www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Ossicular
chain
reconstruction
in
chronic
otitis
media:
hearing
results
and
analysis
of
prognostic
factors
夽
Syriaco
Atherino
Kotzias,
Mariana
Manzoni
Seerig
∗,
Maria
Fernanda
Piccoli
Cardoso
de
Mello,
Leticia
Chueiri,
Janaina
Jacques,
Martin
Batista
Coutinho
da
Silva,
Daniel
Buffon
Zatt
HospitalGovernadorCelsoRamos,DepartamentodeOtorrinolaringologia,Florianópolis,SC,Brazil
Received29January2018;accepted24September2018 Availableonline18October2018
KEYWORDS
Chronicotitismedia; Ossicularchain; Ossiculoplasty; Cartilagegraft; Ossicularprosthesis
Abstract
Introduction: Thegoalofossiculoplastyistoimprovehearingandthesuccessofthisprocedure dependsonseveralfactors.
Objective: Analyzethehearingresultsinpatientswithchronicotitismediaundergoingossicular chainreconstruction,aswellaspredictivefactorsforsuccessfulsurgery.
Methods:Chartsofpatientsundergoingossiculoplastybetween2006and2016werereviewed. Sixty-eightpatientswereincluded,totaling72ears.Thefollowingdatawasanalyzed:gender, age,smokingstatus,laterality,pathology,audiometricexams,typeofsurgery,previoussurgery, characteristicsofthemiddleear,otorrheaandossicularchainstatus.Patientswerealso clas-sifiedaccordingtotwoindices:middleearriskindexandossiculoplastyoutcome parameter staging.Theresultswereevaluatedbycomparingtheair-bonegapbeforeandaftersurgery. The successof reconstructionwasdefined as air-bonegap≤20dB andthe improvementof speechreceptionThresholds,calculatedthroughthemeanfrequencies0.5,1,2and3kHz. Results:Reconstructionsuccessratewas61%.Themeanpreoperativeairbonegapwas34.63dB anddecreasedto17.26dBaftersurgery.Therewasacorrelationbetweenlowriskinmiddleear riskindexandossiculoplastyoutcomeparameterstagingindiceswithpostoperativesuccess.The mostfrequentlyerodedossiclewastheincusandthetypeofprosthesismostusedwastragal cartilage.Inthepatientswithoutincus,weachievedsuccessin74.2%ofthesurgeries.Inthe absenceofthestapes,thesuccessratedecreasedto63.3%.Intheabsenceofthemalleus,85% ofthepatientshadandairbonegap≤20dB.
夽 Pleasecitethisarticleas:KotziasSA,SeerigMM,MelloMF,ChueiriL,JacquesJ,SilvaMB,etal.Ossicularchainreconstructioninchronic otitismedia:hearingresultsandanalysisofprognosticfactors.BrazJOtorhinolaryngol.2020;86:49---55.
∗Correspondingauthor.
E-mail:mariseerig@gmail.com(M.M.Seerig).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.09.005
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion: We achievedgood audiometric outcomesinossiculoplasty andthe resultsare comparabletoothercenters.Ossiclestatusinfluencedpostoperativeresults,especiallyinthe presenceofstapes.Wealsoconcludedthattheindexesanalyzedmayhelptopredictthesuccess ofthesurgery.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Otitemédiacrônica; Cadeiaossicular; Ossiculoplastia; Enxertode cartilagem; Próteseossicular
Reconstruc¸ãodacadeiaossicularnaotitemédiacrônica:resultadosauditivose análisedefatoresprognósticos
Resumo
Introduc¸ão: A ossiculoplastia tem como objetivo amelhoria da audic¸ão e o sucesso desse procedimentodependedediversosfatores.
Objetivo:Analisarosresultadosauditivosempacientescomotitemédiacrônicasubmetidosa reconstruc¸ãodacadeiaossicular,bemcomoosfatorespreditivosdesucessocirúrgico. Método: Prontuáriosdepacientessubmetidosaossiculoplastiaentre2006e2016foram revis-tos.Sessentaeoitopacientesforamincluídos,totalde72orelhas.Osseguintesdadosforam analisados:sexo,idade,tabagismo,lateralidade,doenc¸a,examesaudiométricos,tipode cirur-gia, cirurgia prévia, característicasda orelhamédia, otorreia eestado dacadeia ossicular. Ospacientestambémforamclassificadosdeacordocomdoisíndices:índicederiscodaorelha médiaeestadiamentodoparâmetrodedesfechodaossiculoplastia.Osresultadosforam avalia-doscomparandoogapaéreo-ósseoanteseapósacirurgia.Osucessodareconstruc¸ãofoidefinido comogapaéreo-ósseo≤20dBeamelhoriadoslimiaresderecepc¸ãodefala,calculadospelas frequênciasmédiasde0,5,1,2e3kHz.
