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The authors describe the various surgical indications and techniques of the argon laser and Gherini-Causse Endo-Otoprobe in otologic surgery, from otosclerosis to chronic otitis. The advantages are numerous, permitting the surgeon to vaporize or coagulate tissue with optimal effect, avoiding excessive mobilization of the ossicular chain and diminishing the risk of damage to the facial nerve and inner ear structures.
OBJECTIVE: The success and safety of argon lasers in stapedotomy surgery is now well documented. This study reviews results in problematic situations in which the argon laser may be of particular advantage to successful completion of the stapedotomy procedure. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review of the author's most recent 200 stapedotomy cases was performed, identifying 32 patients who at surgery were either found to have a prolapsed dehiscent facial nerve (three cases), developed a floating footplate (eight cases), or were undergoing a revision stapedotomy (21 cases). Four-frequency, pure-tone average air and bone conduction thresholds were computed before and after surgery. Success was defined as closure of the air-bone gap to within 10 dB, while an air-bone gap within 20 dB was considered improvement. RESULTS: Successful closure of the air-bone gap was achieved in all eight patients with a mobilized footplate, in all three patients with a prolapsed dehiscent facial nerve, and in 43% of the patients undergoing a revision stapedotomy. The rate of improved air-bone gap in the revision cases was 62%. In one revision stapedotomy patient a decrease in speech discrimination occurred. Otherwise, there were no cases of sensorineural hearing loss. Neither intraoperative nor postoperative dizziness was reported by any patient, and all were discharged on an outpatient basis. CONCLUSION: The argon laser was found to be safe, effective, and a valuable adjunct for the difficult stapedotomy cases when unexpected obstacles such as a prolapsed dehiscent facial nerve or a mobilized footplate are encountered, as well as for the planned, more difficult revision cases.
OBJECTIVES: Laser Doppler interferometry (LDI) of the eardrum allows noncontact optical analysis of its vibrations in response to sound. Although LDI has been widely used in research, it has not yet been introduced into clinical practice as an adjunctive test for otological workup. The aim of this study was to evaluate LDI as a diagnostic tool in the clinical sphere. STUDY DESIGN: Prospective. METHODS: A measurement system was developed based on a commercially available scanning He-Ne laser Doppler interferometer. The study included 129 eardrums of 79 subjects that were divided into 3 groups: 1) normal subjects and 2) patients with sensorineural and 3) conductive hearing loss (HL). All the patients suffering from conductive HL underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to the subgroups malleus fixation, incus luxation, and stapes fixation. RESULTS: The modified LDI system allowed bilateral evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural HL were found. However, it was possible to distinguish between normal subjects and patients with conductive HL. Furthermore, the system had the ability to differentiate between various middle ear diseases. These groups differed statistically significantly in terms of manubrium vibration amplitude and resonance frequency. In malleus fixation significant differences in tympanic membrane movement patterns were found. CONCLUSIONS: Our LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain.
Fixed head malleus syndrome is a rare anatomoclinical entity first described by Goodhill in 1966. We present a series of 9 patients who underwent surgery between 1991 and 1997 and discuss the technical procedures used and functional outcome. Ossicular mobility can be re-established with two surgical methods. The more simple method consists in a classical incus transposition with malleus neck section. The more physiological method consists in drilling the synostosis fixing the malleus without disrupting the ossicular chain; stapedotomy is associated in certain cases (Type III).
The sound transmission properties of three different commercially available middle ear implants and the prototype of a complete middle ear prosthesis (CoMEP) were evaluated with a special measurement system that permits standardized conditions. This system uses a mechanical middle ear model (MMM) which approximates the impedances of the tympanic membrane and inner ear. The implants were fitted under defined conditions into the MMM. Displacement of the artificial stapes footplate of the MMM was measured with an optical probe. The measurements of different middle ear prostheses showed that the mass of the implant was the most important factor for optimum high frequency transmission. The lightest implant (4 mg, titanium) showed the best results. The CoMEP revealed the highest sensitivity because of a slight enlargement of the diameter of the artificial tympanic membrane. These findings show that the CoMEP is able to restore sound transmission to a normal range. In a second experiment one of the implants was fitted into the MMM with different forces. The increase of stiffness produced a slightly better high frequency transmission at the expense of low frequency sensitivity. Hence, the fitting of the implant may not be too stiff because of its loss of mobility within a significant frequency range.
The Lempert one stage horizontal semicircular canal fenestration was the surgical procedure of choice for otosclerosis from 1939 to 1954. Subsequently, mobilization and stapedectomy replaced fenestration. In the offices of Drs. Day, Jordan, and Caparosa, the horizontal semicircular canal fenestration was performed from 1940 to 1955; the mobilization, two years; and, thereafter, the stapedectomy. A significant number of patients have had fenestration on one side and stapedectomy on the opposite ear. Fifty patients seen consecutively were reviewed. Reliable office audiological testing has been available only in the more recent years; and, therefore, audiological statistical comparison has limited reliability. It is felt, however, that a review of these patients and the study of their surviving hearing results is a worthwhile inferential comparison.
