Laser vs drill for footplate fenestration during stapedotomy: a systematic review and meta-analysis of hearing results.

OBJECTIVE: Stapes surgery is the gold standard surgical treatment nowadays for otosclerosis. Several controversies on the procedure have been reported; surgical techniques for most favorable outcomes are still on discussion. The objective of this study is to present an update of evidence-based medicine concerning the utilization of lasers and drilling for footplate fenestration during stapedotomy surgery. A systematic review and meta-analysis were conducted. MATERIALS AND METHODS: Publications in English in the last 5 years were searched in the PubMed/MEDLINE database and were systematically reviewed. A total of three articles were included according to the inclusion criteria, obtaining a total of 1531 patients managed surgically for otosclerosis, using laser or drill for footplate fenestration. Data were systematically extracted and hearing results were compared in a meta-analysis. RESULTS: For the drill group, a total of 978 patients were retrieved and data were obtained as follows: mean age was 50 years old; the female proportion was 62%; mean preoperative air-bone gap (ABG) of 28 dB; mean postoperative ABG of 8 dB; mean ABG improvement of 20 dB; an ABG closure rate to < 10 dB of 74%. For the laser group, a total of 553 patients were retrieved, data were obtained as follows: mean age was 47 years old; the female proportion was 63%; preoperative ABG of 26 dB; postoperative ABG of 8 dB; mean ABG improvement of 18 dB; an ABG closure rate to < 10 dB of 72%. CONCLUSION: The results from this study reveal that in regard to postoperative hearing results, surgical outcomes are comparable, and there is no statistically significant difference between the utilization of drills and lasers as a surgical instrument for the fenestration of the stapes footplate during stapedotomy surgery.

Short-term audiological outcomes of stapedotomy: microdrill at low revolutions versus manual perforator to perform a small footplate fenestra. A prospective observational study.

<b>Introduction:</b> Stapedotomy is currently the surgical technique of choice for treating otosclerosis. Despite this, there is no agreement about the best technique to perform a small fenestra footplate, therefore multiple procedures have been proposed. The aim of this study was to investigate the hearing outcomes of microdrill and manual perforator. <br><b>Material and Methods:</b> An observational prospective study was carried out on patients who underwent stapedotomy. We analyzed the hearing threshold in two groups of patients according to the way the fenestra footplate was realized by microdrill or manual perforator. <br><b>Results:</b> A total of 113 patients were evaluated. Postoperative hearing gain of the microdrill group was 23.29 (18.58) dB HL 95% CI (18.40-28.18), while in the manual perforator group, it was 22.67 (12.91) dB HL 95% CI (19.07-26.26). Both groups were statistically significant. Postoperative bone conductive hearing threshold at the frequencies of 0.5, 1 and 2 KHz and postoperative air conductive hearing threshold at the frequencies of 2 and 4 KHz showed statistically significant differences in the manual perforator group. The closure of air-bone gap was higher in the microdrill group with statistically significant differences. <br><b>Conclusion:</b> Both manual perforator and microdrill have good hearing outcomes at six months after surgery. The manual perforator has better audiological outcomes than microdrill. Hence, the manual perforator is a safe technique and can be used in centers that do not have other methods to make the small fenestra.

Stapedectomy Versus Stapedotomy.

Stapedectomy and stapedotomy represent the state-of-the-art surgical procedures in addressing the conductive hearing loss caused by otosclerosis. Their high rates of success and long-term stability have been demonstrated repeatedly in many studies. In comparing the short- and long-term results of the 2 procedures, it is evident that stapedotomy confers better hearing gain at high frequencies and lower complication rates. Modified stapes mobilization procedures may represent the next major development in stapes surgery in a selected patient population.

Enhanced viral-mediated cochlear gene delivery in adult mice by combining canal fenestration with round window membrane inoculation.

