The use of bone cement for ossicular chain defects

OTOLOGY

The use of bone cement for ossicular chain defects

M. Tayyar Kalcioglu • Mehmet Tan •

Jelle Fleerakkers

Received: 25 March 2012 / Accepted: 21 November 2012

� Springer-Verlag Berlin Heidelberg 2012

Abstract Bone cement is a good and cheap option for

some ossicular chain problems such as incudostapedial re-

bridging. The purpose of this retrospective study is to

evaluate the audiologic results after reconstruction of three

different types of ossicular chain defects, using bone

cement. Group 1 consists of 42 patients who underwent an

ossiculoplasty using bone cement between the damaged

long process of the incus and an intact stapes superstruc-

ture. Group 2 consists of 46 patients in which incus inter-

position between malleus and stapes superstructure was

performed, using bone cement to fix the interposed incus.

For group 3, consisting of 32 patients who had a present

malleus, a defective long process of the incus and a missing

stapes superstructure, a re-shaped incus was placed

between the stapes footplate and the malleus and bone

cement was again used as a fixator. Preoperative and

postoperative pure-tone audiometric findings were obtained

and hearing differences were assessed. The mean preop-

erative and postoperative air-bone gaps were 34.8 and 15.6,

35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3,

respectively. There was a significant improvement in

hearing outcomes in all the groups when comparing pre-

operative and postoperative mean air-bone gaps

(p \ 0.001). The postoperative air-bone gap was B20 dB

in 76 % of patients in group 1, 64 % of patients in group 2,

and 46 % of patients in group 3. Bone cement is an

effective and cheap option for some ossicular chain prob-

lems such as incudostapedial re-bridging. It may also be

used to fix the interposed incus to the stapes superstructure

and/or malleus to avert displacement.

Keywords Bone cement �Ossicular chain reconstruction �Incus interposition � Incudostapedial bridge

Introduction

Chronic otitis media commonly affects the middle ear

bones with erosion and discontinuation of the ossicular

chain as a result. Especially the long process of incus is

vulnerable and is defective or missing in 60 % of ossicular

chain defects while the malleus and stapes are intact. This

results in a defective incudostapedial joint and as such

creates a conductive hearing loss [1]. Another common

problem of the ossicular chain is a defective stapes

superstructure with or without a defective incus. Recon-

structing these defects is a challenging procedure for the

surgeon with different treatment options such as a total

ossicular chain prosthesis (TORP), a partial ossicular chain

prosthesis (PORP), incus interposition, or bone cement

usage [2]. Cost effectiveness plays an important role in the

decision the surgeon has to make and bone cement has a

promising role in this. Bone cements are already widely

used in dentistry and craniofacial reconstruction surgery

[3], but more recently, they have won the interest of the

This article was partly presented at the 33th Congress of Turkish

Otorhinolaryngology and Head and Neck Surgery and 2nd Joint

Meeting of Turkish and German Societies of Otorhinolaryngology

and Head and Neck Surgery, Antalya, Turkey, October 26–30, 2011.

M. T. Kalcioglu (&)

Department of Otolaryngology, Istanbul Medeniyet University

Medical Faculty, Istanbul, Turkey

e-mail: [email protected]

M. Tan

Department of Otolaryngology, Inonu University Medical

Faculty, Malatya, Turkey

J. Fleerakkers

Ghent University Medical Faculty, Ghent, Belgium

123

Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-012-2296-9

(neur)otologic surgical field because of their inert, bio-

compatible profile and their ease of application in a diffi-

cult region. The cost is minimal, there is a low extrusion

rate and there seems to be proof of neo-osteogenesis [4].

The purpose of this retrospective study is to evaluate the

audiologic results following three different types of ossic-

ular chain reconstruction surgery, involving bone cement

performed by the same surgeon.

Materials and methods

The research protocol was approved by the Inonu Uni-

versity Clinical Researchs Ethic committee (2011/67).

Patients

Of 891 patients who underwent surgery due to chronic

otitis media performed by the same surgeon (M.T.K.)

between January 2000 and November 2011, patients eli-

gible for ossicular chain reconstruction were selected from

a database and data were evaluated retrospectively. Three

different types of ossicular chain reconstruction involving

bone cement were included in the study.

The first group (group 1) consists of an ossiculoplasty

using bone cement to bridge the ossicular defect between

the damaged long process of the incus and an intact stapes

superstructure, only if at least 50 % of the long process was

still present. This procedure allowed us to save the mal-

leoincudal joint and re-build the incudostapedial joint. This

procedure was performed in 42 patients.

