晚期耳硬化症CO2激光辅助镫骨开窗术疗效的初步观察

目的　探讨CO2激光辅助镫骨开窗人工镫骨植入术治疗晚期耳硬化症的效果。方法　2010年1月~2014年1月间15例（16耳）临床确诊为晚期耳硬化症的患者在我科接受了CO2激光辅助镫骨开窗人工镫骨植入术,术前言语频率平均气导听阈70.21 dB HL,平均骨导听阈38.49 dB HL,平均气骨导差（air conduction-bone conduction gap,ABG）31.72 dB HL,所有病例术后随访超过半年。结果　术后半年言语频率平均气导听阈 43.7 dB HL,平均骨导听阈28.95 dB HL,平均气骨导差14.75 dB HL,ABG≤20 dB者9耳,占比56.3%,ABG闭合≤10 dB者6耳,占比37.5%。无一例术后出现顽固性眩晕、感音神经性聋及面瘫等严重并发症。结论  CO2激光辅助技术降低了镫骨开窗手术严重并发症的几率,多数患者术后听力明显提高,是一种安全、实用、相对经济的选择。     

CO2激光辅助Fisch人工镫骨技术治疗耳硬化症疗效观察

目的探讨CO2激光辅助Fisch人工镫骨技术治疗耳硬化症的疗效。方法2001年10月至2003年12月间,30名临床确诊为耳硬化症的患者在上海交通大学附属第六人民医院接受CO2激光辅助Fisch人工镫骨技术治疗,术前言语频率平均气导听阈为63.33dB HL,气骨导差为24.5~50.25dB,平均为36dB。全部病例随访12个月以上,平均随访18个月。结果24例患者于术后6个月复查听力,言语频率平均气导听阈为26.82dB HL,气骨导差≤15dB者23例,占95.83%;气骨导差≤10dB者21例,占87.5%;平均气骨导差为8.50dB。30例患者术后12个月时复查听力,言语频率平均气导听阈为27.52dB HL,气骨导差≤15dB者28例,占93.33%;气骨导差≤10dB者25例,占83.33%;平均气骨导差为8.60dB。术后半年与一年复查听力结果相比,差异无统计学意义(P>0.05)。结论CO2激光辅助Fisch人工镫骨技术治疗耳硬化症疗效显著,术后反应轻,远期疗效稳定,是治疗耳硬化症的可靠技术。     

镫骨修正术的疗效分析

目的探讨镫骨修正术对耳硬化症患者初次手术后复发传导性聋的疗效,总结再次手术中的注意事项。方法回顾性分析我院自2004年至2014年行31例镫骨修正术患者的术中发现及术前、术后听力学资料。结果耳硬化症患者初次手术失败的主要原因是纤维粘连,砧骨固定和假体移位。镫骨修正术后患者气骨导差(听力级,下同)在20d B以内的21人(67.7%)。术后平均气骨导差13.4d B,平均纯音听阈气导由术前58.5d B减至术后42.7d B,提高15.8d B,术后未发现极重度感音神经性聋患者。结论镫骨修正术手术成功率虽较初次手术低,仍可明显改善多数传导性聋患者的听力。     

耳硬化症患者镫骨底板造孔术后高频感音神经性听力下降原因分析

目的探讨耳硬化症患者镫骨底板切除术后高频感音神经性听力下降的原因。方法回顾性总结中山大学附属第二医院2004年2月～2009年2月行镫骨底板切除术的30例（49耳）耳硬化症患者的临床资料,比较所有患者术前2天、术后1、3、6个月纯音测听结果,并分析年龄、术后耳鸣对听力的影响。结果术后1个月气导8000Hz平均听阈比术前提高了约8dB,骨导4000Hz平均听阈提高约10dB（P〈0.01）。≥40岁组术后高频平均听阈比〈40岁组明显提高（P〈0.01）。术后1个月有25耳（51%）出现耳鸣,其中约80%患者术后3个月耳鸣消失,听力明显改善。结论耳硬化症患者行镫骨底板切除术后大部分患者可出现暂时性高频感音神经性听力下降,术后3个月听力明显改善,≥40岁患者高频听力受损明显。其原因可能为手术过程中对镫骨底板的过度非生理性振动,通过耳蜗内淋巴液导致靠近底板的外毛细胞功能受到影响,从而使高频听力暂时下降。     

