Recurrent Conductive Hearing Loss Research Articles

Indications, Surgical Strategies And Hearing Outcomes of Revision Stapes Surgery for Otosclerosis: A Systematic Review and Meta‐analysis on 2602 Patients

AbstractObjectiveTo summarize current knowledge on the indications, surgical strategies, and auditory outcomes of revision stapes surgery (RSS) for otosclerosis.Data SourcesThe search was conducted in PubMed, Scopus, and Web of Science online databases, including papers published since 2000.Review MethodsThe study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. We considered original series describing RSS for otosclerosis, reporting postoperative hearing outcomes according to the American Academy of Otolaryngology–Head and Neck Surgery guidelines for conductive hearing loss (CHL) for at least 30 consecutive cases. The quality of included studies was assessed with the Joanna Briggs Institute checklist. Pooled proportion and odds ratio (OR) meta‐analysis were conducted using random effect models.ResultsNineteen studies were included, for a total of 2602 patients (2735 ears) and 2359 postoperative hearing results. RSS was mostly performed for recurrent CHL with air‐bone gap (ABG)>20 dB. Multiple concomitant causes were often present, with prosthesis placement defect and incus necrosis as the most common causes. The pooled proportion of postoperative ABG<10 dB and ABG<20 dB was 57.2% (95% confidence interval [CI]: 52.8%‐61.4%) and 79% (95% CI: 76.0%‐81.8%), respectively. Dead ears were 1.2% (95% CI: 0.7%‐2.1%). Compared to primary surgery, RSS had a significantly lower rate of ABG<10 dB (OR = 0.36, 95% CI: 0.24%‐0.54%; P < .001). Both revision incudostapedotomy with/without incus reconstruction and malleovestibulopexy are viable options with nonsignificant differences in ABG closure rates (P = .182).ConclusionRSS is challenging and requires the surgeon to carefully evaluate all potential causes of previous failure and tailor the intervention according to intraoperative findings. In most cases, ABG closure within 20 dB can be achieved with a relatively low risk of dead ears.

Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes.

Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. Retrospective review. Single tertiary neurotology center. Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB (P < .0005). The most common intraoperative findings for these patients were prosthesis displacement with incus necrosis (38%) or without it (43%), normal anatomy with seemingly good prosthesis placement (6%), and abundant scar tissue (6%). Patients with recurrent hearing loss achieved lower mean ABGs than patients with persistent hearing loss (8.8 vs 13.2 dB, P = .02). There were no associations between onset pattern of CHL or intraoperative findings and hearing outcomes (P > .05). Four patients (2.7%) developed sensorineural hearing loss after revision, defined as an increase in bone conduction pure tone average ≥15 dB, all of whom had previous replacement of a malpositioned prosthesis. Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

Impact of surgeons' experience and the single-shot perioperative antibiotic prophylaxis on outcome in stapedotomy.

BackgroundThe aim of this study was to evaluate whether surgeons´ experience and perioperative single-shot antibiotic prophylaxis affect outcome of patients undergoing stapes surgery.Patients and methodsWe retrospectively evaluated audiological outcomes and postoperative complications of 538 consecutive patients who underwent stapes surgery at a single tertiary referral center between 1990 and 2017. Effects of different clinical variables, including single-shot antibiotic prophylaxis and surgeons’ experience on outcome were assessed.Results538 patients underwent 667 stapedotomies and postoperative complication rate was 7.5% (n = 50). Air conduction and air-bone gap closure improved significantly after surgery (14.2 ± 14.8 dB, p = 0.001; 14.5 ± 12.8 dB, p = 0.001). Multivariate analysis revealed that 6 years or less of surgical experience was independently associated with a higher incidence of persisting or recurrent conductive hearing loss (p = 0.033, OR 5.13) but perioperative application of antibiotics had no significant effect on outcome.ConclusionFirst, clinical outcome regarding persisting or recurrent conductive hearing loss caused by incus necrosis and prosthesis luxation is linked to surgical performance. This underlines the need for a meticulous training and supervision of less experienced surgeons performing stapes surgery. Second, our results do not support the need for perioperative antibiotic prophylaxis in stapes surgery. Potential standard limitations of retrospective cohort studies (selection bias, confusion bias etc.) could play a role in interpreting our results. However, the probability for these limitations is minimized due to the large patient sample.

Revision Stapes Surgery in a Tertiary Referral Center: Surgical and Audiometric Outcomes.

