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Necrosis of the Long Process of the Incus Following Stapes Surgery: New Anatomical Observations

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Necrosis of the Long Process of the Incus Following Stapes Surgery: New Anatomical Observations The Laryngoscope VC 2009 The American Laryngological, Rhinological and Otological Society, Inc. Necrosis of the Long Process of the Incus Following Stapes Surgery: New Anatomical Observations Imre Gerlinger, MD, PhD; Miklo´sTo´th, MD, PhD; La´szlo´ Lujber, MD, PhD; Istva´n Szanyi, MD; Pe´ter Mo´ricz, MD; Krisztina Somogyva´ri, MD; Adrienn Ne´meth, MD; Ga´bor Ra´th, MD; Jo´zsef Pytel, MD, PhD; Wolfgang Mann, MD, PhD, FACS Objectives/Hypothesis: The most frequent incudes revealed 1-4 nutritive foramina on the long complication (generally recognized during revision processes of 48% (24) of the left-sided incudes and procedures) following seemingly successful stapedoto- 56% (28) of the right-sided incudes. The positions of mies and stapedectomies is necrosis of the long pro- these foramina differed, however, from those previ- cess of the incus. This is currently ascribed to a mal- ously described in the literature. They were mostly crimped stapes prosthesis or to a compromised blood located not on the medial side of the incus body or on supply of the incus. The two-point fixation can cause the short process or on the cranial third of the long a mucosal injury with a resulting toxic reaction, and processes, but antero-medially, mostly on the middle also osteoclastic activity. An important aspect in the or cranial third. In 48% of all the incudes examined, engineering of ideal stapes prostheses is that they an obvious foramen was not observed either in the should be fixed circularly to the long process of the body or in the long process of the incus. No relation- incus with appropriate strength. The objective of this ship was discerned between the chronological age of study was to compare current knowledge relating to the incus specimens and the numbers and/or locations the blood supply of the ossicular chain with the pres- of the nutritive foramina. In each case, the opening of ent authors’ observations on cadaver incudes. Most of the foramen was the beginning of a tunnel running the papers dealing with this issue appeared in the obliquely and medially upward through the corticalis mid-20th century. of the long process of the incus. The foramina are Methods: The published data were compared thought to be capable of ensuring a richer blood sup- with the authors’ findings gained from photodocumen- ply between the surface and the inside of the long tation on 100 cadaver incudes. The photos were taken process, allowing the arteries to run in and out. with a Canon EOS 20 digital camera (Canon, Inc., Conclusions: These observations indicate that Lake Success, NY) with a 5:1 macro-objective. The long conclusions drawn from classical anatomical works processes of the incudes were examined from four appear to need reconsideration. The present authors directions under a Leica surface-analyzing microscope consider that the reason for the necrosis of the long (Leica Microsystems GmbH, Wetzlar, Germany). process of the incus is not a compromised blood sup- Results: Analysis of the positions of the entran- ply, except in some exceptional anatomical situations. ces of the feeding arteries (nutritive foramina) on the They discuss the possible reasons why malcrimping may lead to necrosis of the long process of the incus. To prevent such malcrimping, attention is paid to the From the Department of Otorhinolaryngology and Head Neck new generation of prostheses. Surgery, University of Pe´cs, Pe´cs, Hungary (I.G., L.L., I.S., P.M., K.S., A.N., Key Words: Incus, necrosis, piston, long process G.R., J.P.) and the Department of Otorhinolaryngology and Head and Neck of the incus, stapes, stapes surgery. Surgery, University of Mainz, Germany (M.T., W.M.). Laryngoscope, 119:721–726, 2009 Editor’s Note: This Manuscript was received on July 26, 2008 and accepted for publication on October 28, 2008. Presented during the meeting of the 8th Conference on Cholestea- toma and Ear Surgery in Antalya, Turkey, June 15–20, 2008. INTRODUCTION This study is supported by grants from the HSR Fund (OTKA After an initial hearing improvement, stapedecto- NKTH3 68476). mies or stapedotomies sometimes fail, the main reasons Conflict of interest: none. being erosion or necrosis of the long process of the incus, Send correspondence to Imre Gerlinger, MD, PhD, Department of 1–7 Otorhinolaryngology and Head Neck Surgery, Medical School, University caused by the different prostheses. The shape of the of Pe´cs, Pe´cs, Munka´cy Miha´ly utca 2, H-7621, Hungary. E-mail: i.gerlin- piston and its attachment to the incus are additional im- [email protected]. portant factors. Crimping that is too strong causes DOI: 10.1002/lary.20166 damage to the mucosal lining or to the