Patients with a defective incus were included into the

second group (group 2), provided that an intact stapes and

malleus were present (including cases in which the incus

had to be removed from the original position because of

cholesteatoma). The original incus was used for interpo-

sition when it was possible to clear it from cholesteatoma

and when it was large enough. Incus interposition was

performed in 46 patients and bone cement was used to

fix the interposed incus to the malleus and stapes

superstructure.

Next, 65 cases had a present malleus and a missing

stapes superstructure. In 32 of these 65 patients, the

defective incus was removed to control cholesteatoma and

this was used between the stapes footplate and malleus

after reshaping it and using bone cement as a fixator for the

autograft, making up the third group (group 3). In the other

38 cases, type IV or V tympanoplasty or radical

mastoıdectomy was performed (5 type IV tympanoplasties;

1 type V tympanoplasties; 11 radical mastoıdectomies) or

they are still waiting for a second look tympanomas-

toıdectomy to control cholesteatoma and obtain hearing

restoration (16 cases).

Inclusion criteria for the study were a minimum of

6 months postoperative follow-up data and bone cement

ossiculoplasty using solely bone cement or using an auto-

graft with bone cement as an adjuvant. Preoperative and

postoperative pure-tone audiometric findings of the

patients were obtained and hearing differences at 500,

1,000, 2,000, and 4,000 Hz frequencies were assessed

based on the American Academy of Otolaryngology-Head

and Neck Surgery Committee on Hearing and Equilibrium

guidelines (AAOHNS-CHEG) [5].

Surgical technique

The middle ear usually was exposed with a retroauricular

approach. Rarely, an endaural approach was performed. An

inside-out mastoidectomy was performed for some cases if

it was necessary because of a cholesteatoma or polyp. In

group 1, there was only a discontinuity between the incus

and stapes because of a defect on the long process of the

incus (Fig. 1a). Incudostapedial re-bridging ossiculoplasty

was performed using bone cement (Fig. 1b).

In group 2, because of cholesteatoma, it was necessary

to remove the incus even if the long process was not

defective. If these cases had a present and mobile stapes

with superstructure and a malleus (Fig. 2a), then the

removed incus was shaped in an L figure (Fig. 2b). This

Fig. 1 a Incus necrosis is present with a gap between the incus and

stapes superstructure. b Incudostapedial bridge using bone cement


123

re-shaped incus was placed between stapes and malleus

and then fixed using bone cement to avert displacement

(Fig. 2c).

In group 3, the stapes superstructure and the long pro-

cess of incus were eroded. The patients had a malleus, a

stapes footplate, and a defective incus. The incus was

removed because of cholesteatoma (Fig. 3a). After clean-

ing the cholesteatoma from the middle ear and mastoid, an

L shape with long arms were given to the removed incus

(Fig. 3b). This re-shaped incus was placed between the

stapes footplate and malleus and was fixed with bone

cement to avert displacement (Fig. 3c).

AquaCem, a glass ionomer luting cement (Dentsply,

Konstanz, Germany), was used in these procedures. One

scoop of powder and 2 drops of water were put on a glass

plate and mixed. The mixture becomes muddy before it

hardens in a few minutes. Bone cement was applied drop

by drop, using a needle. To avoid secondary displacement,

the mucosa was completely removed from the ossicles in

the area where bone cement was applied. Bleeding was

controlled carefully to prevent spread of the bone cement.

Statistics

Statistical analysis was performed using SPPS 16.0 for

Windows. Paired t test was used to compare preoperative

and postoperative air-bone gaps (ABGs) of the patients.

Statistical significance was defined as p \ 0.05.

Results

The population description for all groups and excluded

cases are shown in Table 1.

The mean follow-up period for group 1 was 35 months

(range 6–86) (Table 2). The mean age for this group was 35

(range 10–65). The mean ABG was 32.8 dB preoperatively

and 15.3 dB postoperatively (Table 3). There was a sig-

nificant improvement in hearing outcomes when comparing

preoperative and postoperative mean ABG (p \ 0.001).

The mean age for group 2 was 33 (range 12–68). The

follow-up period ranges from 6 to 92 months (mean 36

months) (Table 2). The mean ABG was 34.3 dB preoper-

atively and 18.5 dB postoperatively (Table 3). The differ-

ence between preoperative and postoperative mean ABG

was statistically significant (p \ 0.001).

