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

OBJECTIVE: To 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. METHODS: Four 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. RESULTS: Among 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. CONCLUSION: Postoperative 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.

Toll-Like Receptor Mediated Activation of Natural Autoantibody Producing B Cell Subpopulations in an Autoimmune Disease Model.

Altered expression and function of the Toll-like receptor (TLR) homologue CD180 molecule in B cells have been associated with autoimmune disorders. In this study, we report decreased expression of CD180 at protein and mRNA levels in peripheral blood B cells of diffuse cutaneous systemic sclerosis (dcSSc) patients. To analyze the effect of CD180 stimulation, together with CpG (TLR9 ligand) treatment, on the phenotype defined by CD19/CD27/IgD/CD24/CD38 staining, and function (CD69 and CD180 expression, cytokine and antibody secretion) of B cell subpopulations, we used tonsillar B cells. After stimulation, we found reduced expression of CD180 protein and mRNA in total B cells, and CD180 protein in B cell subpopulations. The frequency of CD180+ cells was the highest in the CD19+CD27+IgD+ non-switched (NS) B cell subset, and they showed the strongest activation after anti-CD180 stimulation. Furthermore, B cell activation via CD180 induced IL-6 and natural autoantibody secretion. Treatment with the combination of anti-CD180 antibody and CpG resulted in increased IL-6 and IL-10 secretion and natural autoantibody production of B cells. Our results support the role of CD180 in the induction of natural autoantibody production, possibly by NS B cells, and suggest an imbalance between the pathologic and natural autoantibody production in SSc patients.

Comparison of hearing results following the use of NiTiBOND versus Nitinol prostheses in stapes surgery: a retrospective controlled study reporting short-term postoperative results.

The aim of this retrospective study was to compare the 3-month postoperative hearing results following laser stapedotomy with the use of NiTiBOND versus Nitinol prostheses (31 and 39 patients, respectively). The operations were performed between September 2012 and September 2014, and between March 2006 and December 2012 regarding NiTiBOND and Nitinol, respectively. Twenty of the consecutive 31 patients were female and 11 were male for NiTiBOND, while 11 were male and 28 were female for Nitinol. The mean age was 43.8 years (range 22-61) and 46.9 years (range 28-83) for NiTiBOND and Nitinol, respectively. No significant cochlear trauma was documented postoperatively. The mean air-bone gap (ABG) for the frequencies 0.5, 1, 2 and 3 kHz at the 3-month postoperative follow-up was 7.6 dB (SD 4.7), and 9.3 dB (SD 4.1) for NiTiBOND and Nitinol, respectively. The differences between the mean pre- (p = 0.179), and postoperative (p = 0.059) ABG of the two groups were not significant. ABG closure within 10 dB was achieved in 77.4 and 59 % for NiTiBOND and Nitinol, respectively, the difference was not significant (p = 0.10). Two cases of delayed facial paralysis occurred, 1 with Nitinol and 1 with the NiTiBOND. All patients attained an ABG <20 dB following surgery. Laser stapedotomy with the application of either heat-memory piston prosthesis allowed an easy and minimally invasive approach with excellent short-term hearing results when the NiTiBOND prosthesis was applied. Laser application allowed manipulation in a bloodless environment and avoided manual crimping of the incus.

Application of ionomer cement onto the stapedial footplate: impact on the perilymphatic aluminum level.

