A Review of Surgical Nuances and Outcomes of the Reverse Stapedotomy.

The stapes surgery has evolved through different eras of technical and technological development. The current standard of care is creating a stapedotomy with piston placement, and both these aspects have multiple variations and show well-established technological advances. The conventional technique has been fairly standardized,and it offers gratifying results to both the surgeon and the patient. To overcome certain procedural risks and potential complications, the reversal of steps technique was developed and streamlined by Ugo Fisch in the early 1980s. Since its beginning, the technique has been adopted by various centers, and surgical outcomes have been demonstrated to be at par with the conventional technique, with a reduced risk of complications. The aim of the present review is to detail the various surgical nuances and outcomes of this particular technique in a comprehensive narrative manner.

Outcomes in Stapedotomy Surgery: The Learning Curve Redefined.

OBJECTIVE: The aim of this study is to determine if the cumulative summation test for the learning curve (LC-CUSUM) and the cumulative summation graph (CUSUM) can be used to demonstrate landmark points of competence and maintenance of proficiency in stapes surgery over a continuous time period. STUDY DESIGN: Retrospective review from January 1999 until August 2014. SETTING: Tertiary referral hospital. PATIENTS: All adult patients with confirmed otosclerosis. INTERVENTION(S): Two-hundred and four primary and revision stapedotomy. MAIN OUTCOME MEASURE(S): Learning curves were constructed using the CUSUM and LC-CUSUM. Failure was defined as closure of the ABG >10 dB in less than 10% of patients to demonstrate the landmark point of competency and to highlight any fluctuations over a prolonged period. RESULTS: When the failure rate was defined as closure of the ABG >10 dB, it was not possible to create useful LC-CUSUM and CUSUM graphs, but by redefining the failure rate as > 15 dB, competency was reached at case 43 and maintained with natural fluctuations occurring between cases 137 and 149 and again at case 196. CONCLUSIONS: LC-CUSUM and CUSUM are a more robust analytical method of illustrating the learning curve and suggest that the traditional benchmark of closure of the ABG ≤10 dB in more than 90% of patients may need reconsideration. It can also be used as standardized audit tools when monitoring results and used to plan future training programs as they clearly define a point when novice trainees become competent.

[The biomechanical prerequisites for the preservation of stapedius muscle tendon during stapedoplasty].

The objective of the present biomechanical and clinical study was to evaluate the consequences of the preservation of stapedius muscle tendon during stapedoplasty. The biomechanical investigations included mathematical simulation with the construction of the model based on the kinematic approach. The comparative clinical study of the results of stapedoplasty carried out between 2001 and 2010 involved 340 patients (77 men and 263 women) at the mean age of 48.18 years. Twenty patients underwent piston stapedoplasty by the method of Shi, 320 ones were treated by stapedoplasty with the preservation of stapedius muscle tendon. The state of speech hearing and the audiometric air-bone gap (ABG) were deduced from the audiograms. The biomechanical study demonstrated a significant increase in the range of the movements of the long crus of the incus, after the removal of the stapedius tendon muscle and the preservation in part of the acoustic reflex in case of tendon preservation. The preservation of the tendon partly dampened excessive sound vibrations. The clinical study revealed the improvement of speech hearing parameters throughout the three-year postoperative follow-up period; it was especially pronounced within the first year after surgery with the preservation of stapedius muscle tendon. The size of ABG at a the frequencies falling in the 0.5-1 kHz and 6-8 kHz ranges after surgery with the preservation of stapedius muscle tendon was smaller than after the removal of the tendon during the three-year follow-up (p<0.005). The difference was especially well-apparent within the first year after stapedoplasty. The difference in this parameter between the interventions with the preservation of stapedius muscle tendon and with its removal was insignificant (p>0.05).

[The intraoperative monitoring of the gas pressure in the middle ear].

