12070_2015_927_author j

8/16/2019 12070_2015_927_Author j

1/9

Dear Author,

Here are the proofs of your article.

• You can submit your correctionsonline, via e-mail or by fax.

• For online submission please insert your corrections in the online correction form. Always

indicate the line number to which the correction refers.

• You can also insert your corrections in the proof PDF andemail the annotated PDF.

• For fax submission, please ensure that your corrections are clearly legible. Use a fine black

pen and write the correction in the margin, not too close to the edge of the page.

• Remember to note the journal title, article number, and your name when sending your

response via e-mail or fax.

• Check the metadata sheet to make sure that the header information, especially author names

and the corresponding affiliations are correctly shown.

• Check the questions that may have arisen during copy editing and insert your answers/ corrections.

• Check that the text is complete and that all figures, tables and their legends are included. Also

check the accuracy of special characters, equations, and electronic supplementary material if

applicable. If necessary refer to the Edited manuscript .

• The publication of inaccurate data such as dosages and units can have serious consequences.

Please take particular care that all such details are correct.

• Please do not make changes that involve only matters of style. We have generally introduced

forms that follow the journal’s style.

Substantial changes in content, e.g., new results, corrected values, title and authorship are notallowed without the approval of the responsible editor. In such a case, please contact the

Editorial Office and return his/her consent together with the proof.

• If we do not receive your correctionswithin 48 hours, we will send you a reminder.

• Your article will be publishedOnline First approximately one week after receipt of your

corrected proofs. This is the official first publication citable with the DOI. Further changes

are, therefore, not possible.

• The printed version will follow in a forthcoming issue.

Please note

After online publication, subscribers (personal/institutional) to this journal will have access to the

complete article via the DOI using the URL: http://dx.doi.org/[DOI].

If you would like to know when your article has been published online, take advantage of our free

alert service. For registration and further information go to: http://www.link.springer.com.

Due to the electronic nature of the procedure, the manuscript and the original figures will only be

returned to you on special request. When you return your corrections, please inform us if you would

like to have these documents returned.

http://www.link.springer.com/

8/16/2019 12070_2015_927_Author j

2/9

Metadata of the article that will be visualized in

OnlineFirst

ArticleTitle Endoscopic Ear Surgery: Critical Review of Anatomy and Physiology of Normal and Reconstructive

Middle Ear

Article Sub-Title

Article CopyRight Association of Otolaryngologists of India

(This will be the copyright line in the final PDF)

Journal Name Indian Journal of Otolaryngology and Head & Neck Surgery

Corresponding Author Family Name Dinesh Kumar

Particle

Given Name Rajendran

Suffix

Division Department of ENT and Head-Neck Surgery

Organization Navodaya Medical College Hospital and Research Centre

Address Raichur, Karnataka, 584 103, India

Email [email protected]

Author Family Name Udagatti

Particle

Given Name Vithal D.

Suffix

Division

Organization N.R.M ENT Hospital

Address Near Mahila Samaj, Raichur, Karnataka, 584101, India

Email [email protected]

Schedule

Received 9 October 2015

Revised

Accepted 7 December 2015

Abstract Middle ear anatomy is complex hence it is difficult to study the microscopic vibration of tympanic

membrane and ossicles. The basic research has been done in few centres. Our experience is based on

clinical data. The lack of quantitative understanding of structural and functional relationship in the

mechanical response of the normal and reconstructed middle ear is major factor in poor hearing results

after surgery (Merchant et al. in J Laryngol Otol 112:715–731, 1998). The vibration pattern of tympanic

membrane changes with different frequencies. It depends upon shape, position and tension of tympanic

membrane. Sometimes reconstructed tympanic membrane loses its shape and tension and thus its vibratory

response (Pusalkar and Steinbach in Transplants and implants in otology II, 1992). Then what should be

the shape, position, tension of the tympanic membrane and the ossicles. In order to have a serviceable

hearing, dry and safe ear, there is a necessity of answering all these queries by us.