小窗镫骨部分切除术对DPOAE的影响

对２７例耳硬化症患者施小窗镫骨部分切除，并行特氟隆活塞小柱人工镫骨安装术，并于术前、术后２周、２个月行ＤＰＯＡＥ及纯音听阈测试。显示：术后气导听力平均提高２５．８ｄＢ，气骨导间距平均为９．９ｄＢ，ＤＰＯＡＥ术前、术后２周、术后２个月改变无统计学意义。表明耳硬化症患者行小窗镫骨部分切除术后，ＤＰＯＡＥ仍引不出的原因主要在于发射声逆向传递减压较多。     

耳硬化症术后骨导听力改善的探讨

目的　探讨耳硬化症镫骨术后听力尤其是骨导听力改善情况，比较分析镫骨手术不同术式及长短期手术效果，为临床治疗策略选择提供依据。方法　回顾性分析耳硬化症行镫骨手术患者临床资料共56耳，重点关注听力情况。术后6周～6个月和术后1年复查听力。结果　术前气导阈值（56.2±11.1）dB，骨导阈值（22.2±7.9）dB，骨气导差（34.0±8.9）dB；术后气导阈值（33.1±10.9）dB，骨导阈值（19.9±8.3）dB，骨气导差（13.2±7.9）dB。23例（41.1%）术后骨气导差≤10 dB，45例（80.4%）骨气导差≤20 dB。术后0.5、1和2 kHz频率的骨导阈值分别下降了1.0、3.1和3.9 dB，而4 kHz频率的骨导阈值提高了0.6 dB。1和2 kHz频率的术后听力改善具有统计学意义（t 1 kHz=2.536，t 2 kHz=2.666，P 均＜0.05）。结论　镫骨手术可明显改善耳硬化症患者1和2 kHz频率的骨导阈值，缩小骨气导差。不同镫骨手术技术对于改善术后听力无明显区别，术后长期听力可以获得较好保持。     

不同术式治疗耳硬化症的疗效比较

目的：比较治疗耳硬化症不同术式的疗效。方法：回顾性分析1993～2005年行手术治疗且资料完整的耳硬化症患者70例（76耳）的临床资料，按术式分为3组：镫骨全切除术30例（33耳），足板小孔开窗术24例（27耳）和镫骨撼动或提高术16例（16耳），统计3组患者术后各频率段气骨导差闭合、骨导损失及眩晕发生率等指标，比较3种术式问的差异，同时比较镫骨撼动术5例（5耳）与镫骨提高术11例（11耳）2组手术亚型间的疗效差异。结果：3种术式术后言语频率气骨导差闭合无明显差异，但在高频气骨导差改善及减少术后高频感音神经性听力损失和眩晕方面，足板小孔开窗术和镫骨撼动或提高术明显优于镫骨全切除术，并有统计学意义。镫骨撼动术与镫骨提高术无论在听力改善或术后并发症发生率方面差异均无统计学意义。结论：3种术式在提高耳硬化症患者的听力方面均具有较好的疗效，其中以足板小孔开窗术疗效最佳，其次是镫骨撼动或提高术，并且在减少术后并发症方面均优于镫骨全切除术。足板小孔开窗术是治疗耳硬化症较理想的术式。     

