Evaluation of second-ear stapedotomy with the Glasgow benefit plot

This study reports the evaluation of the results after 72 stapedotomies in patients with bilateral otosclerosis. All pre- and postoperative audiological data, together with all relevant information of the operations, were stored in a data base and analyzed retrospectively. The Glasgow benefit plot (GBP) is a useful method to evaluate the hearing results of each individual ear after stapes surgery in a more functional way rather than from a technical standpoint. Therefore, it has been used to assess the benefit obtained after second-ear stapedotomy. From the results it appears that a second operation on the contralateral side increases the chances of achieving at least one 'normal'-hearing ear, and it makes symmetrical 'normal' hearing possible in the majority of the cases.     

Observations on bilateral symmetry of the stapedial footplate lesion and narrowing of the oval window niche in otosclerosis

OBJECTIVES: We consider whether patients with bilateral otosclerosis who have surgery on their second ear show symmetry in the degree of severity of their footplate otosclerosis. METHODS: The severity of the stapedial otosclerotic lesion and the degree of narrowing of the oval window niche by exostoses were recorded for each ear of 269 patients who elected to undergo operation on the second ear. The severities and similarities of the otosclerotic lesion affecting the oval window niche were compared between the ears. RESULTS: The majority of oval window niches were normal in width in both ears. A niche narrowed to less than 0.8 mm in diameter was rare and tended to affect both ears (5.6% first ears and 5.95% second ears; chi2 = 134.6 on 4 df, p < .0001). The degree of footplate otosclerosis was classified and amalgamated into 3 broad categories: minor (47.2%), moderate (21.6%), and severe (31.2%). A high degree of bilateral symmetry of the stapedial footplate lesion was found (chi2 = 162.2 on 4 df; significant at .0001 level). CONCLUSIONS: The findings at the oval window of the first ear in regard to the severity of otosclerotic involvement of the stapes footplate and narrowing of the niche by exostoses do allow a fair prediction of the pathological findings in the second ear, if that ear is suitable for stapes surgery and the patient elects to have an operation. The surgeon is forewarned of possible difficulties and technical challenges if an operation has been performed on the first ear.     

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.     

Stapedotomy technique and results: Ten years' experience and comparative study with stapedectomy

Fifty of the 810 patients who underwent stapedotomy for otosclerosis from 1969 through 1988 were randomly chosen for follow-up of at least 5 years. Most of the patients (65%) had follow-ups of 10 years after stapedotomy, but another 50 patients who underwent stapedectomy had follow-ups of longer than 10 years. In 50 patients, stapedectomy under local anesthesia was performed by removal of the footplate of the stapes, using an endaural incision, and covering the oval window with Gel-foam®. In the other 50 patients, stapedotomy was performed under general anesthesia, using an endopreauricular incision, making a small hole in the footplate, and covering the hole only with blood from the surgical area. Although both groups showed improvement in hearing after the operation, the air-bone gap in the stapedotomy group was significantly better than that in the stapedectomy group. The use of the endopreauricular incision under general anesthesia was preferable to endaural incision under local anesthesia because the operative field was wider, more convenient for the surgeon, and conducive to patient safety. There were no significant complications in either group. Our experience suggests that stapedotomy is the procedure of choice for otosclerosis.     

"Second ear" stapedotomy: is it safe?

This study reports the evaluation of "second ear" stapedotomiesy results in 23 patients with otosclerosis. All pre- and post-operative audiological data, all relevant surgical information and patients' features were analyzed retrospectively. The air-bone gap showed a significant improvement in all patients. The bilateral audiometric thresholds improved in 20 (87.0%) patients; in 1 (4.3%) patient, unilateral improvement occurred with no changes in the other ear and in 2 (8.7%) patients improvement occurred in first operated ear and dropped in the second ear after the last procedure. During the follow-up, there were no incapacitating complications. Based on these findings, we can conclude Our study concluded that second ear stapedotomy is a safe procedure with good results.     