Keywords (separated by '-') Endoscopic ear surgery - Tympanic membrane - Ossicles - Vibratory pattern

Footnote Information

8/16/2019 12070_2015_927_Author j

3/9

U N C O

R R E C

T E D P R

O O F

O R I G I N A L A R T I C L E1

2 Endoscopic Ear Surgery: Critical Review of Anatomy

3 and Physiology of Normal and Reconstructive Middle Ear

4 Vithal D. Udagatti2

• Rajendran Dinesh Kumar1

5 Received: 9 October 2015 / Accepted: 7 December 20156 Association of Otolaryngologists of India 2015

7 Abstract Middle ear anatomy is complex hence it is

8 difficult to study the microscopic vibration of tympanic9 membrane and ossicles. The basic research has been done

10 in few centres. Our experience is based on clinical data.

11 The lack of quantitative understanding of structural and

12 functional relationship in the mechanical response of the

13 normal and reconstructed middle ear is major factor in poor

14 hearing results after surgery (Merchant et al. in J Laryngol

15 Otol 112:715–731, 1998). The vibration pattern of tym-

16 panic membrane changes with different frequencies. It

17 depends upon shape, position and tension of tympanic

18 membrane. Sometimes reconstructed tympanic membrane

19 loses its shape and tension and thus its vibratory response

20 (Pusalkar and Steinbach in Transplants and implants in

21 otology II, 1992). Then what should be the shape, position,

22 tension of the tympanic membrane and the ossicles. In

23 order to have a serviceable hearing, dry and safe ear, there

24 is a necessity of answering all these queries by us.

25

26 Keywords Endoscopic ear surgery

27 Tympanic membrane Ossicles Vibratory pattern

28Introduction

29Endoscope ear surgery is not the technique what we nor-

30mally find and learn from the text books, at least in the

31beginning of the era of the endoscopic ear surgery. Middle

32ear endoscopy was first introduced by Mer and colleagues

33in 1967 but till the last decade endoscopes have been

34mainly used for diagnostic and photographic purposes.

35Recently few surgeons have been doing endoscopic middle

36ear surgery [3] (Fig. 1).

37In the 70’s of last century, the concept of the ear surgery

38was dry cavity and dry ear. Some seniors were doing

39grafting to cover the perforated ear drum and the concept

40changed to safe ear. Though ossiculoplasty and tym-

41panoplasty was primarily much talked subject but hearing

42restoration was secondary in nature. Even up to 90’s of last

43century, every third child we saw in our practice used to be

44with ear discharge.

45Now there is dramatic reduction in ear discharge cases.

46This probably is due to

47(1) Introduction of newer molecules of antibiotics, anti-

48inflammatory and anti allergy drugs.

49(2) Good health education by medical faculty.

50(3) Practice of hygienic condition by parents.

51Nowadays the patient’s symptomatology has changed to

52hard of hearing after one or two bouts of discharge during

53their childhood and they are desirous of prompt rectifica-

54tion and restoration of hearing. We did reconstructive

55surgery with our old technique by using the microscope;

56pts were not satisfied with results.

57Then we sat back and started critically reviewing our

58technique. At that movement we peeped through endo-

59scope into the ear. Better illumination, higher magnifica-

60tion, ability to have repeated observation and better

A1 & Rajendran Dinesh Kumar

A2 [email protected]

A3 Vithal D. Udagatti

A4 [email protected]

A5 1

Department of ENT and Head-Neck Surgery, Navodaya

A6 Medical College Hospital and Research Centre, Raichur,

A7 Karnataka 584 103, India

A8 2

N.R.M ENT Hospital, Near Mahila Samaj, Raichur,

A9 Karnataka 584101, India

AQ1

AQ2

1 3Journal : Large_Springer-India12070 Dispatch : 14-12-2015 Pages : 6

Article No. : 927h LE h TYPESET

MS Code : IJOO-D-15-00449 h CP h DISK 4 4

Indian J Otolaryngol Head Neck Surg

DOI 10.1007/s12070-015-0927-3

http://crossmark.crossref.org/dialog/?doi=10.1007/s12070-015-0927-3&domain=pdfhttp://crossmark.crossref.org/dialog/?doi=10.1007/s12070-015-0927-3&domain=pdfhttp://orcid.org/0000-0001-6136-130X

8/16/2019 12070_2015_927_Author j

4/9

U N C O

R R E C

T E D P R

O O F

61 documentation changed our perspective views regarding

62 the normal anatomy physiology of ear and its reconstruc-

63 tive technique [3].

