Chronic suppurative otitis media is characterized by persistent or recurrent middle-ear inflammation and tympanic membrane perforation, often accompanied by ossicular erosion. The incus, particularly its long process, is commonly affected because of its relatively limited vascular supply and its exposure to inflammatory and enzymatic processes. Ossicular discontinuity produces a conductive hearing deficit that may persist even after successful eradication of infection or cholesteatoma. Reconstruction therefore has two complementary goals: control of disease and restoration of an efficient sound-conduction mechanism.

Ossiculoplasty has evolved from simple autologous ossicle interposition to a wide range of cartilage, bone, cement and alloplastic prostheses. Published evidence does not demonstrate universal superiority of a single reconstructive material; outcomes are strongly influenced by residual ossicular anatomy and the middle-ear environment. [1,14] Long-term studies also show that postoperative hearing may deteriorate over time, making stable reconstruction and adequate follow-up essential. [11,13]

The present narrative   summarizes the evidence relevant to ossicular reconstruction in CSOM, with particular emphasis on reconstructive materials, PORP/TORP selection, hearing outcomes, prosthesis stability, and prognostic factors.

This article was prepared as a narrative review using PubMed-indexed literature and peer-reviewed studies published through December 2020, identified with combinations of the terms “chronic suppurative otitis media,” “chronic otitis media,” “ossiculoplasty,” “ossicular reconstruction,” “autologous incus,” “titanium PORP,” “titanium TORP,” “cartilage ossiculoplasty,” and “hearing outcomes.” Priority was given to systematic reviews, comparative studies, large cohort studies and long-term outcome studies. The review is intended to synthesize published evidence rather than report a new patient cohort; therefore, no original patient-level results are presented. 3. Pathophysiology and Patterns of Ossicular Damage Figure 1. Schematic anatomy of the normal ossicular chain and common sites of ossicular erosion in CSOM. Ossicular erosion in CSOM may result from chronic inflammation, osteitis, pressure effects from granulation tissue or cholesteatoma, and enzymatic bone resorption. The long process of the incus is particularly vulnerable. The functional consequence depends on which ossicles remain intact. When the malleus and stapes superstructure are present, an incus interposition or PORP can often re-establish the conductive pathway. When the stapes superstructure is absent but the footplate is mobile, a TORP or an autologous cartilage/bone columella may be required. The quality of the middle-ear mucosa and control of active disease are critical because persistent inflammation can destabilize a reconstruction. 4. Reconstructive Materials and Techniques Figure 2. Schematic overview of common ossicular reconstruction options according to residual ossicular anatomy. 4.1 Autologous incus Refashioned autologous incus is one of the most established options for ossicular reconstruction. It is biologically compatible, inexpensive and readily available during tympanoplasty. Comparative and prospective studies have demonstrated meaningful postoperative hearing improvement with refashioned incus, with results that can be comparable to alloplastic reconstruction in selected patients. [15,16] Potential limitations include severe incus erosion, inadequate remaining bone, technical difficulty in sculpting the graft, and concern about epithelial remnants when an eroded ossicle has been exposed to cholesteatoma. [15] 4.2 Cartilage and cortical bone Cartilage can be fashioned as an interposition graft, cartilage block, umbrella or boomerang. It is inexpensive, well tolerated and particularly useful when an autologous ossicle is unavailable. Prospective and comparative studies have demonstrated useful postoperative hearing outcomes with cartilage and other autologous graft materials, although technique and hearing definitions vary between series. [16,18] Cortical bone and other autologous bone grafts are additional options, while comparative studies suggest that titanium may provide favorable results in selected settings. [15,16] 4.3 Titanium prostheses Titanium is widely used because it combines low mass, rigidity, biocompatibility and resistance to corrosion. PORP is generally used when the stapes superstructure is intact, whereas TORP is used when the superstructure is absent. Long-term studies of titanium ossiculoplasty have reported useful postoperative hearing with relatively low extrusion rates, although hearing outcomes may decline with longer follow-up. [10,11,13] 4.4 Fluoroplastic/Teflon prostheses and bone cement Fluoroplastic/Teflon prostheses remain an alternative to titanium, particularly where cost or local availability influences material selection. A comparative study of autograft ossicle and Teflon reconstruction reported clinically useful hearing improvement with both approaches, with Teflon performing favorably in that cohort. [15] Bone cement reconstruction can provide a simple method of bridging a limited incudostapedial defect when the stapes superstructure is intact; this approach should be reserved for appropriately selected small defects. [1] 5. PORP versus TORP The choice between PORP and TORP is principally anatomical. A PORP transfers vibration from the reconstructed tympanic membrane or malleus to the stapes head and therefore requires an intact, mobile stapes superstructure. A TORP extends from the tympanic membrane/malleus region to the mobile stapes footplate when the stapes superstructure is absent. Long-term titanium data support both approaches, with outcomes influenced substantially by the underlying ossicular anatomy and middle-ear condition rather than prosthesis type alone. [6,10,11] Cartilage-based alternatives are especially relevant when the stapes superstructure is absent or when an alloplastic prosthesis is unsuitable. Clinical studies of autologous graft materials and ossicular reconstruction