The effect of stapedectomy on hearing of patients with otosclerosis and Meniere's disease

To determine new guidelines for stapedectomy in patients with both Meniere's disease and otosclerosis, we studied the position of the saccular membrane and Reissner's membrane in relation to the stapes footplate in eight temporal bones from patients with Meniere's disease. We also reviewed charts of four patients with both otosclerosis and Meniere's disease who had stapedectomy. Histologic and clinical findings were compared with preoperative bone conduction levels at 500 Hz and at high frequencies. We found that the saccular and Reissner's membranes did not contact the stapes footplate ain bones of patients with preoperative bone conduction levels of 35 dB or better at 500 Hz and no high-frequency loss. We also found that stapedectomy was successful in patients with the same criteria. We therefore conclude that stapedectomy does not increase the risk of sensorineural hearing loss for patients with otosclerosis and Meniere's disease who have bone conduction levels of 35 dB o better at 500 Hz and no high-tone loss, but it is contraindicated for patients with 45 dB at 500 Hz or worse and with high-tone loss.     

Predictive factors in pediatric stapedectomy

OBJECTIVE/HYPOTHESIS: The objective of the study was to investigate predictive factors in the postoperative hearing outcomes in pediatric stapedectomy. STUDY DESIGN: Retrospective case series. The study was performed in a tertiary academic otological practice. METHODS: The outcome of 66 stapedectomies in children 17 years of age and younger were analyzed according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines. Factors evaluated included patient age, underlying diagnosis (tympanosclerosis, otosclerosis, congenital fixation), type of footplate graft and type of prosthesis used, associated ossicular abnormalities, and revision surgery. RESULTS: The mean postoperative air-bone gap following stapedectomy in children with tympanosclerotic footplate fixation (24.9 dB [+/-11 dB]) was significantly worse than in patients with an underlying diagnosis of congenital stapes fixation (15.7 dB [+/-9 dB]) or otosclerosis (13.1 dB [+/-3 dB]) (P =.024). Revision stapedectomy was also associated with a poorer outcome, but patient age and prosthesis and graft type did not contribute to the outcome in a statistically significant manner. CONCLUSIONS: Pediatric patients with stapes fixation resulting from tympanosclerosis showed poorer outcomes from stapedectomy than patients with congenital or otosclerotic fixation. Outcomes for congenital or otosclerosis fixation more nearly matched the outcomes in the literature for adult series.     

Otosclerosis surgery: hearing results and complications

A retrospective study was made of 183 stapedectomies performed at the Santiago de Compostela Hospital from 1989 to 1996. Sixty-seven percent (67.3%) of patients were women and 32.7% were men. Good results were obtained in 87% of cases (79% had an air-bone gap closure difference under 10 dB, and 8% 10-20 dB). Ten pefect had not change in air threshold and the rest deteriorated. There were no significant differences between stapedectomy and stapedotomy. The 4. 000-Hz improvement obtained was inferior to those in 500, 1,000 and 2,000 Hz. In 8.7% of patients with obliterated footplate, heaving outcome was significantly worse. In patients with exposed or overhanging facial nerve, floating footplate, middle ear fibrosis, and necrosis of the long incus process had better results. Total sensorineural hearing loss occurred in 1.1% of cases.     

Evidence of otospongiosis obtained by computerized tomography. Does it compromise the post-stapedectomy auditory gain?

To study the influence of tomographic otospongiosis/otosclerosis on the audiometric gain after stapedectomy, we evaluated 34 patients (mean age 39.9 years, S.D. 9.8) with otosclerosis and mixed hearing loss. We performed Computed Tomography (CT) with densitometry before stapedectomy and audiometry before and 4 weeks after the surgery. CT results were classified as compatible or not for otospongiosis (< 1000 UH) or for otosclerosis (> 2000 UH). According to the affected turns of the cochlea, the studies were classified in 3 groups. In 43% of the patients the CT showed otospongiosis. After stapedectomy, air conduction thresholds of the low (125-500 Hz), middle (500-2000 Hz) and high frequency bands (2000-8000 Hz) and for the air/bone gap were similar for the ears with or without otospongiosis (p > 0.05, ANOVA). However, patients with otospongiosis in all the cochlea showed the lowest audiometric gain for the high frequency band (p < 0.05 ANOVA). Evidence of otospongiosis evaluated just by CT has a low impact on the audiometric outcome after stapedectomy.     

