Vestibular complaints secondary to a deeply medialized ossicular prosthesis have been documented following stapedotomy1 but infrequently reported following total ossicular replacement prosthesis (TORP) placement. Lateral TORP displacement through the tympanic membrane (TM) occurs in 5% to 9% of cases2; however, medial displacement, with violation of the footplate, is rare and has only been reported following canal wall down mastoidectomy.3 For the below case, institutional review board approval was obtained from the University of Massachusetts Medical School Human Subjects Committee

Polanik, Marc D.

Remenschneider, Aaron K.

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University of Massachusetts Medical School eScholarship@UMMS Open Access Articles Open Access Publications by UMMS Authors 2020-04-16 Medialized Total Ossicular Replacement Prosthesis Marc D. Polanik University of Massachusetts Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/oapubs  Part of the Equipment and Supplies Commons, Otolaryngology Commons, and the Otorhinolaryngologic Diseases Commons Repository Citation Polanik MD, Remenschneider AK. (2020). Medialized Total Ossicular Replacement Prosthesis. Open Access Articles. https://doi.org/10.1177/2473974X20916432. Retrieved from https://escholarship.umassmed.edu/oapubs/4225 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Open Access Articles by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. Case ReportsMedialized Total Ossicular ReplacementProsthesisOTO Open2020, Vol. 4(2) 1–3 The Authors 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/2473974X20916432http://oto-open.orgMarc D. Polanik1,2,3, and Aaron K. Remenschneider, MD, MPH1,2,3,4Keywordsstapedotomy, ossiculoplasty, total ossicular replacementprosthesis, hearing loss, conductive hearing loss, temporalbone imaging, treatment outcomeReceived February 9, 2020; accepted March 10, 2020.IntroductionVestibular complaints secondary to a deeply medializedossicular prosthesis have been documented following stape-dotomy1 but infrequently reported following total ossicularreplacement prosthesis (TORP) placement. Lateral TORPdisplacement through the tympanic membrane (TM) occursin 5% to 9% of cases2; however, medial displacement, withviolation of the footplate, is rare and has only been reportedfollowing canal wall down mastoidectomy.3 For the belowcase, institutional review board approval was obtained fromthe University of Massachusetts Medical School HumanSubjects Committee.Case ReportA 58-year-old woman with chronic right-sided middle earinfections and conductive hearing loss was referred for per-sistent sensations of right-sided aural fullness, pressure, andotalgia following multiple middle ear reconstructive proce-dures dating to 15 years prior. Surgical history includedintact canal wall mastoidectomy, ossiculoplasty using a 7.0-mm-length calvarial bone strut TORP from the malleus tostapes footplate, and cartilage-backed tympanoplasty. Themajority of the patient’s current symptoms appeared follow-ing the aforementioned ossiculoplasty, which also renderedher significantly vertiginous for a 2- to 3-week periodbefore self-resolving. At the time of presentation, the patientendorsed disequilibrium but denied otorrhea or fluctuationsin hearing. Antibiotics and steroids had provided minimalsymptomatic relief. The patient benefited from ipsilateralamplification for right-sided conductive hearing loss. Therewas no history of recent otitis media, serous effusion, posi-tional vertigo, or neurological disorders.On exam, the right external auditory canal was normaland the TM was thickened at the location of the cartilagegraft. There was no evidence of effusion. Examination of theleft ear was normal. Tuning fork exam lateralized to the rightwith bone greater than air conduction on that side. The remain-der of her exam was normal. Initial audiogram (Figure 1A)demonstrated asymmetric right-sided conductive hearing losswith preserved discrimination. Tympanometry was type A onthe right and type C on the left. Computed tomography (CT)imaging of the temporal bones without contrast (Figure 2)demonstrated a right-sided ossicular prosthesis sitting adjacentto the umbo of the malleus with a medial segment extendingthrough the oval window, deep into the vestibule, with theprosthesis tip contacting the medial vestibule wall.Given the severity and chronicity of her symptoms incombination with a suggestive etiology on imaging, thepatient underwent a revision exploratory tympanotomyunder general anesthesia. Intraoperative visualization of themiddle ear revealed a calvarial bone strut extending fromthe remnant manubrium through the stapes footplate, deepinto the vestibule. The malleus head, body of the incus, andbone strut were removed. A 5.0-mm-length nitinol-Teflonstapes piston prosthesis was placed with the wire crimpedinto position around the manubrium of the malleus and themedial tip extending shallowly through the footplate fenes-tration. A lobular fat graft was used to seal the fenestrationof the oval window.Postoperatively, the patient experienced