Introduction

Speech communication is essential to survival. Television, radio and smart phones are all now a basic part of our everyday life. Anyone with a hearing impairment loses this vital communication and becomes severely handicapped when competing in the present industrial world. Children with hearing loss suffer from delays in academic achievement, which in turn affects social and emotional development. In adults, hearing loss results in psychosocial complications and fewer interpersonal contacts; it also poses a significant economic burden, as it is so difficult for deaf persons to occupy professional, technical or managerial positions.^{Reference Dobie and Van Hemel1}

Conductive hearing loss is commonly a result of ossicular chain abnormalities. The first main type of abnormality is the loss of ossicular continuity as a result of trauma, surgical intervention or cholesteatoma. The second main type of abnormality is ossicular fixation in cases of otosclerosis or adhesions.^{Reference Mudhol, Naragund and Shruthi2}

In more than 80 per cent of patients, the cause of ossicular damage (i.e. discontinuity, fixation) is cholesteatoma or chronic suppurative otitis media. The incus is the most commonly found necrotic ossicle, which demands ossicular chain reconstruction. The lenticular process of the incus is vulnerable to necrosis because it has less blood supply and a proximal narrow pedicle.^{Reference Albera, Canale, Piumetto, Lacilla and Dagna3}

The most frequently seen ossicular problem is a defective or missing incus with an intact and mobile stapes and malleus, which represents 60 per cent of all ossicular defects.^{Reference Iurato, Marioni and Onofri4}

Austin, in 1971, classified ossicular defects into four groups: group A – erosion of the long process of the incus with an intact malleus and stapes, which is the most common defect;^{Reference Sismanis, Glasscock and Gulya5} group B – only the malleus is present and the stapes is absent; group C – only the stapes is present and the malleus is absent; and group D – absent malleus and stapes suprastructure. Kartush added three more classes to the Austin classifications: classification 0 – an intact ossicular chain; group E – fixation of the malleus head; and group F – fixation of the stapes.^{Reference Sismanis, Glasscock and Gulya5,Reference Frootko and Brooth6}

The ideal prosthesis for ossicular reconstruction should be biocompatible, safe, readily available, stable and capable of yielding optimal sound transmission. Nowadays, ossiculoplasty surgery using alloplast materials is becoming popular, but the fate of these synthetic materials in the human middle ear requires further studies.^{Reference Mudhol, Naragund and Shruthi2}

Autologous ossicle or cortical bone grafts maintain their physical integrity, morphological contour, shape and size for long periods of time, and these remain the ‘gold standard’ choice for ossiculoplasty. The choice of the surgical technique depends on many factors, including the causative pathology, graft availability and surgeon experience.^{Reference Wiet and Wiet7,Reference Mehra, Mahich, Mathur and Singh8}

In 1957, Hall and Ryztner performed the first trial of ossicular reconstruction using autograft ossicles.^{Reference Hall and Rytzner9} In 1966, House et al. used homograft ossicles for ossicular repair by sculpting the ossicles and fixing properly. ^{Reference House, Patterson and Linthicum10} This has been superseded by the use of synthetic biomaterials such as gold and titanium, which are claimed to have equally good results.

In the late 1960s, Teflon and Proplast were used as biocompatible materials for polyethylene tubing. In the late 1970s, a high-density polyethylene sponge that had non-reactive properties was introduced. Wehrs, in 1972, used homograft ossicles for reconstruction of the ossicular chain.^{Reference Wehrs11} Later, in 1989, Wehrs designed a hydroxyapatite prosthesis, aiming to minimise the preparation time and obviating concerns about disease transmission.^{Reference Wehrs12}

In 1960, Utech was the first to describe cartilage ossiculoplasty.^{Reference Utech13} He introduced sculptured auricular cartilage as an interposition graft from the tympanic membrane to the stapes head or footplate.

In 2008, Yamane et al. described a new technique to repair the ossicular chain with conchal cartilage using a lever method to reduce the post-operative air–bone gap.^{Reference Yamane, Takayama, Sunami, Morinaka, Minowa and Yoshioka14}