Cholesteatoma following stapedectomy

Among the possible complications of stapedectomy for otosclerosis, cholesteatoma is extremely rare. We report a case which was secondary to implantation of keratinising squamous epithelium inadvertantly included in the fat graft taken from the ear lobe to seal the footplate.     

Encoche De Carhart Et Chirurgie Stapédienne

The authors, in the light of an observation of a Carhart notch recovered after a bilateral otosclerosis operated on at the same time during the same stay in hospital, emphasize on one hand the possibility to forsee the postoperative gain with the modern techniques of deafness surgery in otosclerosis by adding to the audiometric Rinne the otosclerotic Carhart notch, (rectified by Fournier according to the calibration of european audiometers); on the other hand the absence of unknown elements owing to the contro-lateral ear, that does not have an effect at all upon the rate of the post-operative B.C. of the ear operated on. The techniques through which those results have been achieved, are stapedectomy with vein graft and polyethylene tube, and “teflon-interposition”.     

Low frequency air-bone gap in Menière's disease without middle ear pathology. A preliminary report

The audiograms of some patients suffering from Meniere's disease show an unexplained conductive component, or air-bone gap (ABG), predominantly in the low frequencies. Neither the history nor physical findings support poor eustachian tube function, ossicular chain abnormalities, chronic ear disease, physical trauma, or otosclerosis as a cause of this audiometric finding. In the present study, 40 patients diagnosed as suffering from classical Meniere's disease were evaluated audiometrically. Thirteen (32.5%) of these patients demonstrated a low frequency ABG. An otologic evaluation was performed on each patient who exhibited the abnormal finding, but no middle ear pathology was discovered. An otherwise unexplained low frequency ABG in patients with Meniere's disease suggests the possibility of an "inner ear" conductive hearing loss. This conductive component may result from endolymphatic hydrops or perilymphatic hypertension (i.e., an inner ear hyperpressure exerted against the medial surface of the stapedial footplate) rather than from middle ear pathology. "Inner ear" conductive hearing loss is thought to be caused by an increase in inner ear fluid volume (endolymphatic hydrops) and pressure (endolymphatic or perilymphatic hypertension), which dampens footplate mobility medially and which is directly related to a relative inner ear or labyrinthine hyperpressure. Since the footplate mobility is only dampened and not fixed, a stapedial reflex may still be elicited.     

Recent and future trends in the management of otosclerotic conductive hearing loss

The protection of cochlear function following stapedectomy has emerged as the major problem in the surgical treatment of otosclerosis. Both immediate and delayed sensorineural losses continue to occur in spite of refinements of technique. The frequency and extent of these complications has been investigated by prospective and retrospective studies of the author's patients. It has been concluded that the size of the footplate fenestration plays a major role in the outcome, both immediately, and in the long term. Revision operations are necessary when initially good results rapidly deteriorate, both to resolve complications such as perilymphatic fistulae and also to restore function. Although second ear operations are usually worthwhile, they should be performed only when certain specific criteria have been met. The expected duration of unaided hearing gain, although often adequate when a standard large fenestra operation is performed, is considerably prolonged by restricting the size of the footplate to less than half its total area. For reasons unknown, bone conduction thresholds appear to be better, eventually, in operated as compared to unoperated ears.     