The objective of the present work was to elucidate the patterns and mechanisms underlying the changes of gas pressure in the middle ear during the operation of stapedoplasty with a view to the application of the data obtained for objective recording of the stapedial reflex at the time of surgical intervention. Ten subjects with the unaffected hearing function were recruited for the study. Tympanometry was carried out at one-minute intervals starting from the onset of feeding nitrogen monooxide till the completion of septoplasty. It was shown that the surgical intervention under inhalation anesthesia is associated with periodic rises and drops in the gas pressure in the middle ear within a range from 500 dPA to 88 dPA with a period from 5.7 to 22 minutes. It is argued that these changes can be attributed to the periodic opening of the Eustachian tube when the gas pressure reaches a certain level due to continuous diffusion of nitrogen monooxide into the middle ear (the "preventive" release of pressure) followed by the passive closure of the auditory tube. The authors propose based on the results of the study recommendations on the performance of stapedial reflexometry during the surgical intervention with the use of impedancometry.

[The results of laser-assisted piston stapedoplasty in the patients with otosclerosis].

The objective of the present study was to compare the immediate result of laser-assisted piston stapedoplasty with the use of prosthetic stapes of different diameter in the patients with otosclerosis. The patients of both (study and control) groups underwent the measurement of the bone conduction (BC) auditory threshold before, 10-12 days, and 1 month after surgery. The bone-air interval (BAI) was measured in the same time periods. A CO2 laser was used to form a hole 0.5 mm in diameter at the base of the stirrup bone in the patients of group 1; titanium prostheses (Heinz Kurz GmbH) were 0.4 mm in diameter and 4.25 mm in length. The patients of group 2 were treated similarly, but the hole at the base of the stirrup bone had a greater diameter of 0.7 mm while the prostheses were 0.6 mm in diameter and 4.25 mm in length. The BC auditory thresholds were not significantly different after surgery in the patients of A and B subgroups (mixed forms I and II of otosclerosis, respectively). The postoperative BAI values in the patients with a larger hole at the base of the stirrup bone and prostheses of greater diameter were significantly lower than in the patients of the other group (p≤0,05). These data suggest that the use of prostheses of greater diameter has certain advantages for stapedoplasty by the methos employed in the present study.

Depth of stapes prosthesis in the vestibule: baseline values and correlation with stapedectomy outcome.

CONCLUSION: Deeper protrusion of the prosthesis into the vestibule does not correlate with worse postoperative hearing outcome. OBJECTIVES: To establish baseline values for the depth of the stapes prosthesis in the vestibule after stapedectomy and to investigate a possible correlation between the relative prosthesis depth (actual depth expressed as a percentage of the vestibule depth) and the hearing results. METHODS: This was a prospective case study. Sixteen patients underwent stapedectomy and were examined by high-resolution CT of the temporal bone during the first week after surgery. They then underwent audiometric follow-up at specified intervals during the first postoperative year. The actual depth of the prosthesis in the vestibule, its relative depth, and correlations between the relative depth and postoperative hearing results (at 1 week, 1 month, and 1 year) or postoperative complications (prolonged vertigo and sensorineural hearing loss) were measured. RESULTS: The actual depth of the prosthesis in the vestibule (mean +/- SD) was 2.39 +/- 0.42 mm (range 1.83-3.39 mm). The depth of the prosthesis relative to the depth of the vestibule was 52 +/- 9.74% (range 41.3-74.2%). In general, deeper protrusion of the prosthesis into the vestibule did not correlate with a worse hearing outcome. On the contrary, the correlation between prosthesis depth and better hearing results was positive at several frequencies.

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW: The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis? RECENT FINDINGS: A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients. SUMMARY: Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Promontory drilling in stapedectomy: an anatomical study.