Cochlear gene therapy holds promise for the treatment of genetic deafness. Assessing its impact in adult murine models of hearing loss, however, has been hampered by technical challenges that have made it difficult to establish a robust method to deliver transgenes to the mature murine inner ear. Here in we demonstrate the feasibility of a combined round window membrane injection and semi-circular canal fenestration technique in the adult cochlea. Injection of both AAV2/9 and AAV2/Anc80L65 via this approach in P15-16 and P56-60 mice permits robust eGFP transduction of virtually all inner hair cells throughout the cochlea with variable transduction of vestibular hair cells. Auditory thresholds are not compromised. Transduction rate and cell tropism is primarily influenced by viral titer and AAV serotype but not age at injection. This approach is safe, versatile and efficient. Its use will facilitate studies using cochlear gene therapy in murine models of hearing loss over a wide range of time points.

The Effect of Piston Diameter in Stapedotomy for Otosclerosis: A Temporal Bone Model.

HYPOTHESIS: The use of larger-diameter pistons in stapedotomy leads to better hearing outcomes compared with the use of smaller-diameter pistons. There is an interaction between stapes piston diameter and fenestration diameter. BACKGROUND: Otosclerosis can be treated surgically by removing part of the stapes and bypassing the stapes footplate with a prosthesis. Available piston shaft diameters range between 0.3 and 0.8 mm. There has been a tendency toward the use of smaller-diameter pistons, because of a suspected decreased risk of cochlear trauma and subsequent sensorineural hearing loss (SNHL) with smaller pistons. However, mathematical models, temporal bone studies, and clinical studies suggest that the use of larger-diameter pistons is associated with better hearing outcomes. METHODS: Three fresh-frozen, non-pathologic temporal bones were harvested from human cadaveric donors. Acoustic stimuli in the form of pure tones from 250 to 8000 Hz were generated at 110 dB sound pressure level. A total of 16 frequencies in a 1/3-octave series were used. Stapes and round window velocities in response to the acoustic stimuli were measured at multiple equally spaced points covering the stapes footplate and round window using a scanning laser Doppler interferometry system. Eight sets of measurements were performed in each temporal bone: 1) normal condition (mobile stapes), 2) stapes fixation and stapedotomy followed by insertion of 3) a 0.4-mm-diameter piston in a 0.5-mm-diameter fenestration, 4) a 0.4-mm-diameter piston in a 0.7-mm-diameter fenestration, 5) a 0.4-mm-diameter piston in a 0.9-mm-diameter fenestration, 6) a 0.6-mm-diameter piston in a 0.7-mm-diameter fenestration, 7) a 0.6-mm-diameter piston in a 0.9-mm-diameter fenestration, and 8) a 0.8-mm-diameter piston in a 0.9-mm-diameter fenestration. RESULTS: At midrange frequencies, between 500 and 4000 Hz, round window velocities increased by 2 to 3 dB when using a 0.6-mm-diameter piston compared with a 0.4-mm-diameter piston. Using a 0.8-mm-diameter piston led to a further increase in round window velocities by 2 to 4 dB. CONCLUSION: Our results suggest a modest effect of piston diameter on hearing results following stapedotomy.

Comparing mechanical effects and sound production of KTP, thulium, and CO2 laser in stapedotomy.