鼓室硬化镫骨固定的手术疗效分析

目的分析不同手术方法治疗鼓室硬化镫骨固定的疗效。方法回顾性分析1992～2004年于我科手术且资料完整的鼓室硬化镫骨固定病例56例（62耳）,按Wielinga分型Ⅲ型40耳;Ⅳ型22耳,其中镫骨撼动术15耳（Ⅲ型12耳、Ⅳ型3耳）、全人工听骨赝复物（tatolossicular replacement prosthesis,TORP）重建听骨链25耳（Ⅲ型16耳、Ⅳ型9耳）、自制Teflon小柱活塞型人工镫骨（Piston）重建听骨链22耳（Ⅲ型14耳、Ⅳ型8耳）。术后随访1～5年,分析患者言语频率（0.5、1、2kHz）平均纯音气导阈值及气骨导差,应用SPSS13.0软件包进行统计分析。结果鼓室硬化Ⅲ型、Ⅳ型患者术前言语频率平均纯音气导阈值及气骨导差差异无统计学意义（P〉0.05）;镫骨撼动组、TORP组、Piston组术前3组病例平均纯音气导阈值及气骨导差差异无统计学意义（P〉0.05）;术后1、3、5年3组病例平均纯音气导阈值及气骨导差差异有统计学意义（P〈0.01）;术后5年Piston组在纯音气导阈值及气骨导差方面疗效优于TORP组,差异有统计学意义（P〈0.01）。结论鼓室硬化镫骨固定无论锤、砧骨固定与否,最好去除锤骨头及砧骨,予人工听骨重建听骨链,镫骨足板造孔术是安全的,而且疗效稳定。     

听骨链畸形患者的听力学特征及耳内镜手术效果

目的　探讨听骨链畸形患者的听力学特征和耳内镜手术效果分析。方法　对35例（38耳）听骨链畸形患者行手术前后纯音听力测试,并对听骨链畸形根据Cremers Classification分型,对各个分型进行听力学特征分析。35例（38耳）均在耳内镜下进行手术,其中13耳行人工镫骨置换术,17耳行鼓室成形Ⅱ型术,8耳行鼓室成形Ⅲ型术。通过比较手术前后气骨导差变化来分析术后效果。结果　析35例（38耳）听骨链畸形患者的纯音测听。结果,2000 Hz骨导听阈处有明显听阈下降。35例（38耳）听骨链畸形患者,11耳为镫骨底板固定（Ⅱa）,占29.0%,平均气骨导差为（44.6±7.5）dB HL。2耳为镫骨底板固定伴砧镫关节假连接或固定（Ⅱb）,占5.3%,平均气骨导差为（42.9±8.9）dB HL。17耳为镫骨畸形但底板可活动（Ⅲa）,占44.7%,平均气骨导差为（37.8±9.7）dB HL;4耳为镫骨底板可活动但伴砧镫关节假连接或固定（Ⅲb）,约占10.5%,平均气骨导差为（34.1±10.6）dB HL;4耳为镫骨底板可活动但锤砧关节假连接或固定（Ⅲc）,约占10.5%,平均气骨导差为（39.0±7.8）dB HL。耳内镜术后3个月,行人工镫骨置换术者平均气骨导差为（21.0±11.4）dB HL,较术前缩小（24.0±11.1）dB HL;行Ⅱ型鼓室成形术者平均气骨导差为（17.1±10.5）dB HL,较术前缩小（20.0±8.3）dB HL;行Ⅲ型鼓室成形术者平均气骨导差为（22.0±14.1）dB HL,较 术前缩小（20.0±13.0）dB HL。结论　先天性听骨链畸形患者的纯音测听结果中,2000 Hz骨导听阈有明显的听阈下降,在听力图上呈现与耳硬化症相似的V型切迹形状。先天性听骨链畸形分型中,先天性镫骨底板活动伴听小骨畸形为常见。采用耳内镜下不同手术方法进行治疗可明显提高听力,缩小气骨导差。     

人工镫骨植入手术术中配合及疗效分析

目的：总结人工镫骨植入术中配合技巧并分析手术效果。方法回顾性分析331例耳硬化症并行人工镫骨植入患者手术过程及手术前后的临床资料。结果人工镫骨植入手术中助手重点配合术者对人工镫骨的修剪、使用适当吸力的小吸管、镫骨底板开窗后避免冲洗及钻孔处的吸引;331例患者均顺利完成人工镫骨植入手术,平均手术时间66．43±29．14分钟,所有患者术后均自觉听力明显改善,随机提取68例患者术后250、500、1000、2000、4000 Hz 各频率平均听阈,31例术后术耳（左耳）听力改善21．4±9．59 dB,37例术后术耳（右耳）听力改善23．9±8．46 dB。除一例术后出现镫骨脱出需二次修正手术外,其余病例均无并发症发生。结论娴熟的手术技巧和良好的手术配合对保证人工镫骨植入术的成功及疗效非常重要。     

Stapedectomy for far-advanced otosclerosis.

