Stapedectomy techniques in residency training.

The KTP-532 laser has decreased the technical difficulty involved in teaching and performing a stapedectomy in our residency program. Use of this laser has resulted in improved hearing and a decreased number of major and minor complications compared to an equal number of large fenestra stapedectomies performed with hand-held instruments. The major disadvantages of the KTP-532 laser are its cost and limited availability, and the inconvenience of a micromanipulator. The laser should not be relied upon entirely in performing a stapedotomy on a thick footplate. The University of Texas Medical Branch experience in training residents in both large and small fenestra stapedectomy is reported.     

Experimental and clinical results of fiberoptic argon laser stapedotomy

Since 1992 a small air-cooled opthalmological argon laser (Augus system, 3 W max.) equipped with a fiberoptic microhandpiece has been used for stapedotomy at the Inselspital, Berne. The microhandpiece has been developed especially for otological purposes in our electronic laboratory. In order to measure the effect of argon laser pulses applied through the handpiece to the ear, we performed temperature measurements in a saline-filled inner ear model by using ultrathin (2 m thick), ultrafast (4 ns) thermosensitive rhodamine-coated polyurethane films. Multiple laser pulses of 1–2.5 W and 0.1 s duration — as used in clinical applications — produced a temperature elevation of about 1 ° C in the liquid of the inner ear model. The local laser effect was then examined histologically on the isolated stapes. The thermal damage zone around the stapedotomy perforation was limited to about 100 m. In a clinical study we compared the results of argon laser stapedotomy (n = 54) with those of a skeeter microdrill stapedotomy (n = 29). Substantial hearing gains were found in all cases in both groups. In the laser stapedotomy group the mean residual air-bone gap (0.5–2 kHz) was 10 dB or less in all cases but one. Inner ear function remained unchanged except for a 40-dB loss at 4000 Hz in one case. Transient vertigo with nystagmus occurred in one case. Facial nerve dysfunction did not occur in any patient. The most important advantage of the laser found was the absence of mechanical trauma to the stapes. Stapes luxation and a floating footplate were avoided. In contrast, thick footplates were more easily perforated with the skeeter. Use of an argon laser equipped with a fiberoptic microhandpiece and a skeeter microdrill as needed seems particularly advantageous for stapedotomy.Adapted from presentations at the Politzer Society Meeting in Punta Ala, 29 August–2 September 1995 and the 65th Annual Meeting of the German Society for ENT, Head and Neck Surgery, Chemnitz, 14–18 May 1994     

KTP-532 laser tonsillectomy: a comparison with standard technique

It has been stated that laser excision of oral and oropharyngeal lesions result in less intraoperative blood loss, reduced postoperative pain, and quicker wound healing, but few controlled studies have been done to substantiate these claims. A study was undertaken to examine the benefits of the KTP-532 laser in a group of 31 patients who underwent tonsillectomy. One tonsil was removed with the KTP-532 laser and the other was excised with conventional dissection and snare technique. Patients were not told which tonsil was removed with the laser. Pain, healing, and intraoperative blood loss comparing one side to the other was assessed. On the evening of surgery, 83% of patients selected the side that underwent standard dissection and snare tonsillectomy as the most painful. By midweek, however, approximately equal numbers of patients selected the laser side as the most painful. At the end of 1 week, 63% of patients felt more pain on the laser dissection side. Possible reasons for these results are discussed. Intraoperative blood loss was significantly reduced with the use of the KTP-532 laser, but healing was not accelerated.     

CO2 and KTP-532 laser cordectomy for bilateral vocal fold paralysis

Laryngeal obstruction due to bilateral vocal fold paralysis has been treated in many different ways. The CO2 laser or KTP-532 laser endoscopic cordectomy described in this report is a slight modification of the posterior partial cordectomy proposed by Dennis and Kashima. This technique was used in 18 patients (14 with the CO2 and four with the KTP-532 laser). Prophylactic tracheostomy was performed pre-operatively. Post-operative results were excellent in nine cases, good in seven cases and poor in two cases who had to remain with a permanent tracheostomy tube with a speaking valve. The main complications noted were the formation of a granuloma (seven cases) and arytenoid oedema (six cases). Revision surgery was performed in the seven cases with granuloma formation and in the two with persistent oedema. The results and the post-operative findings from the use of the two lasers were similar.     

Fully endoscopic laser stapedotomy: is it comparable with microscopic surgery?

Abstract

Background: Microscopic stapedotomy is very successful and has long history, but it still has some constraints. Thus, otoendoscopy is increasingly popular nowadays.

Aims/Objectives: The retrospective review study was to investigate the role of endoscopic laser stapedotomy in treating patients with otosclerosis.