HYPOTHESIS: The mechanical and acoustic effects that occur during laser-assisted stapedotomy differ among KTP, CO2, and thulium lasers. BACKGROUND: Making a fenestration in stapedotomy with a laser minimizes the risk of a floating footplate caused by mechanical forces. Theoretically, the lasers used in stapedotomy could inflict mechanical trauma because of absorption in the perilymph, causing vaporization bubbles. These bubbles can generate a shock wave, when imploding. METHODS: In an inner ear model, we made a fenestration in a fresh human stapes with KTP, CO2, and thulium laser. During the fenestration, we performed high-speed imaging from different angles to capture mechanical effects. The sounds produced by the fenestration were recorded simultaneously with a hydrophone; these recordings were compared with acoustics produced by a conventional microburr fenestration. RESULTS: KTP laser fenestration showed little mechanical effects, with minimal sound production. With CO2 laser, miniscule bubbles arose in the vestibule; imploding of these bubbles corresponded to the acoustics. Thulium laser fenestration showed large bubbles in the vestibule, with a larger sound production than the other two lasers. Each type of laser generated significantly less noise than the microburr. The microburr maximally reached 95 ± 7 dB(A), compared with 49 ± 8 dB(A) for KTP, 68 ± 4 dB(A) for CO2, and 83 ± 6 dB(A) for thulium. CONCLUSION: Mechanical and acoustic effects differ among lasers used for stapedotomy. Based on their relatively small effects, KTP and CO2 lasers are preferable to thulium laser.

Effect of KTP laser cochleostomy on morphology in the guinea pig inner ear.

BACKGROUND: The main advantage of using the KTP (potassium-titanyl-phosphate) laser for stapedotomy instead of the conventional micropick instrument is the smaller risk for mechanical damage. However, the KTP laser could theoretically inflict damage to inner ear structures. We hypothesize that KTP laser light [wavelength (λ) = 532 nm] is hardly absorbed in perilymph but well absorbed in solid structures. The aim of this pilot study was to assess if damage occurred after KTP laser cochleostomy in an animal model and, if so, to what extent and at which settings. MATERIALS AND METHODS: In six guinea pigs, a KTP laser cochleostomy at the basal turn was created. Laser settings of 1, 3 and 5 W and 100 ms pulse time (n = 2 each) were used. Histological preparations were studied for damage to neuroendothelial cells and intrascalar blood. RESULTS: No damage to inner ear neuroendothelial cells was observed, even at the highest power. Blood clots in the scala tympani from vessels in the cochlear wall were seen. The effects were minimal in the lowest, currently clinically used settings. CONCLUSION: KTP laser cochleostomy gives no damage to inner ear neuroendothelial cells but may cause intrascalar hemorrhages.

Laser versus conventional fenestration in stapedotomy for otosclerosis: a systematic review.

OBJECTIVES/HYPOTHESIS: To assess hearing results and complications following primary stapedotomy in otosclerosis patients comparing the use of laser and conventional techniques for fenestration. STUDY DESIGN: Systematic literature review. METHODS: A systematic bibliographic search was conducted in PubMed, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Studies reporting original data on the effect of laser fenestration, compared to conventional techniques, on closure of air-bone gap in patients undergoing primary stapedotomy were included. Directness of evidence and risk of bias of the selected articles were assessed. Studies with low directness of evidence, high risk of bias, or both were not further analyzed. The absolute risks, risk differences, and 95% confidence intervals were extracted only for studies with moderate to high directness of evidence and moderate to low risk of bias. RESULTS: In total, 383 unique studies were retrieved. Eight of these (including 999 procedures) provided high or moderate directness of evidence and carried a moderate risk of bias, and were considered eligible for data extraction. The included studies show no consistent difference in postoperative air-bone gap closure or immediate postoperative vertigo. CONCLUSIONS: Both footplate fractures and sensorineural hearing loss appear to occur more frequently in the conventional group than in the laser group. Therefore, we prefer laser above conventional methods for footplate fenestration in primary stapedotomy. LEVEL OF EVIDENCE: NA.

Factors affecting fenestration of the footplate in stapes surgery: effectiveness of Fisch's reversal steps stapedotomy.