Resultados: Ataxadesucessodareconstruc¸ãofoide61%.Ogapaéreo-ósseopré-operatório médiofoide34,63dBediminuiupara17,26dBapósacirurgia.Houvecorrelac¸ãoentrebaixo risconoíndicederiscoparaorelhamédiaeosíndicesdeestadiamentodoparâmetrode desfe-chodaossiculoplastiacomsucessopós-operatório.Oossículocomerosãomaisfrequentefoia bigornaeotipodeprótesemaisutilizadafoiacartilagemtragal.Nospacientessembigornao sucessofoialcanc¸adoem74,2%dascirurgias.Naausênciadoestribo,ataxadesucessodiminuiu para63,3%.Naausênciadomartelo,85%dospacientesapresentaramgapaéreo-ósseo≤20dB. Conclusão:Melhorasignificativadaaudic¸ãofoiobservadaempacientessubmetidosà ossicu-loplastia, osresultados foramcomparáveisaosde outroscentros.O‘‘status’’dosossículos influenciouosresultadospós-operatórios,principalmenteapresenc¸adoestribo.Também con-cluímosqueosíndicesanalisadospodemajudarapreverosucessodacirurgia.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
ChronicOtitisMedia (COM)is defined as; thepresence of irreversibleinflammatory disease in the ear cleft. It usu-allyaffectstheossicularchainleadingtoconductivehearing loss.Totalor partialerosionoftheossicular chainis seen in about 80% of patients who present with ChronicOtitis MediawithCholesteatoma(COMC)whereasintheabsence ofcholesteatoma itcan bepresent inapproximately20%. Theincusistheossiclemostfrequentlyaffected,followed bythestapesandmalleus.1
The objective of ossicular chain reconstruction is to restore the hearing impairment. There are many factors that can affect outcomesin this procedure includingthe middle ear environment, status of the eustachian tube, surgicaltechnique,typeofprosthesisandstatusofresidual
ossicular remnants.2,3 In 1971, Austin classified ossicular chain disruptionin 4 groups (A---D)based onthe presence or absence of the malleus handle and the stapes arch. Kartushaddedthreecategoriestothisclassification:intact ossicular chain (0), fixation of the malleus head (E) and fixationof thestapes(F).4 Kartushalsodescribedascore, named MERI (Middle Ear Risk Index), to stratify patients accordingtotheseverityoftheirdisease.MERIscoretakes into consideration the presence or absence of otorrhea and cholesteatoma, tympanic membrane perforation, ossicularchainstatus(Austin---Kartushcriteria),middleear granulation and previous surgery (Table 1).5 In order to predicthearingoutcomesinossicularchainreconstruction, Dornhoffer and Gardner developed another index titled OOPS (Ossiculoplasty Outcome Parameter Staging). This index analyzes almost the same parameters as the MERI
Table1 MiddleEarRiskIndex(MERI).
Riskfactor Riskvalue
Otorrhoea
IDry 0
IIOccasionallywet 1
IIIPersistentlywet 2
IVWet,cleftpalate 3
Perforation Absent 0 Present 1 Cholesteatoma Absent 0 Present 1
Ossicularstatus(Austin/Kartush)
O:M+I+S+ 0
A:M+S+ 1
B:M+S− 2
C:M−S+ 3
D:M−S− 4
E:Ossicleheadfixation 2
F:Stapesfixation 3
Middleeargranulationoreffusion
No 0 Yes 1 Previoussurgery None 0 Staged 1 Revision 2
MERI0,normal;MERI1---3,milddiseases;MERI4---6,moderate disease;MERI7---12,severedisease.
score does, however it classifies the ossicular chain as follows:normal orabnormalwithor without malleus, not takingintoaccountthestatusofstapes(Table2).2,6,7
Theaimofthisstudyistoverifytheefficiencyofthese scoresin predictingoutcomesin ossiculoplasties,andalso toevaluatetheimpactof thestatusof ossicularchain on theresults.
