title: Malleus-to-footplate ossicular reconstruction prosthesis positioning: cochleovestibular pressure optimization.
abstract: OBJECTIVE
  To determine 1) the best position for hydroxylapatite malleus-to-footplate (MFP), ossicular replacement prosthesis (ORP) in reconstructed ears, and 2) whether preserving the stapes superstructure (SS), when present, has acoustic advantages.
  
  
  BACKGROUND
  Positioning of the MFP-ORP head beneath the neck of the malleus may produce maximal force, whereas positioning beneath the manubrium of the malleus may produce the greatest displacement. It is not clear which is the optimal placement position. In addition, we look at the effect of the SS on sound transmission to the inner ear in ossicular reconstruction.
  
  
  METHODS
  The ear-canal air pressure and vestibular hydro-pressure were measured in human cadaver temporal bones with incus intact, removed, and replaced with the MFP-ORP; the ORP head was placed at three different positions on the malleus (head, mid-manubrium, and umbo) while keeping its base at the center of stapes footplate with intact or removed stapes SS. The vestibular pressure ratio between the ear with intact incus and MFP-ORP reconstructed ear is defined as Lmfp, the loss caused by the prosthesis in relation to the normal ossicular chain.
  
  
  RESULTS
  The mean magnitude of Lmfp, averaged in the important speech frequency region of 0.5 to 3 kHz, is approximately 7.8 dB at the neck with stapes SS. In comparison, mean magnitude of Lmfp for mid-manubrium without stapes SS is 15 dB (p = 0.04), and with the stapes SS it is 16 dB (p = 0.05), whereas at the umbo without SS it is 15 dB (p = 0.03). In the 8 kHz region, the mean magnitude of Lmfp is approximately 1 dB with the stapes SS intact and approximately 8.5 dB when it was removed (p < 0.09).
  
  
  CONCLUSIONS
  There are significant physiologic advantages to placing the hydroxylapatite MFP-ORP beneath the neck of the malleus and preserving the SS.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, USA. puria@stanford.edu
authors.forename: Sunil
authors.initials: S
authors.lastname: Puria
authors.forename: Larisa D
authors.initials: LD
authors.lastname: Kunda
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Roberson
authors.forename: Rodney C
authors.initials: RC
authors.lastname: Perkins
mesh_terms: D000368:Aged; D001274:Atmospheric Pressure; D002102:Cadaver; D003051:Cochlea / Q000503:physiopathology*; D004424:Ear Canal / Q000503:physiopathology; D006801:Humans; D007188:Incus / Q000601:surgery; D008307:Malleus; D008875:Middle Aged; D019933:Ossicular Replacement / Q000379:methods*; D011312:Pressure; D013199:Stapes; D013701:Temporal Bone / Q000601:surgery; D014722:Vestibule, Labyrinth / Q000503:physiopathology*