Decision Making by Dr. Robert Vincent
La app SurgSchool, a world leader in online surgical training, has just added a new case from the renowned otologist Dr. Robert Vincent (Causse Ear Clinic, Béziers), where he performs a complex tympanoplasty with ossicular reconstruction, exemplifying the process of intraoperative decision-making in middle ear surgery.
Initial evaluation and surgical findings
During the examination, Dr. Vincent identifies a anterior dislocation of the stapes and a fracture of the anvil, still keeping the perilymphatic membrane visible. Given this structural alteration, he decided to remove the fractured incus and plan a complete reconstruction of the ossicular chain, taking special care to avoid injury to the stirrup plate.
Surgical strategy
The surgery focuses on replace the hammer and assess the stability of the tympano-malleolar ligaments. After sectioning the tendon of the tensor tympani muscle and release adhesions, a is identified partial dislocation of the malleus, which the surgeon carefully repositions to restore the physiological mobility of the system.
During the procedure, Dr. Vincent stresses the importance of maintaining contact with the bone at all times to prevent tears of the tympanic membrane, and mentions that if this occurs, it can be repaired with vein or pericardium graft.
Ossicular reconstruction and prosthetic placement
Once the hammer is released and the residual portion of the incus is removed, reconstruction is carried out using a titanium partial denture (PORP) with hydroxyapatite head, adjusted with a final length of 6,5 mm, carefully measured with reference to the hammer axis.
The surgeon emphasizes the precision of the fit between the prosthesis and the tympanic membrane, ensuring proper vibration transmission without subsequent implant displacement. The final stability of the construct is verified by the synchronous mobility of the malleus and stapes, achieving a satisfactory anatomical and functional reconstruction.
Results and technical considerations
Dr. Vincent emphasizes that this type of case requires a constant decision-making and a millimetric assessment of ossicular mobility. hammer repositioning, prosthetic choice and control of tympanic membrane tension are determining factors for optimizing hearing outcomes.
The case demonstrates once again the level of precision and experience required in advanced otologic surgery, and how a well-planned reconstruction can restore the ossicular chain even under unfavorable anatomical conditions.
This procedure of the Dr. Robert Vincent constitutes a masterful example of functional middle ear surgery, combining meticulous technique with dynamic surgical reasoning in the face of complex anatomy.
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