OBJECTIVE: Evaluate in stapedectomy the clinical outcome and audiometric results (particularly bone conduction) of drilling the promontory because of a narrow oval window niche. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center, private otology practice. PATIENTS: Twenty-five stapedectomy patients requiring promontory drilling who had surgery between 1995 and 2000. METHOD: A total of 25 patients were evaluated with a minimum 6-month follow-up. Only patients who required promontory drilling and who had complete preoperative and postoperative audiometric testing including bone conduction were included. Promontory drilling was performed with a skeeter drill to thin the promontory. Twenty-five stapedectomy patients who did not undergo promontory drilling were randomly selected from this same period as a comparison group. RESULTS: In addition to the narrow oval window niche, associated anatomical findings were facial nerve overhang in five patients and an obliterated footplate in three patients. Ninety-six percent of cases were successful (<10 dB postoperative air-bone gap). The one unsuccessful case was a strut over the mobile footplate that was later successfully revised. No patients suffered from intraoperative or postoperative tinnitus or vertigo. The mean 4-frequency (500-4,000 Hz) pure-tone average revealed slight improvement in bone conduction postoperatively. CONCLUSION: Drilling of the promontory in stapedectomy is required in only a small percentage of cases. Although audiometric results indicated the possibility of a slight amount of acoustic trauma from the drilling, the effect on hearing was minimal and not considered a contraindication to this procedure.
The records of 34 children and teenagers with a conductive hearing impairment and an intact and mobile tympanic membrane have been reviewed; 20 patients had a congenital hearing impairment. Stapedectomy was performed on 13 patients with satisfactory results in 12. In 3 cases the operation was terminated because of oval window or facial nerve abnormalities. In 4 cases there was no evidence of an ossicular problem, a so-called inner ear conductive hearing loss. Fourteen patients had otosclerosis, the youngest being 9 years old. Twenty-four stapedectomies were performed on this group with satisfactory results in 22. We conclude that the results of stapedectomy in children appear to be as satisfactory as results in adults.
Stapedectomy is a safe surgical procedure used in patients with otosclerosis. However, complications may occur and decrease hearing gain after the operation. The aim of the work was to analyze hearing results in patients with incus subluxation during stapedectomy. In 15 (5%) of 292 patients with otosclerosis, the incus was unintentionally luxated during surgery. In one patient the incus was completely dislocated and malleovestibulopexy with autoincus had to be applied. In 14 stapedectomies the incus was subluxated and though it was pathologically mobile it was held in position by its ligaments. This situation allowed delicate reposition of the incus and insertion of the piston prosthesis on the long incus process. Mean AC threshold improved by 24 dB. Mean ABG improved from 34.6+/-8.3 dB before to 13.1+/-6.3 dB 8 months after stapedectomy (t=9.7; p<0.0001). Ten years after surgery average ABG was 10.6+/-4.4, which means stable hearing result. In 6 patients including the individual with complete incus luxation, postoperative ABG was less than 10 dB. In 9 patients postoperative ABG was between 10 and 15 dB. When the incus is subluxated good hearing results can be expected after insertion of the prosthesis on the repositioned incus.
Two-component tympanometry with a high probe-tone frequency enables a better distinction to be made between mobile but normal middle-ear systems and middle-ear systems suffering from necrosis, luxation, or disruption. Susceptance and conductance tympanograms obtained from 14 patients with confirmed pathological middle-ear lesions and 8 postmortem temporal bones, experimentally manipulated either surgically or with a 1 N HCl solution, were compared to tympanograms obtained from 80 normal subjects of an earlier study. With a 660-Hz probe tone, normal middle ears generate bell-shaped or normal sharp W-shaped patterns, whereas the pathologies of the middle ear give rise to irregular multi-extrema tympanograms. The differences between the two types of multi-extrema curves are discussed in detail. The use of phase-angle tympanometry is recommended to enable a quick and accurate distinction between normal and abnormal types of multi-extrema tympanograms. This study also points out clearly that 220-Hz tympanograms do not allow clear differentiation between pathological and normal middle ears.
In terrestrial mammals, hearing starts with the perception of acoustic pressure by the tympanic membrane. Vibrations in this membrane are then transduced into the inner ear by the ossicle chain of the middle ear, composed of the malleus, incus and stapes. The proper connection of the ossicle chain with the tympanic membrane, provided by the insertion of the manubrium of the malleus into the eardrum, is essential for the functionality of the hearing apparatus. We describe here the mechanisms regulating the development of the manubrium and its integration into the tympanic membrane. We show that the external acoustic meatus (EAM), which eventually forms the outer epithelium of the tympanic membrane, plays an essential role in this developmental process. Histological and expression analyses indicate that the manubrium develops close to the EAM with a similar temporal sequence. In addition, when the middle ear ossicles are allowed to develop in vitro under conditions that do not support further EAM development, the manubrium develops only up to the stage of its induction at the time of explantation. Moreover, genetically or teratogenically derived alterations in the EAM also have an effect on manubrial development. Finally, we show that the EAM is the source of two quite opposite activities, one that induces chondrogenesis and another that represses it. The combination of these two activities results in the proper positioning of the manubrium.