Materials and methods: Seventeen patients who received endoscopic laser stapedotomy from April 2014 to July 2017 were enrolled and compared to 13 patients who had microscopic stapedotomy from February 2009 to March 2012. The anatomical structures, operative time, and postoperative hearing outcomes were assessed in two groups. Relation between external acoustic canal and operative time was also analyzed.

Results: Using an endoscope, the operative field was clear, with easily identified anatomy, without need to sacrifice bony structures. The operative time was significantly longer in the endoscopic group in 2014 and decreased in the following years. There was no significant difference of hearing improvements between the two groups. There was a weak correlation between the width of the external auditory canal and the operative time.

Conclusions and significance: Fully endoscopic stapes surgery is a feasible and safe surgical technique and results in satisfactory hearing outcomes. However, surgeons take longer to master the technique and to achieve shorter endoscopic operative times.     

A study of the intra‐operative effect of the Argon and KTP laser in stapes surgery

The intraoperative effect of the Argon and KTP laser was studied on 20 patients who had primary stapes surgery under local anaesthetic; 10 had Argon and 10 had KTP laser stapedotomy. Symptoms of inner ear disturbance such as dizziness and tinnitus were systematically recorded during the laser procedure. Both dizziness and tinnitus were relatively uncommon when the laser was used on the promontory. When the laser was used to transect the posterior crus, all the patients reported transient dizziness, probably from the thermal effect through the posterior crus into the inner ear. However, tinnitus was unusual during this stage. When the laser was used to fenestrate the footplate, only 30% of patients reported a transient dizziness as less laser energy was used. On the other hand, 55% of the patients experienced tinnitus during this stage, which indicates an acoustic effect on the inner ear. There is no difference between the Argon and KTP laser.     

Use of the KTP-532 Laser in Acoustic Neuroma Surgery

The potassium titanyl phosphate (KTP-532) laser has been applied to otologic surgery with a proven record of both safety and efficacy. The aim of this study was to demonstrate the use, safety, and advantages of laser dissection in the surgical treatment of acoustic neuromas. The authors' experience with 111 patients in whom laser surgery was used in acoustic neuroma is presented, with emphasis on surgical technique employed and facial nerve functional outcome. The method of laser dissection did not result in deleterious neurologic sequelae or laser-specific complications. In addition, laser dissection afforded certain advantages to traditional techniques, especially in larger tumors. The facial nerve functional outcome as assessed by the House-Brackmann grading system revealed that 90.2% of small tumors, 72.2% of medium tumors, and 75.0% of large tumors achieved satisfactory (grades I and II) functional results. These results compare favorably with the literature describing nonlaser dissection techniques. The observations and results reported in this article demonstrate the safety of the KTP-532 laser in the posterior cranial fossa, and specific advantages that this technology may offer to the surgical armamentarium of the neuro-otologist are outlined.     

逆行性镫骨足板开窗术治疗耳硬化症的疗效分析

目的:探讨逆行性镫骨足板开窗术治疗耳硬化症的疗效。方法:回顾性分析2006-01-2009-12期间进行镫骨足板开窗术的耳硬化症70例(81耳),将其分为传统镫骨足板开窗术组41耳,逆行性镫骨足板开窗术组40耳,对2组的术后纯音测听结果、术中镫骨、砧骨并发症及术后眩晕发生率进行评估。结果:2组术后的气骨导差≤20dB的比例分别为70.7%和80.0%,差异无统计学意义(P>0.05)。逆行性镫骨足板开窗术的镫骨、砧骨并发症较少,而且术后眩晕发生率明显低于传统镫骨足板开窗术(P<0.05)。结论:逆行性镫骨足板开窗术能有效的提高耳硬化症患者的听力,并能减少手术并发症。     

Preservation of the stapedius tendon in laser stapes surgery

Objectives/Hypothesis: The stapedius tendon is routinely transected during stapes surgery. The objective of this study was to evaluate the technique of stapedial tendon preservation during stapes surgery and to compare results of these cases with cases where the stapedial tendon was not preserved. Study Design: Retrospective study. Methods: Four groups of patients were evaluated. Two groups had undergone stapes surgery with preservation of the stapedial tendon. One of these groups underwent a laser stapedotomy minus prosthesis (laser STAMP) procedure, while the other group had a prosthesis inserted. The other two groups had undergone laser stapedotomy with one of two different prostheses being used. Audiometric data were obtained and reviewed both preoperatively and at approximately 6 weeks postoperatively. Results: All groups had overall successful results demonstrating that stapedial tendon preservation is technically possible and does not compromise outcomes. Conclusions: Based on the results, it is recommended that the stapedius tendon be preserved whenever possible during laser stapes surgery. Reasons justifying its preservation are discussed. Laryngoscope, 108:1453–1458, 1998     

Experimental studies on the suitability of the erbium laser for stapedotomy in an animal model

