Long‐Term Results of Small Fenestra Stapedectomy Compared With Large Fenestra Technique

Objectives/Hypothesis A comparison is made of the postoperative long‐term hearing results of small fenestra stapedectomy versus large fenestra techniques. Several reports in the literature favor improved hearing results in small fenestra stapedectomy compared with large fenestration and/or total stapedectomy. Methods A retrospective review of 34 patients who had stapedectomy performed by the same surgeon between 1982 and 1992. All patients have been followed for up to 10 years postoperatively. Results In 18 ears of 17 patients, surgery was performed with small fenestra technique, and 17 ears of 17 patients had total stapedectomy or posterior‐half fenestration. After small fenestra stapedectomy, initial average air–bone gap at 500, 1000, and 2000 Hz was 9 dB hearing loss. Hearing thresholds at 4000 Hz deteriorated to 4% over the study period. Speech reception thresholds declined 15%. After total or posterior‐half stapedectomy the average air–bone gap at 500, 1000, and 2000 Hz was 5 dB hearing loss. Hearing thresholds at 4000 Hz deteriorated 8% and 18% for the small fenestra and large fenestra groups, respectively, over time. Statistically, there was no difference in hearing deterioration rate between these two groups. Conclusions An experienced surgeon can obtain excellent results using either large or small fenestra technique for otosclerosis. After initial successful closure of the air–bone gaps at all measured frequencies, hearing thresholds over the study period were stable for both groups.     

An evaluation of revision stapes surgery

The expected success rate in primary stapedectomy is well documented in recent literature, but few reports have commented on the difficulties or the expected results in revision stapes surgery. Reports have dealt with different techniques, but the surgeon and the patient should be aware of the problems and risks involved in revision stapedectomy. The records of 35 patients who had undergone revision stapedectomy were analyzed to determine the following: 1. cause of failure, 2. how to avoid these difficulties, 3. hearing results, and 4. possible identifying factors which might pinpoint those patients with a high risk for sensorineural hearing loss. A review of these cases demonstrates that the results of revision stapedectomy are different than those for primary stapedectomy.     

Stapedectomy in the Pediatric Patient

The purpose of this study was to evaluate and compare the results of stapedectomy in pediatric patients with otosclerosis and tympanosclerosis. A retrospective review of 14 patients (15 ears) who underwent stapedectomy from 1993 to 1995 was conducted. In 5 ears stapedectomy for tympanosclerosis was performed; 9 patients had otosclerosis and 1 had Treacher Collins syndrome. Patients were evaluated for preoperative and postoperative air-bone gaps, preoperative and postoperative speech reception thresholds, postoperative air conduction hearing improvement, and preoperative and postoperative speech discrimination. Children with otosclerosis who underwent stapedectomies had an average postoperative airbone gap of 16 dB with an average air conduction hearing improvement of 17.6 dB. Children with tympanosclerosis who underwent stapedectomies had an average air-bone gap of 14 dB with an average air conduction hearing improvement of 28 dB. Stapedectomy is a safe and effective treatment for otosclerosis and tympanosclerosis in pediatric patients.     

A review of 308 cases of revision stapedectomy

Objective/Hypothesis: Identify causes of primary and revision stapedectomy failure in 308 patients, assess whether these are different based on source of initial surgery, and evaluate hearing results in revision stapedectomy to improve outcome. Study Design: Retrospective, nonrandomized chart review of patients undergoing revision stapedectomy in a referral otology practice in a large metropolitan region. Materials and Methods: Intraoperative findings, preoperative and postoperative revision stapedectomy air and bone conduction pure-tone averages, speech discrimination scores, postoperative air-bone gaps, complications, and repeated revisions were noted in 308 patients. Results: Leading causes of primary stapedectomy failure included dislocated prosthesis (24.4%), inadequate prosthesis length (14%), long process resorption (14%), and fibrous adhesions (13.6%). Revision stapedectomy air-bone gaps were less than 10 dB in 80% and greater than 30 dB in 6.8% of cases. Increased sensorineural hearing loss occurred in 0.8% of revision stapedectomy cases. Five of seven cases of vertigo associated with primary stapedectomy resolved after revision surgery. Conclusion: Revision stapedectomy by experienced surgeons is highly effective in attaining successful air-bone gap closure in 80% and improved closure in 84.8% of operative cases. Risk of vertigo and/or sensorineural hearing loss was not any higher in this patient population when compared with reports of primary stapedectomy.     

Stapedectomy following tympanoplasty.