64 Anatomy

65 Ear is series of compartments- external ear, middle ear and

66 internal ear. The external ear permits sound to reach the ear

67 drum, it is elliptical (Fig. 2). Middle ear pneumatic cavity,

68 bounded by bony walls except laterally where, tympanic

69 membrane is located, which is cone shaped, obliquely

70 placed tense and transparent with surface area of 80 sq

71 mms and vibrative area of 55 sq mms. Tympanic mem-

72 brane is formed by endothelial, fibrous and epithelial lay-

73 ers. Fibrous layer is converging from annulus tympanicus

74 which is tugged into tympanic sulcus and is attached to

75 handle of malleus (Figs. 3, 4).

76 Eustachian tube is trachea of the ear connecting middle

77 ear to nasopharynx. Tensor palati muscle guards its

78 nasopharyngeal end and acts like sphincter and regulates

79 the air flow [4] (Fig. 5).

80Round window is covered with semi permeable mem-

81brane and takes part in pressure release of inner ear and its

82surface area is 2 sq mms. Oval window is closed by foot

83plate of stapes which has surface area of 3.2 sq mm.

84Ossicles extend from tympanic membrane to oval window.

Fig. 1 Endoscopic view of middle ear

Fig. 2 Endoscopic view of external auditory cannal. It is elliptical

Fig. 3 Endoscopic view of tympanic membrane, it is cone shaped,

Obliquely placed, tensed and transparent

Fig. 4 Endoscopic view of middle ear (bone), Tympanic sulcus, Oval

window and round window, Surface area and plane

Fig. 5 Endoscopic view of eustachian tube opening in middle ear

AQ3





8/16/2019 12070_2015_927_Author j

5/9

U N C O

R R E C

T E D P R

O O F

85 The articular facet covers 90 % of surface area of

86 malleus head. Other two bones to have this type of articular

87 facet are Humerus and Femur. They articulate over fixed

88 bones, scapula and pelvis. Both Shoulder and hip joints are

89 dynamic synovial joints and articulate to 360 degrees.

90 Though having same articulate facet but malleus will not

91 articulate over medial wall of middle ear (attic region).

92 It hangs by ligaments in middle ear space, only handle

93 attached to the tympanic membrane and articulate with

94 incus. Incus has four articular facets two on its body which

95 articulates with the malleus head, thus it vibrates along

96 with malleus as a single unit (Figs. 6, 7).

97 This ossicle also hangs in middle ear space by liga-

98 ments, except articulate with fossa incudis by articular

99 facet over its short process, causing axial vibration. Facet

100 over the long process articulate with facet over stapes head.

101 Stapes is not a solid ossicle but is like inverted tuning fork

102 with a foot plate (Figs. 8, 9). All synovial joints, whether

103 they are hinge joints also and move in particular direction.

104Where are the Muscles to Cause the Movements?

105Two muscles- tensor tympani originate in tympanic canal.

106Stapes muscle originates in the pyramid and inserted to the

107ossicles. Thus they take part in the stability and protecting

108the inner ear against loud sounds but will not cause the

109movements, because muscles do not originate and insert in

110the neighboring ossicles.

111Then, What Does This Ossicular Chain Do?

112Probable it is only a vibration along with tympanic mem-

113brane and transforming the vibration to foot plate and

114cochlear fluid.The chronological reduction of weight of

115ossicles helps to enhance the stapes linear movement.

116Mucus membrane is composite having stratified ciliated

117columnar epithelium and squamous epithelium and quan-

118tum of air space is 6 ml in volume including mastoid air

119cells [1, 4].

