Clinical Research Of Audiology And Surgery Technique In Patients With Tympanosclerosis

PartⅠClinicopathologic and electron-microccopic studies intympanosclerosisObjective Light and electron-microccopic studies of the tissue from middleears diagnosed as having tympanosclerosis. The main purpose of this article is to tryto show some light on the speculations regarding the feature and pathogenesis oftympanosclerosis.Methods1.1 Material The materials for histopathologic and electron-microccopicstudies were taken from the tympanic mucosa in various localities, especially fromthe whitish sclerotic masses in the tympanum, during middle ear surgery in patientswith diagnosis of tympanosclerosis at the Zhu Jiang Hospital between 2005 and2006.1.2 Experiment Process:1.2.1 Specimens were divided into two groups: one group of specimens wasfixed and stained for lightmicroscopic study with hematoxylin-eosin,1.2.2 The other group of specimes: when the issue was dissected out, it wasfixed in phosphate-buffered 2.5 percent glutaraldehyde and post-fixed with 2 percent osmic acid. After dehydration in a series of graded alcohol, the specimens wereembedded in Epon and sectioned. Section were stained with uranyl acetate andstudied in the electron microscope. Specific procedure: 1 Tissue dissected out andplaced in fixing solution. 2 After washing, the tissue is dehydrated by placing it inhigher and higher concentrations of alcohol, then it is placed in dilute solution ofplastic embedding medium Epon. 4 Tissue is placed in final embedding mixture andthe plastic is polymerized in an oven. When the plastic is hard, the block is trimmedand is ready for sectioning. Sections are cut on an ultramicrotome with a glass ordiamond knife. The sections are floated off the edge of the knife onto the surface of awater trough and then they are picked off the surface with a copper grid. 5 Sectionsdry. 6After the sections dry, they are ready for staining with heavy metal solutionsuranyl acetate and viewing in the electron microscope.ResultsThe specimens from tympanic mucosa, around where the drum was adhesive,showed granulation tissue with infiltration of chronic inflammatory cells, slightfibrosis in the submucosal layer, and epithelial metaplasia. In another specimen,infiltration of acute inflammatory ceils was also noted. The specimen taken fromwhitish sclerotic masses around the incus revealed scarring with hyalinization anddystrophic calcification in the submucosa. Moderate fibrosis with hyalinization wasnoted in the subepithelial layer. Histopathology of the plaques after haemaoxylin andeosin staining revealed dense bundles of collagen with hyaline degeneration andscattered areas of calcification. In certain areas they were seen to overlie granulationtissue where their avascular appearance contrasted sharply with the vascularappearance of the granulation tissueElectron-microscopic study revealed cells having oval nuclei, with clusters ofmitochondria in perinuclear cytoplasm and with strands of tonofilaments making uptonofibrils in the cytoplasm. Ultrastructural examination of these specimens revealedfibrocytes that were irregularly shaped, elongated, and degenerating. Most of themhad electron-dense nuclei, and the osmiophilic cytoplasm contained vesicles. Markedly increased bundles with different-sized collagen fibers ran in variousdirections. Among the collagen bundles and fibers, various sizes of mostlymembrane-bound corpuscles with amorphous electron-dense materials were seen.The corpuscles or vesicles tended to be aggregated about the areas where thedegenerating fibrocytes and fragmented collagen fibers were noted.Conclusion Histopathologic studies of tympanosclerosis revealed densefibrous and collagenous connective tissues, poor in cell, with hyaline degenerationand occasional calcification in the tympanic mucosa. Electron-microscopic studiesfurther revealed marked proliferation of collagen fibers and electrondense calcareousdeposits within lysosomes and degenerated mitochondria in fibrocyte cells. PartⅡAudiological Assessment in Patients with TympanosclerosisObjective To assessment hearing status in patients with tympanosclerosis.Methods1.1 Material Retrospective review of complete collected data from the most ofpatients with tympanosclerosis between 1992 and 2006. in this group, all patientspresented with a history of chronic suppurative otitis media (CSOM) with a rangeof 5 to 40years, the mean age was 29.37±10.15 years. Clinical examination showeddry inactive ear over one month with perforation of the ear drum and presence oftympanosclerotic plaques. There were all 79 patients(79ears), in which 30 patients(30 ears) were fixed Malleus-incus complex, 29 patients (29 ears) were fixed Stapesand 20 patients (20 ears) were fixations of both the stapes footplate and theMalleus-incus complex.. Measure tool: GSI 61 clinical audiometer of American.1.2 Method1.2.1 Experiment Process:Audiometry was carried on all the patients,one or two days before operation,The hearing results were compared statistically..1.2.2 Clinical classificationIn this paper, tympanosclerosis involvement of the middle ear is classified intofour different types depending on the extent of the desease and the site oftympanosclerosis. This is based on the intra-operative findings of thetympanosclerotic involvement of the ossicular chain, tympanic membrane andmiddle-ear cavity.1.2.3 main review index:Seventy-nine cases of tympanosclerosis were studied retrospectively in theperiod from 1992 to 2006 in ZhuJiang hospital. In all the 79 patients, pure toneaudiometry using GSI 61 clinical audiometer of American where both airconduction (AC) and bone conduction (BC) were tested at the frequency of 250,500,1000,2000 and 4000Hz. Both AC and BC were taken as the average of 500, 1000 and 2000Hz values. All the patients with tympanosclerosis underwent surgery,during surgery, the site of tympanosclerosis, the ossicular mobility and degree oftympanosclerosis in middle ear and ossicles were inspected.1.2.4: Statistical Disposal:All data among typeⅡ,typeⅢand typeⅢⅠWere compared by One-wayANOVA(a=0.05), Results are expressed by means x±sD.Results In our series,most of them(65.8%) were conductive hearing loss, 32.9% were mixed type,one case had sensorineural hearing loss.There was notstatistically significant differences in speech (0.5,1K,2K) air conduction pure toneaverage (PTA) and in air-bone gap (ABG) of the three groups(p＞0.05).Conclusion Most of the patients with tympanosclerosis were conductivehearing loss, There is not direct relationship between extent and site oftympanosclerosis and severity of hearing loss. Objective To study the effectiveness of ossicular reconstruction with PartialOssicular Replacement Prosthesis(PORP) in patients with tympanosclerosis.Methods1.1 Material Retrospective review of prospectively collected data from themost of patients with tympanosclerosis of typeⅡ(that is Malleus-incus complexfixed) between 1992 and 2006 was used, at the Zhu Jiang Hospital.. The average ageof the patients was 30.63±9.18years, with a range of 16 to 52 years. Clinicalexamination showed dry inactive ear over one month. All the cases werefollowed-up for 3-24months. Measure tool: GSI 61 clinical audiometer of American.1.2 Method:1.2.1 Experiment Process:Audiometry was carried on all the patients ,one or two days before operation anda range from 3 months to 24 months after operation, The hearing results werecompared statistically..1.2.2 Clinical classificationIn this paper,, all the patients belong to typeⅡ: attic fixation of the malleus-incuscomplex with a mobile stapes,which depending on the extent of the desease and thesite of tympanosclerosis. This is based on the intra-operative findings of thetympanosclerotic involvement of the ossicular chain, tympanic membrane andmiddle-ear cavity.1.2.3 Main Observation Indexs:Thirty cases of tympanosclerosis were studied retrospectively in the period from1992 to 2006 in ZhuJiang hospital. In all the 30 patients, Pure-tone air andbone-conduction thresholds were obtained before and after surgery, pure tone audiometry using GSI 61 clinical audiometer of American where both airconduction (AC) and bone conduction (BC) were tested at the frequency of 250,500,1000,2000 and 4000Hz. Both AC and BC were taken as the average of 500,1000 and 2000Hz values. Air and bone from the same test were used to calculate theair-bone gap(ABG). The Pure-tone averages(PTA) of the ears before and aftersurgery were collected, with thresholds at 500,1000,2000Hz.1.2.4 Surgery technique:Allthe patients with tympanosclerosis underwent surgery, the tympanomeatal flapwas elevated after making incisions in the canal skin at the 6 and 12 o'clock. Thetympanic membrane perforation was closed by autologous temporalis fascia. Theexposure of all the patients may be achieved by a simple endomeatal atticotomy.15patients (15 ears) were performed by atticotomy with mobilization, while theother 15 patients (15 ears) included removal of the malleus head and incus through astandard transcanal approach, after which an ossicular reconstruction was carried outas follows: Partial Ossicular Replacement Prosthesis(PORP) placed between theintact,mobile stapes and the tympanic membrane.Offending plaques should becompletely removed. Several technical points concerning the PORP should bementioned. The shaft of these prostheses should be cut to the desired length, if theprosthesis is too short and not in good contact with the tympanic membrane, theconductive hearing loss will persist; if the prosthesis is too long, the tympanicmembrane will necrose owing to the pressure and the prosthesis will exposure,thereby accomplishing secure placement of the prosthesis, fascia or tragalperichondrium must be interposed between the prosthesis and the undersurface of thetympanic membrane.1.2.5 Statistical disposal:All data of the two groups between preoperative and postoperative werecompared by Paired T-test (a=0.05, two-tailed). All data between PORP andmobilization groups were compared by Independent T-test (a=0.05, two-tailed). Results are expressed by means x±sD.ResultsThe average postoperative air conduction was 35.33±14.38 dBHL for PORPgroup, 47.44±9.23dBHL for mobilization group;The average postoperative air-bonegap was 22.89±9.12 dB for PORP group, 31.67±9.88dB for mobilization group. Forthe two groups, p＜0.05 for comparison between Pre and Post by Paired T-test,while p＜0.05 for comparison between PORP and mobilization groups byIndependent T-test. As can be see, patients with PORP had significantly betterhearing results than those with mobilization. Ears treated by ossicular reconstructionwith PORP showed statistically better air-bone gap(ABG)and pure-toneaverages(PTA)(p＜0.05).ConclusionWhen the attic is the only site of ossicular fixation, two surgical options havebeen applied: removal of the entire outer attic wall with mobilization of the ossicles.The other method is an ossiculoplasty procedure removing the incus and malleus andre-positioning Partial Ossicular Replacement Prosthesis(PORP) between thetympanic membrane and the intact,mobile stapes, the results with the biocompatibleimplants are so far superior to the other older technique. Ossicular reconstructionusing PORP in patients with tympanosclerosis can yield better results than domobilization of the major ossicles.