Methods
Ethicalcommitteeapproval
This study was approved by the ethics committee of our institution in July 4th, 2017 under protocol number 073627/2017.
Patientselection
The records of all patients who underwent otological surgery by the senior author between February 2006 and December2016werereviewed.Weincludedpatientswith chronicotitismediaandossicularchainerosionordisruption identifiedduringthesurgeryinwhomossiculoplastywas per-formed.Congenitalandtumorcaseswereexcluded.Wealso excludedpatients whodidnothaveproperrecordsof the
Table2 OssiculoplastyOutcomeParameterStaging(OOPS) index.
Rickfactor Riskvalue
Middleearfactors Drainage
None 0
Present>50%ofthetime 1 Mucosa Normal 0 Fibrotic 2 Ossicles Normal 0 Abnormal,malleus+ 1 Abnormal,malleus− 2 Surgicalfactors Typeofsurgery Nomastoidectomy 0
Canalwallupmasctoidectomy 1 Canalwalldownmastoidectomy 2 Revisionsurgery
No 0
Yes 2
surgeryandpre- or postoperativeaudiograms.In patients requiringrevisionsurgery,onlythefirstossiculoplasty per-formedbytheseniorauthorwasincludedandifthesurgery wasstaged,weincludedonlytheprocedureinwhich ossicu-loplasty was performed. However patients who had prior ossiculoplastyelsewhereandunderwentrevisionalsurgery wereincluded. The followingdata wasobtainedfromthe reviewedcharts:patient’ssex,ageatsurgery,smoking sta-tus, COM with or without cholesteatoma, indication for surgery,lateralityofprocedure,procedureperformed, his-tory of previous surgery and if it wasstaged or revision, presence of preoperative otorrhea, intraoperative status ofthemucosaandossicles (presenceorabsenceof incus, stapesandmalleus).Ossicularchainreconstructionwas per-formed using autologous ossicles, cortical bone or tragal cartilage.PatientswereclassifiedaccordingtotheOOPSand MERIindex.
Audiometricmethods
Air-Conduction(AC)andBone-Conduction(BC)thresholdsat 0.5, 1, 2 and 3kHz were recorded and used to calculate Pure-ToneAverages (PTAs). Ifthe3kHzthresholdwasnot recorded, the average of the 2 and 4kHz was used. The PTA-ABGwasthedifferencebetween ACPTAandBCPTA. Preoperativeand postoperative SpeechReception Thresh-olds(SRTs)wererecorded.
Statisticalanalysis
Datawas analyzed using IBM/SPSS19 (Statistical Package ofSocialScience). Continuous variablesweretestedusing Pearson’stest. Comparisonsof categorical variables were
performedusingthecoefficientofContingency.Avalueof
p<0.05wasconsideredindicativeofstatisticalsignificance.
Outcomemeasures
Primary outcome measures included hearing results and were measured from 90 days to 5 years after surgery. We considered a minimum follow-up period of 6 months. Successful ossiculoplasty was defined as a postoperative PTA-ABG≤20dB. The MERI and OOPS scores were deter-minedforall patients.Tocomparethe riskcategoriesthe patientswere dividedintosix groups: for theOOPS index patientswereclassifiedaslowrisk(1---3),intermediaterisk (4---6)andhighrisk(7---9),andaccordingtotheMERIscore theywere divided intomild disease (1---3), moderate dis-ease(4---6)andseveredisease(7---12).Then,foradetailed analysis, the type of surgery, middle ear disease, ossicu-lar chain status according toAustin---Kartush classification presented in Table1, the prosthesesused wereassessed, andthepatientsweredividedintogroupstocomparethe hearingresults.
Results
Atotalof269chartswerereviewedbetweenFebruary2006 andDecember2016.Fivepatientswereexcluded because theydidnothaveadiagnosisofchronicotitismedia(three patients had temporal bone paragangliomas and twohad congenitalatresiaoftheear)and88didnotundergo ossicu-loplasty. We also excluded 104 patients without proper recordsrelatedtotheirdiagnosis,surgery,clinicalor audio-metricdata.Intotal,68patientswereincludedinthestudy, totaling72ears.
