The distribution of diphosphopyridine nucleotide diaphorase, triphos-phopyridine nucleotide diaphorase, lactic dehydrogenase, malic dehydrogenase, succinic dehydrogenase, isocitric dehydrogenase, glucose-6-phosphate dehydrogenase, and β-hydroxybutyric dehydrogenase, cytochrome oxidase, alkaline and acid phosphatase, leucine- and alanine-aminopeptidase activity was demonstrated histochemically in the endolymphatic sac and in the perisaccular connective tissue. Enzyme activity was stronger in the epithelial cells lining the intermediate portion and in the cells floating free in the endolymph than in other parts of the sac, except for aminopeptidase activity which was marked in the perisaccular connective tissue, too.Foreign protein (peroxidase) was injected into the cochlear duct and after two days was found phagocytized in cells floating free in the endolymphatic sac but not in the lining cells themselves or elsewhere in the membranous labyrinth. Peroxidase was also observed in fibroblasts of the perisaccu...

Otolaryngology–Head and Neck SurgeryVolume 139, Issue S2 p. P21-P21 Miniseminars New Controversies in the Management of Meniere's Disease Michael E Hoffer MD (moderator), Michael E Hoffer MD (moderator)Search for more papers by this authorHerbert Silverstein MD, Herbert Silverstein MDSearch for more papers by this authorSteven D Rauch MD, Steven D Rauch MDSearch for more papers by this authorBrian W Blakley MD, PhD, FRCSC, Brian W Blakley MD, PhD, FRCSCSearch for more papers by this authorJohn P Carey MD, John P Carey MDSearch for more papers by this author Michael E Hoffer MD (moderator), Michael E Hoffer MD (moderator)Search for more papers by this authorHerbert Silverstein MD, Herbert Silverstein MDSearch for more papers by this authorSteven D Rauch MD, Steven D Rauch MDSearch for more papers by this authorBrian W Blakley MD, PhD, FRCSC, Brian W Blakley MD, PhD, FRCSCSearch for more papers by this authorJohn P Carey MD, John P Carey MDSearch for more papers by this author First published: 20 June 2017 https://doi.org/10.1016/j.otohns.2008.05.068Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume139, IssueS2August 2008Pages P21-P21 RelatedInformation

OBJECTIVE:To assess the efficacy, morbidity, and patient satisfaction of the SOUNDTEC semi-implantable hearing aid.STUDY DESIGN:Retrospective case review.SETTING:Two tertiary referral centers (the Silverstein Institute and the Atkins Institute).PATIENTS:Sixty-four (four bilateral placements) patients with bilateral moderately severe sensorineural hearing loss: 47 patients had previously worn hearing aids.INTERVENTIONS:After separating the incudostapedial joint, a magnet encased in a titanium canister with a ring was introduced onto the stapes neck. Gelfoam or adipose tissue was used to stabilize the magnet. After 3 months, the external processor was fitted.MAIN OUTCOME MEASURES:At 1 month, audiometric testing was performed and functional gain was assessed. Patient acceptance and implant performance were measured by a visual analogue questionnaire.RESULTS:The device produced an average functional gain of 26 dB. Fifty-five percent of patients complained of magnet movement; this was eliminated in 80% of Silverstein Institute patients when the external processor was worn and fat was used to stabilize the magnet.CONCLUSION:The SOUNDTEC direct device is well tolerated in the majority of patients, with a significant increase in functional gain. Magnet instability and noise were the most frequent complaints and improved with processor placement and anchoring the magnet with fat. This electromagnetic semi-implantable hearing aid confers greater functional gain over conventional hearing aids and reduces occlusion effect and feedback.

Using the MicroWick to deliver otic medication to the inner ear fluids isa new, unique, effective, safe, efficient, and inexpensive method to treat inner ear disease. This self-treatment method using otic medication represents a major breakthrough in the treatment of inner ear disease. It allows the otologist to treat inner ear disease much as the ophthalmologist treats eye disease using eye drops. In the future, new drugs and medications will likely be developed that will relieve vertigo attacks, improve certain types of sensorineural hearing loss, and reduce tinnitus. The MicroWick will be available for patients to self-administer these medications to the inner ear through the round window membrane.