Objectives:To evaluate pure-tone audiometric results in otosclerosis patients undergoing revision stapes surgery following previous middle ear interventions.Methods:A retrospective cohort study was performed in a tertiary referral center. Consecutive otosclerosis patients who underwent revision stapes surgeries, following previous middle ear interventions, for persistent conductive hearing loss, recurrent conductive hearing loss, or vertigo and had available postoperative pure-tone audiometry were included. Mean pre- and postoperative air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2, and 3 kHz were obtained. Audiometric outcomes were obtained at 7 weeks postoperatively.Results:In total, 63 consecutive otosclerosis patients who underwent 66 revision stapes surgeries were included. Air-bone gap improved significantly with a mean gain of 19 dB (95% CI, 15-22). Air conduction improved significantly with a mean gain of 18 dB (95% CI, 14-23). Bone conduction did not change significantly, with a mean deterioration of 0 dB (95% CI, –2 to 1). Air-bone gap closure to 10 dB or less was achieved in 38% of cases and to 20 dB or less in 80% of cases. Indication for surgery, previous type of procedure, primary cause of failure, and current surgical technique were not significantly associated with air-bone gap closure to 10 dB or less. Indication for surgery and primary cause of failure were associated with one another.Conclusions:Compared to the available literature, a slightly larger gain in air conduction and air-bone gap was achieved in our study. Air-bone gap closure to 10 dB or less was achieved less often in our study.

Review of a single surgeon’s stapedotomy cases performed with a nickel titanium prosthesis over a 14-year period

Conclusion: Stapes surgery with a nickel titanium prosthesis is a safe and well-tolerated procedure that leads to a significant improvement in hearing outcomes.Objective: To identify the efficacy and safety of stapedotomy procedures performed with a nickel titanium prosthesis for patients with otosclerosis.Methods: A review of 431 unique stapedotomies performed over 14 years by a single surgeon at an academic tertiary care center yielded 312 cases with nickel titanium prosthesis that met inclusion criteria of otosclerosis diagnosis, initial surgery in operative ear, and presence of pre-operative and post-operative audiograms. Pure-tone averages (PTA) at baseline and 8 weeks after surgery were calculated over four frequencies; 0.5, 1, 2, and 4 kHz. Average air–bone gaps (ABG) were calculated from pre-operative and post-operative audiograms.Results: Average pre-operative baseline PTA was 56.7 dB in the affected ear. Post-operative PTA was 30.1 dB, a 26.6 dB improvement. Initial average ABG was 29.7 dB, while post-operative ABG averaged 5.4 dB, a 24.2 dB improvement. Surgical success (closure of ABG within 10 dB) was achieved in 263 (84%) patients. Rate of surgical success was not correlated with age, gender, race, or affected ear. Complications included recurrent conductive hearing loss (14), progressive SNHL (4), and post-operative BPPV (3).

Speech-Language Disorders in Children with Hearing Loss Connected with Otitis Media with Effusion

Introduction: Otitis media with effusion is accompanied with conductive hearing loss. The aim of the study is to find out effect of long term or recurrent conductive hearing loss on speech descrimination. Method: Tonal audiometry timpanometry, speech audiometry (free sound field, head phone for left and right ear respectively) performed in 18 girls (mean age 8 years) and 27 boys (mean age 7 year). All of the children undergo speech/language screening tests. Results: Results of speech recognition showed no ear side effect in girls and right ear advantage in boys. Girls showed earlier in age central auditory processing disorder. Boys showed lower scores in words discrimination while hearing throught the head-phones on left ear. Poorer speech recognition at boys is accompanied with motorical immaturty, undeveloped articulation, poor vocabulary, lack of syntax in sentences, substitution of R and L, unable to focus on school tusk. Conclusion: Children with conductive hearing loss associated to otitis media with effusion are pronounced auditory processing disorder and speech/language discrimination disturbance. Associative thinking and solving of abstract problems are more affected in females than males.

