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[Experiences with incus autografts and preserved incus homografts in ear surgery (author's transl)].

The healing process of free-transplantated incus autografts and preserved homografts in the middle-ear is largely non-irritating. They are suited for sound transmission. Under the osteoinductive influence of the non-vital graft, ingrowing vascular connective tissue of the host differentiates itself in osteoblasts, osteoclasts and chondroblasts. The grafts are revitalised in relation to time. Rarely a marked resorption of preserved incus homografts was noticed in consequence of an antigen-antibody-reaction between the host and the implant which, however, never occurred in autografts.

Antigen-Antibody Reactions

Incus window in transposition.

In aiding the positioning of the incus in incus transposition, a hole, the incus window, is drilled completely through the body of the incus. Through the window the surgeon has a visual as well as a tactile reference to the head of the stapes. At one year results show that 182 of 201 patients closed the air-bone gap to within 20 dB of the preoperative bone level.

Bone Transplantation

The histopathology of the incus after stapedectomy.

Twenty-two temporal bones subjected to stapedectomy were examined by light microscopy for histological changes in the long process of the incus. In 19 cases a stainless steel wire technique had been used and in three a polyethylene tube operation had been performed. Twenty healthy unoperated ears were examined as controls. In all operated ears fibrosis and reduced vascularity of the mucosa was noted. In the polyethylene tube group, 1 ear showed the growth of new bone into the lumen of the tube and 1 showed minor resorption of the long process of the incus. In the stainless steel wire group bone resorption of the long process of the incus. In the stainless steel wire group bone resporption was seen in 5 cases and 1 incus also showed an area of necrosis adjacent to the tip; 2 of the 5 incudes showed some loss of the lenticular process. The main factor relating to bony resorption in this group was the presence of other histological changes resulting from postoperative inflammation. These findings represent a critical histological examination; the hearing results obtained appear to be good, although full audiometry is lacking.

Adult

Virtual image of the incus from a saline lens: an aid to safe dissection of the mastoid antrum.

Dissection of the antrum requires judicious visualization of the tegmen, horizontal canal, incus, and facial nerve. Inadvertent contact with the incus by the power drill may cause significant acoustic trauma. An effective "early warning device" accurately predicting exposure of the incus may be constructed with the saline irrigation fluid. The formation of the meniscus at the antrum permits visualization of the image of the incus around the corner of the bony canal wall overhang. A thin-lens model of this phenomenon has been created for first-order analysis of the optics, and it provides useful criteria for using this image. Image minification, displacement, and distortion were analyzed. A more complex model was then created to assess the impact of changing meniscus shape. The latter helped in understanding an added "swinging-door effect" noted as the meniscus was altered. The model predicted accurately the phenomena as observed in the temporal bone preparation. Illustrative examples of the optics and photographic demonstrations of the phenomena are presented.

Dissection

Allograft stapes-incus assembly. A new ossiculoplasty.

In 45 patients with absence of the stapedial arch, including 24 with a history of radical surgery and without ossicles, the head of an allograft stapes was placed on the patient's footplate and on top of this an incus body, either as allograft or autograft. The results of this assembly, judging by different methods of analysis, are the same as in 45 ears having approximately the same pathologic condition treated by an autograft or allograft incus as the columella between the footplate and eardrum. The allograft stapes-incus assembly is an alternative method to the commonly used incudal columella, particularly in patients previously subjected to radical surgery in whom all ossicles are absent.

Ear Ossicles

Allograft stapes-incus assembly. Long-term results.

In 35 patients with absence of the stapedial arch, with a history of radical surgery, and without ossicles, the head of an allograft stapes was placed on the patients' footplates and an allograft incus body on the top of this. The long-term results of this assembly, judging by different methods of analysis, are still somewhat better than those of 98 ears with approximately the same pathologic condition treated by an allograft incus as the columella between the footplate and fascia. The allograft stapes-incus assembly is an alternative method to the commonly used incudal columella. The allograft stapes has not been resorbed to a significant degree during the years after surgery.

Ear Ossicles

[A comparison of the results of incus interposition in the Wullstein type III and type IV tympanoplasty (author's transl)].