OBJECTIVES/HYPOTHESIS: From an acoustic aspect, fixation of the medial end of an ossicular replacement prosthesis to the stapedial footplate would be desirable. Technically, ionomer cement seems an ideal material for this purpose. The objective was to determine the aluminum level of the perilymph after the application of ionomer cement on the stapedial footplate. STUDY DESIGN: An experimental study on rabbits. METHODS: A total of 25 Pannon White rabbits were divided into three groups. Five rabbits (group I) underwent sham operation; in 15 animals (group II) ionomer cement was applied onto the stapedial footplate; and in 5 cases (group III) the application of the cement onto the footplate was followed by opening of the vestibulum. In groups of 5, the animals were killed on day 1, 7, 30, 180, or 365 postoperatively. Fluid samples were taken from the vestibulum and their aluminum levels were determined. RESULTS: The average aluminum level in the fluid was insignificantly lower in group II than in group I, but significantly lower in groups I and II than in group III. CONCLUSION: As a glue, ionomer cement safely can be applied directly onto the footplate without the threat of raising the perilymphatic aluminum level, provided that there is no perilymph leakage. However, in the event of an open vestibulum, the application of cement onto the footplate is to be strongly discouraged due to the danger of a consequent increase in the aluminum level in the perilymph and the cerebrospinal fluid. LEVEL OF EVIDENCE: NA.

KTP laser stapedotomy with a self-crimping, thermal shape memory Nitinol piston: follow-up study reporting intermediate-term hearing.

The aim of this study was an evaluation of the mid-term hearing results after the implantation of a self-crimping heat memory Nitinol piston in stapes surgery. The 12-month postoperative results were compared with those at a minimum of 3 years (maximum 6.7, average 4.4 years). The medical records of all 44 patients who underwent surgery with a Nitinol piston for stapes fixation between November 2005 and January 2007 were evaluated retrospectively. The prostheses used in all cases measured either 4.5 or 4.75 × 0.6 mm. We hypothesized that the 12-month postoperative hearing results would be permanent after an average follow-up of 4.4 years. Thirty-two of the 44 consecutive patients were females and 12 were males. Their mean age was 40.4 years (range 27-69). All underwent a 12-month postoperative audiometric evaluation. 38 (30 females, 8 males, average age 45, range 28-77 years) of the 44 were available for mid-term 4.4-year (minimum 3 years, maximum 6.7 years) postoperative audiometric evaluation. The mean air-bone gap (ABG) for the frequencies 0.5, 1, 2 and 3 kHz at the 12-month postoperative follow-up was 11 dB (SD 4.1) and that after an average 4.4-year postoperative evaluation was 6.4 dB (SD 3.6). The mean decrease in ABG after 12 months was 19.5 dB, and that after the average 4.4 years was 21.3 dB. ABG closure within 10 dB was achieved in 77.2 % after 12 months and in 89.5 % after the average 4.4 years. No patient with an ABG > 20 dB was recorded after the average 4.4 years. The mean air conduction threshold at 4 kHz was examined pre and postoperatively so as to indicate any possible inner ear damage. At the 12-month follow-up, the difference between the pre and postoperative values was -2.5 dB, whereas after the average 4.4 years the difference was surprisingly +13 dB. The individual AC improvements were also demonstrated with the use of Amsterdam Hearing Evaluation Plots (AHEPs). The Nitinol prosthesis allowed excellent intraoperative handling and no postoperative complication was reported. As compared with conventional stapes prostheses, the Nitinol-based SMart prosthesis is a safe and reliable stapes prosthesis. Our mid-term audiometric evaluations revealed that the audiometric parameters demonstrated a hearing improvement between the postoperative 12-month and average 4.4-year examinations. We consider the elimination of manual crimping and the use of a "non-touch" hand-held laser technique has a positive impact on the mid-term audiometric results. Most of the previous studies presented only relatively short-term (from 6 weeks up to 6-12 months) audiometric evaluations. Complications are rare, but a longer follow-up is needed to establish the long-term stability.

Propranolol for infantile haemangioma: striking effect in the first weeks.