cortical bone of Laryngoscope 119: April 2009 Gerlinger et al.: Long Process of the Incus Necrosis 721 Two main arteries can be observed along the tendon of the stapedial muscle, one on the lower surface, and the other on the lateral surface of the tendon (Figs. 1 and 2). These arteries are branches of the stylomastoid artery leaving the facial canal in the region of the pyramidal process. Occasionally, they originate from the depth of the oval window, supplying the surrounding mucosa as branches of the superficial petrosal artery. The arteries running along the stapedial tendon partici- pate exclusively in the blood supply of the incus. An artery arriving directly from the pyramidal process has never been observed. The blood supply of the incus mucosa originates from a posterior branch of the anterior tympanic ar- tery.17 An arc-shaped artery, running in a considerable mucosal fold, can frequently be observed on the medial side of the incudostapedial joint, running on the long process of the incus to the lenticular process and the Fig. 1. The blood supply of the surroundings of the incudostape- head of the stapes (Fig. 1). Vessels can also be seen run- dial joint as described by Alberti in 1963 (reproduced with kind ning distally in the mucosa of the long process of the permission from The Laryngoscope 1963;73:605–628). incus, similarly to the vessels inside the long process. In the mid-20th century, the blood supply of the the incus; this adverse consequence is less common long process and the body of the incus was intensively when bucket-type or self-crimping pistons are used.8 investigated.9,10,17,18 A cavernous vascular network Whereas some authors accentuate the likely damage inside the body of the incus may reach as low as the to the blood supply of the long process of the incus during middle third of the long process. A supplying artery gen- surgery,9–11 caused by too strong over-crimping or circum- erally enters the long process anterolaterally through ferential fixation of the piston, others do not consider the the nutritive foramen, immediately under the body of mucosal damage of the incus to be an important factor, the incus, at the beginning of the long process (in some pointing out the anastomosing vessels between the stapes cases a little more distally).17 The nutritive foramen can andtheincus,andbetweenthedeepandsuperficialparts be located laterally, or less frequently medially, on the of the incus.12,13 A relevant and interesting clinical obser- body of the incus, close to the surface of the incudomal- vation is that the incus deprived of its blood supply can be leolar joint, or occasionally on the short process of the used as an ossicular replacement prosthesis immediately, or even a year later in staged tympanoplasties, with excel- lent long-term results.14 Moreover, cortical bone columella was utilized for ossicular chain reconstruction for a period of 34 years, and necrosis was experienced in only one case.15 Relatively frequent necrosis of the distal end of the long process of the incus might be anticipated after disar- ticulation of the incudostapedial joint, due to damage to the vessels coming along the stapedius tendon, but this is not observed clinically.16–18 We felt it important to review the available relevant publications from the mid-20th century that described the blood supply of the tympanic cavity and the osssicular chain, in order to highlight the possible con- tradictions resulting from more recent research findings in stapes surgery.7,9–13,17–19 It has previously been reported that small vessels arriving from the medial wall of the tympanic cavity run on the crura of the stapes toward the incudostapedial joint, cross the capsule of the joint, and then make an incomplete vascular ring around the capsule of the joint, creating anastomoses with vessels running on the sur- face and inside the incus in a distal direction (Fig. 1). Fig. 2. Endoscopic photograph of the blood supply of a cadaver The locations of these anastomoses are always the part incudostapedial joint. Note the two arteries along the stapedial ten- of the incudostapedial joint adjacent to the incus. Its don (thin black arrow), the artery on the lower surface of the lenticu- lar process (thick black arrow), the artery supplying the head of the blood supply is ensured across the hiatus in the lenticu- stapes (white arrow), and the artery on the anterior stem of the sta- lar process, but an artery supplying the neck of the pes (white pentagon). [Color figure can be viewed in the online stapes can also be found here (Figs. 1 and 2). issue, which is available at www.interscience.wiley.com.] Laryngoscope 119: April 2009 Gerlinger et al.: Long Process of the Incus Necrosis 722 Fig. 3. Variable blood supply of the long process of the incus according to Alberti in 1965 (reproduced with kind pemission from The Journal of Laryngology & Otol- ogy 1965;79:966–970.).
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