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A retrospective study of 73 consecutive stapedotomies is reported. The technique of reversal of steps was achieved in 59% of cases. Closure of the air-bone gap to within 10 dB was achieved in 84% of the reversal group, and 81% of the standard technique group, with no statistically significant difference between the two groups.
Although successful stapedectomy is very gratifying for both the patient and surgeon, complications can arise, often with disastrous results. Certain clues may alert the surgeon to risk prevention or possible complications, allowing early definitive management. This assumes critical importance today as fewer younger surgeons acquire extensive experience in stapedectomy. A thorough knowledge of possible problems and their management is mandatory for the otologist who undertakes this most challenging of operations.
Changes in auditory perception can cause disturbances in development and personality. This phenomenon has been studied in particular in children hearing loss or in progressive or sudden hearing loss in the adult. We present the case of a patient with psychobehavioural alterations after restoration of hearing following a small fenestra stapedectomy for bilateral otosclerosis with moderate-severe hearing impairment. The diagnosis, physiopathology and medicolegal implications are discussed.
We have treated 50 cases of otosclerosis by transplatinary piston. We made a statistical study of the recuperation modalities concerning frequency and time. The highest hearing gain was obtained each time between 250 cps and 500 cps. The maximum hearing recuperation occurs usually, three weeks after the intervention for the lower and mid-frequencies, two months for the higher frequencies. Finally we have noticed that the intervention was helpful as well for the opposite ear as for the operated one.
Laser has been used for 21 years in otology. This technique was introduced to decrease the number of complications after micromanipulations within the middle ear. Continuous-wave laser and pulsed laser have clinical application. In the ENT Dept. in Poznań pulsed Er-Yag laser (Zeiss Corp.) is used in the treatment of otosclerosis. First experiences and results of treatment of 35 patients using this method were presented. In all patients recovery of hearing was observed. No damage of the inner ear (deafness or hypoacusis) was found.
Perilymphatic fistulae, developing even years after stapedectomy, open a communication between the perilymph and middle ear. These fistulae constitute a potential pathway for flora of the middle ear to invade the subarachnoid space by way of the cochlear aqueduct. Our patient developed pneumococcal meningitis 14 months after stapedectomy. The history of stapedectomy in a patient with meningitis is an indication for reexploration+ion of the operative site. The appearance of fistula symptoms in patients who have had stapedectomy indicates a high risk for development of intracranial infection.
From a group of 1,111 patients who had stapedectomy or stapedotomy performed in a 10-year period, a thorough investigation was made of 11 patients who had a total hearing loss and 8 patients who developed a partial sensorineural hearing loss after operation. The data obtained indicate that postoperative infection with influenza virus may be responsible for unexpected complications following stapedectomy. A close relation was found between the appearance of complications and periods of epidemics of influenza.
To standardize the reporting of hearing results after middle ear surgery, the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery proposed 2 levels of guidelines: level 1 for reporting summary data and level 2 for reporting raw data. The Committee encourages the reporting of raw data from each individual case. However, in studies in which the examined population is too large, this can yield difficulties. With respect to this point, we designed a method for a simple visual presentation of hearing results in an attempt to provide data from each individually operated ear in a patient group. In this method the relation between the preoperative and postoperative bone-conduction levels is evaluated to assess overclosure and iatrogenic cochlear damage, and the relation between postoperative gain in air conduction and the preoperative air-bone gap is evaluated as a measure of technical success rate. This results in 2 plots, which we called the Amsterdam Hearing Evaluation Plots. Audiometric data from 451 stapes operations were used to demonstrate the use of the Amsterdam Hearing Evaluation Plots.
Osteogenesis imperfecta is not in itself a contraindication to stapedectomy. Thirty stapedectomies were performed on 24 patients with osteogenesis imperfecta. Thin ossicles, crural fractures, and thick, mushy, granular footplates predominate in this condition. Deficient, short crura that did not contact the footplate were noted in three patients; this is possibly a new clinical observation. Three times in this small series the endosteum was so thick that it was possible to fenestrate the soft, granular, mush-like footplate without invading the vestibule. Extreme caution in handling the incus is necessary. Conductive hearing loss can be relieved through stapedectomy in patients with osteogenesis imperfecta with about the same level of predictability as in those with otosclerosis.