The aim of this study was to evaluate the success of stapedectomy in patients who have previously had a tympanoplasty because of chronic otitis media (COM). Fourteen patients from a private otology practice had undergone tympanoplasty for COM and subsequently underwent stapedectomy. Measurements were taken of the air-bone gap (ABG) closure and pure tone average (PTA) which showed hearing improvement. Patients had a mean 36.9 dB PTA hearing gain with 79 per cent closing the ABG to within 20 dB. The need for stapedectomy alone is a rare occurrence for patients with a history of COM requiring a tympanoplasty. Hearing improvement following stapedectomy in these cases was significant, although somewhat less than following traditional stapedectomy in otosclerosis alone.     

Glasgow Benefit Plot for evaluation of stapedectomy result

In a group of 153 patients, the result of unilateral stapedectomy was evaluated using Glasgow Benefit Plot. Pure tone average at frequencies 0.5; 1; 2; and 3 kHz of operated and non-operated ear were used to distribute patients to pre- and post-operative groups. In 26 (79%) of 33 patients with unilateral hearing loss, bilateral normal hearing was achieved. Thirty one (46%) of 68 patients with asymmetric bilateral hearing loss and 37 (71%) of 52 patients with symmetric bilateral hearing loss had unilateral normal hearing after the operation. Twenty (29%) patients of the group III had bilateral symmetrical hearing loss after surgery. Stapedectomy was less beneficial for 17 (25%) of 68 patients with asymmetric hearing bilateral loss and 15 (29%) 52 of patients with symmetric bilateral hearing loss, who still had asymmetric hearing loss after the operation. Evaluation of hearing tests using the Glasgow Benefit Plot enables to evaluate patient's hearing disability and to predict possible benefit from surgery for individual cases.     

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.     

Improvement of bone conduction after stapes surgery in otosclerosis patients with mixed hearing loss depending from surgical technique

This study investigate the effect of stapes surgery on bone conduction (BC) improvement in otosclerotic patients with mixed hearing loss and also compare the effect of three different types of surgery (complete stapedectomy, partial stapedectomy and microfenestration stapedotomy) on this improvement. We retrospectively reviewed surgical database of 84 otosclerotic patients with mixed hearing loss. Sixty-two patients (75%) had significant improvement in BC after surgery (P = 0.03). In 85% of patients with follow-up time longer than 1 year, this improvement had remained. Improvement in BC after surgery was better in partial stapedectomy group (82.6%) and complete stapedectomy group (80.8%) in comparison with microfenestration stapedotomy group (63%) (P = 0.052).     

Revision stapedectomy]

Early and delayed complications in the inner or middle ear may follow stapedectomy and require revision surgery. The records of 72 patients who had undergone revision stapedectomy were analyzed to determine: 1. the causes of failure. 2. how to revise the conditions due to the failure following previous operation. 3. hearing results. These 72 revision operations consisted of 66 case of conductive deafness and 6 sensorineural loss. The commonest cause of failure was dysfunction of prosthesis (23.6 per cent), followed by otosclerotic regrowth (22.2 per cent), incus dislocation (13.9 per cent), reparative granuloma (12.5 per cent), incus necrosis (11.1 per cent), and fibrous adhesions (9.7 per cent). A review of these cases demonstrates that the results of revision stapedectomy are different from those for primary stapedectomy. The revision operations resulted in post-operative air-born gaps of 15 dB or less in 39.4 per cent of cases. Primary stapedectomy resulted in successful closure of the air-bone gap to 15 dB or less in 97.2 per cent of cases. 'Dead ears' were encountered in 9.1 per cent as against 2.1 per cent in the primary cases. Thus the surgeon should be aware of the problems and risks involved in revision stapedectomy.     

Far-advanced otosclerosis

OBJECTIVES: The aim of this study was to report a series of patients with far-advanced otosclerosis who were unable to benefit from hearing aids. Among patients with profound hearing loss, it is particularly useful to diagnose far-advanced otosclerosis even if relatively rare, because stapes surgery can improve hearing to a level allowing conventional hearing aid use (sometime the only choice before cochlear implant). MATERIAL AND METHODS: We retrospectively reviewed the charts of 7 patients (9 operated ears) in order to highlight diagnostic criteria, surgical indications and results of stapes surgery (stapedectomy or stapedotomy). RESULTS: Diagnosis of far-advanced otosclerosis was based on clinical presentation, course of hearing loss, positive family history of otosclerosis, and results of CT scan which was helpful in all the cases. Obliterative otosclerosis was found in 55% of the cases. Success of stapes surgery was observed in 89%, with no significant difference between stapedectomy or stapedotomy. CONCLUSION: Although rare, far-advanced otosclerosis must be diagnosed because patients can benefit from stapes surgery (and subsequently fitting of appropriate hearing aids).     