Outcome of Management of Otosclerosis by Stapedotomy Compared to Stapedectomy in a Jordanian Population

To study the success results rates and complications of stapedotomy compared to stapedectomy in the operative management of otosclerosis. This is a retrospective study of 50 patients who were treated surgically for otosclerosis. The medical records of these patients were reviewed for the type of operation performed, complications and the serial pure tune audiometries pre- and postoperatively for at least one year. Patients with conductive hearing loss not due to otosclerosis were excluded from this study. The medical records of equal number of patients (25 patients with stapedotomy and 25 patients with stapedectomy) were analyzed for hearing improvement or loss, postoperative nausea, vomiting, vertigo, nystagmus, perilymph fistula, reparative granuloma, labyrinthitis, tinnitus and perforation of the tympanic membrane. All operations were performed by the senior consultant-otologists of our department. Stapes superstructures were removed by crural scissors and stapes footplate was perforated by microdrill. Out of 25 patients with stapedotomy, 22 (88%) developed complete closure (≤10 dB) of the air-bone gap on pure tune audiometry; in two patients (8%), the air-bone gap improved to less 20 dB, and recurrent conductive hearing loss (due piston slipping) in one patient (4%). On the other hand, in patients with stapedectomy, only 16 patients (64%) developed complete closure of the air-bone gap (≤10 dB) on pure tune audiometry, and in four patients (16%) the air-bone gap improved to less 20 dB, while recurrent conductive hearing loss occured in three patients (12%), one patient developed complete sensorineural hearing loss (4%), there was one case of fluctuating hearing loss due to reparative granuloma (4%), perilymph fistula was reported in one case (4%) and no cases of facial palsy or perforation of the tympanic membrane were recorded. The results of this study clearly show that stapedotomy gives better hearing results and fewer complications than stapedectomy.

Hearing loss in Pompe disease revisited: results from a study of 24 children.

Little information is available regarding the auditory function in Pompe patients. Hearing loss has been reported in classic infantile patients, but it is still unknown whether central nervous system involvement interferes with auditory function and whether enzyme replacement therapy can improve hearing. Auditory function has not been studied in children with milder forms of the disease. We analyzed repetitive auditory brainstem response measurements and pure tone audiometry in 24 children with Pompe disease. Only 1 of 13 patients with milder phenotypes showed recurrent conductive hearing loss, while 10 out of 11 classic infantile patients had sensorineural hearing defects. These patients also had a high prevalence of conductive hearing loss. Five patients showed evidence of mild retrocochlear pathology, suggestive of glycogen accumulation in the central nervous system. Hearing loss persisted during therapy in all patients. The results emphasize the need for careful monitoring of auditory function in classic infantile Pompe patients, and for early implementation of hearing aids to protect speech and language development.

Conductive hearing loss in children with bronchopulmonary dysplasia: A longitudinal follow-up study in children aged between 6 and 24 months

Aims To determine the occurrence of isolated and recurrent episodes of conductive hearing loss (CHL) during the first two years of life in very low birth weight (VLBW) infants with and without bronchopulmonary dysplasia (BPD). Study design, subjects and outcome measures In a longitudinal clinical study, 187 children were evaluated at 6, 9, 12, 15 18 and 24 months of age by visual reinforcement audiometry, tympanometry and auditory brain response system. Results Of the children with BPD, 54.5% presented with episodes of CHL, as opposed to 34.7% of the children without BPD. This difference was found to be statistically significant. The recurrent or persistent episodes were more frequent among children with BPD (25.7%) than among those without BPD (8.3%). The independent variables that contributed to this finding were small for gestational age and a 5 min Apgar score. Conclusions Recurrent CHL episodes are more frequent among VLBW infants with BPD than among VLBW infants without BPD.

Revision Stapedectomy

Recurrent or persistent conductive hearing impairment as well as vertigo or tinnitus after a stapes operation can be treated by means of stapes revision surgery. We analyzed stapes revisions performed during the last 15 years at our institution. The aim was to ascertain the causes that led to the failure, to analyze the postrevision results, and to compare them with data from the literature. This retrospective study analyzes 201 stapes revisions performed in 175 patients between 1992 and 2006. The indications, intraoperative findings, and surgical techniques were analyzed. Functional results were evaluated by means of hearing tests before and after surgery (1-15 yr). Revisions were mainly performed by the transcanal approach through the fixed speculum under local anesthesia using the fiber-optic argon laser and the Skeeter microdrill. Indications for revision in 172 operations included lack of hearing improvement or recurrent conductive hearing loss. Six patients additionally had symptoms of vertigo. Sixteen patients experienced isolated vertigo despite improved hearing, 1 patient experienced intolerable tinnitus, and in 6 patients, the indication was deafness after stapedotomy.The most common intraoperative observations were prosthesis lateralization (53%), partial or total incus necrosis (33%), reossification of the footplate (31%), and loosening of the loop on the incus (9%). Hearing improved postoperatively in 88% of the patients. In 55% of the patients, there was a residual air-bone gap of 10 dB or less, and in 84%, the gap was 20 dB or less. Stapes revisions are more challenging procedures with less perfect results compared with primary operations. Nevertheless, a postoperative hearing improvement was achieved in 88% of our patients. Modern techniques, such as the laser and microdrill, demonstrate their full usefulness.