Objective: The objective of this study was to compare short-and long-term hearing outcomes for patients undergoing primary laser stapedotomy minus prosthesis (STAMP) versus conventional laser stapedotomy.Study Design: We conducted a retrospective case review of 167 consecutive patients from 1993 to 2002.Setting: Otology/neurotology tertiary referral center.Patients: We studied those with clinical otosclerosis without previous otologic surgery.Interventions: Patients with otosclerosis confined to the fissula ante fenestram underwent STAMP. Patients with more extensive otosclerosis or anatomic contraindications to STAMP underwent standard laser stapedotomy.Main Outcome Measures: Pure-tone audiometry was performed before surgery, postoperatively, and on routine followup examination.Results: Of the 183 ears in 167 patients, 128 (67.1%) underwent laser stapedotomy and 55 (32.98%) underwent STAMP. The STAMP mean air-bone gap (ABG) closed from a preoperative value of 22 dB (standard deviation [SD], 10 dB) to 6 dB (SD, 7 dB) on average follow up of 778 days. In 128 laser stapedotomy patients with an average follow up of 747 days, the preoperative mean ABG closed from 27 dB (SD, 10 dB) to 8 dB (SD, 7 dB). There was a trend toward improvement in high-frequency air conduction thresholds after STAMP versus worsening of high-frequency thresholds in the conventional stapedotomy group. There was a statistically significant improvement in most recent postoperative high-frequency (60008000 Hz) air conduction thresholds in the STAMP patients compared with patients who underwent conventional laser stapedotomy.Conclusion: Laser STAMP, when used for isolated anterior footplate otosclerosis, provides excellent high-frequency hearing, yields lasting results similar to conventional laser stapedotomy, and has a low incidence of refixation necessitating revision surgery.

OBJECTIVE:To compare hearing results as a function of vestibular ablation in the treatment of Ménière's Disease, using gentamicin perfusion.STUDY DESIGN:A retrospective review of patients with Ménière's Disease treated by gentamicin perfusion of the inner ear via the MicroWick device.SETTING:A tertiary otologic referral center.PATIENTS AND INTERVENTIONS:The charts of patients treated with gentamicin perfusion via the MicroWick between the years 1998 and 2000 were reviewed. The results for patients with functional hearing in the affected ear were analyzed and were compared with the results in patients without functional hearing.MAIN OUTCOME MEASURES:Audiologic and vestibular test results as well as subjective symptoms.RESULTS:There were 45 patients who met the inclusion criteria. The averages for speech discrimination score and pure tone average before treatment were 92% and 38 dB, and after treatment were 82% and 47 dB. Patients were divided into two groups: Group 1 (20 patients), less than 75% ice air caloric reduced vestibular response (RVR); Group 2 (25 patients), those who reached greater than 75% ice air caloric RVR. There were 8 patients (17.6%) with persistent vertigo; 7 were from Group 1, and 1 was from Group 2, which was statistically significant (p = 0.007)wwww. The pure tone average dropped an average of 3 dB for Group 1 and 15 dB for Group 2. The difference in hearing loss between the two groups was statistically significant (p = 0.01).CONCLUSION:This study suggests that there is a correlation between the degree of vestibular ablation, the control of vertigo, and the risk of hearing loss. Patients with functional hearing seem to have a similar success rate for vertigo control, compared with patients who already had lost functional hearing before treatment. Future investigation may determine if less than 100% RVR, but greater than 75% RVR, is an alternative end point with adequate vertigo control and reduced risk of hearing loss.

