Audit of stapedectomy results in a teaching hospital

The number of stapedectomies performed annually has declined since 1963. Also, surgery has become available at an increasing number of centres, resulting in a further fall in the number of such operations performed in teaching hospitals. Several studies have suggested benefit might be gained, both by patients and by otology as a speciality, from limiting training to post-graduates who show an aptitude for otology, and concentrating surgery in a small number of specialized centres. We report a series of 179 patients who had stapedectomy performed for otosclerosis in a teaching hospital. We have retrospectively compared the audiological outcome and complication rates for consultants and surgical trainees. For the two groups, there is no significant difference in postoperative hearing levels and complication rates are similar. Our success rate is comparable to other major series. We conclude that stapedectomy is a safe procedure to teach adequately experienced and supervised trainees.     

Juvenile stapedectomy

Stapedectomy in children has long been regarded as taboo and published accounts of this surgery in this age group are few. This paper presents a small series of 29 stapedectomies in patients aged 21 or less; 19 for otosclerosis, 10 for other pathologies associated with stapedial fixation. The results on the otosclerotic group (17 [89%] success, 2 no change, O sensorineural loss) were comparable with stapedectomy in adults. The results in the non-otosclerotic group (5 better, 2 no change, 3 sensorineural losses) were not satisfactory, and stapedectomy for stapedial fixation caused by conditions other than otosclerosis cannot be recommended in this age group.     

Current practice of stapedectomy in Great Britain

Since the introduction of stapedectomy with reconstruction of the ossicular chain to Great Britain, many modifications in practice have taken place. The changes include patient selection, operative technique and the type of prosthesis used, as well as the number of operations performed yearly. The aim of this study is to attempt to establish the actual practice among British otolaryngology consultants by means of a simple questionnaire. Two hundred (50.3%) forms were analysed anonymously. The study confirms the decrease in the number of operations performed annually, the absence of centralization for this type of surgery in Great Britain and also demonstrated the trends towards stapedotomy and the practice of bilateral surgery amongst younger consultants.     

The histopathology of the incus after stapedectomy

Twenty-two temporal bones subjected to stapedectomy were examined by light microscopy for histological changes in the long process of the incus. In 19 cases a stainless steel wire technique had been used and in three a polyethylene tube operation had been performed. Twenty healthy unoperated ears were examined as controls. In all operated ears fibrosis and reduced vascularity of the mucosa was noted. In the polyethylene tube group, 1 ear showed the growth of new bone into the lumen of the tube and I showed minor resorption of the long process of the incus. In the stainless steel wire group bone resorption was seen in 5 cases and i incus also showed an area of necrosis adjacent to the tip; 2 of the 5 incudes showed some loss of the lenticular process. The main factor relating to bony resorption in this group was the presence of other histological changes resulting from postoperative inflammation. These findings represent a critical histological examination; the hearing results obtained appear to be good, although full audiometry is lacking.     

Balance after stapedectomy: the measurement of spontaneous sway by posturography

Sway was measured by static posturography in 25 patients undergoing stapedectomy. 16 first-side and nine second-side operations. Measurements were taken pre-operatively and at 1 week and 6 months after surgery, 25 age-matched controls were also tested. In both the first and second side groups, sway was greater at 1 week after surgery than pre-operatively when relying on vestibular function alone (P =0.01) first-side, 0.05 second-side, 0.01 both sides taken together). By 6 months, sway measurements were no longer significantly different from pre-op or control values. Thus, it appears that there is a measurable increase in patients sway following stapedectomy but this is well compensated by visual and proprioceptive information. and resolves fully with time. Patients undergoing a second side stapedectomy do not appear to fare worse than those undergoing first-side surgery.     

The Glasgow benefit plot used to assess the effect of bilateral stapedectomy

The Glasgow benefit plot has encouraged surgeons to look at the results of their surgery from a more functional standpoint rather than in purely technical terms. Our aim was to use the plot to examine the efficacy of second side stapedectomy. A retrospective study of 17 second side stapedectomies showed that the addition of the second operation significantly increased the chances of achieving at least one‘normal’hearing ear and made‘normal’and symmetrical hearing possible.     