OBJECTIVE: To analyze the factors affecting the fenestration of the footplate in stapes surgery and to evaluate the effectiveness of Fisch's reversal steps stapedotomy. STUDY DESIGN: Retrospective study. PATIENTS: A total of 191 patients with otosclerosis in whom 230 primary stapes surgeries were performed by 1 surgeon in 3 tertiary hospitals. MAIN OUTCOME MEASURE: Evaluation of factors affecting the fenestration of the footplate in stapes surgery by logistic regression analysis. RESULTS: Stapedotomy (small hole in stapes footplate) was performed in 148 ears (64.3%). Partial stapedectomy (half removal of stapes footplate) was performed in 65 ears (28.3%). Total stapedectomy (total removal of stapes footplate) was performed in 17 ears (7.4%). Stapedotomy could be performed in 72.1% of cases (75/104) in which the stapes suprastructure was removed after insertion of the prosthesis and in 57.9% of cases (73/126) in which the stapes suprastructure was removed before the insertion. Stapedotomy could be performed in 65.4% of cases (117/179) in which a 0.6-mm-thick Schuknecht-type Teflon wire piston was used and in 60.8% (31/51) in which a whole Teflon piston was used. Multivariate analysis of factors affect stapedotomy using logistic regression analysis showed that the surgical order of the removal of the stapes suprastructure and insertion of the prosthesis were the most important 2 factors. CONCLUSION: Fisch's reversal steps technique was useful in performing stapedotomy in all otosclerosis patients. Manipulation of the prosthesis when crimping it to the incus is also important. The prosthesis should be crimped onto the incus and inserted in the footplate opening gently and atraumatically.

Otosclerosis: anatomy and pathology in the temporal bone assessed by multi-slice and cone-beam CT.

OBJECTIVE: To assess the use of cone beam computed tomography (CBCT) compared with multi-slice computed tomography (MSCT) in otosclerosis, with special emphasis on middle- and inner-ear anatomy. STUDY DESIGN: Prospective study. PATIENTS: Twenty patients who underwent a stapedectomy 30 years ago were selected on the basis of bone conduction threshold values. Their mean age was 65 years (range, 48-76 yr). INTERVENTION: All patients underwent CBCT and MSCT with a slice thickness of 0.5 to 0.6 mm. MAIN OUTCOME MEASURES: Sixteen middle- and inner-ear anatomic structures and stapedial prostheses were analyzed by visual grading analysis. To assess critical reproduction and thereby the clinical applicability of CBCT, a dichotomization was made. Assessment of otosclerotic foci was performed using a grading system dividing the lesions in; (1) sole fenestral lesions, (2) retrofenestral lesions with or without fenestral lesions and (3) severe retrofenestral lesions. RESULTS: The 16 anatomic structures were clearly reproduced by both imaging techniques. However, there was an interobserver variation in judging the superiority of 1 method in favor of the other. Otosclerotic lesions were diagnosed in 80/95% using MSCT and 50/85% using CBCT (evaluators 1 and 2, respectively). Retrofenestral lesions were diagnosed in 5 of 10 of ears with severe-to-profound hearing loss, whereas no retrofenestral lesions were diagnosed in the 10 ears with mild-to-moderate hearing loss. The stapedial prostheses were adequately or very well reproduced by both methods. CONCLUSION: CBCT is a new imaging technique with a considerably lower radiation dose than conventional MSCT. Our study indicates that CBCT is suitable and, in many ways, equivalent to MSCT, for temporal bone imaging in otosclerosis.

[Maurice Sourdille, otologist of Nantes, famous and unknown]. / Maurice Sourdille, otologiste nantais, célèbre et inconnu.

Fenestration was the first surgical operation to improve deaf persons affected by otosclerosis. Its story is on a par with Maurice Sourdille's. Not only this author had perfected this surgery even before the use of antibiotics and audiometry but he was a forerunner in the field of ear surgery and in medical otology.

[Therapeutic effects of small fenestra stapedotomy with semiconductor diode laser: a comparison with microdrill].