A variety of different implants are available today for use by the otologic surgeon. All prostheses are well tolerated, and the risks of complication as a result of their implantation are comparable. The most commonly used prostheses are the wire-Teflon piston and the stainless steel bucket handle. Although the otologic surgeon has a wide variety of prostheses to choose from, most have a preference for one particular type. Results of hearing improvement following a successful stapedectomy is more a function of the surgeon's experience than of the type of prosthesis used. As James L. Sheehy, MD, so often says, "if a technique is working well for you, don't change for change's sake" (personal communication, 1994).
Aim of the present study was to investigate the tonotopic reorganization of the primary auditory cortex in otosclerotic patients following functional stapedioplasty. Characteristics of auditory cortex activation have been evaluated in a series of 10 otosclerotic patients before and after surgery. In these patients, a magnetoencephalographic recording of evoked magnetic fields has been performed by means of tone-burst monoaural stimulation with frequency octaves between 250 and 2000 Hz. Brain topography of cortex response generators (wave N100m) in patients with otosclerosis has been compared with that observed in a control group of 10 healthy subjects: changes before and after surgery have also been correlated with the functional result as far as concerns improvement in hearing. A significant reduction has been observed in the cortical tonotopic extension in response to the acoustic stimulus in patients "pre-surgery" in comparison with controls: after surgery, tonotopic mapping showed an increase, dimensions becoming comparable to those in control subjects. This increase in size was found to be significantly correlated with duration of the post-operative period. Data emerging from the present study suggest that the cortical auditory areas in man are involved in a "plastic" functional reorganization following changes in the receptor or peripheral deprivation. Reduction in the cortical tonotopic mapping resulting from prolonged lowering of auditory "input" is modified by reorganization of the cortex after the recovery of auditory function: this process occurs over a period of a few weeks.
This article reports the postoperative results of 76 operations addressing otosclerosis. All procedures were performed by the same surgeon and took place within a 4-year period. We compared the postoperative audiometric results of 54 laser-assisted procedures with those of 22 nonlaser operations. Our findings revealed a statistically significant improvement in the air-bone gap closure of the laser-operated patients: the air-bone gap was narrowed to within 10 dB in 72% of laser-operated cases versus 54% in nonlaser cases. Furthermore, laser use does not induce high-frequency sensorineural hearing loss. We believe that a laser entails less risk of inner ear microtrauma and improves the accuracy and reliability of stapedotomy.
This prospective study aims to evaluate the efficacy of stapedotomy in relation to age. Eighty-four ears of 82 consecutive patients who underwent stapedotomy were studied. Patients were divided into five groups according to their age. In each patient, we evaluated the pre- and postoperative auditory thresholds, according to the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology - Head and Neck Surgery guidelines. Statistically significant (P < 0.05) differences between the pre- and postoperative air conduction thresholds were observed in all groups. Statistically significant reductions of air-bone gap were observed at lower-medium frequencies (250, 500 and 1000 Hz) in the elderly as well as in the younger patients. We did not find a higher susceptibility of the inner ear to surgical trauma in the elderly in comparison to the younger patients. Our data show that stapedotomy results in older adults are comparable to those obtained in the younger, without an increased incidence of complications.
OBJECTIVE: A contemporary analysis of trends in the surgical management of otosclerosis in the United States is presented. DATA SOURCES: U.S. population demographics were obtained from the U.S. Census Bureau. Surgical case data was obtained from publications of the National Center for Health Statistics. Physician population statistics are published by the American Medical Association. DATA EXTRACTION: Available estimates for otologic operations are interpreted according to clinical setting used for data acquisition and surgical practice patterns. Linear regression of included data defines trends in operations performed. Population statistics are used to define changes in the incidence of surgical cases. CONCLUSIONS: The number of stapedectomy cases has declined over the past 30 years. During this same interval, the U.S. population (including the white population) and the number of surgeons has increased. This indicates that the incidence of surgical otosclerosis is declining. Although the true etiology of the decline is uncertain, widespread immunization for measles is a plausible hypothesis.