Déhiscence du canal semi-circulaire antérieur mimant une otospongiose : intérêt de l'imagerie

Objectives To emphasize the role of computerized tomography (CT) in the etiologic work-up of stapes surgery failure. Material and methods Helical high resolution CT scan of the temporal bone with axial and coronal views and multiplanar reconstructions was performed in a patient who had undergone unsuccessful stapedectomy. Results CT scan demonstrated a well located prosthesis, the absence of the radiological hallmarks of otosclerosis, and revealed a superior semicircular canal dehiscence (SSCD). The diagnosis of SSCD was retrospectively considered accountable for the preoperative clinical and audiometric presentation that had mimicked otosclerosis. Conclusion CT is the diagnostic test of choice in elucidating stapes surgery failure (with persistent or recurrent conductive hearing loss), whereas SSCD should be systematically considered among its causes.

Causes of conductive hearing loss after stapedectomy or stapedotomy: a prospective study of 279 consecutive surgical revisions.

To analyze the causes for residual or recurrent conductive hearing loss following stapedectomy or stapedotomy and then propose surgical techniques to avoid these complications. Prospective study of 279 consecutive stapedectomy or stapedotomy revisions performed by the author. Tertiary referral center. The study included 260 patients who presented with a 20 dB or greater average air-bone gap in the speech frequencies 1 month to 35 years following stapedectomy or stapedotomy (19 patients were explored for possible oval window perilymph fistula). Stapedectomy (stapedotomy) surgical revision. Microscopic inspection and palpation assessed the mobility and continuity of the malleus, incus, and prosthesis. Infrared laser vaporization thinned the oval window neomembrane to identify the precise depth and margins of the oval window, the presence of residual stapes footplate, and finally, the relationship of the prosthesis to the fenestra into the vestibule. Prosthesis displacement out of the oval window fenestration with fixation of the prosthesis against the residual stapes footplate or otic capsule margin was demonstrated in 81% (211/260) of the patients. Of these patients, 31% had complete incus erosion, and an additional 60% demonstrated partial incus erosion, usually on the undersurface of the incus. Residual fixed stapes footplate was found in 14%, and malleus fixation in 4%. Incus dislocation was found in 4%, and incus fixation in 2%. Prosthesis migration and subsequent fixation caused the majority of stapedectomy failures. Collagen contracture of the oval window neomembrane lifts the prosthesis out of the oval window fenestration. Prosthesis displacement then results from adhesions pulling the prosthesis or mechanical forces further tilting the prosthesis. Incus erosion results from vibration against the fixed prosthesis. Six specific stapedotomy recommendations are made to minimize postoperative prosthesis migration.

Screening all newborns for hearing loss using transient evoked otoacoustic emissions

The importance of identifying hearing loss before 12 months of age is well established. Although recent research provides some evidence for the value of transient evoked otoacoustic emissions (TEOAEs) in newborn hearing screening, data are needed from large-scale clinical evaluations about the value of using TEOAE for screening high-risk and healthy babies. A cohort of 1850 infants from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) were screened with TEOAE using a 2-stage process. Infants referred from the first stage prior to being discharged from the hospital were rescreened 4 to 6 weeks later. Those who did not pass the second-stage TEOAE screening were referred for diagnostic auditory brainstem response (ABR) and/or behavioral audiological evaluation for confirmation of hearing loss, fitting with amplification, and enrollment in early intervention programs. Eleven infants with unilateral or bilateral sensorineural hearing loss > 25 dB (a prevalence of 5.95 per 1000) and 37 with unilateral or bilateral recurrent conductive hearing loss > 25 dB (a prevalence of 20.0 per 1000) were identified from this cohort. These results suggest that TEOAE is a promising technique for screening newborns for hearing loss and should be evaluated further as a tool for universal newborn hearing screening.

