1869. And be described as middle ear mucosa deepest fibrous tissue sclerosis in1873.The general incidence of tympanosclerosis among patients with chronic suppurative otitis media (CSOM) is rate of20%-43%in foreign literature, however,3.7%-11.7%in domestic reports. The etiology and pathogenesis of tympanosclerosis is not yet clear, and there is no clear diagnostic criteria that mostly rely on clinical audiological diagnosis, confirmed by pathological. The treatment of tympanosclerosis is surgery. Tympanosclerosis surgery indications continue to expand and increasing number of surgical procedures, With the ear microscopy and tympanoplasty extensively developed, especially the emergence of the Partial ossicular replacement prostheses (PORP), bone conduction hearing aids, and artificial middle ear, but The technique of choice has been controversial, Both are the current problem of otology.Tympanosclerosis is usually classified into four different types depending on the the Wielinga and Kerr classification method. Tympanic sclerosis (type Ⅰ), fixed Malleus-incus complex (type Ⅱ), fixed Stapes (typeⅢ), fixations of both the stapes footplate and the Malleus-incus complex with or without cholesteatoma (typeⅥ). Which type I is easier to diagnose in preoperative through the pure tone hearing threshold and ear endoscopic, but the other three types are difficult to accurately diagnose in preoperative. The literature is extensive with studies characteristics of the pure tone Audiology in tympanosclerosis patients, but rarely studies characteristics of the pure tone Audiology in different type of tympanosclerosis patients. To learn the pure tone Audiology characteristics in different type of tympanosclerosis patients, May provide a theoretical reference for the clinical diagnosis and the prognostic evalation.Ossicular chain reconstruction (OCR) is the sound transmission connection between the eardrum and the perilymph to restore stability, and the surgery to achieve recovery or improve the function of the middle ear transmission system. Since the1950s, Wullstein and Zollner conducted the OCR, otologist whom carried out a lot of exploration, much progress has been made,But the surgical is still the difficulty for ear ossicle have lesions of otitis media cases such as tympanosclerosis Eleftheriadou etc reports, OCR with PORP and followed up14years postoperative, the efficiency of operation is only68.8%. The literature is extensive with studies comparing techniques, materials, and patient factors that influence OCR outcome, but has not formed a unified opinion, and more rarely reported of malleus processing impact of the efficacy in the OCR.In this study, Retrospective analysis was used in patients with tympanosclerosis. Study the characteristics of the pure tone Audiology in different type of tympanosclerosis patients and the malleus processing in OCR impact of efficacy in patients with tympanosclerosis. Provide a theoretical reference for the preoperative diagnosis, techniquesand assessment of surgical efficacy.Part IThe characteristics of the pure tone Audiology analysis in different type of tympanosclerosis patientsObjectiveTo investigate the pure tone Audiology characteristics in patients with Tympanosclerosis. Provide a theoretical reference for the clinical diagnosis.Methods1.1Material:Retrospective review of102cases(102ears) of tympanosclerosis patients among a total of1021patients with chronic otitis media with or without cholesteatoma who were surgically treated at Zhujiang hospital from January2002to January2012. Of the102patients,40males and62females, aged12to60years, the mean age was34.15±11.26years, all patients presented with a history of chronic suppurative otitis media (CSOM) with a range of2to50years, with an average of17.97±10.13years. Clinical examination showed dry inactive ear over one month. The main clinical manifestations is recurrent otorrhea associated with hearing loss, and some patients with tinnitus.1.2Method: 1.2.1Experiment process:The pure tone Audiology and ear endoscope were carried on all the102patients within a week before operation, The air conduction (AC) and bone conduction (BC) were tested at the frequency of250、500、1000、2000and4000Hz. The speech frequency pure tone average (PTA) with the average hearing threshold at0.5,1.0,2.0kHz. Tympanic membrane was examined by ear endoscope, Pure tone audiometry using GSI61clinical audiometer of American. The hearing results were compared statistically.1.2.2Clinical classification:In this paper, tympanosclerosis involvement of the middle ear is classified into four different types depending on the extent of the desease and the site of tympanosclerosis and the Wielinga and Kerr classification method. There were all102patients(102ears), in which24patients (24ears) were Tympanic sclerosis,30patients (30ears) were fixed Malleus-incus complex,23patients (23ears) were fixed Stapes and25patients (25ears) were fixations of both the stapes footplate and the Malleus-incus complex and with or without cholesteatoma.1.2.3Main review index:The speech frequency air conduction (AC), bone conduction (BC) and the mean air bone gap (ABG) were tested at the frequency of500、1000and2000Hz in each group. The AC and BC were tested at the frequency of250,500,1000,2000and4000Hz in group A, The mean AC and BC were tested at the frequency of250,500,1000,2000and4000Hz in all cases of the other three groups. During surgery, the site of and degree of tympanosclerosis in middle ear and ossicles were inspected. Tympanic membrane was examined by ear endoscope,1.2.4Statistical disposal:Results are expressed as mean±standard deviation. All data among group A, group B, group C, and group D were compared by One-way ANOVA and LSD test. P<0.05was considered statistically significant, All statistical analysis through the SPSS13.0software.Results The pre-operation mean air bone gap (ABG) in these groups were40.07±77.56dB,37.31±76.45dB,36.75±76.72dB, The hearing in group A is better than the other three groups (p<0.05). The difference in group B, group C and group D had no statistical significance (p>0.05). In all the patients,3ears of the tympanic membrane integrity, perforation99ears,47ears