11Bellucci and SPITE: Grading Disease and Surgical Difficulty

FWhy grade the disease, not just the chain

Most classification systems a trainee meets first — Wullstein’s types, Austin’s A–D quadrants — describe the anatomy of the ossicular chain: which ossicles survive and what can be grafted against them. They are essential, but they answer only half of the prognostic question. Two ears with an identical missing incus and intact stapes can behave completely differently if one is dry and well aerated while the other discharges, granulates and refuses to ventilate. The difference lies not in the chain but in the environment the reconstruction must survive in.

Two influential systems address exactly that environment. Bellucci, in 1973, proposed a dual classification of tympanoplasty: one axis recorded the reconstruction possible, while a second graded the ear’s stability against infection by the frequency and persistence of otorrhoea [1973]. Nearly two decades later Blackanalysed a large ossiculoplasty series statistically and gathered the features that mattered into a memorable acronym — SPITE — for individualised counselling [1992]. Both fold history, infection and tissue quality into the prediction of hearing success.

The clinical pay-off is that these systems tell you when to operate and how confidently to counsel, not just how. A favourable Austin type does not rescue an actively draining ear; an unfavourable disease environment is often the reason to stage the operation rather than attempt it in one sitting.

FBellucci’s grading of otorrhoea

Bellucci’s contribution that endures in everyday practice is a simple, clinically observable, four-grade scale of otorrhoea— ear discharge — reflecting the activity of the underlying disease and, by inference, the health of the middle-ear mucosa and the competence of the Eustachian tube [1973]. The grades run from a permanently dry ear to an ear that discharges despite treatment.

The grade is a proxy for the biology of the cleft. Grades I and II are associated with better aeration, preserved mucosal integrity and a lower risk of fibrosis and adhesion — the conditions under which a partial prosthesis sits quietly and closes the air–bone gap. Grades III and IV signal active or recurrent infection, hypertrophic or fibrotic mucosa, adhesions and a high likelihood of prosthesis displacement or extrusion. The explorer below summarises what each grade predicts for the operation.

Because the scale is so easy to apply at the clinic chair, it was absorbed almost wholesale into the later weighted indices: the otorrhoea term in Kartush’s Middle Ear Risk Indexis, in effect, Bellucci’s grade [1994], and drainage status remained an independent predictor of outcome in Dornhoffer and Gardner’s OOPS derivation [2001]. Few classification ideas in otology have proved so durable on so little machinery.

TBlack’s SPITE method

Where Bellucci graded a single dimension, Black set out to capture everything that moved the result. He examined a series of 535 ossiculoplasties and used chi-square testing to find which preoperative features were significantly linked to adverse audiologic outcomes. Twelve features reached significance, and rather than reduce them to an opaque score he organised them into five intuitive categories whose initials spell SPITE [1992].

• Surgical — previous operations, canal-wall status and, above all, whether the malleus handle is present to anchor and align the prosthesis. Black regarded the malleus as the single most important stabiliser of the reconstruction.
• Prosthetic — the reconstruction demanded: a partial (PORP) bridge to a mobile stapes head versus a longer, less forgiving total (TORP) resting on the footplate, and the security of that coupling.
• Infection — active or recurrent discharge and granulation, the very dimension Bellucci graded.
• Tissue — the quality of mucosa and drum: fibrosis, adhesions, atelectasis and tympanosclerosis.
• Eustachian — tubal function and the middle-ear ventilation that follows from it.

It is worth keeping two SPITE-labelled systems apart. Black’s SPITE is the prognostic method described here. Kartush separately used the same five headings as an organising mnemonic alongside his Middle Ear Risk Index [1994]; the acronym is shared but Black’s statistical derivation is distinct. Select a letter below to see what Black grouped under each domain and how it shifts the odds.

The strength of SPITE is that it is a counselling toolrather than a single number. Faced with a particular patient, the surgeon can point to the adverse domains — active infection, a missing malleus, a long TORP, poor tube function — and give an honest, individualised account of the likelihood of success. Black’s own conclusion was that this preoperative stratification let him counsel patients far more accurately than ossicular status alone allowed [1992].

TFrom grade to surgical plan

These systems earn their place because they change decisions. The most important is timing. In Bellucci Grade III and IV ears, and in any ear whose SPITE profile is dominated by active Infection and poor Tissue, the orthodox advice is to stage the reconstruction: control the disease, eradicate cholesteatoma, achieve a sustained dry interval, and only then commit a prosthesis to a cleft that can keep it [1973]. Operating a prosthesis into a wet, granulating ear invites extrusion, medialisation and re-adhesion regardless of how elegant the chain reconstruction is.

The grade also informs prosthesis and technique choices:

None of this overrides the anatomy — an absent malleus and footplate still demand a TORP — but it frames the anatomy in the disease context. The grade tells you whether to operate now, what to protect the prosthesis with, and what to tell the patient to expect.

CHow well do the systems predict?

It is fair to ask whether these schemes actually forecast hearing. Several groups have tested them head-to-head. A representative study scored the same cohort of 179 earswith the Middle Ear Risk Index, Black’s SPITE and the OOPS index and correlated each with the achieved postoperative air–bone gap [2020]. All three correlated significantly with outcome, but the correlations were weak, and only SPITE emerged as an independent predictor of the postoperative gap — without being overwhelmingly superior to the others. The chart shows the mean scores the three systems assigned to that single cohort.

Two cautions follow. First, the scales are not interchangeable: a mean MERI of 4.5, a SPITE of 2.8 and an OOPS of 3.1 describe the same ears on different rulers, so the bars compare ranges, not severity. Second, no index is a crystal ball. Their value lies less in the precise number than in forcing the surgeon to record the variables that matter— drainage, mucosa, prior surgery, malleus status, tube function — in a standardised way that supports audit and honest counselling [2001].

It is also instructive where the systems disagree. Dornhoffer and Gardner found in their derivation that the presence of the stapes superstructure and of cholesteatoma did not independently predict the result, challenging assumptions baked into earlier schemes [2001]. Smoking, by contrast, proved adverse enough that it was added as an explicit term in the revised MERI [2001]. The systems are living tools, refined as cohorts accumulate.

CUsing Bellucci and SPITE at the bedside

In practice the two systems work best together and alongside the anatomic classifications. A workable mental routine for any candidate ear runs through three layers. What is the chain?— the Austin/Kartush question of malleus and stapes that selects PORP versus TORP [1971]. What is the disease?— Bellucci’s otorrhoea grade and the Infection and Tissue domains of SPITE that decide whether to operate now or stage. What will you say? — the composite SPITE picture that supports an honest, individualised prognosis [1992].

Bellucci’s later writing on case selection makes the same point: success depends as much on choosing which ears to reconstruct and when as on the technical reconstruction itself [1989]. An ear that is dry, ventilated and quiet forgives a great deal; an ear that is wet, scarred and airless punishes even a perfect prosthesis.

The enduring lesson of both systems is therefore a discipline of attention. Record the discharge history. Inspect the mucosa. Ask whether the malleus is there to hold the prosthesis and whether the tube can keep the cleft aerated. Then decide not only how to rebuild the chain but whether the environment is ready to receive it — and if it is not, have the patience to make it ready first. That, more than any acronym, is what Bellucci and Black were trying to teach.