Otosclerosis in children and adolescents: a clinical and CT-scan survey with review of the literature

OBJECTIVE: To assess the role of the CT-scan in the preoperative evaluation of juvenile otosclerosis and to study additional outcome data. DESIGN AND SETTING: We performed a retrospective case series study from an academic referral hospital using data from 1992 to 2005. PATIENTS AND METHODS: We selected patients younger than 18-year-old who had undergone primary stapedectomy for otosclerosis among the 10 stapedectomies performed over the study period and analyzed the patients' systematic pre- and post-operative audiograms and CT-scan findings. RESULTS: For this survey, complete data was available for 7 children, totaling 10 primary stapedectomies for otosclerosis. Their ages at diagnosis ranged from 10 to 17 years. In 4 children, CT-scan demonstrated bilateral findings typical of otosclerosis: poorly calcified foci near the fissula ante fenestram, associated with a hypodense edging surrounding the labyrinthine capsule in 2 children. The youngest patient had no CT-scan abnormalities. Stapedectomy was performed in one case and laser stapedotomy in 9 cases. Seven children were immediately improved following surgery and no postoperative facial palsy or prolonged vertigo was reported. The mean (S.D.) postoperative ABG was 6.5dB (+/-3.7). The mean closure was 19dB (+/-11.2). The mean change in high-tone bone conduction level was 1.8dB (+/-7.5). Six children had a postoperative ABG less than 10dB while in one, the ABG was inferior to 20dB. CONCLUSION: Preoperative CT-scan is useful for the preoperative diagnosis of otosclerosis in children. The images seen must be distinguished from other footplate pathologies or deformities of the ossicular chain which are often associated with poorer surgical results. This survey provides additional evidence that stapes surgery is an effective procedure for treating juvenile otosclerosis.     

Stapes surgery in osteogenesis imperfecta patients

Osteogenesis imperfecta (OI), or the Van der Hoeve-de Kleyn syndrome, is a heterogeneous group of connective tissue disorders. The key features in this disease are bone fragility with a tendency to spontaneous fractures and deformations. The classical triad of symptoms involves a conductive and/or sensorineural hearing impairment together with a tendency to spontaneous bone fractures and blue sclerae. Between January 1988 and December 1994, ear surgery was performed on eight ears of six OI patients who presented with mixed hearing loss preoperatively. Pathological changes observed in the middle ear were atrophy and/or fractures of the stapedial crura in combination with thickening and fixation of the stapes footplate. Partial stapedectomy was performed in seven cases and a neo-window was created in the promontory of one patient when an overhanging facial canal obscured visualization of the oval window niche. Pre- and postoperative bone conduction thresholds did not differ in any of the patients. Postoperatively, mean values of the air-bone gap in the main speech frequency range were below 10 dB. Functional results following stapes surgery in patients with otosclerosis during the same time interval (n = 857) did not differ significantly. These data indicate that stapes surgery in OI patients can be performed with the same functional predictability as in otosclerosis patients, even though the underlying etiology is considerably different. The results were presented in part at the 66th annual meeting of the German Society for Otorhinolaryngology-Head and Neck Surgery (Deutsche Gesellschaft für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie), Karlsruhe, 27–31 May 1995     

Effect of stapedectomy on subjective tinnitus

A series of 149 patients, who had tinnitus associated with otosclerosis, and who underwent stapedectomy by a single operator were questioned about their tinnitus one to 19 years after surgery. Of these, 73 per cent reported that their tinnitus had ceased following surgery, 17 per cent that it had improved and only 10 per cent that it was unchanged. No pre-operative audiometric or patient data were associated with a favourable outcome in terms of tinnitus improvement. Patients who had poor hearing outcomes reported abolition of their tinnitus, suggesting that this was due to the improvement in the fluid mechanics of the cochlea resulting from stapedectomy. The tinnitus status was unrelated to the length of follow-up time.     