Incus interposition for reconstruction of the sound conduction mechanism in a deep tympanic cavity can be effectively utilized in both Wullstein Type III and IV tympanoplasties. In the Type III tympanoplasty, in which the incus is interposed between malleus or tympanic membrane and stapes, the average post-operative air-bone gap approximates 16 db, while incus placement on the stapes footplate results in an air-bone gap of 23.5 db. There is no difference in change of bone conduction when all operative mehtods are compared. Improved results in reconstruction of the second conduction mechanism are best obtained by conserving or reconstructing the tympanic membrane and posterior bony external canal wall through improved audio-physiologic dynamics.

Ear Canal

An incus replacement prosthesis. The ossicle cup.

To achieve better hearing after incus replacement surgery, the ossicle-cup prosthesis is introduced. This prosthesis incorporates part of a Teflon Robinson's stapes prosthesis into the body of an incus. The ossicle-cup prosthesis has a dynamic joint with the stapes capitulum, as well as a variable height above the stapes. Preliminary hearing results of 45 cases show air-bone gap closure of 67% within 10 dB and 98% within 20 dB.

Ear Ossicles

Necrosis of the incus by the chorda tympani nerve.

Ossicular necrosis is often associated with chronic adhesive otitis media. An unusual abnormality discovered in an incus removed during tympanoplasty is reported. The long process appears to have been grooved by pressure from the chorda tympani. An alternative theory to explain the vulnerability of the long process of the incus is suggested.

Chorda Tympani Nerve

The effects of preservation methods on homologous incus transplants in cats.

Experimental incus transplants were performed in cats. The gross findings and histologic data were recorded and correlated to the use of four preservation methods for homografts (alcohol, Cialit, formalin, and freezing). The formalin preserved incudes produced the least middle ear reaction and ossicular fixation. These incudes also exhibited a uniform perivascular bone remodeling throughout the homograft while the bones preserved in Cialit and alcohol were replaced much faster and ossicular chain fixation occurred. The incus bones preserved by freezing were better tolerated than the Cialit and alcohol ones but not as well as the formalin ones.

Animals

[Comparison of the results of incus interposition and artificial columella in tympanoplasty (author's transl)].

The average postoperative air-bone gap after interposition of an incus between tympanic membrane and stapes footplate is too high in case of missing crura of the stapes, it is 27 dB. The interposition of an artificial prosthesis, according to Shea and beeing made of "Platipore", leads to a statistically based lower air-bone gap with a mean of 20 dB. Concerning the change of bone conduction, there is no difference between these two methods of operation. The rate of artificial prosthesis which are perforating the tympanic membrane, increases after seven months up to 15%, but only 4% of the incuses invade the plane of the tympanic membrane after 22 months.

Bone Conduction

[Problems of autologic incus interposition in cholesteatoma operations (author's transl)].

Our clinical study proves whether or not the warning is justified not to reimplantate autologic ossicula in cholesteatoma operations in order to avoid recidives. After interposition of the autologic incus in 18 patients we found cholesteatome recidives--originating from the incus--in two cases. According to histological studies, even the most careful preparation cannot avoid that some cells of the epithelium remain on the ossicula, from which a cholesteatoma recidive may develop. Clinical studies show rather low rates of recidives compared with the histological findings. Possibly remaining squamous epithelium cells in autologic ossicles need not always cause recidives. Clinical and histological studies lead to the demand that because of the possibility of cholesteatoma recidives autologic ossicula should not be reimplated in cholesteatoma operations.

Cholesteatoma

Human incus long process depressions in the surface of the normal ossicle.

Depressions in the bone surface of the normal human incus long process are found with great frequency. This paper reviews the frequency and distribution of these depressions, discusses their histologic appearance, and speculates upon their significance. While their clinical significance is unclear, they may be related to several conditions encountered in otologic practice.

Ear Ossicles

[Incus, controlled deepfrozen or in cialit conserved, after allogenetic implantation. An animal-experimental study with comparing histology (author's transl)].

The histological reactions to the implantation of allogenetic incus after conservation in Cialit or after controlled deepfreezing are described. After 5 months the incusses of both conservation technics show the same good tendency of revitalisation. Therefore the controlled deep-freezing technic does not offer an advantage compared to the Cialit conservation method at least for the present state of knowledge.

Animals

Experimental autogenous incus transposition.

Incus replacement or transposition was performed in 82 rats. Findings were similar in that a degree of vitality was retained or regained, though more slowly in boiled implants. Gelatin sponge induced fibrosis. Activity rapid at first ceased later. Generally replanted includes seemed stable.

Animals