Objective To determine what percentage of patients with otosclerosis could successfully undergo a laser stapedotomy minus prosthesis over a 5-year period, and to determine the percentage of patients in whom refixation develops during follow-up. Study Design Retrospective case review of 136 patients (137 ears) who underwent primary surgery for otosclerosis. Setting An otology/neurotology tertiary referral center. Patients Patients were chosen if they had clinical evidence of otosclerosis without a history of otologic surgery. Interventions A standard stapes approach was used for all patients. For the laser stapedotomy minus prosthesis, a hand-held laser probe was used to vaporize the anterior crus of the stapes and perform a linear stapedotomy across the anterior one third of the footplate. If otosclerosis was confined to the fissula ante fenestram, the stapes became completely mobile. The stapedotomy opening was sealed with an adipose tissue graft from the ear lobe. Main Outcome Measures Pure-tone audiometry with appropriate masking and auditory discrimination testing was performed before surgery, 6 weeks after surgery, and every year thereafter. Results Of the 137 cases, favorable anatomy and minimal otosclerosis allowed 46 (33.6%) of these patients to undergo laser stapedotomy minus prosthesis. Fifty-seven patients (41.6%) could not undergo the procedure because of extensive otosclerosis. The remaining 34 patients (24.8%) did not receive laser stapedotomy minus prosthesis because of other anatomic or technical difficulties. Of the 34 patients in the laser stapedotomy minus prosthesis group with more than 4 months follow-up, the average air-bone gap was closed from a mean of 22 dB (SD 10 dB) to 6 dB (SD 4 dB) 6 weeks postoperatively. Follow-up periods ranged from 5 months to 53 months (mean 767 days, SD 437 days). The long-term air-bone gap improved slightly to an average of 5 dB (SD 6 dB) in comparison with the sixth postoperative week value. Conclusion Laser stapedotomy minus prosthesis is a minimally invasive procedure, which over the follow-up period has a very low incidence of refixation, as evidenced by a lack of progressive conductive hearing loss. The success of this procedure depends on the correct selection of cases. This procedure has been successfully performed on 33.6% of patients undergoing primary stapes surgery. Laser stapedotomy minus prosthesis seems to be a viable alternative to conventional stapedotomy that yields good results without evidence of refixation over an extended time.

Localization of the round window membrane is desirable in order to allow a more direct application of medication to the inner ear. A new procedure has been developed to deliver direct, near-continuous inner ear perfusion to the round window with the Silverstein MicroWick. In this office procedure, the wick is inserted through a tympanostomy tube into the round window niche. Accurate localization of the round window is a necessary component of this procedure. In an effort to ascertain the precise location of the round window, we examined 25 cadaveric human temporal bones and measured the distance from the umbo to the round window in each sample. We found that the round window was an average of 3.44 mm (± 0.68) from the umbo and was situated at an average angle of 113.2° (± 9.8) from the long process of the malleus. Our simple and reliable determination of the relationship between the malleus handle and the round window niche allows for the accurate placement of the Silverstein MicroWick and other devices.

Inner ear perfusion techniques have become a prominent first-line treatment for inner ear disorders. The Silverstein MicroWick™ facilitates prolonged near-continuous perfusion of the inner ear with medication. Gentamicin has been effectively used to treat the vertigo of Menière's disease, and dexamethasone has been used to restore hearing caused by sudden deafness via the MicroWick. The MicroWick is easy to place in the office, with a low associated cost and a high relative safety-efficacy profile. Inner ear perfusion techniques have become a prominent first-line treatment for inner ear disorders. The Silverstein MicroWick™ facilitates prolonged near-continuous perfusion of the inner ear with medication. Gentamicin has been effectively used to treat the vertigo of Menière's disease, and dexamethasone has been used to restore hearing caused by sudden deafness via the MicroWick. The MicroWick is easy to place in the office, with a low associated cost and a high relative safety-efficacy profile.

OBJECTIVE:To evaluate effectiveness of laser-assisted tympanostomy in treatment of pediatric patients with chronic otitis media with effusion. STUDY DESIGN:Retrospective review of 23 pediatric patients who received office laser-assisted tympanostomy. METHODS:A CO2 laser attached to an operating microscope with a microscope laser adaptor device or the handheld Oto-LAM (Needham, MA) was used to perform all of the tympanostomies. The average diameter of tympanostomy was 2 mm; on average, 13.6 W was applied for 0.13 seconds. RESULTS:Laser-assisted tympanostomy was performed on 37 pediatric ears (patient age range, 2-16 y) for the diagnosis of chronic otitis media with effusion. Average follow-up time was 4.7 weeks. At the time of the follow-up examination, 46% of the ears had no evidence of fluid and required no further intervention. Forty-nine percent of the ears required placement of pressure equalization tubes. The average SRT improved from 30.8 dB preoperatively to 21.03 dB postoperatively. CONCLUSIONS:Laser-assisted tympanostomy appears to be an effective treatment for chronic otitis media with effusion in pediatric patients.