Eighteen-year report on stapedectomy. IV. Long-term functional results

This is the last of a series of 4 articles detailing the history of 20 893 stapedectomies over an 18-year period. In this fourth part, the authors study long-term functional results in relation to the type of stapedectomy, the importance of the cochlear involvement and the general pathology, mainly vascular. They come to the conclusion that good long-term functional results imply the necessity of combining a carefully performed stapedectomy using a living tissue graft, a strict audiometric surveillance and an adequate postoperative therapy, including (if necessary) an extensive fluoride therapy.     

Otosclerosis and pregnancy: a study of the influence of pregnancy on the hearing threshold before and after stapedectomy

In a retrospective study of 144 fertile women subjected to operation for otosclerosis by the method of Shea or House, we found a fall in the hearing threshold in the operated ear which seemed to be a little greater in the patients who became pregnant after the operation than in those who did not. However, the hearing loss was significantly greater in the non-operated ear in the patients who became pregnant after the operation than in those who did not.     

半导体激光辅助足板小窗技术的远期疗效

目的探讨半导体激光辅助足板小窗技术的远期疗效.方法回顾性分析39耳耳硬化症患者的临床资料.总结半导体激光辅助的足板小窗技术及人工镫骨置换术的疗效.结果39耳中,除1耳术后听力无改善外,38耳听力均有不同程度提高,其中3耳曾再次手术.术后高频区(4kHz)听力改善明显,卡哈切迹消失,气骨导差缩小或消失.18耳术前耳鸣,9耳术后耳鸣消失.随访3～6年,38耳远期疗效均保持在术后近期水平,无内耳并发症,骨导听力无减退.结论半导体激光辅助足板开窗对内耳的损伤性小,并发症少,远期疗效稳定.     

Technical refinements and precautions during ionomeric cement reconstruction of incus erosion during revision stapedectomy

OBJECTIVE: The study describes the technical precautions and short-term hearing results of fast-setting ionomeric cement (SerenoCem) for managing incus erosion in revision stapedectomy. STUDY DESIGN: Observational and retrospective chart review. METHODS: Consecutive patients undergoing ionomeric cement incus reconstruction during revision stapedectomy had surgery on an ambulatory basis in a tertiary care referral center. Main outcome measures included technical details, precautions, and recommendations for handling this new material and 6-week hearing outcomes comparing preoperative and postoperative air-conduction and bone-conduction thresholds. RESULTS: A small amount of ionomeric cement on the tip of otological picks applied to the incus remnant successfully reconstitutes the original length of the long process of the incus. In revision stapedectomy, a crimp-on prosthesis may be placed on the cement-lengthened incus. Six-week postoperative audiograms demonstrated significant closure of the air-bone gap in operated cases. Our experience in a failed case leads us to recommend that the setting time for the cement be increased to no less than 20 minutes as opposed to the manufacturer's recommendation of 10 minutes. Also, revision stapedectomy was more likely to be successful when the prosthesis was placed to the incus remnant and stabilized with cement, rather than placing the prosthesis on the cement itself. CONCLUSIONS: Ionomeric cement permits direct reconstruction of a pathologically shortened incus in revision stapedectomy. Surgeons must be aware of precaution and limitations of this new material. Preliminary results indicate significant hearing improvement with this technique when appropriate precautions are taken.     

Analysis of long-term hearing after tympanosclerosis with total/partial stapedectomy and prosthesis used