Tinnitus and otosclerosis

Fifty patients with otosclerosis and tinnitus were studied for the course of the tinnitus after stapes surgery. Tinnitus disappeared in 64% of the cases, improved in 16%, was unchanged in 14%, and worsened in 6%. The reduction in tinnitus was more favorable after a small fenestra stapedotomy than after a partial stapedectomy with removal of the posterior half of the footplate. An unfavorable postoperative course of tinnitus did not appear to be linked to the postoperative audiometric result. In our study the subjective evaluation of pitch and loudness of the tinnitus did not provide significant information regarding its prognosis. Received: 18 April 1999 / Accepted: 22 April 1999     

Progressive stapedial fixation in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome is a genetic fetal overgrowth disturbance characterized by organomegaly, abdominal wall defects, postnatal hypoglycemia, and increased frequency of embryonic and postnatal tumors. Hearing loss in connection with this syndrome is rare. We describe a patient with Beckwith-Wiedemann syndrome having a progressive conductive hearing loss caused by a stapedial footplate fixation occurring during preschool age. We studied progression of the hearing impairment audiometrically from the patient's fourth year of life until age 19. In the right ear, it progressed from a mean pure-tone hearing level of 10 dB to 70 dB, with a perceptive component of 30 dB. The hearing level of the left ear remained at 25 dB. An exploratory tympanotomy disclosed stapedial fixation, and a partial stapedectomy improved the hearing level in the right ear to 30 to 35 dB. In patients with Beckwith-Wiedemann syndrome, a progressive conductive hearing loss, caused by stapedial footplate fixation, may develop after birth. Clinically, the fixation is identical to otosclerosis, but the typical family history of otosclerosis is lacking.     

Exploratory tympanotomy revealing incus discontinuity and stapedial otosclerosis as a cause of conductive hearing loss.

OBJECTIVE: To describe a unilateral progressive conductive hearing loss caused by incus discontinuity (without erosion of the long process of the incus), and otosclerosis with fixation of the stapedial footplate. STUDY DESIGN: Case report. SETTING: Department of Otolaryngology, Head and Neck Surgery of the University of Rochester Medical Center, which is a regional tertiary referral center. PATIENT: A 54-year-old woman with multiple otologic complaints including tympanic membrane perforations, otalgia, tinnitus, and hearing loss. Audiography demonstrated 100% speech discrimination bilaterally and a significant conductive right-sided hearing loss. INTERVENTION: The patient underwent a stapedectomy, during which a discontinuity between the long process of the incus and the stapes with no bony erosion was identified. The stapedectomy was completed and an ossicular piston prosthesis was inserted to reestablish ossicular continuity with the tympanic membrane. MAIN OUTCOME MEASURE: Improved subjective hearing confirmed objectively by audiography. CONCLUSION: This is the third reported case of an unusual combination of otosclerosis and ossicular discontinuity, and the first such case report in a patient without head trauma. In addition, it adds a unique item to the differential diagnosis of the pathologic features implicated in an ear with a conductive deficit and normal tympanogram.     

The surgical results of stapes fixation in children

Objectives

The aims of this study were to review the causes of stapes fixation in children undergoing stapes surgery and to analyze the results of stapes surgery in children in the short term, at 1 year, and over the long term.

Methods

The medical records of 18 children (28 ears) who had undergone stapes surgery between January 1999 and December 2012 were retrospectively reviewed. The medical history, computed tomography results, intraoperative findings, video clips, and hearing outcomes of all patients were reported.

Results

The mean age of patients was 11.1 years (range, 5.9–15.3 years). Congenital stapes fixation (22/28 ears, 79%) and juvenile otosclerosis (6/28 ears, 21%) were responsible for all cases of stapes fixation. Intraoperatively, abnormal facial nerves that were downwardly displaced over the stapes footplate were noted in four ears. Incudostapedotomy was performed in 24 ears, malleostapedotomy in three, and partial stapedectomy in one. The early postoperative audiometric outcome was favorable in 21 ears (87.5%). There was no significant difference between early postoperative (87.5%), 1 year postoperative (91%), and long term (92.3%) favorable audiometric results. There was no significant difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis.

Conclusion

Congenital stapes fixation was diagnosed in 22 (79%) ears and juvenile otosclerosis in six (21%) ears from a series of 28 ears that were operated on for stapes fixation. Facial nerve anomalies were found in four of 22 ears (18%) that had congenital stapes fixation. There was no difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis. Regardless of the cause of stapes fixation, stapedotomy is a safe and effective procedure for managing the condition.