Objectives: To examine the hypothesis that for intraoperative facial nerve monitoring, an EMG monitor is more sensitive than a mechanical-pressure monitor. To compare the threshold sensitivity of the two facial nerve monitoring methods-mechanical-pressure versus EMG-by using them simultaneously during surgery. To assess and compare their true- and false-positive responses in otologic and neurotologic procedures.Setting: A tertiary referral private otology/neurotology practice.Study Design: Prospective case-controlled study.Patients and Methods: The facial nerve of 46 consecutive patients undergoing various otologic and neurotologic procedures was stimulated intraoperatively using a pulsed constant-current. Facial responses were monitored using the Silverstein WR-S8 Monitor/Stimulator and the Brackmann EMG System simultaneously. The threshold (i.e., minimal) current level required to elicit a response from each monitor was recorded. Monitor responses to facial nerve manipulation (including false-positive responses) were assessed by continuous recording of all responses, using the Wiegand Monitoring System, and noting the causative event for each response.Results: The EMG monitor responded to lower current threshold (p < 0.001) in every surgical procedure and for every nerve seg ment studied. However, the average threshold difference was <0.05 mAmps and in clinical practice, when using above threshold stimulation, becomes negligible. In posterior fossa surgery, the EMG monitor showed higher sensitivity by responding earlier to various manipulations of the bare facial nerve. The EMG had more false-positive responses than the mechanical-pressure monitor.Conclusions: In otologic surgery, if monitoring is required, the mechanical-pressure monitor is used. In neurotologic surgery, both monitors are used simultaneously.

OBJECTIVE: To evaluate the effectiveness of the round window membrane (RWM) Gelfoam gentamicin technique in patients with Meniere's disease who were unresponsive to medical management or in whom surgical therapy failed.STUDY DESIGN: Protocol 1, single intratympanic gentamicin infusion; protocol 2 (the best method), 2 infusions, 5 days apart with reevaluation at 1 month; and protocol 3, multiple infusions 1 to 4 weeks apart.PATIENTS: In total, 32 patients (19 male, 13 female) were enrolled in the study. The mean age was 65 years (range 34 to 94 years). Seven of these patients were surgical salvage cases.INTERVENTIONS: Laser-assisted otoendoscopy with a 1.7-mm otoendoscope (Smith-Nephew Richards, Memphis, TN) was performed first. If the RWM was obscured by mucosa or adhesions, these were cleared before placing a 2 x 3 mm piece of dry Gelfoam against the RWM. Buffered gentamicin (26.7 mg/mL) was then injected into the middle ear (0.2 to 0.3 mt).RESULTS: Overall, vertigo was controlled in 75% of the patients after the completion of the treatment, with subtotal vestibular ablation in two thirds of patients. Hearing was preserved in 90% of the patients (within 15 dB pure-tone average or 15% speech discrimination score), tinnitus improved in 48%, and aural pressure improved in 62.5%.

A new procedure for delivering medication directly to the inner ear has been developed. This delivery system, called the MicroWick™, involves the use of a small wick that is inserted through a tympanic membrane vent tube into the round window niche. Once the wick has been inserted, the patient can self-administer eardrops into the ear canal, where they are absorbed by the wick and transported to the round window membrane and to the inner ear fluids. Inserting the wick is a minor procedure that is performed in the office. This paper describes the indications for and use of the MicroWick.

Our goal was to investigate the postoperative differences in hearing between patients who had their stapedius tendon sacrificed and those whose stapedius tendon was preserved during laser stapes surgery for otosclerosis. To that end, we performed a retrospective review by mailing extensive questionnaires to patients who had been operated on between 1994 and 1997. We also performed routine and special audiometric testing to augment the subjective data. Seventy-nine of 124 questionnaires (64%) were returned. Of the respondents, 75 patients had undergone additional pre- and/or postoperative audiometric testing, including tests to evaluate "hearing in noise" and to determine the "uncomfortable loudness level" (dynamic range). We found no statistically significant differences between the two groups with respect to their subjective responses and their audiologic test results. The responses to the questionnaire indicated that in most cases, hearing was improved by stapes surgery. We conclude that the stapedius tendon should be preserved whenever possible during stapes surgery, provided that it does not jeopardize the exposure or outcome.