Thirteen of 32 patients who underwent incus interposi-

tion between the stapes footplate and malleus, fixed by

bone cement and who came to regular follow-up for at least

6 months (6–92; mean 39 months) were included to the

study (Table 2). This group consists of 8 males and 5

females. The mean age was 28 years old (range 14–57).

The mean ABG was 43 dB preoperatively and 20.8 dB

postoperatively (Table 3). Also in the third group, preop-

erative and postoperative mean ABG differences were

statistically significant (p \ 0.001).

76, 64 and 46 % of patients in respectively, group 1, 2

and 3 had a postoperative ABG B20 dB, while 14, 16 and

8 % had a respective postoperative ABG B10 dB (Table 4).

Discussion

Loss of ossicular continuity is a common problem fol-

lowing chronic middle ear infections but many different

Fig. 2 a Malleus and stapes shown. Eroded incus was removed.

b Re-shaped autograft incus for incus interposition. c Autograft

ossicle between stapes superstructure and malleus and fixed to the

malleus and stapes superstructure using bone cement


123

options exist to treat this. Successful ossiculoplasty

requires a good connection between the tympanic mem-

brane and the inner ear. The aim of any functional ossicular

reconstruction is to get permanent hearing restoration

and to minimize conductive hearing loss. There are three

main types of ossicular chain reconstruction: autograft,

homograft and allograft prostheses [3]. Autograft recon-

struction has a low extrusion rate, no risk of transmitting

disease (contrary to homograft) and has a proven

biocompatibility, and additionally it is a cheap option

compared to allograft prosthesis. Disadvantages include

displacement, absorption and possibility of harboring

Fig. 3 a Malleus shown. Incus

and stapes superstructure were

eroded and incus was removed.

b Re-shaped autograft incus.

c Autograft ossicle between

stapes footplate and malleus and

fixed to the malleus using bone

cement

Table 1 Population description

and excluded casesGroup 1 (n = 42) Group 2 (n = 46) Group 3 (n = 32)

2 excl. for reperforation 3 excl. for reperforation

2 excl. for residual cholesteatoma

3 excl. for reperforation

3 excl. for residual cholesteatoma

1 excl. for graft lateralization

4 lost to follow-up 12 lost to follow-up 9 lost to follow-up

7 \6 months follow-up 4 \6 months follow-up 3 \6 months follow-up

29 patients included 25 patients included 13 patients included

Table 2 Study populationStudy population Group size Age Follow-up period

Mean (years) Range Mean (months) Range

Group 1 29 32 10–65 35 6–86

Group 2 25 33 12–68 36 6–92

Group 3 13 28 14–57 39 6–92

Total 67


123

remaining disease [6]. Hearing restoration rates of these

three types of reconstruction seem comparable and no

studies as of now demonstrated any techniques being

superior to the others. Therefore, advantages and disad-

vantages are important for the surgeon to choose the

appropriate technique suitable for each individual patient.

In the study performed by O’Reilly et al. [1], who used

autologous or homologous sculpted incus interposition,

hearing rates were comparable with current allograft

prostheses. There appeared to be a very low extrusion rate

and they remained stable over time.

This was supported by Bahmad et al. [7] who per-

formed a histopathological analysis on ossicular grafts and

implants and showed that autograft incus and malleus struts

maintained contour, size, shape and physical integrity for

long periods of time (at least 25 years).

For some ossicular chain problems, bone cement can be

used to restore these defects as a cost-effective option [4, 8,

9]. Ossiculoplasty with bone cement is a very cheap and

simple procedure. It is known to be safe, not affecting inner

ear functions and there is also proof of biocompatibility

and osseointegration [7]. Although there is a literature

about the side effect of bone cement reported as encepha-

lopathy [10], the results of an experimental animal study

using bone cement showed no abnormal auditory brainstem

responses but only slight gliosis on the cerebral cortex and

acoustic nerve after histological examination [11]. Dornh-

offer and Simmons [12] reported the results of their

experimental animal study, showing no ototoxicity even if

the cement was implanted in close proximity to the round

window. Hoffmann et al. [13] demonstrated already that

bone cement can bind adequately to ossicular bone with

new bone growth and no inflammation occurring at the site

of application, making this suitable as an agent to fix the

sculpted autograft to the remaining ossicular chain.

Since the first bone cement use for otologic surgery,

some studies especially reported its usage for defective

incus long processes as an incudostapedial bridge, pro-

viding good hearing results [3, 4, 8, 9]. These results are

plausible, because incudostapedial re-bridging with bone

cement maintains the normal anatomy. Our result for the

incudostapedial bone cement bridged cases showed suc-

cessful hearing results comparable to the previous studies

published in the literature. Seventy-six percent of our study

population in group 1 achieved a good hearing result of an

ABG \20 dB (Table 4), based on the AAOHNS-CHEG

[5]. This is supported by the study of Bayazit et al. [8]

which showed a success rate of 78.6 % (postop ABG

\20 dB) for incudostapedial bridging.