OBJECTIVE: Discuss effect and dynamics of propranolol (PR) treatment in infantile haemangioma (IH) of head and neck in children during follow-up. METHODS: Between 2010 and 2011, 22 children with head and neck infantile haemangioma (IH) treated by PR were recruited into the study. In a retrospective chart review clinical data were analyzed at 5 consecutive, different check-up time from 1 week to 12-14 months. Effectiveness of PR treatment was assessed by a symptom score method. RESULTS: In the whole series a significant regression was observed in 13 patients (59%) in the first week of the therapy. Further five patients showed this time a marked, two mild improvements, and two children did not respond initially to the PR therapy. In one of them (case #8) later on a mild improvement could be seen too. At the second check-up (1 month after initiating PR therapy) 50% of children showed definitive improvement compared to the first visit. Difference between first and second check-ups was significant, and between the 4th and 5th visits the improvement showed the lowest rate. Comparison of IH regression between the 2nd and the 5th check-ups resulted in a p value a little larger than 0.05. There was not significant correlation between the initial IH severity and the treatment effectiveness at the follow-ups (p>0.05). No significant differences were found in treatment effectiveness concerning the IH localizations, too. CONCLUSION: PR treatment is highly effective in children with IHs. The most striking effect is seen at the first week of treatment; later improvement is much slower, sometimes with periods of stagnations. The cause of this is probably the spectacular early effect of vasoconstriction, though other impacts of PR to the individual molecular markers of IH seemed to be less impressive clinically. However, treatment should be continued for at least 6 months because early cessation can cause a relapse.

Effects of cytochrome P450 1A1 and uridine-diphosphate-glucuronosyltransferase 1A1 allelic polymorphisms on the risk of development and the prognosis of head and neck cancers.

We studied the effect of allelic polymorphisms of cytochrome P450 1A1 (CYP1A1) and uridine-diphosphate-glucuronosyltransferase 1A1 (UGT1A1) on the risk of development of head and neck cancers and overall survival. One hundred and forty-two head and neck cancer patients (48 with laryngeal, 42 with hypopharyngeal and 52 with mesopharyngeal tumours) were included in the study. The control group (150 individuals) included volunteers without malignant tumours. There was no statistically significant difference in age, sex distribution, or smoking habits between the two groups. The participants were genotyped for the CYP1A1 isoleucine/valine (Ile/Val) polymorphism in exon 7 and for the UGT1A1 thymine-adenine-repeat polymorphism (*1 and *28 alleles) in the promoter region of the gene. The effect of the allelic variants on survival was studied using the log-rank test, whereas the χ-test and odds ratios (OR) with 95% confidence intervals (CI) were used to compare the allelic frequencies between patients and controls. Our study revealed a significant link between the occurrence of the CYP1A1 Ile/Val, Val/Val (OR: 1.72, 95% CI: 1.02-2.96, P=0.044) and UGT1A1*28 alleles (OR: 2.74, 95% CI: 1.45-5.18, P=0.002) and an increased risk of head and neck cancers. These alleles decreased the duration of survival significantly (P=0.018 and 0.006). The survival was significantly more strongly reduced when the two high-risk alleles were carried simultaneously (OR: 2.149, 95% CI: 1.111-4.157, P=0.001). Our results suggest that the use of the CYP1A1 Ile/Val and Val/Val variants and UGT1A1*28 as biomarkers can aid risk assessment while their prognostic value can aid planning of individual therapy.

Should the ossicle be denuded prior to the application of glass ionomer cement? An experimental study on rabbit.

The objective of this study was to assess whether denudation of the auditory ossicle prior to the application of glass ionomer cement (GIC) durably strengthens the adhesion between bone and GIC. The tympanic bullas of 34 rabbits were opened bilaterally. The mucosa was removed from the lateral surface of the right-side incudi with a diamond burr, while the left-side incudi were left intact. GIC was then applied bilaterally to the lateral surface of the incudi of 30 of these rabbits which were subsequently killed 1, 3, 7, 14, 21, 30, 60, 90, 180 or 365 days postoperatively. The 4 sham-operated animals were killed on day 1, 7, 30 or 365. The incudi were removed and processed for histological evaluation. On exploration, the cement was visible on the incus within the tympanic bulla in all 30 GIC-treated animals. During surgical removal, the GIC was separated from the incus in 3 ears. Histological examination further revealed separation in 5 ears after processing. All 8 separations occurred in the right (not denuded) ears, and at least 60 days postoperatively. The difference between the two sides in the number of separations was significant (p < 0.05). The initial inflammatory reaction elicited by the surgical trauma to the right-side ossicles had substantially decreased by day 7. No foreign body reaction was observed and the GIC became overgrown with mucosa by day 60. In conclusion, the GIC proved biocompatible, and preliminary denudation of the ossicle resulted in stronger and more durable bone-GIC adhesion.