support cartilage as a practical alternative in appropriately selected ears. [16,18] 6. Hearing Outcomes Postoperative ABG is the most commonly reported functional endpoint. A postoperative ABG ≤20 dB is frequently used to define successful ossiculoplasty, although some studies use ≤25 dB, AC gain, speech thresholds, or composite criteria. This lack of uniformity complicates direct comparison between studies. [3,5,14,16] Clinical series have reported substantial rates of postoperative ABG improvement, while the presence of a functional stapes and favorable middle-ear conditions are repeatedly associated with better outcomes. [6,12,14] Comparative studies also demonstrate that both autologous and alloplastic materials can improve hearing, emphasizing that the reconstructive material is only one component of the final result. [15,16] 7. Prognostic Factors Figure 4. Conceptual determinants of ossiculoplasty success. Several patient-, disease- and surgery-related variables influence ossiculoplasty results. Important factors include the presence of the malleus and stapes, middle-ear mucosal status, active otorrhea, cholesteatoma, Eustachian tube dysfunction, previous surgery, surgical approach, and the type of reconstruction. Long-term multivariate analyses have identified the presence of the stapes and primary surgery as favorable predictors of successful hearing reconstruction. [6] Other long-term studies have shown that the presence of the malleus is associated with better outcomes, whereas absent malleus, otorrhea and adverse middle-ear conditions may be unfavorable factors. [4,5,13] Failure analysis also indicates that persistent or recurrent middle-ear pathology can contribute to late failure in addition to prosthesis-related technical problems. [13] Published prognostic studies and risk-index analyses suggest that higher Middle Ear Risk Index (MERI) or related staging scores, unfavorable ossicular status, active disease, and poor middle-ear conditions are associated with poorer hearing outcomes. [3,6,12,14] 8. Practical Surgical Algorithm Figure 3. Practical decision algorithm for selecting reconstruction according to residual ossicular anatomy and middle-ear status. Intraoperative finding Preferred reconstruction Key considerations Malleus + stapes superstructure intact; incus long process deficient Refashioned autologous incus, cartilage or PORP Stable contact, appropriate length, avoid excessive pressure Stapes superstructure intact; autologous incus unavailable Titanium PORP / cartilage / fluoroplastic prosthesis Cover/secure prosthesis with cartilage where appropriate Stapes superstructure absent; mobile footplate Titanium TORP or cartilage/bone columella Stable footplate contact; avoid excessive medial pressure Active infection or unstable middle ear Prioritize disease control; staged reconstruction when indicated Inflammation and poor mucosa increase risk of failure Cholesteatoma with ossicular erosion Complete disease eradication followed by appropriate reconstruction Avoid retaining epithelium within eroded ossicles; consider staging 9. Complications and Causes of Failure Potential complications include prosthesis extrusion or displacement, persistent conductive hearing loss, recurrent or residual disease, tympanic membrane retraction, middle-ear adhesions and, rarely, sensorineural hearing loss or vertigo. Long-term titanium series demonstrate relatively low extrusion rates, but hearing may gradually deteriorate. [10,11,13] Late failures are often related to persistent middle-ear disease, recurrent cholesteatoma, scarring, poor Eustachian tube function or changes in the reconstructed sound-conduction mechanism rather than simply the material itself. [5,13] 10. Evidence Summary Material/technique Main advantage Main limitation Evidence summary Autologous incus Biocompatible, inexpensive, readily available Requires usable ossicle; shaping required Good hearing outcomes; often comparable to alloplasts in selected patients [15,16] Cartilage/bone Autologous, low cost, useful when incus unavailable Variable shape/stability; technique dependent Useful option, particularly with intact stapes or selected reconstruction strategies [16,18] Titanium PORP/TORP Lightweight, rigid, standardized Cost; displacement/extrusion possible Predictable outcomes and low reported long-term extrusion in large series [10,11] Fluoroplastic/Teflon Established alternative; available in many settings Material-specific handling and cost Useful hearing improvement; favorable outcomes reported in selected cohorts [15] Bone cement Simple for small incudostapedial defects Not suitable for major discontinuity Effective in selected small incus long-process defects [1] 11. Research Gaps and Future Directions Current evidence is limited by heterogeneous patient populations, inconsistent definitions of CSOM and cholesteatoma, different reconstruction techniques, variable follow-up duration, and nonuniform hearing endpoints. Prospective multicenter studies using standardized audiometric outcomes and reporting disease status, ossicular anatomy, middle-ear mucosa, Eustachian tube function, surgical staging and prosthesis type would improve comparability. Future research should also distinguish short-term hearing gain from long-term stability and should report prosthesis extrusion/displacement and disease recurrence separately.

Ossicular reconstruction is an important component of hearing rehabilitation in appropriately selected patients with CSOM. Autologous incus and cartilage remain valuable because of their biocompatibility and low cost, whereas titanium PORP/TORP systems provide standardized reconstruction with favorable hearing outcomes and low reported extrusion rates. However, postoperative hearing is determined by the entire middle-ear environment, particularly the status of the stapes and malleus, mucosal health, disease control and whether the procedure is primary or revision surgery. Material selection should therefore be individualized to the residual ossicular anatomy and the condition of the middle ear rather than based on a single universally superior prosthesis.