Themeanageofpatientswas36.6±15.52:54.1%were female and 48.61% were male. There was no prevalence ofanyear(50%leftor50%right).Themostcommon diag-nosiswasprimarychronicotitismediawithcholesteatoma (58.4%),followedby COMwithout cholesteatoma in41.6% andinthislastgroup20.8%ofthepatientspresented sup-purative disease. Overall, otorrhea was found in 64% of theears.Only14%ofthepatientsweresmokers(Table3). Intotal,23 tympanoplasties,38Canal Wall-Up Mastoidec-tomies (CWUM) and 11 Canal Wall-Down Mastoidectomies (CWDM)wereperformed(Fig.1).
Erosionofincuswasthemostfrequentossicular abnor-malityanditwasseenin31(43%)oftheears,followedby erosionof stapes in 19 (26%) and erosion of malleus and stapesin15 (21%).Malleuserosionwithintactstapes was observedinonly7ears(10%)(Fig.2).
The mostly widely usedprosthesis wastragal cartilage (n=47)correspondingto65%ofthecases.Autologousincus wasusedin17(24%)patientsandcorticalbonewasusedin 8(11%).Thegroupoftragal cartilagepresenteda postop-erativePTA-ABG≤20dBin72.3%ofthecases,while59%of thepatientsofautologousincusand62.5%ofcorticalbone presentedaPTA-ABG>20dB(p=0.04).
The average preoperative PTA-ABGwas34.63±9.94dB andpostoperativePTA-ABGwas17.26±12.92dB.Themean preoperativeSRTwas54.72±14.98dBandaftersurgerywas 40.42±20dB, demonstrating an improvement of 14.30dB (p<0.05).
Table3 Demographicinformation. Numberofears 72
Meanage(years) 36.6±15.52
Sex,n(%) Male Female
35(48.6%) 37(51.4%) Laterality,n(%) Rightear Leftear
36(50%) 36(50%) Smokingstatus,n(%) Yes No
10(14%) 62(86%) Othorrea,n(%) Yes No 46(64%) 26(36%) Diagnosis,n(%) Chronic non-suppurative otitismedia 15(20.8%) Chronic suppurativeotitis media 15(20.8%) Primaryacquired cholesteatoma 40(55.6%) Secondary acquired cholesteatoma 2(2.8%) 53% Tympanoplasty
Canal wall-up mastoidectomy Canal wall-down mastoidectomy
32% 15%
Figure1 Typeofsurgeryperformed.
Before surgery, 87.5% of the patients presented an ABG>20 and 61% of the patients achieved a postopera-tive PTA-ABG≤20dB (Fig.3).Animprovement inSRTwas observedin77.8%aftersurgery,whereas7%maintainedthe sameSRTand15.3%presenteddeterioratingresults.
Three patients groups, based on low-risk (OOPS 1---3; Group 1),intermediaterisk (OOPS4---6;Group2) andhigh risk(OOPS7---9;Group3)werearbitrarilycreatedto evalu-atetheimpactoftheseverityofthediseaseintheresults oftheossicularchainreconstruction.Seventythreepercent ofthepatientsingroup1achievedaclosureofABGtoless thanorequalto20dB,althoughthistrenddidnotachieve statisticalsignificance(p=0.265)(Table4).
Patientswerealsodividedintothreegroupsaccordingto theMERIindex:milddisease(MERI1---3;Group4),moderate disease(MERI4---6;Group5)andseveredisease(MERI7---12; Group6).Weobservedthat70%ofpatientsinGroup4 pre-sentedan ABG≤20dBat follow-up,whileinGroup 6,64%
21% 26% M+S+ M-S+ M-S- M+S-43% 10%
Figure2 Pre-operativeossicularchainstatus.M+S+indicates MalleusandStapespresent;M+S−,MalleuspresentandStapes absent;M−S+,Malleus absentandStapespresentandM−S−, MalleusandStapesabsent.
88% 61% 39% 13% PRE-OP POST-OP ABG ≤ 20 ABG > 20
Figure 3 Comparison between pre-operative and post-operativeABG(AirBoneGap).
Table 4 Correlation between OOPS Index and pre-operativeAirBoneGap(ABG).