We reviewed the records of 498 primary stapedectomy cases in regard to duration of disease, age at surgery, oval window pathology, hearing results, dizziness, and tinnitus. Ninety percent of the cases in which a tissue graft had been used as an oval window covering obtained a postoperative hearing level within 10 dB of the preoperative bone conduction. Postoperative sensorineural hearing impairment occurred infrequently and was two to three times more common in cases in which Gelfoam had been used as an oval window covering as compared to tissue grafts. Postoperative dizziness of one degree or another persisted at four months in 2 percent of the cases and was a problem for the patient in two cases (0.4%). This dizziness was likewise more common in Gelfoam cases. We concluded that tissue grafts are a better covering for the oval window than Gelfoam both in regard to hearing improvement and lack of postoperative complications.
In a retrospective study, hearing results before and after stapedectomy were compared with those of individuals not undergoing surgery. Subjects were 51 patients who were surgically diagnosed as having otosclerosis and who could be followed up for more than 5 years. Of these, 31 contralateral ears surgically diagnosed as otosclerotic did not undergo surgery (nonsurgery group). Nineteen ears underwent stapedectomy using a wire loop prosthesis (TS group). Thirty-eight ears underwent stapedotomy using a wire piston prosthesis (SFS group). In the nonsurgery ear group, the last air conduction threshold deteriorated equally at all frequencies. Deterioration of the high frequency air conduction threshold seemed to cause deterioration of the bone conduction threshold. Deterioration of the last air conduction threshold in the SFS group was somewhat less than that in the TS group, although not significantly. In patients up to 50 years old, the air conduction loss/year in the SFS group was significantly less than that in the nonsurgery ear group at 0.25 kHz and 0.5 kHz. The bone conduction loss/year in the SFS group was less than that in both the TS group and nonsurgery ear group at 1 kHz. No significant differences was seen in either air or bone conduction loss/year among the 3 groups in patients 51 years or older. We concluded that stapedotomy and wire piston prosthesis are the surgical techniques of choice in the treatment of otosclerosis.
OBJECTIVE: This study reports the results of 14,449 stapedectomy operations performed during the past 40 years. STUDY DESIGN: The study design was a retrospective case review. Approximately 100 operations were selected from each of the past 40 years, for a total of 5,444 operations, from which the results with the whole group were extrapolated. SETTING: All operations were performed in a hospital during the first 30 years and in an ambulatory surgery center in the past 10 years. PATIENTS: All patients in the study were the private patients of the author and were operated on by him personally. These patients had otosclerosis only. INTERVENTIONS: Stapedectomy was performed on all patients. MAIN OUTCOME MEASURES: The change in hearing after the operation was reported. Using the hearing of the average for 500, 1,000, and 2,000 Hz, the criteria for success were defined as closure of the air-bone gap to 10 dB or less and no decline in speech discrimination of >10%. RESULTS: In the primary stapedectomy group, success was achieved in 95.1% of ears after 1 year, 94.7% of ears after 2-5 years, and 62.5% after >30 years. In the revision stapedectomy group, success was achieved in 71.1% after 1 year, 62.4% after 2-5 years, and 59.4% after 6-36 years. CONCLUSIONS: The immediate success rate after primary and revision stapedectomy declines slowly over time, because of delayed conductive hearing loss and further sensorineural hearing loss, more than one would expect in matched control subjects without otosclerosis. Stapedectomy has stood the test of time as the first successful microsurgical operation.
Early and late postoperative findings in 78 cases of stapedial surgery with 0.6 mm Schuknecht Teflon Wire Pistons only, performed from 1983 to 1987, were analysed to evaluate the supposition of an inverse relationship of the size of the footplate fenestration and functional long-term results. In respect of the size of fenestration our surgical strategy resulted in 3 different situations: stapedotomy (26)--partial platinectomy (34)--stapedectomy (19). Mean air conduction thresholds for frequencies 0.5-4 kHz were evaluated preoperatively, one month and > 5 years postoperatively. The results were postoperatively significantly better in all 3 groups without significant intergroup differences. > 5 years postoperatively the best results were seen in the partial platinectomy group better than after stapedotomy and significantly better than in the stapedectomy group. With regard to overclosure, closure of the air bone gap and deterioration of bone conduction thresholds at 4 kHz for the same groups, no significant differences were noticed. In conclusion, the best long-term results were obtained after partial platinectomy, i.e. there was no inverse relation of the size of the footplate perforation and the best results. The perforation should be large enough to prevent tilting of the piston at the edge. Removal of larger parts should be omitted. In case of early mobilisation and stapedectomy good long-term results can still be expected.