OBJECTIVE: This study aimed to describe far-advanced otosclerosis and to present the authors' results with stapedectomy in 78 ears with far-advanced otosclerosis. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was conducted at an Otology/Neurotology tertiary referral center. PATIENTS: Stapedectomy was performed on 78 ears of 60 patients with far-advanced otosclerosis, and the results followed from 1 to 21 years with a mean of 5 years. INTERVENTION: Stapedectomy was performed on all ears with far-advanced otosclerosis. MAIN OUTCOME MEASURE: Hearing for air conduction (AC) and bone conduction (BC), speech discrimination, and impedance were tested on all patients before and after operation. The Rinne test was performed on all ears with a 256-cycle magnesium tuning fork. The pure-tone average for AC and BC was computed for 500, 1,000, and 2,000 Hz. Hearing improvement was defined as air-bone gap closure to 10 dB or less and/or AC improvement of 20 dB or more, with no decline in speech discrimination score of more than 10%. RESULTS: Hearing improvement was achieved in 52 (66.7%) of 78 ears of all operations. In group 1, AC was greater than 90 dB, BC was greater than 60 dB, and hearing improved in 26 (81.2%) of 32 ears of operations. In group 2, AC was greater than 90 dB and no measurable BC and hearing improved in 11 (68.8%) of 16 ears of operations. In group 3, there was no measurable AC and BC greater than 60 dB and hearing improved in two (50%) of four ears of operations. In group 4, there was no measurable AC and BC and hearing improved in 11 (42.3%) of 26 ears of operations. Nonmeasurable BC became measurable in 42.9% of ears, nonmeasurable AC became measurable in 73.3% of ears, and all of these became aidable after operation. CONCLUSIONS: A negative Rinne test result with a 256-Hz magnesium tuning fork proved to be the best test to separate far-advanced otosclerosis from sensorineural hearing loss of other causes. Stapedectomy is of benefit in most ears with profound hearing loss of far-advanced otosclerosis, especially in those ears with some measurable hearing by AC.     

Small fenestra stapedotomy for otosclerosis in a Canadian teaching centre

OBJECTIVE: This study reports the results of 112 primary stapedotomies and 13 revision stapedotomies performed by the senior author. STUDY DESIGN: Retrospective case review of all primary and revision stapedotomies performed at University Hospital between 1994 and 1999. All patients in this series had otosclerosis and underwent stapedotomy using a 0.6-mm diameter platinum wire/Teflon piston prosthesis. The air-bone gap was calculated as the difference between the preoperative boneconduction and the postoperative air-conduction thresholds. The average follow-up time post-stapedotomy to audiometric testing was approximately 2.5 months. OUTCOME MEASURES: An average air-bone gap closure at 500, 1000, and 2000 Hz to 10 dB or less was used as the criterion for success. The effects of stapedotomy on speech reception thresholds (SRTs), speech discrimination scores (SDSs), and airconduction thresholds are also reported. RESULTS: In primary stapedotomy, an air-bone gap closure of 10 dB or less was achieved in 85.7% of patients. A significant hearing gain was achieved at all frequencies (250-8000 Hz), with the greatest benefit being achieved at the lower frequencies. The SRT was significantly improved post-stapedotomy by an average of 26.7 dB, and no significant change was found in the SDS. In revision stapedotomy, 38.5% of patients had a significant hearing gain at 250 to 4000 Hz. The SRT was significantly improved postoperatively by an average of 12.7 dB, and no significant change was found in SDS. Overall complication rates were similar to other series with two cases of partial hearing loss (1.6%), one incus fracture (0.8%), one large tympanic membrane perforation (0.8%), and one perilymphatic fistula (0.8%), which was successfully repaired. No patients in this series experienced complete sensorineural hearing loss, facial nerve injury, worsened tinnitus, or reparative granuloma. CONCLUSIONS: The results of this study are comparable to other similar studies examining the use of stapedotomy in patients with otosclerosis. The high success rate and low incidence of serious complications support stapedotomy, without a laser but with resident involvement, as a highly effective treatment for otosclerosis.     