Objective: To determine whether hearing can be restored using a laser without a prosthesis in patients with minimal otosclerosis.Study Design: Retrospective case review of 12 patients with minimal otosclerosis who underwent a laser stapedotomy without prosthesis (laser STAMP) procedure.Setting: An otology/neurotology tertiary referral center.Patients: Patients were chosen for the procedure if there was a blue footplate with minimal otosclerosis confined to the fissula antefenestram.Interventions: Using a hand-held probe (CeramOptic), and the HGM argon laser, the anterior crus of the stapes was vaporized. Next, a linear stapedotomy was made across the anterior one third of the footplate. If otosclerosis is confined to the fissula antefenestram, the stapes becomes completely mobile. The stapedotomy opening is sealed with an adipose tissue graft from the ear lobe.Main Outcome Measures: Pure-tone audiometry with appropriate masking and auditory discrimination testing were performed before surgery, 6 weeks after surgery, and 1 year after surgery.Results: The average air-bone gap was closed to a mean (SD) of 2.6 dB (3.3 dB). The average improvement in air-bone gap was 17.4 dB (7.6 dB). The discrimination scores remained unchanged. Audiometric testing of five cases with 1 year follow-up demonstrates that excellent hearing results are maintained.Conclusions: In selected cases of minimal otosclerosis confined to the fissula antefenestram, normal mobility of the ossicular chain can be obtained without a prosthesis by vaporizing the anterior crus and making a linear stapedotomy across the anterior one third of the footplate. The advantages of the procedure are that the stapedius tendon and most of the normal stapes remain intact, eliminating hyperacusis. The procedure is less invasive so it reduces inner ear trauma, possible prosthesis problems are avoided, and postoperative barotrauma risk is minimized. Minimal surgery is done for minimal disease. If the stapes refixes at some time in the future, a conventional stapedotomy can still be performed.

OBJECTIVE:Evaluate melatonin as a treatment for subjective tinnitus.STUDY DESIGN:Randomized, prospective, double-blind, placebo-controlled crossover trial. Patients were given 3.0 mg melatonin, which was taken nightly for 30 days followed or preceded by a placebo nightly for 30 days, with a 7-day washout period between medications.SETTING:Outpatient, private, neurotology practice.PATIENTS:Thirty patients with subjective tinnitus.MAIN OUTCOME MEASURES:Tinnitus matching, Tinnitus Handicap Inventory (THI), patient questionnaire and interview.RESULTS:The average pretreatment THI score was 33.91 as compared with 26.43 after the placebo and 26.09 after melatonin. The difference in the THI scores between melatonin and placebo treatment were not statistically significant. The average pretreatment THI score for patients who reported overall improvement with melatonin was statistically higher (P = 0.02) than the average pretreatment THI score for patients who reported no improvement with melatonin. Among subjects reporting difficulty sleeping attributable to their tinnitus, 46.7% reported an overall improvement after melatonin compared with 20.0% for placebo (P = 0.04). There was also a statistically significant difference in improvement with melatonin for those patients with bilateral tinnitus compared with those with unilateral tinnitus (P = 0.02).CONCLUSION:Melatonin has been shown to be useful in the treatment of subjective tinnitus. Patients with high THI scores and/or difficulty sleeping are most likely to benefit from treatment with melatonin. In light of its minimal side effects, melatonin should be a part of the physician's armamentarium in the treatment of tinnitus.

Objectives/Hypothesis: The stapedius tendon is routinely transected during stapes surgery. The objective of this study was to evaluate the technique of stapedial tendon preservation during stapes surgery and to compare results of these cases with cases where the stapedial tendon was not preserved. Study Design: Retrospective study. Methods: Four groups of patients were evaluated. Two groups had undergone stapes surgery with preservation of the stapedial tendon. One of these groups underwent a laser stapedotomy minus prosthesis (laser STAMP) procedure, while the other group had a prosthesis inserted. The other two groups had undergone laser stapedotomy with one of two different prostheses being used. Audiometric data were obtained and reviewed both preoperatively and at approximately 6 weeks postoperatively. Results: All groups had overall successful results demonstrating that stapedial tendon preservation is technically possible and does not compromise outcomes. Conclusions: Based on the results, it is recommended that the stapedius tendon be preserved whenever possible during laser stapes surgery. Reasons justifying its preservation are discussed. Laryngoscope, 108:1453–1458, 1998