immediate symp-tomatic improvement. One month following surgery, her ini-tial complaints of right-sided aural fullness, pressure, andotalgia were completely resolved. Postoperative audiogram(Figure 1B) demonstrates a narrowed air-bone gap with1Department of Otolaryngology, Massachusetts Eye and Ear Infirmary,Boston, Massachusetts, USA2Department of Otolaryngology, UMass Memorial Medical Center,Worcester, Massachusetts, USA3University of Massachusetts Medical School, Worcester, Massachusetts,USA4Department of Otolaryngology, Harvard Medical School, Boston,Massachusetts, USACorresponding Author:Aaron K. Remenschneider, MD, MPH, Department of Otolaryngology,Massachusetts Eye and Ear Infirmary, Eaton-Peabody Laboratories, Suite469, 243 Charles Street, Boston, MA 02114, USA.Email: aaron_remenschneider@meei.harvard.eduThis Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproductionand distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages(https://us.sagepub.com/en-us/nam/open-access-at-sage).unchanged bone conduction and improved discriminationscores.DiscussionMedial TORP displacement is likely a rare occurrence inthe setting of an intact stapes footplate since it is commonpractice to (1) use cartilage or titanium shoes to dispersepressure across the footplate4 and (2) minimize pressure onthe footplate by measuring for appropriate prosthesis lengthprior to placement. Considering the typical horizontal reachfrom the footplate to the malleus is between 4 and 5 mm,5the use of a 7-mm calvarial bone strut was likely in partresponsible for the footplate penetration seen in this case.Footplate manipulation resulting in microfractures may alsopredispose to TORP medialization, a complication previ-ously observed in radical tympanomastoidectomy.3 Our casehighlights that this event may occur even with an intactcanal wall and preserved tympanic space.A number of patient complaints may suggest medializa-tion of an ossicular prosthesis into the vestibule, includingpersistent dizziness or vertigo after surgery, head trauma, orbarotrauma. Dizziness with belching, eustachian tube dila-tion, and/or swallowing are also classic indications of amedialized prosthesis.6 Present in this case are complaintsof otalgia, aural pressure, and fullness. Although thesesymptoms are not typically associated with a medializedprosthesis, the immediate resolution following surgeryoffers evidence that these symptoms may be improved byreplacement of a deeply placed prosthesis.Management of a patient with a medialized prosthesislargely depends on the symptom nature and severity. Giventhe higher risk of deafness associated with revision stape-dectomy,6 hearing aids may be an acceptable alternative ifconductive hearing loss is the only complaint. If aural full-ness or vestibular symptoms are severe, revision exploratorytympanotomy is reasonable.AcknowledgmentsThe authors acknowledge the mentorship and advice of Dr MichaelMcKenna on this challenging case.Author ContributionsMarc D. Polanik, writing and editing manuscript, literaturereview; Aaron K. Remenschneider, conception/design, clinicalcontributions, editing manuscript.Figure 1. (A) Initial audiogram demonstrates right-sided conductive hearing loss. (B) Postoperative audiogram and speech audiometryreveal improved air conduction and unchanged bone conduction thresholds. Air-bone gap is narrowed and word recognition score (WRS)is improved. PTA, pure-tone average.Figure 2. Preoperative noncontrast axial computed tomographyof temporal bones. A 7.0-mm, right-sided calvarial bone strut totalossicular replacement prosthesis (arrow) sitting adjacent to theumbo with a medial segment extending through the oval window,deep into the vestibule.2 OTO OpenDisclosuresCompeting interests: None.Sponsorships: None.Funding source: None.References1. Whetstone J, Nguyen A, Nguyen-Huynh A, Hamilton BE.Surgical and clinical confirmation of temporal bone CT findingsin patients with otosclerosis with failed stapes surgery. AJNRAm J Neuroradiol. 2014;35(6):1195-1201.2. Sheehy JL. TORPs and PORPs: causes of failure—a report on446 operations. Otolaryngol Head Neck Surg. 1984;92(5):583-587.3. Sanei-Moghaddam A, Kumar S, Donnelly N, Axon P.Medialization of total ossicular replacement prosthesis in mas-toid obliteration. Int Adv Otol. 2013;9(1):110-114.4. Luers JC, Schwarz D, Anagiotos A, Gostian AO, Beutner D,Huttenbrink KB. Long-term follow-up study of the sandwichcartilage shoe technique in cases of insecure stapes footplate.Otol Neurotol. 2016;37(7):e197-e202.5. Dornhoffer J. Ossiculoplasty with synthetic PORPS andTORPS. In: Dornhoffer J, Gluth M, eds. The Chronic Ear. NewYork, NY: Thieme; 2016. https://medone-otolaryngology.thieme.com/ebooks/1566052?fromSearch=true#/ebook_1566052_SL64812114. Accessed July 3, 2019.6. Sarac S, McKenna MJ, Mikulec AA, Rauch SD, Nadol JB Jr,Merchant SN. Results after revision stapedectomy with malleusgrip prosthesis. Ann Otol Rhinol Laryngol. 2006;115(4):317-322.Polanik and Remenschneider 3

Medialized Total Ossicular Replacement Prosthesis

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