OOPS ABG≤20dB ABG>20dB Lowrisk(1---3) 73.1%(19) 26.9%(7) Intermediaterisk(4---6) 53.5%(23) 46.5%(20) Highrisk(7---9) 66.7%(2) 33.3%(1) Total 61.1%(44) 38.9%(28)
p>0.05.
Table5 CorrelationbetweenMERIindexandpre-operative AirBoneGap(ABG).
MERIindex ABG≤20dB ABG>20dB Milddisease(1---3) 70%(7) 30%(3) Moderatedisease(4---6) 72.5%(29) 27.5%(11) Severedisease(7---12) 36.4%(8) 63.3%(14) Total 61.1%(44) 38.9%(28)
p<0.05.
presentedanABG>20dB,demonstratingthatpatientswith milddiseaseaccordingtotheMERIindexhadbetter postop-erativeresultsthanpatientswithsevere disease(p=0.01) (Table5).
Table6 CorrelationbetweenAustin---Kartushcriteriaand hearing results according to post-operative Air Bone Gap (ABG).
ABG≤20dB ABG>20dB Total M+S+ 23(74.2%) 8(25.8%) 31(100%) M+S− 12(63.2%) 7(36.8%) 19(100%) M−S+ 6(85.7%) 1(14.3%) 7(100%) M−S− 3(20%) 12(80%) 15(100%) Total 44(61%) 28(39%) 72(100%) M+S+,Malleusandstapespresent;M+S−,Malleuspresentand stapesabsent;M−S+;Malleusabsentandstapespresent;M−S−, Malleusandstapesabsent.
p<0.05.
Inregardtotheossicularchain,wefoundthattheossicle thatwasthemostfrequentlyerodedwastheincus(n=31). The best results of ossicular chain reconstruction were achievedin Austin---Kartush Group A (74% of the patients presenting an ABG≤20dB), followed by Group C (85.7% achievinganABG≤20dB),andtheworstresultswerefound inpatientswithstapeserosion(ABG≤20dBin63.2%ofthe patients)andpatientswithout malleusandstapes (80%of thempresentanABG>20dB)(p=0.02)(Table6).
Discussion
In patients with COM the objective of the surgery is to provideadryear,ensurethefunctionofEustachiantube, andrestorethesound-conductingsystemofthemiddleear. Ossicularchainreconstructionrepresentsachallengeeven forexperiencedotologistsandthesuccessisachievedwith goodandlong-lastingaudiometricoutcome,representedby closureofpostoperativeABGlessorequaldo20dB.2,5Inour study,61% ofthe patientspresented withan ABG≤20dB, and this result was similar to other series.2,8---11 We also observedan improvement of a mean14.3dB in postoper-ative speechreception thresholds. The mean ABG before surgerywas34.63dBanddecreasedto17.26dBafter recon-struction,showinganimprovementof17.36dB.
Theidealreconstructionshouldbeeasytoperformand thematerialsshouldbewelltoleratedbythepatient,with lowreabsorption orextrusionrates, andit shouldprovide goodhearingresultsoverthetime.Awidevarietyof mate-rialscanbeusedforossicularreconstruction,i.e.autografts (autologous incus, tragal cartilage, cortical bone), bone cementoraprosthesis.Webelievethatautograftmaterials areagoodalternativebecauseofthebiocompatibility,low extrusionrate,andtheirlowerpricecomparedwithother groups of prosthesis. Emir et al., reported 58.1% of suc-cessusingautologousincusand71.4%usingcorticalbone.11 O’Connel et al., described a series of 156 patients who underwentossiculoplastywithtitaniumprosthesis,andthey found 67% of the patients achievingABG≤20dB in short-termfollow-up (<6 months).12 In this series,the majority ofthe reconstructions werewithtragal cartilage, achiev-ing72.3% ofsuccessandwithameanfollow-up(including audiometricexams)ofoneyear.Wegenerallyusetragal car-tilageinthepresenceofthestapes,placingitbetweenthe capitulumandhandleofmalleus.Ifthestapesisabsentor
erodedweusecorticalbone,placingitfromthefootplate to the handle of the malleus, or to the tmpanic mem-brane if malleus is absent. We suggest that the absence of stapes probablyexplains our poor results withcortical bone.
