Although we typically prefer reconstruction to the stapes superstructure, this is not always the optimal procedure. The superstructure can be significantly rotated toward the promontory, as is typically the case with severe middle ear fibrosis. The resultant vector of any reconstruction placed on top of this superstructure will develop a significant degree of torque instead of a pure piston motion. Thus, we prefer to use a TORP to bypass the superstructure altogether when the oval window niche also allows room for the prosthesis. A previous review by Moretz14 analyzed such reconstructions and found
FIGURE 20—3 Critical distances for prosthesis design.
postoperative results to be stable and acceptable. When the oval window niche cannot accommodate the shaft of the prosthesis, one should consider removal of the superstructure altogether. Removal of the superstructure in the face of a mobile footplate is clearly difficult, however, and should not be undertaken lightly. The carbon dioxide laser appears to be the safest option for removing the superstructure as it theoretically displaces the footplate the least amount.
In the absence of a malleus for reconstruction, the most reliable anatomic relationship is the average height of the malleus above the stapes (2 mm) or the height of the malleus above the footplate when the stapes is absent (5 mm). Our own technique in this situation involves creating a neo-malleus for reconstruction, which also assists in establishment of adequate reconstruction length (see Chapter 6).
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