Osikuloplastide kemik çimentosu uygulaması M. Tayyar KALCIOĞLU

Kemikçik zincir sorunları Kulak cerrahisi gereksinimi duyulan olgularda yaklaşık %60 kemikçik zincir sorunu ile karşılaşılabilmekte Cerrahinin başarısını etkileyen intraensekt faktörlerden biri Fonksiyonel başarının önemli ayaklarından biri

Kemikçik zincir sorunları Kolesteatoma yada polip gibi patolojik dokunun kitle etkisi ile erozyon, destrüksiyon veya adezyonlar yoluyla ossiküler zincir etkilenebilmektedir En sık inkus uzun kolu defekti izlenmekte bunu stapes suprastrüktürünün erozyonu takip etmektedir.

Austin sınıflandırması* Malleus (+), stapes suprastrüktürü (+), inkus (-)    İyi prognoz Malleus (+), stapes suprastrüktürü (-),  inkus (-)  İyi prognoz Malleus (-),  stapes suprastrüktürü (+), inkus (-) Kötü prognoz Malleus (-),  stapes suprastrüktürü (-),  inkus (-), mobil footplate (+)   *Austin DF. Ossicular reconstruction. Arch Otolaryngol 1971;94: 525-535.

Becvaroski ve Kartush’un orta kulak risk indeksine göre; Risk Faktörü Risk Değeri Kemikçiklerin Durumu M+, I+, S+ M+, S+ 1 M+, S- 2 M-, S+ 3 M-, S-   4 Becvarovski Z, Kartush JM. Smoking and tympanoplasty: implications for prognosis and the Middle Ear Risk Index (MERI). Laryngoscope 2001;111:1806-11

Kemikçik zincir onarımında Kemikçikler bir bütün halinde hareket etmelidir Lateral duvarlara temas olmamalıdır Mümkün olduğunca kemikçiklerin doğal pozisyonları korunmalı, ileti malleus, inkus ve stapes yolunu takip ederek oval pencereye iletilmelidir.

Kemikçik Zincir Problemlerinde Kullanılan Materyaller; Otogreft kemik veya kıkırdak Homogreft kemik veya kıkırdak Alloplastik mateyaller Seramik Kemik çimentosu Metaller; TORP, PORP

Kemik Çimentosu 1969 yılında Wilson tarafından geliştirildi Polimaleinat molekülü Diş dolgu maddesi olarak diş tedavisinde 1974 den beri kullanılagelmekte Poliakrilik asid ve calsium aluminium florosilicat (baz) ın karışımından elde edilen bir tuz; glass ionomer cement 1-2 dakika içerisinde istenilen şekilin verilebilmesi 5-10 dakikada sertleşme özelliği Sertleştikten sonra etraf sıvılarından etkilenmeme

Otolojik Cerrahilerde Kullanımı Babighian G. Use of a glass ionomer cement in otological surgery: a preliminary report. J Laryngol Otol 1992;106:954-956. Geyer G, Helms J. Reconstruction of the posterior auditory canal wall dawn and obliteration of the mastoid cavity using glass iyonomer cement. In: Yanagihara N, Suzuki JL, eds. Transplant and Implants in otology. edn 2. Amsterdam: Kugler, 1992:165-170.

Uyumluluk

Komplikasyon

Dikkat ! Kemikçikler üzerinde uygulanacak alandan mukozal kalıntılar temizlenmeli ve mümkün olduğunca kansız ve kuru alanda çalışılmalıdır Özellikle stapes tabanı açıksa iç kulağa olası toksik etki nedeniyle dikkatli olunmalıdır Olası nöral toksik etki nedeniyle fasiyal dehissans varsa temastan kaçınmalıdır Eger uygulanan alandan akmışsa fiksasyonu önlemek için temizlenmelidir

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 1 M (+); I (-); S (+) Defektif inkus uzun kolu

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 2 M (+); I (-); S (+) Defektif inkus uzun kolu, kortikal kemik ve kemik çimentosuyle iletimin restorasyonu

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 3 M (+); I (-); S (+) İnkus interpozisyonu

İnkus ile stapes tabanı arasına köprü Kemik Çimentosu Uygulamaları Vaka Örnekleri : 4 M (+); I (+); S (-) İnkus ile stapes tabanı arasına köprü

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 5 M (+); I (-); S (+) Malleus ile stapes arasına köprü

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 6 M (+); I (-); S (-)

Kemik Çimentosu Uygulamaları Vaka Örnekleri : 7 Stapedotomi’de

Patients Out 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 eligible for ossicular chain reconstruction were selected from a database and data were evaluated in retrospect. 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, if the defect of the long process of incus was not bigger than half of the long process. This procedure let us saving the malleo-incudal joint and re-build incudo-stapedial joint. This procedure was performed for 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. If the authograft incus clear from the cholesteatoma and big enough for to use between stapes and malleus, was used for interposition. Incus interposition was performed for 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. For 32 of these 65 patients, the defective incus was removed to control advanced disease 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). For the other 38 cases, type IV or V tympanoplasty or radical mastoïdectomy was performed (5 type IV tympanoplasties; 1 type V tympanoplasties; 11 radical mastoïdectomies) or they are still waiting for a second look tympanomastoïdectomy to control cholesteatoma and obtain hearing restoration (16 cases).

RESULTS The population description for all groups and excluded cases were put in the 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 air-bone gap (ABG) was 34,8 dB preoperatively and 15.6 dB postoperatively (Table 3). There was a significant 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) (Table 2). The mean ABG was 35 dB preoperatively and 18,4 dB postoperatively (Table 3). The differentiation of preoperative and postoperative mean ABG was statistically significant (p<0.001). Thirteen of 32 patients who underwent incus interposition 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 43,4 dB preoperatively and 19,8 dB postoperatively (Table 3). The differentiation of preoperative and postoperative ABG was statistically significant (p<0.001). Seventy-four%, 72% and 60% of patients in respectively group 1, 2 and 3 had a postoperative ABG ≤20dB, while 11%, 22% and 20% had a respective postoperative ABG≤10dB (Table 4).

TEŞEKKÜRLER

Stapedial timpanoskleroz ve piston uygulaması Kemal GÖRÜR Osikuloplasti Stapedial timpanoskleroz ve piston uygulaması Kemal GÖRÜR