Fig. 6 Endoscopic view of malleus. Articular surface cover 90 % of

its head

Fig. 7 -Endoscopic view of incus. It has four articular facets two on

body and one on each in long and short processes

Fig. 8 Endoscopic view of stapes. It has only one articular facet on

head

Fig. 9 Endoscopic view of stapes (lateral view). Stapes is not a solid

bone instead it is a hallow arch like tyre





8/16/2019 12070_2015_927_Author j

6/9

U N C O

R R E C

T E D P R

O O F

120 Stapes, long process of incus and tendons of the muscles

121 are visceral contents of mesotympanum. Chorda tympani

122 and handle of the malleus are in tympanic membrane. No

123 mucosal folds in mesotympanum which help in the free air

124 flow (Fig. 10).

125 Thus annulus, handle of malleus, fibrous layer and two

126 muscles take part in changing the shape and tension of

127 tympanic membrane and ossicles [5]. Malleus and incus

128 acts as a unit and are in horizontal plane where as stapes in

129 vertical plane and two planes are of 45 degree angulation

130 [1].

131 Physiology

132 External Auditory Canal

133 Ear canal acts as resonator and it resonates between 2000 to

134 5000 cycles/s.

135 Middle Ear

136 If sound energy hits inner ear directly most of energy

137 would be reflected because of resistance of fluid media

138 hence there is need for transformer mechanism that is filled

139 by middle ear (Air media to solid media to fluid media).140 The cone shaped, tensed transparent tympanic mem-

141 brane provides optimal acoustic pick up, at this level first

142 transduction takes place (i.e. sound energy converts to

143 mechanical energy) Vibrative pattern of tympanic mem-

144 brane is complex and it changes with different frequency.

145 The sound energy that reaches tympanic membrane

146 (vibrative area 55 sq mms) is conducted across the chain

147 and concentrated on stapes foot plate (3.2 sq mm) and the

148 ratio being 17.1:1. Length of handle of malleus is 9 mm

149and long process of incus is 7 mm and the ratio being 1.3:1

150which two factors combined enhance the sound transmis-

151sion through the middle ear and overcome the resistance of

152liquid media.

153Middle ear aeration helps for optimal vibration and

154middle ear muscles provide stability and tension to ossicles

155and tympanic membrane. After acoustic pickup and

156transduction of sound energy into mechanical vibration, it157passes through the ossicular coupling. Vibration of the

158tympanic membrane also travels through the air in the

159middle ear and vibrates both foot plate of stapes and round

160window membrane. This is called acoustic coupling.

161• Net vibrative pressure difference at

162Oval window and round window is = Ossicular cou-

163pling ? Acoustic coupling.

164• Stapes volume vibrative velocity = Linear vibration of

165stapes 9 area of foot plate.

166• Net Vibrative pressure transfer to the cochlear

167fluid = Ossicular coupling ? Acoustic cou-

168pling 9 area of foot plate/Impedance of fluid ? annu-

169lar ligament of stapes.

170Following are the functions of tympanic membrane.

1711. Lateral border of middle ear.

1722. Protects against spreading of the infection from the

173External auditory canal.

1743. Creates air column- thus protects against the entry of

175nasal regurgitation, autophonia and also clearance of

176the middle ear.

1774. Maximum acoustic pick up.1785. Transduction

1796. Middle ear gain

1807. Bone Conduction gain.

181Certain questions are thus raised during reconstructive

182surgery.

183Question

184Whether stenosis of the EAC reduces the resonating

185quality? Does canaloplasty enhance it? Does mastoid

186cavity alter it? [1] (Goode et al. 1997)

187 Answer

1881. Middle ear pathology is tackled transmeatally and

189mastoid post aurally without elevating the meatal skin

190because Endoscope brings the surgeons eye to tip of

191the scope, hence the view through endoscope is not

192restricted by the narrow segment of external auditory

193canal and anterior and posterior buldge, so no need of

Fig. 10 Endoscopic view of middle ear. Stapes long process of incus

and tendons of the muscles are visceral contents of the mesotympa-

num. Chorda tympani and handle of the malleus are in the tympanic

membrane





8/16/2019 12070_2015_927_Author j

7/9

U N C O

R R E C

T E D P R

O O F

194 canaloplasty. Doesn’t amount to risk of meatal

195 stenosis.