BACKGROUND: Anatomical variants such as an overhanging facial nerve or promontory can impede access to the footplate during stapedectomy. Drilling away bone from the cochlear promontory may be required. In the case of a floating or depressed footplate, it has been recommended that a "pothole" be drilled in the inferior margin of the oval window. There is little published information on the anatomy of the promontory with respect to these maneuvers. MATERIALS AND METHODS: Twenty temporal bones were studied. A series of measurements was made to assess how much bone may safely be removed without risking damage to the underlying cochlear endosteum and, hence, spiral ligament and stria vascularis. RESULTS: The bony promontory is thickest posteriorly, and here, the endosteum has least lateral projection. The promontory becomes thinner closer to the oval window. Moving anteriorly, the bone becomes thinner and the underlying endo steum more closely follows the bony contour. The stria vascularis and spiral ligament may be less than 0.2 mm inferior to the inferior margin of the oval window posteriorly. This distance is at least 0.3 mm at the midpoint of the footplate (range, 0.3-0.5 mm). CONCLUSION: Bone may be removed inferiorly to the posterior one-third of the footplate from lateral to a line that makes an angle of 35 degrees with the superoinferior axis of the footplate. In creating a "pothole" in the case of a floating or depressed footplate, the authors recommend that it be created at the midpoint of the inferior margin of the oval window and should not exceed 0.3 mm in diameter.

Stapes surgery: the diameter of the long process of the incus.

HYPOTHESIS: The aim of this study was to examine the long process of the incus in respect of its shape and its dimensions at the site of the attachment of a stapes prosthesis. BACKGROUND: One of the complications in stapes surgery is the erosion of the long process of the incus at the site of the attachment of the prosthesis, resulting in a fluctuating conductive hearing loss. Knowing the dimensions of the attachment site of the prosthesis at the long process of the incus will make it possible to optimize the size of the prosthesis loop. METHODS: The incus was obtained from 11 patients who had undergone middle ear surgery for hearing improvement or cholesteatoma removal. The ossicles were kept in 4% paraformaldehyde and were processed for histological examination after decalcification in ethylenediamine tetra-acetic acid. The 5-microm slices were stained with toluidine blue and examined in the light microscope. Using digitized video images of the histological slices, the diameters, circumference, and surface of the specimens were determined. RESULTS: The diameter of the long process of the incus at 1.4+/-0.28 mm from the tip, which is the average site of prosthesis attachment, showed an oval shape with a minimum diameter of 0.66+/-0.05 mm, a maximum diameter of 0.81+/-0.1 mm, and a circumference of 2.46+/-0.23 mm. CONCLUSION: The loop of a stapes prosthesis should have the following dimensions: diameter 0.9 mm, loop length of 2.2 mm, and opening of loop 0.7 mm. However, the material of the prosthesis and its malleability are also important factors.

Technical refinements and precautions during ionomeric cement reconstruction of incus erosion during revision stapedectomy.

OBJECTIVE: The study describes the technical precautions and short-term hearing results of fast-setting ionomeric cement (SerenoCem) for managing incus erosion in revision stapedectomy. STUDY DESIGN: Observational and retrospective chart review. METHODS: Consecutive patients undergoing ionomeric cement incus reconstruction during revision stapedectomy had surgery on an ambulatory basis in a tertiary care referral center. Main outcome measures included technical details, precautions, and recommendations for handling this new material and 6-week hearing outcomes comparing preoperative and postoperative air-conduction and bone-conduction thresholds. RESULTS: A small amount of ionomeric cement on the tip of otological picks applied to the incus remnant successfully reconstitutes the original length of the long process of the incus. In revision stapedectomy, a crimp-on prosthesis may be placed on the cement-lengthened incus. Six-week postoperative audiograms demonstrated significant closure of the air-bone gap in operated cases. Our experience in a failed case leads us to recommend that the setting time for the cement be increased to no less than 20 minutes as opposed to the manufacturer's recommendation of 10 minutes. Also, revision stapedectomy was more likely to be successful when the prosthesis was placed to the incus remnant and stabilized with cement, rather than placing the prosthesis on the cement itself. CONCLUSIONS: Ionomeric cement permits direct reconstruction of a pathologically shortened incus in revision stapedectomy. Surgeons must be aware of precaution and limitations of this new material. Preliminary results indicate significant hearing improvement with this technique when appropriate precautions are taken.

Forty years of stapes surgery.

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.