Stapedectomy: Long‐term hearing results

The initial improvement in hearing following stapedectomy usually deteriorates with the passage of time. We studied the long-term results of stapedectomies performed on 42 patients (49 ears) between 1959 and 1969 who had a minimum follow-up of 18 years. Both air conduction (AC) and bone conduction (BC) thresholds progressively deteriorated over the long term. The degree of BC loss paralleled that expected from presbycusis alone. A greater deterioration was noted in the AC levels, producing a recurrent conductive hearing loss in the speech frequencies. Age at the time of surgery had no effect on the long-term outcome. Comparison of the average preoperative speech discrimination scores (SDS) to the 1-year postoperative SDS and the long-term SDS revealed a 1.1% and 16.7% drop, respectively. The improvement in the average speech reception threshold (SRT) obtained 1 year postoperatively deteriorated by less than 1 dB per year over the long term. Patients with a higher SDS (more than 95%) preoperatively fared better in the maintenance of speech discrimination than those with a lower SDS (less than 95%). The preoperative SRT level was predictive of the timing for the requirement of hearing amplification. The postoperative SRT level was predictive of the timing for the requirement of hearing amplification. The caused by presbycusis, combined with a recurrent conductive loss in the speech frequencies rather than cochlear otosclerosis. Although the decline in hearing following stapedectomy exceeds the rate of hearing loss due to presbycusis, many individuals, after successful stapes surgery, are able to delay the need for hearing amplification for longer periods than had been previously reported.

Speech perception: The effects of recurrent conductive hearing loss in young children

The ability of five-year-old children with histories of recurrent otitis media (OM) and associated conductive hearing loss to perceive syllable initial stop consonants was investigated. Naturally produced, computer-edited stimuli were created to form continua that ranged in voice onset time (VOT) from 7 to 60 ms. The ability of children to assign these stimuli to adult phonetic categories was assessed by identification and discrimination tasks. Three subject groups were identified: One group (group C) had no history of OM and was linguistically age appropriate; another group (group OM) had considerable involvement with OM and was also linguistically normal; the third group (group OMDL) had an equal involvement as group OM with otitis media, but was linguistically delayed. All groups were matched for age, IQ, socioeconomic class, and educational experience. Results indicate that OM was associated with poorer discrimination scores, regardless of the linguistic status of the individual.

Long‐Term Experience with Biocompatible Ossicular Implants

The senior author's 8-year personal experience with biocompatible ossicular implants is reviewed. Four hundred sixty-one consecutive operations, in which high-density polyethylene sponge ossicular replacement prostheses were used, are grouped according to the Bellucci classification of chronic otitis media. The prostheses used were the drum-to-footplate prosthesis (TORP, total) and the drum-to-stapes prosthesis (PORP, partial). Each group's short- and long-term hearing results are compared. Prosthesis extrusion and persistent or recurrent conductive hearing loss are the most common causes of operation failure. Failures within each group are analyzed, and techniques to prevent these complications are outlined.

Long‐Term Experience with Biocompatible Ossicular Implants

The senior author's 8‐year personal experience with biocompatible ossicular implants is reviewed. Four hundred sixty‐one consecutive operations, in which high‐density polyethylene sponge ossicular replacement prostheses were used, are grouped according to the Bellucci classification of chronic otitis media. The prostheses used were the drum‐to‐footplate prosthesis (TORP, total) and the drum‐to‐stapes prosthesis (PORP, partial)*. Each group's short‐ and long‐term hearing results are compared. Prosthesis extrusion and persistent or recurrent conductive hearing loss are the most common causes of operation failure. Failures within each group are analyzed, and techniques to prevent these complications are outlined.

Stapes prosthesis: evaluation with CT.

We used computed tomography (CT) to evaluate 44 patients who had undergone stapedectomy with insertion of a prosthesis. Several patients had poor surgical results, including recurrent conductive hearing loss, vertigo, and sensorineural hearing loss. Conductive hearing loss occurring immediately after the procedure was most often caused by anatomic limitations or surgical technique. Causes of delayed or recurrent conductive hearing loss included reparative granuloma formation, incus necrosis (at the attachment of the wire), prosthesis subluxation (most often posterior), and regrowth of otosclerosis, which occasionally is further complicated by incus dislocation. We found that CT is often diagnostic when these complications occur. Immediate sensorineural hearing loss or vertigo can be self-limited if caused by serous labyrinthitis. When delayed, these symptoms may be due to perilymph fistula. If caused by the latter, CT may not yield abnormal findings unless subluxation of the prosthesis into the vestibule has occurred.