196 2. Endoscope mounted with camera and visualized

197 through monitor will remove the disadvantage of

198 monocular vision which would have lead to the loss of

199 depth of perception.

200 3. Endoscope view gives better illumination and higher

201 magnification, it gives flexible movements and middle202 ear can be observed in different angles and fields

203 easily.

204 4. Endoscope gives wide angled view which includes the

205 entire tympanic membrane the graft and medial end of

206 external auditory canal at one frame so positioning the

207 graft was much easier and precise.

208 Question

209 1. Whether in tympanoplasty removal of annulus from

210 sulcus (inlay and inter lay grafting) changes shape and

211 tension of tympanic membrane?

212 Answer

213 Yes. Do not remove the annulus from sulcus either do

214 onlay or inlay to onlay technique.

215 Question

216 2. Can the graft which is dry dead inert material (tem-

217 poralis fascia) and absorbed by phagocyte activity and 218 healed with only endothelial and epithelial layer main-

219 tain the tension shape of tympanic membrane?

220 Answer

221 The aim of the grafting is epithelization, endothelial-

222 ization and vascularisation (converting the graft material

223 into fibrous layer). So use the wet graft which is not

224 scraped and crushed, it can act like fibrous layer and

225 over it endothelial and epithelial layer develops.Minimal

226 dissection and creating tympanomeatal epithelial flaps

227 will help in vascularisation.

228 Question

229 Is it necessary only malleus is attached to tympanic

230 membrane?

231 Answer

232Yes, it is necessary to have free movements of malleus

233and incus and it can be achieved only when graft

234material placed lateral to the handle of malleus.

235Question

236Whether ratio of tympanic membrane and foot plate of

237stapes is to be maintained?

238 Answer

239Yes.

240Then how to maintain it in stapedectomy? (Rasowsky

241and Merchant 1995)[6].

242Question

243Whether middle ear air space & pressure is necessary

244 for vibration?

245 Answer

246Yes. In canal down technique bony canal can be reduced

247up to annular sulcus only and graft should put over it

248because at least 0.5 ml of air has to be maintained in the

249middle ear.

250Question

251 Is it necessary to maintain horizontal plane of

252malleoincus unit and vertical plan of stapes?

253 Answer

254Needs further evaluation ossicles weight share stout and

255cramping should be appropriate for free vibration of

256them in middle ear air chamber. It is an observation that

257presence of the supra structure of the stapes helps in the258good hearing than only a foot plate.

259The inverted tuning fork shape and the resonance of the

260stapes are entirely different of columella effect.(How can

261columellar vibrative pattern replace the pattern of the

262chain system). Thus, we have limited understanding of

263mechanics of ossicular reconstruction.





8/16/2019 12070_2015_927_Author j

8/9

U N C O

R R E C

T E D P R

O O F

264 Question

265 Is it necessary to have muscle attachment to ossicles to

266 maintain shape and tension of the ossicles?

267 Answer

268 Yes.

269

270 1. Try to preserve the ossicles and muscle attachments.

271 Do not become too radical to middle ear during

272 cholesteatoma clearance because it is very difficult

273 to create muscles, ossicles and their articular

274 surfaces [7].

275 2. Continuity of the mucosa of middle ear avoids

276 adhesions

277 3. Patency of Eustachian tube should be maintained by

278 clearing and suctioning the tube.

279 4. No gel foam in the middle ear- creates instantaneous280 air chamber, soaked with the blood and swollen gel

281 foam may change position of graft material.

282 Question

283 What about the patency of Eustachian tube?

284 Answer

285 Should be maintained by clearing and suctioning the

286 tube.