Transmeatal excision of pars tensa retraction pockets with simultaneous ventilation tube insertion in children: a prospective study.

Grade II and III (according to Sadé's classification) retraction pockets (RPs) in 40 ears of 30 children were excised transmeatally with simultaneous ventilation tube insertion. At a mean follow-up of 16.1 months, an intact tympanic membrane and mild, grade I retractions not requiring treatment were observed in 32 ears (80%). The mean air-bone gap had decreased from 22.4 to 9.7 dB. Two residual perforations and six recurrent grade II RPs were detected, all these eight ears undergoing further surgery. The second surgery solved both of the residual perforations and four of the six grade II recurrences. The age of the children did not influence the success rate, whereas bilateral pathology, a higher grade and more extensive RPs were associated with a higher rate of unsuccessful cases. A staging system is introduced to ease the selection of candidates with a good prognosis for this procedure.

Necrosis of the long process of the incus following stapes surgery: new anatomical observations.

OBJECTIVES/HYPOTHESIS: The most frequent complication (generally recognized during revision procedures) following seemingly successful stapedotomies and stapedectomies is necrosis of the long process of the incus. This is currently ascribed to a malcrimped stapes prosthesis or to a compromised blood supply of the incus. The two-point fixation can cause a mucosal injury with a resulting toxic reaction, and also osteoclastic activity. An important aspect in the engineering of ideal stapes prostheses is that they should be fixed circularly to the long process of the incus with appropriate strength. The objective of this study was to compare current knowledge relating to the blood supply of the ossicular chain with the present authors' observations on cadaver incudes. Most of the papers dealing with this issue appeared in the mid-20th century. METHODS: The published data were compared with the authors' findings gained from photodocumentation on 100 cadaver incudes. The photos were taken with a Canon EOS 20 digital camera (Canon, Inc., Lake Success, NY) with a 5:1 macro-objective. The long processes of the incudes were examined from four directions under a Leica surface-analyzing microscope (Leica Microsystems GmbH, Wetzlar, Germany). RESULTS: Analysis of the positions of the entrances of the feeding arteries (nutritive foramina) on the incudes revealed 1-4 nutritive foramina on the long processes of 48% (24) of the left-sided incudes and 56% (28) of the right-sided incudes. The positions of these foramina differed, however, from those previously described in the literature. They were mostly located not on the medial side of the incus body or on the short process or on the cranial third of the long processes, but antero-medially, mostly on the middle or cranial third. In 48% of all the incudes examined, an obvious foramen was not observed either in the body or in the long process of the incus. No relationship was discerned between the chronological age of the incus specimens and the numbers and/or locations of the nutritive foramina. In each case, the opening of the foramen was the beginning of a tunnel running obliquely and medially upward through the corticalis of the long process of the incus. The foramina are thought to be capable of ensuring a richer blood supply between the surface and the inside of the long process, allowing the arteries to run in and out. CONCLUSIONS: These observations indicate that conclusions drawn from classical anatomical works appear to need reconsideration. The present authors consider that the reason for the necrosis of the long process of the incus is not a compromised blood supply, except in some exceptional anatomical situations. They discuss the possible reasons why malcrimping may lead to necrosis of the long process of the incus. To prevent such malcrimping, attention is paid to the new generation of prostheses.