Comparison of titanium and Robinson stainless steel stapes piston prostheses.

OBJECTIVE: Although stainless steel stapes prostheses have generally been considered magnetic resonance imaging safe, there is concern that this may change with the development of more powerful imaging systems. The objective of the study was to determine whether a titanium piston stapes prosthesis would be audiometrically and surgically equivalent to a Robinson stainless steel piston for stapedectomy. STUDY DESIGN: Retrospective chart review. SETTING: Private otology practice. PATIENTS: In all, 50 patients underwent stapedectomy with a Gyrus titanium piston prosthesis. These patients were matched on the basis of age and preoperative bone-conduction scores with patients who underwent stapedectomy with a Robinson stainless steel piston prosthesis. MAIN OUTCOME MEASURES: Audiometric results are analyzed, and surgical complications noted. RESULTS: There was no significant difference between groups in hearing improvement or postoperative air-bone gap. The mean four-frequency hearing improvement was 27.7 dB for the stainless steel group and 27.8 dB for the titanium group. The mean postoperative air-bone gap was 2.65 dB for the stainless steel group and 2.60 for the titanium group. Neither group had a surgical complication. CONCLUSION: The titanium stapes prosthesis is a good alternative to a stainless steel prosthesis.     

Stapedectomy revision in elderly patients

OBJECTIVE: the objective was to determine the effectiveness of stapedectomy revision in patients 65 years of age or older. Although stapedectomy revision has been discussed in the literature, as well as primary stapedectomy surgery for elderly patients, we could find no study dedicated to stapedectomy revision in elderly patients. STUDY DESIGN: Retrospective. METHODS: One hundred twenty patients 65 years of age or older who had a stapedectomy revision between 1980 and 2001 were included. A randomly selected group of 120 patients younger than 65 years of age who had stapedectomy revision were included for comparison. Audiometric results were compared for the two groups. Surgical findings for each group are also discussed. RESULTS: The mean pure-tone average hearing improvement for each group was 17.6 dB. The success rate was 70.8% for the elderly group and 67.6% for the younger group. Surgical findings during revision in elderly patients were generally the same as those found for younger patients. CONCLUSION: Advanced age should not be seen as a contraindication to stapedectomy revision.     

The value of exploratory anterior tympanotomy in differentiating causes of conductive hearing loss and assessment of their treatment results

The aim of examination was value of exploratory anterior tympanotomy in differentiation causes of conductives hearing loss and assessment of results treatment. Materials of examinations determined 34 patients aged 15-66 years, treated in 1995-2000 years, who qualified to exploratory anterior tympanotomy in aim decision of cause of conductives hearing loss. Among of examined were 14 patients with suspicion of otosclerosis (41.2%), 12 patients with unclear etiology of hypoacusis (35.3) and 8 patients with deterioration of hearing after stapedectomy (23.5%). Preoperative diagnostic embraced: a history, otolaryngologic examination, full audiologic examination and chosen cases of radiologic assessment of temporal bone by computer tomography. After perioperative decision cause of conductive hypoacousis were performed of operations of improved hearing and comprised of average hearing loss by CPT and PTA pre- and postoperative treatment. After performed of exploratory tympanotomy there vere stated following causes of conductive hypoacusis: otosclerosis (61.8%), separated of prosthesis after stapedectomy (14.7%) synechia of prosthesis with tympanic membrane (8.8%) and in singles causes of ossicular synechia in tympanic cavum (5.9%), tympanosclerosis (5.9%) and vitium of middle ear (2.9%). The best of hearing improvement after repairment operations of conductive system were obtained in cases of stapedectomy, exchange of prosthesis after stapedectomy, reconstruction of system by TORP prosthesis, however smaller improvement after operations of synechias of stapes prosthesis with surroundings and postoperation of tympanosclerosis.     

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.     

Stapedectomy Causes of failure and revision surgery in otosclerosis

With the proliferation in the varied techniques of surgery for restoration of hearing in patients with conductive loss secondary to otosclerosis, the need does arise for revision surgery in selected cases of corrigible failures or complications. The merits of stapedectomy employing the preserved posterior stapedial crus or homograft stapes prosthesis are discussed. Stapedotomy is suitable for obliterative otosclerosis. Revision stapedectomy should be attempted only by the experienced surgeon after critical appraisal of all factors likely to benefit the patient.     