287 Conclusion

288 Endoscope view gives better illumination and higher

289 magnification. It gives flexible movements and middle ear

290 can be observed in different angles and fields easily. Shape,

291 position, tension of tympanic membrane and ossicles are at

292 most important to maintain during reconstruction surgery.

293 It is very much difficult to create articular surface of

294 ossicles and muscles to have proper chain movements

295along with vibrating tympanic membrane so try to preserve

296them wherever possible. Creation of near normal anatomy

297of middle ear in reconstructive surgery will provide max-

298imum hearing improvement.

299Lastly this helps in creating good hearing, safe and dry

300ear. Endoscope ear surgery is far easier than microscopic

301surgery. 302

303Compliance with Ethical Standards

304Conflict of interest None.

305Ethical Approval All procedures performed in studies involving306human participants were in accordance with the ethical standards of 307the institutional and/or national research committee and with the 1964308Helsinki declaration and its later amendments or comparable ethical309standards.

310Informed Consent Informed consent was obtained from all indi-311vidual participants included in the study.

312References

3131. Merchant SN, Ravicz ME, Voss SE, Peake WT, Rosowski JJ314(1998) Middle ear mechanics in normal, diseased and recon-315structed ears. J Laryngol Otol 112:715–7313162. Pusalkar AG, Steinbach E (1992) Gold implants in middle ear317reconstructive surgery. In: Yanagihara N, Suzuki J (eds) Trans-318plants and implants in otology II. Matsuyama, Japan, pp 111–1133193. Haragop S, Mudhol RS, Godhi RA (2008) A comparative study of 320endoscope assisted myringoplasty and micrsoscope assisted321myringoplasty. Indian J Otolaryngol Head Neck Surg 60:298–3023224. Udwadia R (2000) Brief review of current studies on otitis media323with effusion. In: Shah VH, Karnik P (eds) Otolaryngology review3242000, a collection of review articles. Alembic Limited, Surat,

325pp 46–493265. Hawkins JE (2014) Human ear. http://www.britannica.com/ 327science/ear#toc65029. Accessed 14 Dec 20143286. Merchant SN, Rosowski JJ, Raicz ME (1995) Middle ear329mechanics of type 4 and 5 tympanoplasty—clinical analysis and330surgical implantation. Am J Otol 16(5):565–5753317. Desai ABR, Desai A (2000) Tympanomastoid surgery today–the332principle & practice. In: Shah VH, Karnik P (eds) Otolaryngology333review 2000, a collection of review articles. Alembic Limited,334Surat, pp 54–673358. Mahadevaiah A, Parikh B (2009) Use of autogenic and allogenic336malleus in tympanic membrane to footplate assembly—long-term337results. Indian J Otolaryngol Head Neck Surg 61:9–13

AQ4





http://www.britannica.com/science/ear%23toc65029http://www.britannica.com/science/ear%23toc65029http://www.britannica.com/science/ear%23toc65029http://www.britannica.com/science/ear%23toc65029

8/16/2019 12070_2015_927_Author j

9/9

Journal : 12070

Article : 927 1 3the language of science

Author Query Form

Please ensure you fill out your response to the queries raised below and return this form along

with your corrections

Dear Author

During the process of typesetting your article, the following queries have arisen. Please check your typeset proof carefully

against the queries listed below and mark the necessary changes either directly on the proof/online grid or in the ‘Author’s

response’ area provided below

Query Details Required Author’s Response

AQ1 Please check and confirm the author name and initials are correct for the author (Rajendran DineshKumar).

AQ2 References [1, 2] are cited in Abstract section only. As per style all references should be cited in text.Please appropriate citations for references [1, 2].

AQ3 Please confirm the section level headings are correctly identified.

AQ4 Reference [8] was provided in the reference list; however, this was not mentioned or cited in themanuscript. As a rule, if a citation is present in the text, then it should be present in the list. Please providethe location of where to insert the reference citation in the main body text. Kindly ensure that allreferences are cited in ascending numerical order.

12070_2015_927_author j

Documents