OBJECTIVE: To compare the effects of small fenestra stapedotomy with semiconductor diode laser and microdrill in patients with otosclerosis. METHODS: Twenty-six patients (29 ears) undergoing stapedotomy with semiconductor diode laser and 19 patients (21 ears) with microdrill were compared for the hearing results and complication rates. RESULTS: No statistically significant differences were found in postoperative speech frequency and high frequency pure tone average in closing the air-bone gap between the two groups. The ears treated by stapedotomy with semiconductor diode laser showed significantly better preoperative minus the postoperative air-bone gap and milder dizziness. CONCLUSION: In spite of the good hearing outcomes in both groups, small fenestra stapedotomy with semiconductor diodelaser can achieve better results and reduce the incidence of complications.

Microtraumatic stapedotomy.

Several modifications have been introduced during the 35 years following the first stapedectomy. The size of the footplate fenestration into the vestibule defines the type of the surgical technique, varying from total stapedectomy to partial stapedectomy or small fenestra stapedotomy. This paper presents a new microtraumatic modification of stapedotomy. After the incudostapedial joint is separated and following the fracture of the stapes crura, the stapes superstructure with the stapes tendon intact is left lying or bending on the promontory. Then, a 4.5-mm-long Schuknecht prosthesis is inserted and the oval window is sealed with small pieces of connective tissue filling the oval window niche and the area between the stapes crura. The results of the new microtraumatic technique with regard to hearing were similar to the standard small fenestra stapedotomy (closure of the air-bone gap). However, multifrequency tympanometry revealed that the new technique provides the patient with a complete physiological middle ear function postoperatively, which was not the case when the other stapedotomy techniques were used. This was reflected in a better hearing quality and less loud-noise intolerance reported by the patients who had been operated on with the new microtraumatic technique.

Stapedectomy versus stapedotomy.

Four hundred and twelve consecutive stapes operations for otosclerosis performed by the author were analyzed. A fat wire stapedectomy prosthesis (Schuknecht) was used in 160 cases and a Fisch Teflon wire piston in 252 ears. Ninety-four percent of the patients with a fat wire prosthesis had a closure within 10 dB and the remaining 6% one within 10-20 dB. As for patients with a Fisch Teflon wire piston, 85% had a closure within 10 dB, and 98-100% within 0-20 dB. Speech reception was better after the operation in 97% of patients with the fat wire prosthesis and in 99% of patients having the Teflon wire piston. There was a significantly different improvement in speech reception (p < 0.02) at the 20-dB level in favor of the Teflon wire piston. Our results show that the small fenestra technique with a 0.4-mm piston causes better speech reception at high frequencies.

The influence of Er. YAG laser application in fenestration to the inner ear.

OBJECTIVE: Erbium (Er.) YAG laser may be usable for middle ear surgery because of its ability to ablate bony tissue. We investigated the inner ear damage caused by the fenestration to the inner ear with Er. YAG laser. DESIGN: We investigated the influence of Er. YAG laser on the inner ear using electrophysiological technique. RESULTS: Several cases had a decrease in endocochlear potential (EP) and cochlear microphonics (CM) after the fenestration to the inner ear. CONCLUSIONS: Er. YAG laser is safe if it is used for the small and superficial fenestration to the stapes footplate. However, a few extra pulses after fenestration are dangerous.

[Effects of small fenestra stapedotomy in comparison with total stapedectomy].

OBJECTIVE: To compare the effect of small fenestra stapedotomy and total stapedectomy in patients with otosclerosis. METHODS: Twenty-seven patients (30 ears) undergoing small fenestra stapedotomy and 36 patients (43 ears) receiving total stapedectomy were compared for hearing results and complication rates. RESULTS: No statistically significant differences were seen in postoperative speech pure tone average in closing air-bone gap between the two groups. The ears treated by small fenestra stapedotomy showed statistically better air-bone gap closure at high frequencies with lower rates of sensorineural hearing loss at high frequencies and milder dizziness. CONCLUSION: In spite of the successful hearing outcomes in both groups, small fenestra stapedotomy can achieve better results at high frequencies and reduce the incidence of complications.