Animal experiments in mature guinea pigs were devised to determine whether and to what extent inner ear damage can be caused by in vivo use of the erbium laser for stapedotomy. The present study examined the laser effect in connection with perforation of the basal convolution of the cochlea and subsequent application in the opened cochlea. Acoustic evoked potentials as compound action potentials (CAP) were recorded for changes in inner ear function. Findings demonstrated that five applications of the erbium:YSGG (yttrium-scandium-gallium-garnet) laser (energy, 85 mJ/pulse; energy density, 36 J/cm²) were needed to create a footplate perforation of 500–600 m and did not lead to CAP alteration in any animal (n = 20). An increase of the repetition rate from 1 to 5 Hz likewise caused no CAP alteration (n = 17). Application of high total energies in the open cochlea (n = 5) to determine the safety of the laser system for stapedotomy revealed that a 10-fold increase in the total energy required for adequate perforation led to irreversible CAP alterations and no CAP could be recorded at a 15-fold increase in total energy. In contrast, a 5-fold maximum increase in total energy caused no CAP alterations. These results demonstrate the safety of the Er:YSGG laser comparable to that of the CO₂ laser for stapedotomy, supporting its utility as an alternative method for surgery.Adapted from a preliminary presentation at the 64th Annual Meeting of the German Society for Otolaryngology, Head and Neck Surgery, Munster, 23–27 May 1993     

Stapedotomy with incus vibroplasty – A novel surgical solution of advanced otosclerosis and its place among existing therapeutic modalities – Hungarian single institutional experiences

ObjectiveTo delineate the advantages and steps of stapedotomy with incus vibroplasty, to assess the safety and efficacy of this method via the authors’ experiences, and to overview the literature regarding other surgical options in advanced otosclerosis determining the place of stapedotomy with incus vibroplasty in the therapeutic range.MethodsFour patients were enrolled in the study presenting severe mixed hearing loss of at least one side on pure tone audiometry. Based on complementary audiological examinations including stapedial reflex test and multifrequency tympanometry, all cases were suspected as advanced otosclerosis. Stapedotomy with incus vibroplasty – the combination of laser stapedotomy and simultaneous Vibrant Soundbridge implantation – was performed in each patient. Preoperative pure tone average, speech recognition thresholds and word recognition scores were compared to one-year postoperative free-field values with the implant switched on focusing on functional gain.ResultsAmong 4 participants (3 females, 1 male) the mean age (SD) was 66 years (35). In three cases Nitinol, in one case NitiBond piston was inserted. One-year postoperative free-field functional gains were 30 dB, 34 dB, 42 dB and 51 dB, respectively. One-year postoperative free-field speech recognition thresholds were 45 dB, 45 dB, 49 dB and 50 dB, respectively, while word recognition scores were 70%, 70%, 70% and 75%, respectively.ConclusionPostoperative results in our serie regarding pure tone average and word recognition score proved to be better than those found in the literature. Stapedotomy with incus vibroplasty – through sufficient air-bone gap closure and simultaneous sensorineural component management – seems to be a promising surgical solution in advanced otosclerosis, requiring further investigation.     

KTP-532 laser in the management of rhinosporidiosis

Rhinosporidiosis, a difficult granulomatous disease of the nose is notorious for its high rate of recurrence and vascularity. Potassium Titanyl Phosphate (KTP) laserization of the mass seems to have provided an optimal solution in the management of this disease. We present our experience with the use of KTP-532 laser for this challenging disease.     

KTP-532 laser cordotomy for bilateral abductor paralysis

Various lateralization procedures have been described in the past to treat bilateral vocal cord paralysis. Though endoscopie lateralization gives good results in terms ofdecannulation rates, the postoperative voice quality is often poor. KTP-532 laser assisted posterior cordotomy was done in 3 cases. This preliminary study showd 100% decannulation rate and good post-operative voice quality. The latter was assessed both subjectively and objectively on VAGMI scales.     

Hypericin: A New Laser Phototargeting Agent for Human Cancer Cells

Laser activation of anthracycline-related drugs combines chemotherapy with photoablation for improved treatment. Hypericin, a structurally related anthraquinone, was tested for laser activation and cytotoxicity in human cancer cells. Viability of P3 squamous cell carcinoma cells incubated with 1 to 20μg/mL hypericin was reduced by more than 95% after 1 minute exposure at 4°C to an argon laser (514 nm, 5 W), a KTP-532 laser (532 nm, 5 W), or a 20-A xenon lamp. Viability was reduced over 90% in six human carcinoma, sarcoma, and melanoma cell lines by this combined treatment, but only trace toxicity was seen after separate exposure to hypericin or light alone. These results show that hypericin is a sensitive agent for phototherapy of human cancer cells in vitro and indicate that this drug may be useful for tumor targeting via minimally invasive imaging-guided laser fiberoptics.     