Multiple auditory steady-state responses to bone-conduction stimuli in adults with normal hearing

ASSR thresholds to bone-conduction stimuli were determined in 10 adults with normal hearing using mastoid placement of the bone oscillator. ASSRs to 0-50 dB HL bone-conduction stimuli and to 30-60 dB HL air-conduction stimuli were compared. The effect of alternating stimulus polarity on air- and bone-conduction ASSRs was also investigated. Stimuli were bone- and air-conduction amplitude-modulated tones (500-4000 Hz carrier frequencies, modulated at 77-101 Hz). ASSRs were recorded using the Rotman MASTER research system. Mean (1SD) bone-conduction ASSR thresholds were 22(11), 26(13), 18(8), and 18(11) dB HL for 500, 1000, 2000, and 4000 Hz, respectively. Except for a steeper slope at 500 Hz, ASSR intensity-amplitude functions for binaural bone- and air-conduction stimuli showed the same slopes; intensity-phase-delay functions were steeper at 1000 Hz for ASSRs to bone-conduction stimuli. ASSR amplitudes and phases did not differ for single- versus alternated-stimulus polarities for both bone- and air-conduction stimuli. The steeper amplitude slope for ASSRs to 500 Hz stimuli may reflect a nonauditory contribution to the ASSR.     

Carhart notch effect in otosclerotic ears measured by electric bone-conduction audiometry

The Carhart notch is an elevation in the middle-frequency bone-conduction threshold of an ear with clinical otosclerosis. The study population consisted of 138 patients with clinical otosclerosis. Conventional air-conduction (AC) and bone-conduction (BC) and electric bone-conduction (EBC, with Audimax 500 audiometer) thresholds were measured 2 weeks before and 7 months after stapes surgery. The EBC thresholds were converted from mA values to dB SPL to compare the results obtained with the different methods. The mean differences in the BC thresholds before and after the operation were 3.2 dB (95% CI 1.9-4.6) at 1 kHz and 7.6 dB (95% CI 6.1-9.1) at 2 kHz. The mean differences in the EBC thresholds were 5.4 dB (95% CI 3.8-6.9) at 1 kHz and 5.3 dB (95% CI 3.4-7.1) at 2 kHz. Thus, both methods showed a distinct Carhart notch effect.     

Stapedectomy versus stapedotomy: a comparison.

Two hundred and fifty consecutively operated stapes procedures operated by the author for otosclerosis are presented. A fat-wire stapedectomy prostheses (Schuknecht) was used in 152 cases and a Fisch teflon-wire piston was used in 98 ears. Of the 250 procedures 33 patients had bilateral surgery. The operations were done in local anaesthesia in most cases and with endomeatal incision. The fat-wire prostheses gave in 95% a closure within 10 dB and the rest 5% closed within 11-20 dB. The Fisch teflon-wire piston gave a closure within 10 dB in 87%, within 11-20 dB in 12% and within 21-30 dB in 1%. The speech reception was better after operation in 97% of patients operated with the fat-wire prostheses and in 99% of patients having the teflon-wire piston. It was a significant difference at 20 dB level of speech improvement (p < 02) in favour of the teflon-wire piston. The surgery for otosclerosis is a special procedure seeking refinements in surgical techniques to increase safety and maintain acceptable results. Our results show that the small fenestra technique with 4 mm piston will give better speech reception and better hearing in the high frequencies. To achieve a high standard the operations for otosclerosis should probably be centralised to let the surgeon do a minimum of 8 to 10 procedures every year.     