[Laser stapedotomy--the modern solution of otosclerotic stapes fixation]. / Lézerstapedotomia--az otoscleroticus stapesfixatio korszeru megoldása.

UNLABELLED: Development of surgical treatment of otosclerotic stapes fixation has been one of the success stories of otology for the past five decades. Nowadays not only stapedectomy and partial stapedectomy, but stapedotomy can also be considered a well established otological procedure. AIM: To introduce this minimally invasive surgical technique into the Hungarian otolaryngology practice, to gain useful experiences, and to analyze the hearing improvements and postoperative complications. METHODS: The authors give account of their first clinical experiences with 14 patients with KTP laser assisted stapedotomies using the self-crimping Nitinol piston. A total of 14 patients (11 females, 3 males) who have undergone the procedure between March 2006 and April 2007 were reviewed. The average age of the patients was 42,2 years, 6 procedures were carried out on left ears and 8 on right ones. The average length of follow-up was 9 months (ranged from 6 weeks to 1 year). RESULTS: Pure tone audiograms documented a hearing threshold improvement of 21,5 dB averaged across 0,5-1-2-3 kHz frequencies. The air-bone gap improvement averaged on the same frequencies was 18,7 dB. After an average 9 months postoperative follow-up period, the average air-bone gap was < 10 dB in 85% of the patients, however, < 20 dB in 100% of the patients. As for the average air conduction result: it was < 30 dB in each patient except for one. In this series, neither facial nerve paresis nor high frequency deterioration of the bone conduction thresholds was reported in the postoperative follow-up period. CONCLUSIONS: Based on the authors' favourable experiences and the review of the literature, KTP laser assisted stapedotomy with the use of Nitinol piston has several advantages: 1) the laser-activated memory effect of the piston prevents the disadvantages of the crimping manoeuvre made around the long process of the incus; 2) vertigo, experienced in the early postoperative period is milder and takes shorter time, reducing the length of hospitalisation; 3) the procedure is cost-effective and minimally invasive; 4) application of KTP laser assures bloodless operating field and minimal cochlear trauma; 5) migration of the prosthesis can be prevented, the degree of the surrounding granulation is less; 6) high frequency hearing improvement can be achieved in the long run; 7) the frequency and seriousness of complications is less, therefore this technique can be recommended for inexperienced ear surgeons, too; 8) the procedure can be used in difficult situations, too, e.g.: in the presence of stapedial artery, obliterative otosclerosis, flooting footplate, abnormal position of the facial nerve in the middle ear, revision cases; 9) the interindividual differences of hearing results are much less. Based on their favourable initial experiences, the authors plan to conduct a long-term follow-up on greater number of patients.

Myringoplasty for anterior and subtotal perforations using KTP-532 laser.

A retrospective study was performed on patients who underwent myringoplasty for either anterior or subtotal perforations over an 8-year period (from 1994 till 2004). We used the KTP-laser assisted anterior anchoring technique combining with anterior "pull-back" method. Patients' ages ranged from 6-62 years (median 36.5). The mean follow-up period was 2.8 years (minimum 6 months). The audiological results were analysed with the "Pytel software", which was developed in our department. As for the procedure, the drum remnant was freed from the malleus handle with the use of the laser and elevated out of it's sulcus anterior-superiorly. Large fascia graft was fashioned with a split of 4-5 mm in the middle of one edge. The graft was placed using the underlay technique medial to the handle of the malleus. A pull-back tunnel was created at the border of the anterior quadrants to further facilitate the survival of the graft. In this series the graft taking rate was 100%. Reperforation due to an undersized fascia was observed in one case. Post-operative audiological results indicated no bone conduction threshold elevation in any frequencies. Using the laser, cochlear trauma can be prevented, double fixation of the drum prevents lateralisation and blunting. Wide canalplasty makes both the approach and the follow-up very easy. Thorough soft tissue and bone work is advantageous from the fascia taking rate point of view.