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.     

Application of potassium-titanyl-phosphate (KTP) laser in the excision of pyriform fossa hemangioma

Pyriform fossa hemangioma, especially of the cavernous type, is a rare case and very few such lesions have been encountered in general otolaryngological practice. We report such a lesion in a 36-year-old, middle-aged woman presenting with complaint of foreign body sensation in the throat. Examination revealed a hemangioma in the right pyriform fossa that was successfully managed using KTP-532 laser and bipolar cautery.     

Laser Photochemotherapy With Anthracyclines on Cultured Human Squamous Carcinoma Cells

A new treatment for cancer has been tested in vitro using light-sensitive anthracyclines followed by laser photoactivation, as described by several investigators. We previously reported 10-fold enhanced laser killing after 2 hours of incubation with daunomycin by cultured human carcinoma cells. This short-term uptake leads to drug localization in cytoplasmic and membrane sites prior to nuclear accumulation and topoisomerase inhibition. In the present study, daunomycin was incubated for 2 or 24 hours with P3 squamous carcinoma cells to directly compare cytoplasmic vs. nuclear drug targeting before and after KTP-532 laser activation. Monolayer cultures of the P3 cells sensitized with daunomycin for 2 hours, then chilled (4°C), and exposed to the KTP laser (532 nm, 94.2 J/cm²) had a 2- to 10-fold increased therapeutic response compared with drug or laser alone when measured by MTT tetrazolium assays. After 24 hours of incubation with daunomycin, the chemotherapeutic response of P3 tumor cells was amplified 2-fold by laser exposure. The results suggest that daunomycin and laser treatment can be combined for improved therapy of human cancer.     

Effect of the pulsed Er:YSGG and Ho:YAG laser on the organ of Corti of the guinea pig cochlear--a scanning electron microscopy study

BACKGROUND: Recent experimental studies have demonstrated that, apart from the continuous wave lasers, several pulsed laser systems are also suitable for stapedotomy. The aim of this study was to clarify whether irradiation of the basal convolution of the guinea pig cochlea could cause morphological inner-ear changes using the Er:YSGG and Ho:YAG laser with laser parameters required for stapedotomy. METHODS: After opening the bulla, the basal convolution of the guinea pig cochlea, whose thickness is similar to that of the human stapes footplate, was irradiated with the Er:YSGG and Ho:YAG laser. The laser parameters used were those necessary for an adequate perforation of a human stapes footplate (500-600 microns). The cochleae were removed 90 minutes, 1 day, 2 weeks, or 4 weeks after laser application. The organ of Corti was examined by scanning electron microscopy in all convolutions. RESULTS: Application of Er:YSGG laser parameters effective for stapedotomy (5 pulses, energy: 85 J/pulse, energy density: 36 J/cm2, total energy: 0.425 J) had no adverse effects on the organ of Corti in the guinea pig cochlea. On the other hand, effective Ho:YAG laser parameters (10 pulses, energy: 210 J/pulse, energy density: 90 J/cm2, total energy: 2.1 J) caused damage to the outer hair cells with fusion of stereocilia and formation of giant cilia leading to partial or total cell loss. The inner hair cells and supporting cells were usually normal. CONCLUSION: Our results clearly demonstrate that the Er:YSGG laser has high application safety. It could prove to be a viable alternative to the thermically acting CO2 laser for stapedotomy. The Ho:YAG laser is not well tolerated in animals and has low application safety. Its use in stapedotomy would be unreliable and dangerous for the inner ear.     

EARLY HEARING EVALUATION AFTER MICRODRILL STAPEDOTOMY

Stapedectomy is known to give good results for otosclerosis. In this study, an audiometric evaluation of patients who underwent small-opening stapedotomy has been carried out at an early stage (3 and 5 days after surgery), and 1 month after surgery. At day 5 almost 60% of the patients showed a good functional result (mean residual post-op air conduction/pre-op bone conduction gap within 5 dB). While the timing of 4 kHz recovery overlapped that of the lower frequencies, recovery for 8 kHz was evident only at day 30, and was less likely to occur than for 4 kHz.     

Stapedotomy with and without stapedius tendon preservation versus stapedectomy: long-term results

Stapedectomy and stapedotomy are presently the techniques utilized in the surgical treatment of otosclerosis. The technique of choice at the ENT Department of the University of Verona has changed from stapedectomy to stapedotomy with and without stapedius tendon preservation. From January 1975 to December 1985, 805 ears were operated on for otosclerosis at our department. A statistical analysis has been performed on three groups of patients (stapedectomy, stapedotomy without and with stapedius tendon preservation) at short and long term. The results suggest that stapedotomy with stapedius tendon preservation should be the preferred surgery in the treatment of otosclerosis.