Long term results stape surgery

For many years otosclerosis has been an interesting otologic problem in regard to pathological and clinical aspects. Many various conceptions of otosclerosis development which finally lead to the stapes immobility in the oval window were discussed. Resent genetic studies indicate that genetic factors as a cause of otosclerosis possibly in combination with other factors localize 3 genes responsible for otosclerosis to chromosom 15q25q-q26, 7q34-36, 6p21-22. The aim of the study was audiometric evaluation of 1380 patients out of 1716 stapes operations performed in years 1973-2004. Audiometric assessment for air and bone conduction was performed according to the European Academy of Otology and Neuro-Otology (EAO-NO) criteria. Postoperative air-bone gap 11-20 dB for speech frequencies (500, 1000, 2000, 4000 Hz) was obtained in 64.8% and in 28.9% was less than 10 dB. Postoperative air-bone gap (11-20 dB) recognized as a good result is determined by factors such as preoperative hearing loss, onset and duration of the disease, advanced and multiple otosclerotic foci, patient's age etc. Actually postoperative air-bone gap shows the improvement of air and bone thresholds obtained post stapedotomy versus preoperative air bone gap. In previous years an "over-closure" effect was taken into consideration. Hearing improvement post stapes surgery which included the "over closure" effect was obviously better. The authors indicate the necessity of standardization of audiometric results post ear surgery.     

Diode laser in otosclerosis surgery: first clinical results.

OBJECTIVE: To evaluate the functional results of otosclerosis surgery using diode laser. STUDY DESIGN: Retrospective cohort analysis. PATIENTS: One hundred seven patients operated on for otosclerosis with a diode laser (119 ears, all primary cases) and 141 patients operated on with a conventional technique (141 ears, all primary cases). Revision cases using the diode laser were also described. METHODS: Preoperative tomographic computed scan findings and intraoperative observations were collected. Pure-tone and vocal audiometry was performed preoperatively and postoperatively (at 3 mo and 1 yr). RESULTS: In the laser group, the air-bone gap was 29 +/- 0.8 dB (n= 112) preoperatively and 9 +/- 0.6 dB (n = 58) at 1 year. Air conduction was improved by 22 +/- 1.7 dB at 1 year (n = 58). In the conventional group, the air-bone gap was 32 +/- 0.9 dB (n=127) preoperatively and 10 +/- 0.6 dB (n = 127) at 1 year. Air conduction was improved by 25 +/- 1.1 dB (n = 127) at 1 year. No difference of hearing gain was observed between the 2 groups at 1 year. A decreased rate of footplate fracture was observed with the diode laser (3.6%) compared with the conventional technique (21.3%). CONCLUSION: Diode laser is a reliable and safe device for otosclerosis surgery. The functional results were similar to those reported in other series.     

Normal brief-tone bone-conduction behavioral thresholds using the B-71 transducer: three occlusion conditions

Behavioral thresholds were measured from 31 adults with normal hearing for 500, 1000, 2000, and 4000 Hz brief tones presented using a B-71 bone oscillator. Three occlusion conditions were assessed: ears unoccluded, one ear occluded, and both ears occluded. Mean threshold force levels were 67, 54, 49, and 41 dB re:1 microN peak-to-peak equivalent in the unoccluded condition for 500, 1000, 2000, and 4000 Hz, respectively (corrected for air-conduction pure-tone thresholds). A significant occlusion effect was observed for 500 and 1000 Hz stimuli. These thresholds may be used as the 0 dB nHL (normal-hearing level) for brief-tone bone-conduction stimuli for auditory brainstem response testing.     

Obliterative otosclerosis

From January 1990 to December 1996, 293 primary stapedectomies for otosclerosis were performed, among which 14 had obliterative otosclerosis (4.7 per cent). Probability of bilateral obliterative disease was 50 per cent. With this particular condition, a drill-out procedure was used to perform either a stapedectomy or a stapedotomy. In two patients with bilateral 'far-advanced otosclerosis', surgery was effective in enabling the patient to benefit from hearing-aids. In patients with a measurable hearing-loss, an air-bone gap closure to within 10 dB was achieved in 62.5 per cent of the cases and to within 10-20 dB in 37.5 per cent of the cases, with no deterioration of air-conduction thresholds at 8 kHz. A mild sensorineural hearing loss at 4 kHz was observed in 25 per cent of the cases. There was no statistical difference between stapedectomy and stapedotomy. According to these results, the drill-out technique is a safe and effective procedure in cases of obliterative otosclerosis.