OBJECTIVE:This study aimed to challenge the classical hypothesis that a negative preoperative 512-Hz Rinne tuning fork test (bone conduction greater than air conduction) is a necessary condition to allow consistent objective and subjective hearing improvement with surgery for otosclerosis.STUDY DESIGN:The study design was retrospective (chart review and questionnaire).SETTING:The study was conducted at a Florida Ear and Sinus Center at Sarasota, Florida, a tertiary otology-neurotology referral center.PATIENTS:Patients who underwent primary laser stapedotomy with equivocal (air=bone) preoperative 512-Hz Rinne test results participated.INTERVENTION:KTP laser stapedotomy was performed.MAIN OUTCOME MEASURES:Audiologic measurements of air-bone gap closure and patient assessment of hearing improvement and satisfaction were conducted.RESULTS:The air-bone gap was closed to within 10 dB in all cases. There were no complications. Eighteen patients were questioned about their results. Hearing improvement was subjectively described as "excellent" or "good" by 17 (94%), and 16 (89%) thought the surgery was "absolutely" worthwhile.CONCLUSIONS:The preoperative 512-Hz Rinne test results need not be negative to achieve significant air-bone gap closure and subjective appreciation of improved hearing.

OBJECTIVE:To investigate the benefits of intratympanic administration of dexamethasone in the treatment of unilateral Meniere's disease, with particular attention to the symptoms of hearing loss and tinnitus.STUDY DESIGN:A prospective, randomized, double-blind, crossover study comparing improvements in hearing loss, tinnitus, aural fullness, and caloric vestibular response secondary to intratympanic dexamethasone and sodium hyaluronate injection versus placebo consisting of saline and sodium hyaluronate.SETTING:A private otology/neurotology practice.PATIENTS:Twenty patients diagnosed with either definite or probable Meniere's disease as defined by the American Academy of Otolaryngology Head and Neck Surgery Committee on Hearing and Equilibrium. All patients were < or =21 years old and were not receiving any other form of treatment for their Meniere's disease. Each patient's primary symptoms of concern were hearing loss, aural fullness, and roaring tinnitus.INTERVENTIONS:Three consecutive daily administrations of intratympanic dexamethasone or placebo to the involved ear.MAIN OUTCOME MEASURES:Changes in audiometric pure-tone averages, speech reception thresholds, caloric vestibular responses, scores on the tinnitus handicap inventories, questionnaires, and telephone interview responses.RESULTS:No significant changes were observed in any measured parameter. Patients were unable to consistently identify which medication was dexamethasone and which was placebo.CONCLUSIONS:Intratympanic administration of dexamethasone in a group of patients with unilateral Meniere's disease (Shea's stage IV) showed no benefit over placebo for the treatment of hearing loss and tinnitus.

OBJECTIVE:This study aimed to evaluate the hearing results obtained using the Silverstein Incus-Stapes Connection in ossicular reconstruction among patients with chronic ear disease.STUDY DESIGN:The study was performed as a retrospective review. A control group consisted of patients undergoing similar surgery but in which no prosthesis was used.SETTING:The Florida Ear and Sinus Center outpatient offices of the senior author.PATIENTS:Forty-seven patients with a mean age of 48 years comprised the treatment group. Thirty-eight patients (mean age, 49.4 years) acted as control subjects.INTERVENTION:All patients underwent surgery for chronic ear disease. Reconstruction surgery for patients requiring separation of the incudostapedial was performed with a Silverstein Incus-Stapes Connection or by reapproximating the joint capsule to allow primary healing.MAIN OUTCOME MEASURE:The patients were categorized according to how the prosthesis was used. Results comparing the preoperative air-bone gap and postoperative air-bone gap were evaluated. The change in air-bone gap was reported according to the guidelines set forth by the Committee on Hearing and Equilibrium.RESULTS:The mean postoperative air-bone gap for reconstruction with the prosthesis was 17.6 dB compared to a mean of 11.8 dB among control subjects. An air-bone gap of 16.5 dB was achieved when the prosthesis was used to bridge an area of lenticular resorption. When a composite prosthesis, made by adding cartilage to the disk, was used to bridge larger defects, an air-bone gap of 14.3 dB was seen. Finally, when the prosthesis was used as a partial ossicular replacement prosthesis and directly contacted the tympanic membrane, the air-bone gap was 9 dB. The prosthesis was found to be stable when re-exploration was required and modification of the prosthesis with cartilage was accomplished easily intraoperatively.CONCLUSION:The Silverstein Incus-Stapes Connection is a middle ear prosthesis that can provide a mechanism for overcoming incus resorption in selected cases. In addition, the prosthesis can be modified easily with the addition of cartilage when needed.