A confidential comparative audit of stapedectomies: results of the Royal College of Surgeons of England Comparative Audit of ENT surgery 1994.

This paper presents the results of a national confidential comparative audit of stapedectomy: 185 operations by 28 consultants over a two-year period were retrospectively analysed. This included 10 revision procedures. Small fenestra stapedectomies accounted for 63 per cent of the total. Thirty-nine per cent of consultants operated on the second ear. Of the 168 stapedectomies in which the hearing change was known at six months, 87 per cent achieved improved hearing, eight per cent had no change and five per cent were worse. The overall complication rate was 30 per cent with a 'dead ear' rate of two per cent.

The future of stapedectomy--the Singapore problem.

Concern has been expressed in the recent literature regarding the problem of a dwindling number of stapedectomy cases and an increasing number of surgeons trained to do this operation. In Singapore, the problem is made worse by the very low incidence of this disease in its main ethnic groups of Chinese and Malays who together make up more than 90 per cent of the population. We report here an audit of 47 ears that underwent stapedectomy in a teaching hospital over a six-year period. The hearing results for consultants and surgical trainees were compared. Closure of the air-bone gap to within 10 dB was obtained in 64 per cent of Consultants' cases and 68 per cent of trainees' cases. These results fall short of the 90 to 95 per cent figure reported by experts in this procedure and only comparable to the less satisfactory results of several series recorded by residents in North America. We conclude that the unsatisfactory results arise from the small number of surgical cases available for each surgeon to improve and maintain his skills in a technically demanding procedure. It is proposed that such cases be directed to those pursuing otology as a subspecialty rather than all otolaryngologists in general.

[Surgical treatment of otosclerosis. Long-term results]. / Kirurgisk behandling af otosklerose. Langtidsresultater.

UNLABELLED: At Glostrup Hospital, Copenhagen, exceptionally few stapedectomies were performed during the period 1979-1985. The audiological results five to eleven years after the operation were investigated in 64 patients. About half of the patients were operated using large fenester technique, the other half using small fenester technique. All patients but two were operated by the same expert surgeon. The initial results showed good stability with an unchanged median hearing gain of 30 dB. Eighty-five percent of the patients had an SRT < or = 35 dB HL in contrast to 89% at the 1-year follow-up (and five percent preoperatively). Eighty-two percent had an air-bone gap < or = 20 dB in contrast to 93% at 1-year follow-up (and 10% preoperatively). None of the patients had spontaneously developed severe sensorineural hearing loss, which was, however present in two patients as a direct result of the operation. In one of the patients it was caused by granuloma formation around the prosthesis, in the other patient it developed after a revision procedure. Both patients were operated using large fenester technique, which in general gave less satisfactory primary hearing improvement and less stable thresholds than small fenester technique. IN CONCLUSION: Even under conditions with few operations per year the overall long term results of stapedectomy are satisfactory when performed by few trained ear surgeons, and in particular if small fenester technique is used. The risk of sensorineural hearing loss is primarily related to the operation.

Stapedectomy in residency--the UAB experience.

A retrospective study of the resident-performed stapedectomies at the University of Alabama-Birmingham over the last 10 years was done. "Satisfactory" results, depending on the audiologic criteria used, were obtained in 60-64 percent of cases, far below the 90-95% success rate of established otologic surgeons. The reason for the low success rate is extremely limited experience, an average of 0.78 cases per residency at this institution. Other training programs have reported slightly higher success rates, all in the 60-80 percent range, but each had a higher average number of stapedectomies per resident. Some comments and suggestions are offered on the continuing controversy of stapedectomy in residency.

Stapes surgery: implications for training.

The worldwide decline in surgery for otosclerosis had been reflected by a similar pattern here in Great Britain. Unless we are prepared to accept poorer results than have formerly been achieved, we will have to adopt measures to ensure that the skills of stapes surgery are transferred to the next generation of surgeons. Using the results of our experience, at the Queen Elizabeth Hospital, over the past 18 years, I have examined the implications for surgical training and for the management of future patients with otosclerosis.