To study the most appropriate ossicular reconstruction of patients with an absent malleus, a comparison was made utilizing a homograft tympanic membrane with attached malleus and shaped incus (TMMI) columella and the alternative use of underlay fascia tympanoplasty with a cartilage covered TORP. Forty‐six patients were reconstructed with a homograft TMMI and 38 with cartilage covered TORP and underlay fascia technique; 4.5 years postoperatively, 84% of those patients reconstructed with a homograft TMMI maintained an average A/B gap of 25 dB or better. Though 1 year postoperatively the TORP hearing results were satisfactory, only 18% of the TORP patients maintained a hearing level within 25 dB A/B gap at 4 years postoperatively.
Primary causes of failure of the TORP were instability with migration off the stapes footplate, protrusion or extrusion through the TM and finally, long‐term softening and bending secondary to biodegradation of the Plastipore®. The discouraging long‐term hearing results found in the TORP patients in this study confirm similar findings reported in 1982 by Smyth in a 5 year follow‐up on. 116 TORP patients.
If homograft tympanoplasty is to be of value, specific instances in which homograft tympanic membrane, malleus, and incus (TMMI) provide significant hearing and anatomical advantages over standard techniques should be identified. This author has performed 305 homograft tympanoplasties limited to the reconstruction of the severely damaged middle ear. Indications include: previous failure with standard tympanoplasty techniques; high risk of anatomic or hearing failure with standard techniques (total perforation with absent malleus, slag burns); reconstruction of radical mastoidectomy; congenital aural atresia. The first 125 consecutive homograft tympanoplasties were reported in 1982. One hundred eighty additional homograft tympanoplasties have been performed since then. In the past 3 years the anatomic success rate has risen to 97% (174/180) with refinement of surgical techniques. Eighty-five percent of all patients have maintained an average air-bone gap of 25 dB or better. Formalin preserved homograft tympanic membranes with attached malleus offer significant advantages over standard tympanoplasty techniques in these specific indications.
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