Conclusion. Long-term hearing gain results are good after prosthetic reconstruction of the stapes in the tympanosclerotic ear. The type of stapedectomy, whether partial or total, does not affect the result of the surgery very much. Objectives. Comparative evaluation of the hearing results of total/partial stapedectomy technique and the prosthesis used within a 10-year follow-up period after stapedectomy in cases with dense tympanosclerosis and completely fixed stapes. Patients and methods. Twenty-five cases with completely fixed stapes due to generalized tympanosclerosis were included in this retrospective study between 1995 and 2005. Two-stage canal wall up procedure was planned for all cases, and stapedectomy was performed at the second stage. After the second stage, 25 ears in the sixth month, 18 ears in the first year, 14 ears in the second year, and 7 ears in the tenth year were available for follow-up. Preoperative and postoperative air–bone gap values of the patients and their hearing gain were compared. Total stapedectomy was carried out in 17 of the patients and partial stapedectomy in 8 of them. For ossiculoplasty, a plastipore total ossicular replacement prosthesis was used in 17 patients, homograft ossicle in 2 patients, and Teflon piston in 6 patients. Results. In 17 cases in which we used total stapedectomy, the average preoperative air–bone gap value improved from 40.23 to 18.47 in the sixth month, and from 38.4 dB to 9.6 dB in the tenth year. In eight cases in which we used partial stapedectomy, the average preoperative air–bone gap improved from 38.63 dB to 24.38 dB and from 35 dB to 17 dB, respectively. The average postoperative hearing gain with total stapedectomy was 21.76 dB in the sixth month and 28.8 dB in the tenth year. Hearing gain with partial stapedectomy was successively 14.25 dB and 18 dB. When we compared the results of total prosthesis and Teflon pistons among the materials used in ossiculoplasty, although hearing gain with total prostheses was better, the results were not statistically significant.     

以学生为主体的耳鼻咽喉科教学查房的探索与实践

教学查房是住培医生规范化培训阶段中获取临床实践能力及知识的重要环节.本研究以耳鼻咽喉科亚专科耳科教学查房为例,采用"逐级评价"教学法,让3个年级住培医生成为教学查房的主体进行逐级评价,同时充当"教"与"学"的角色,充分发挥住培医生的学习主动性及自省自强能力.教学查房后住培医生的理论成绩优于查房前,且出科实践考核成绩良好...     

Audit of stapedectomy results in a teaching hospital.

The number of stapedectomies performed annually has declined since 1963. Also, surgery has become available at an increasing number of centres, resulting in a further fall in the number of such operations performed in teaching hospitals. Several studies have suggested benefit might be gained, both by patients and by otology as a speciality, from limiting training to post-graduates who show an aptitude for otology, and concentrating surgery in a small number of specialized centres. We report a series of 179 patients who had stapedectomy performed for otosclerosis in a teaching hospital. We have retrospectively compared the audiological outcome and complication rates for consultants and surgical trainees. For the two groups, there is no significant difference in postoperative hearing levels and complication rates are similar. Our success rate is comparable to other major series. We conclude that stapedectomy is a safe procedure to teach adequately experienced and supervised trainees.     

Advanced head and neck surgical techniques: A survey of US otolaryngology resident perspectives

Objectives

To assess the perspectives of OHNS residents with regards to their training in the following advanced head and neck surgery techniques: transoral robotic surgery (TORS), transoral laser microsurgery (TLM), sialendoscopy, and surgeon-performed ultrasound (SP-US) for possible curricula development.

SURGEONS‘ WORKSHOP: Eighteen-year report on stapedectomy. I. Problems of stapedial fixation

This first section deals with various techniques performed by the authors who conclude in favour of a living tissue graft sealing the oval window, particularly Teflon-piston against veingraft, i.e the ‘Teflon-interposition’ technique. Intra-operative problems of associated diseases and of the technical difficulties encountered during stapedectomy, are related and their treatment explained. Revision operations and immediate postoperative therapy end this first part.     

History of stapedectomy

The history of stapedectomy dates back to the late 19th century. Although otologists in both the United States and Europe were performing stapedectomy operations at the turn of the century, stapes surgery ceased in the early 1900s. This paper examines the early and recent history of stapes surgery. An analysis of the early literature elucidates the reasons for the previous discontinuation of stapes surgery.     