Theuseof ariskstratificationindexallowssurgeonsto comparepatientsaccordingtopreoperativeconditions,can helptopredict hearingresultsandrisksfor complications orrecurrence,andit alsocan beusefulfor patients, pro-vidingthemusefulinformationabouttheirdisease,sothey canmodifyriskfactorsrelatedtothefailureofthesurgery. However,the creationof anidealtoolis difficult because ofvariationsindifferentpopulations,surgeon’sskills, sur-gicaltechniques,andelementsextrinsictothemiddleear (smokinghabits,adenoidaldisease,livingenvironmentand gastroesophagealreflux).6DornhofferandGardnercreated theOOPS index,consideringthat theabsenceof malleus, fibroticmiddle ear mucosa,and otorrhea couldbe useful inprognosticatinghearingoutcomesafterossiculoplasties.7 Coxetal.identifiedastrong positivecorrelationbetween OOPSindexscoreandaveragepost-operativePTA-ABGand theyfoundthathearingresultstendtoremainstable, espe-ciallyinlower-riskpatients.2Inourstudywedemonstrated better audiometric outcomes in Group 1 patients (73.1% achievedaPTA-ABG≤20dB)butitwasnotstatistically sig-nificant.Whenusingthisindexwefoundmorethanhalfof thepatientsclassifiedasintermediaterisk,andonlythree patientsinthehigh-riskgroup.
MERI index, described by Kartush, stratifies patients accordingtotheenvironmentofthemiddleear(presenceof otorrhea,granulation)perforationoftympanicmembrane, existenceofcholesteatomaanditgivesadifferentscorefor eachkind ofossicular erosionorfixation.11 Inthe present study,70%ofpatientsclassifiedasmilddisease(score1---3) presentedapost-operativeABGclosure≤20dB,whileinthe groupof severedisease(score 7---12)we achievedsuccess onlyin36.4%ofthepatients(p=0.017).
Whenitcomestothedamageofindividualossiclesasa determinantofhearingresultsinossiculoplasties,the liter-aturedatais controversial. Manyauthors believethatthe presenceofthemalleuspredictsthebestoutcomes regard-lessoftheconditionofstapes.4,7,13,14Blometal.analyzed Austin---Kartush groups in their meta-analysis and demon-strated a significant difference in mean ABG in favor of GroupB(11.1) whencomparedtoGroup C (15.7).4 Bared andAngelireportedpresenceofmalleushandleasa favor-ableprognosticfactor onossicular chain reconstruction.14 Itis knownthatthemalleuscontributestothestabilityof the tympanic membrane and consequent stability of the ossicular chain. It also prevents graft lateralization and acts to improve sound conduction through the catenary lever.
On the other hand, there are some authors who con-siderthatthe presenceofstapes superstructureis crucial inaudiometricoutcomes.Castroetal.reviewed153 ossicu-loplasties and found that the mean postoperative ABG inpatients withstapes superstructure was11.6±10.2dB, while in patients without stapes this mean increased to 17.7±9.91, associating the success rate to the presence ofthisossicle.3Inourstudy,weobserved thatinpatients withamissingorerodedincus(Austin---KartushGroupA)the
interpositionwassuccessfulin74.2%.Comparingpatientsin Group BandC,we achievedbetter resultsin GroupC, in which thestapessupraestructure waspresent, with85.7% ofsuccess.PatientsinGroupBpresentedABG≤20dBin63% ofthecasesandpatientsinGroupDhadtheworstresults (80%remainedwithABG>20dB).Therefore,basedonthis series,wecan observethatthepresenceof stapes super-structureis agoodpredictorfor successinossicular chain reconstruction.
Conclusion
Inthepresentstudywehaveclassifiedourpatients accord-ing to two classification systems and concluded that the OOPS index seems not to be accurate on prognosticating hearingoutcomes,while theMERIindexcanbeavaluable toolforsurgeonstoestimatetherisks,predictsuccessofthe surgeryaswell astoselectthebestcandidatesfor recon-struction.Regardingtheossicularchainweconcludedthat thestatusofeachossicleisimportantforsurgicalsuccess, especiallythepresenceofstapes.This seriessurgical suc-cesswas61%ofthecasesanditalsoshowedanimprovement of17.26inPTA-ABGaftersurgery.Inthepresenceofstapes superstructurethesuccessratewas85.7%.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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