Some studies reported successful results for bone

cement use between the malleus and stapes [8]. It may be

similar to incus interposition surgery between the stapes

superstructure and malleus. We have a limited number of

cases which have a bone cement bridge between malleus

and stapes but it is too early to publish our results for this

procedure.

Somers et al. [14] reported and discussed the results of

24 cases. They used bone cement in 10 cases of incudo-

stapedial re-bridging and performed incus interposition in

14 cases. According to their results, bone cement bridging

ossiculoplasty offers a better intermediate hearing result

than incus interposition. In a similar study, Dere et al. [3]

reported their results on 23 bone cement re-bridged cases

and 23 incus interposed cases and noted that no techniques

was superior to the other.

Ossicular displacement accounts for half of the failures

requiring revision surgery [13]. According to us, the main

problem for interposed incus surgery is the shifting from

the inserted area. This led us to the idea to fix the

Table 3 Comparison of mean preoperative and postoperative ABG

and ABG closure

Audiometry

results

ABG preop

(dB)

ABG postop

(dB)

ABG closure

(dB)

Group 1

500 Hz 36 15 21

1,000 Hz 36 14 22

2,000 Hz 28 12 16

4,000 Hz 31 20 11

Mean 32.8 15.3 17.5

Group 2

500 Hz 39 18 21

1,000 Hz 35 16 19

2,000 Hz 29 14 15

4,000 Hz 34 26 8

Mean 34.3 18.5 15.8

Group 3

500 Hz 47 20 27

1,000 Hz 48 21 27

2,000 Hz 37 16 21

4,000 Hz 40 26 14

Mean 43 20.8 22.3

Table 4 Postoperative air-bone gap success rates

Postoperative air-bone

gap (dB)

Group 1 Group 2 Group 3

n % n % n %

0–10 4 14 4 16 1 8

11–20 18 62 12 48 5 38

21–30 6 21 6 24 4 31

[30 1 3 3 12 3 23

Total 29 100 25 100 13 100


123

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123

interposed incus to the malleus and stapes superstructure to

avert removing. The results of these cases were as suc-

cessful as our bone cement re-bridging cases. Sixty-four

percent of our study population in group 2 achieved a good

hearing result of an ABG \20 dB (Table 4), based on

AAOHNS-CHEG. These hearing results and a sufficiently

long follow-up period using bone cement as fixation

material for incus interposition surgery may be safe and

effective. Very long-term analysis comparing two series

with and without cement is necessary and it will help

demonstrate the long-lasting stability.

For the missing stapes superstructure cases, preoperative

hearing levels are worse compared to the other groups and

management to solve this problem is more difficult than the

other cases already discussed above. For these cases, an

autograft or homograft incus as an incus interposition graft

or a TORP may be treatment options. TORP has the

advantage of being readily available but it has some

problems such as extrusion and stability problems [14]. In

almost half of revisions required for TORP patients, pros-

thesis displacement may be the cause of failure [13, 14].

For some of these cases, we used a reshaped incus between

the stapes footplate and malleus and fixed the interposed

incus to the malleus using bone cement to avert displace-

ment. The results were surprisingly good in 46 % of

patients in group 3 study population achieving a good

hearing result of ABG less than 20 dB (Table 4), based on

the AAOHNS-CHEG. To our knowledge, these last two

applications of bone cement to fix the interposed incus to

the stapes and/or malleus, to avert displacement (group 2

and 3) have not been published before. Results of different

ossiculoplasty types in the literature comparing with the

present results were summarized into the Table 5.

Conclusion

Bone cement is a good and cheap option for some ossicular

chain problems to achieve successful hearing improve-

ment. It has the ability to firmly bond ossicular bone and

allows new bone to grow at the site of application. It may

be used for incudostapedial re-bridging as previous studies

and the present one showed. It may also be used to fix the

interposed incus to the stapes superstructure and/or malleus

to avert displacement. More studies and longer follow-up

periods for autograft chain reconstruction with bone

cement anchoring are needed to acknowledge the effec-

tiveness and to reduce the need for revision surgery.

Acknowledgments The authors would like to thank Nazire Bulam,

M.S. for her help with statistical evaluation.

Conflict of interest None.

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