presence of calcified plaque in the remnants of the tympanic membrane,74ears sufferedconductive hearing loss,28ears had mixed deafness, Carchart-like notch changes were found in audiogram for39ears. Almost all the other cases except group A the ABG was greater than30dB.ConclusionMost of the patients with tympanosclerosis suffer conductive hearing loss, No significant relationship between the degree of hearing loss and the scope and extent of the Sclerosis lesions in group B, group C and group D. when ABG was greater than30dB, may presage ossicular chain lesions. However we can not diagnosed tympanosclerosis by preoperative pure tone threshold features, but for long-term CSOM patients, the ABG greater than30dB should to be key consideration tympanosclerosis and OCR fixed or damaged. Part IIThe malleus processing in ossicular chain reconstruction impact of efficacy in patients with tympanosclerosisObjectiveTo investigate the effect of malleus treatments on the postoperative efficacy in the Tympanosclerosis patients with ossicular chain reconstruction.Methods 1.1Material:Retrospective review of prospectively collected data from the most of patients with tympanosclerosis of type Ⅱ(that is Malleus-incus complex fixed) and ossicular reconstruction with Partial Ossicular Replacement Prosthesis(PORP) from January2002to January2012were used, at the Zhu Jiang Hospital. The average age of the patients was30.63±9.18years, with a range of16to52years. Of the102patients,22males and37females, aged14to59years, the mean age was29.37±10.15years, a history of up to40years, the shortest five years, an average of17.47±8.21years.all patients presented with a history of chronic suppurative otitis media (CSOM) with a range of5to40years, with an average of32.19±9.66years. Clinical examination showed dry inactive ear over one month. All the cases were followed-up for15-21months, with an average of16.1months. Measure tool:GSI61clinical audiometer of American.1.2Method:1.2.1Experiment process:In this study, there are59patients (62ears) with tympanosclerosis were treated by ossicular chain reconstruction who divided into three groups. All the patients were divided into three groups, including (A) malleus removal group (24ears),(B) retaining only the malleus handle group(18ears) and (C) the intact the malleus group (20ears); this is based on the malleus processing in ossicular chain reconstruction. All the patients were followed up pre-operation,3months and lyear postoperation through audiometric measurement (the average hearing threshold at0.5,1.0,2.0(kHz HL).Tympanic membrane was examined by ear endoscope. The hearing results were compared statistically. To investigate the different malleus processing in OCR impact of efficacy in patients with tympanosclerosis.1.2.2Surgery technique:Cases of general anesthesia below the age of18,the rest were all local anesthesia, take the patient supine, head to the contralateral and surgery ears up.All the patients with tympanosclerosis underwent surgery, the tympanomeatal flap was elevated after making incisions in the canal skin at the6and12o,clock. The tympanic membrane perforation was closed by autologous temporalis fascia. The exposure of all the patients may be achieved by a simple endomeatal atticotomy. Exploration of the ossicular chain, Clear sclerosis lesions around the malleus and incus, Separation of Malleus-incus joint and incus-stapes joint, removal of the incus through a standard transcanal approach, Handle of the malleus are malleus removal, retaining only the malleus handle and the intact the malleus. after which an ossicular reconstruction was carried out as follows:Partial Ossicular Replacement Prosthesis (PORP) placed between the intact, mobile stapes and the Malleus handle or tympanic membrane. Offending plaques should be completely removed. Myringoplasty were operation with the temporal fascia built-law.Fascia or tragal perichondrium must be interposed between the prosthesis and the undersurface of the tympanic membrane to accomplishing secure placement of the prosthesis, because of the tympanic membrane graft will necrose owing to the pressure and the prosthesis will exposure.1.2.3Main observation indexs:In all the59patients (62ears), The Pure tone average (PTA) were followed up pre-operation,3months and lyear postoperation through audiometric measurement (the average hearing threshold at0.5,1.0,2.0kHz HL), pure tone audiometry using GSI61clinical audiometer of American, Both air conduction (AC) and bone conduction (BC) were taken as the average of500,1000and2000Hz values. AC and BC from the same test were used to calculate the air-bone gap (ABG). The preoperative ABG minus the postoperative ABG is the improve ABG, With ear endoscopic observation how the tympanic membrane graft growth postoperative.1.2.4Statistical disposal:Results are expressed as mean±standard deviation. All data of the three groups between preoperative and postoperative were compared by Paired T-test. All data among the three groups were compared by analysis of variance (One-way ANOVA), the pairwise comparisons using LSD test. P<0.05was considered statistically significant, All statistical analysis through the SPSS13.0software.ResultsThe pre-operation mean ABG in these groups were40.07±77.56dB,37.31±76.45dB,36.75±76.72dB, The difference had no statistical significance (P>0.05).After3months operation, the ABG in all cases was improved at0.5,1and2KHz.The difference among these three groups had no statistical significance (P>0.05). One year after surgery, the ABG of the three goups were decreased by17.92±9.28dB,16.76±5.19dB,10.58±7.38dB respectively. The hearing improvement in group C is worse than the other two groups (p=0.03, p=0.016). The difference between group A and group B had no statistical significance (p=0.630).Group A and group B each have one case of tympanic membrane, artificial ossicle off.ConclusionThe operating processes of malleus treatments in ossicular chain reconstruction with tympanic were introduced. In terms of short-term efficacy, the three groups showed no signfficant difference. However, the long-term efficacy of the patients in the group A and group B were better compared with the group C.