Clin Exp Otorhinolaryngol.  2013 Sep;6(3):127-134.

Clinical Significance of beta-Tricalcium Phosphate and Polyphosphate for Mastoid Cavity Obliteration during Middle Ear Surgery: Human and Animal Study

• Lee HB
• Lim HJ
• Cho M
• Yang SM
• Park K
• Park HY
• Choung YH

Abstract

OBJECTIVES
Mastoid obliteration is used to obliterate the mastoid cavity following a mastoidectomy or to prevent the formation of a retraction pocket. This study evaluated the effectiveness of beta-tricalcium phosphate and polyphosphate (beta-TPP) for mastoid obliteration in middle ear surgeries in prospective human and animal studies.
METHODS
Twenty patients with chronic otitis media underwent mastoid obliteration using beta-TPP after a intact canal wall mastoidectomy or simple mastoidectomy. The clinical data were prospectively evaluated including: the diagnosis, temporal bone computed tomography (TBCT), otoscopic findings, pure tone audiogram, and complications. In the animal experiment, beta-TPP was applied into the right bulla in five rats, and the opposite bulla was used as the control in the non-obliterated state. The skulls of five other rats were drilled out and the holes were obliterated with beta-TPP. TBCT were obtained at 3, 6, and 9 months after the obliteration and histologic analysis was done at 3 and 9 months after surgery.
RESULTS
In the human study, fourteen TBCTs were obtained at 12 months after the surgery. All demonstrated no bone resorption in the obliterated mastoids. Among the 15 cases displaying retracted tympanic membranes preoperatively, 11 showed no retraction, 2 showed retraction postoperatively, 1 was lost to follow-up and 1 was a case of postoperative wound infection. Among 20 cases, one case developed a postoperative infection that necessitated a second operation. Sixteen underwent ossiculoplasty; hearing improvements were obtained in 15 cases and 1 case showed decreased hearing. In the animal study, new bone formation without significant bone resorption in the radiologic and histologic findings were noted in both the skull and bulla groups.
CONCLUSION
Although beta-TPP is a foreign material having the possibility of infection, mastoid obliteration with it can be a treatment option in middle ear surgeries to prevent retraction pockets or the recurrence of diseases.

Keyword

Chronic otitis media; Cholesteatoma; Mastoidectomy; Treatment; Recurrence; Prevention

MeSH Terms

Animal Experimentation
Animals
Blister
Bone Resorption
Calcium Phosphates
Cholesteatoma
Ear, Middle
Hearing
Humans
Lost to Follow-Up
Mandrillus
Mastoid
Osteogenesis
Otitis Media
Prospective Studies
Rats
Recurrence
Skull
Surgical Wound Infection
Temporal Bone
Tympanic Membrane
Calcium Phosphates

Figure

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  Fig. 1 Surgical techniques of mastoid obliteration using PolyBone®. (A) Inflammatory tissues in the mastoid cavity were completely removed. (B) The mastoid cavity was obliterated with PolyBone®. (C) PolyBone® in the mastoid cavity was covered with a harvested autologous bone pate.

• 

  Fig. 2 The human study flow diagram. PTA, pure tone audiometry; TM, tympanic membrane.

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  Fig. 3 Preoperative and postoperative tympanic membrane (TM) otoscopic findings. (A) Attic destruction was noted in preoperative TM findings (case 1). (B) No retraction in postoperative TM findings (case 1). (C) A retraction pocket was noted in preoperative TM findings (case 4). (D) The retraction pocket had recurred in postoperative TM findings (case 4).

• 

  Fig. 4 Temporal bone computed tomography (CT) before and 12 months after the operation in case 6. The preoperative CT (A, axial; B, coronal) showed mastoid hazziness in the right side. Images obtained at 12 months after surgery (C, axial; D, coronal) demonstrated high density which suggested that the PolyBone® graft remained in the right obliterated mastoid area.

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  Fig. 5 Complications in case 10. In the intraoperative finding, a wet middle ear mucosa was noted. (A) We blocked the aditus ad antrum with an autologous bone pate, gelfoam and glue. (B) The mastoid cavity was obliterated with PolyBone® and covered with a bone pate. (C, D) However, operation site swelling and otorrhea were found on postoperative day 5. We performed a canal wall down mastoidectomy on postoperative day 10.

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  Fig. 6 Computed tomography (CT) images of the skull and bulla at 3, 6, and 9 months after obliteration in the animal study. A-C are coronal views obtained from of the same rat in the skull group, and D-F are from the same rat in the bulla group. After drillings were done in both sides, PolyBone® grafts were performed in only the right side. CT images demonstrated high density in only right side, suggesting no bone resorption in the right skull and bulla at 3, 6, and 9 months after obliteration. However, there was no change in the left side skull and bulla (control side). (A, D) Three months after obliteration, (B, E) 6 months after obliteration, (C, F) 9 months after obliteration.

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  Fig. 7 Histopathologic findings in the skull and bulla at 9 months after obliteration in the animal study. In the control group (A-D), there was no new bone formation. In contrast, active new bone formation was seen without inflammatory infiltration around the implantation field in the PolyBone® graft group (E-H), (H&E, A, C, E, and G, ×12.5; B, D, F, and H, ×40).

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