Immunohistochemical analysis of paragangliomas

Objective. To find a biological marker that can give information about the clinical behaviour of head and neck paragangliomas. Materials and methods. Immunohistochemical analysis was performed on 114 paragangliomas of which 68 were hereditary. A broad panel comprising eight chief cell (type 1) markers (PGP 9.5, NSE, Leu-Enkephalin, Met-Enkephalin, Chromogranin, Serotonin, Somatostatin, HNK-Leu 7) and two sustentacular cell (type 2) markers (S 100, GFAP) were applied to paraffin embedded slides. Results. It was possible to distinguish between chief andsustentacular cells on the basis of marker specificity but no significant correlation between staining pattern and clinical criteria indicative of tumour progression, DNA-ploidy or tumour localization was found. Conclusion. Clinically immunohistochemical reactivity ofparagangliomas cannot serve as a marker for their growth pattern, furthermore one could hypothesize for the used panel of markers that the underlying cause of their clinically different behaviour is not reflected by diminished differentiation as might be reflected by decreased production of tumour associated antigens or hormones.     

ENT teaching

All medical schools include undergraduate ENT teaching, but the time allocated is short and the aquisition of practical skills may suffer. Efficiency is essential, particularly with regard to those destined for general practice, where 10–30% of the workload concerns the upper respiratory tract. The students at the Leeds Medical School, during 1 academic year, were surveyed by questionnaire on various aspects of their ENT course. Criticisms and suggestions for improvement were also invited. The results suggested the lecture course should not change but the time spent in operating theatres could be reduced in favour of more time in the outpatient clinics with a greater emphasis on practical skills. This discussion was then extended to consider what an ENT course should include and whether it could be integrated, in some way, with postgraduate education.     

Stapedectomy versus stapedotomy: comparison of results with long-term follow-up

OBJECTIVE/HYPOTHESIS: To compare the effectiveness and long-term stability of hearing results between stapedectomy and small fenestra stapedotomy in patients with conductive hearing loss due to otosclerosis. STUDY DESIGN: Retrospective review of prospectively collected audiometric data. METHODS: The hearing results and complication rates of 209 ears with long-term follow-up that underwent either stapedectomy or stapedotomy by the senior author (h.p.h.) between 1961 and 1989 were compared. Forty-two patients underwent stapedectomy in one ear and stapedotomy in the opposite ear, permitting a paired case review of the results in these patients. The techniques were compared with respect to initial and late hearing results and change of the results over time. RESULTS: Patients undergoing stapedectomy and stapedotomy were followed for an average of 11.5 and 6.0 years, respectively. There were no statistically significant differences in initial or late postoperative pure-tone average (PTA), PTA air-bone gap, speech discrimination scores, or incidence of sensorineural hearing loss between the two groups. Ears treated by stapedotomy showed statistically better initial and late postoperative 4-kHz air-conduction threshold and initial 4-kHz air-bone gap, but the gap difference was not significant with late follow-up. There was no significant difference in the percentage of patients with air-bone gap closure within 10 dB for any frequency other than 4 kHz at the initial postoperative test. Importantly, the successful outcomes in both groups were stable over long-term follow-up. Results were the same when comparing the two procedures in patients having undergone both. CONCLUSION: These results show that, in the hands of an experienced surgeon, either technique provides satisfactory and stable long-term results.     

Closure of septal perforations by means of ‘external rhinoplasty’

Objective. Evaluation of the ‘external rhinoplasty’ approach as a technique in the closure of septal perforations. Materials and methods. Ten patients with a septal perforation were studied. The average largest diameter ( sd ) was 1.48 cm 2 (0.39), as measured by lateral radiography after spreading the margins of the perforation with radiographic contrast fluid. Submucosal tunnels were made using a midcolumellar incision that was lengthened with marginal incisions, and the perforation was filled with aural cartilage. The extramucosalseparation of the upper lateral cartilages from the nasal septum allows the creation of a considerable mucosal flap in the nasal vault. By means of this transposition flap, together with a posterior based flap, all perforations could be covered. Results. Closure of nine septal perforations was successfully accomplished. Although it became smaller, one perforation persisted. Conclusion. The ‘external rhinoplasty’ approach provides a superior operative field. This visualization allows the formation of larger flaps. These advantages are translated into a greater success rate.