Stapedectomy: long-term hearing results

The initial improvement in hearing following stapedectomy usually deteriorates with the passage of time. We studied the long-term results of stapedectomies performed on 42 patients (49 ears) between 1959 and 1969 who had a minimum follow-up of 18 years. Both air conduction (AC) and bone conduction (BC) thresholds progressively deteriorated over the long term. The degree of BC loss paralleled that expected from presbycusis alone. A greater deterioration was noted in the AC levels, producing a recurrent conductive hearing loss in the speech frequencies. Age at the time of surgery had no effect on the long-term outcome. Comparison of the average preoperative speech discrimination scores (SDS) to the 1-year postoperative SDS and the long-term SDS revealed a 1.1% and 16.7% drop, respectively. The improvement in the average speech reception threshold (SRT) obtained 1 year postoperatively deteriorated by less than 1 dB per year over the long term. Patients with a higher SDS (more than 95%) preoperatively fared better in the maintenance of speech discrimination than those with a lower SDS (less than 95%). The preoperative SRT level was predictive of the timing for the requirement of hearing amplification. The postoperative SRT level was predictive of the timing for the requirement of hearing amplification. The caused by presbycusis, combined with a recurrent conductive loss in the speech frequencies rather than cochlear otosclerosis. Although the decline in hearing following stapedectomy exceeds the rate of hearing loss due to presbycusis, many individuals, after successful stapes surgery, are able to delay the need for hearing amplification for longer periods than had been previously reported.     

Early complications following stapedectomy--surgical or conservative treatment?]

The incidence of sensorineural hearing loss after stapedectomy ranges from 0.6% to 5%. There is evidence that reparative granuloma is a major cause: most authors report that it requires urgent surgery, but this view is not universally accepted. This study analyses 14 stapedectomies that resulted in a sudden or gradual sensorineural hearing loss, often combined with vertigo, and presenting between 1 and 6 weeks after an initial hearing improvement. All patients were treated immediately with a combined infusion of an antibiotic, a corticosteroid and a plasma expander. The sensorineural hearing loss began to improve compared with pre-operative values 9 days later. Thus drug therapy might be sufficient in most cases of sensorineural hearing loss early after stapedectomy, and surgery can be restricted to patients with perilymph fistulae.     

Does Pregnancy Affect Otosclerosis?

OBJECTIVE: To evaluate the effect of pregnancy on the hearing of women with otosclerosis. STUDY DESIGN: A retrospective study of women who had undergone stapedectomy. The women were equally divided into two groups: one group with children and a control group without children. Air and bone conduction, as well as discrimination, were measured before and after stapedectomy in both groups. PATIENTS: Ninety-four women (47 with children and 47 without) were evaluated. Because many of the women had bilateral otosclerosis, the total number of ears studied was 128. RESULTS: Mean pure tone air and bone conduction thresholds were not worse in women with children versus those women without children. In fact, mean pre- and postoperative pure tone air and bone conduction thresholds from 500 Hz through 4,000 Hz in women with children were slightly but significantly better than women without children. There was no difference in discrimination scores between groups. Within the group with children, no significant correlation was found between number of children and hearing loss. Also, no correlation was found between breastfeeding and the amount of hearing loss. CONCLUSION: We found no adverse effect on hearing in otosclerotic women who had children compared with women without children. Even with increasing numbers of pregnancies, no deleterious impact was noted. Air conduction, bone conduction, and discrimination were not worse in women with children versus childless women. No significant correlation was found between the number of children and hearing loss, and neither did breastfeeding affect the amount of hearing loss.     

Patients' perceived outcomes after stapedectomy for otosclerosis

We conducted a retrospective study of 29 patients who had undergone stapedectomy for otosclerosis to determine how well their subjective perceptions of hearing improvement correlated with objective audiometric measurements. Patients expressed their assessments of hearing function by completing two versions of the Hearing Disability and Handicap Scale (HDHS). One version of the HDHS was based on patients' retrospective recollections of their hearing impairment prior to surgery, and the other reflected their assessment of their current function. We evaluated these HDHS data both separately and in conjunction with pre- and postoperative audiometric findings. Following surgery, the group's mean pure-tone average improved significantly, from 58 to 27 dB--that is, the average patient had a moderately severe hearing loss preoperatively and only a mild hearing loss postoperatively. Significant improvement was also reflected in the difference between the mean pre- and postoperative HDHS scores, although some patients indicated that they experienced almost no improvement. Overall, our findings indicated that there was a relationship between objective and subjective assessments of hearing improvement following surgery, but that it was weak. Although most patients perceived significant improvement, the degree of that perceived improvement cannot be predicted from the pure-tone audiogram. We conclude, therefore, that a significant difference between audiometric findings and HDHS self-assessments is useful in identifying patients who might benefit from additional counseling and/or aural rehabilitation.     

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.