Surgical Treatment Of Otosclerosis Research Articles

Endoscopic Findings on Facial Nerve Anatomy During Exclusive Endoscopic Stapedotomy: Clinical Considerations and Impact on Surgical Results.

Variations along the facial nerve (FN) course present considerable challenges in the surgical treatment of otosclerosis, often complicating the procedure. Existing knowledge of its tympanic tract and its implications primarily comes from microscopical procedures. This study aims to assess endoscopic findings of FN anatomy in a healthy tympanic cavity and its impact on the stapedotomy procedure, focusing on the risk of complications and functional hearing outcomes. A retrospective study on exclusive endoscopic stapedotoplasties between October 2014 and October 2021 at our Otorhinolaryngology University Department was carried out. An evaluation of intraoperative endoscopic findings reviewed in surgical descriptive and/or video records was conducted to assess their potential negative impact on the surgery. Demographic data, preoperative and postoperative hearing thresholds, as well as intraoperative and postoperative complications were analyzed. One hundred fifty-seven subjects were included. A FN partially overhanging the oval window was observed in 7.3% (n=12): 10 prolapsing with bony canal dehiscence and 2 without any detected dehiscence. Each procedure was successfully completed without any issues related to the anomalous anatomy, and in no case, switching to the microscope for the handling of the prosthesis near the dehiscent nerve was required. No facial paralysis occurred, with an early- or long-term postoperative House-Brackman grade of 1 (n=157, 100%). Only 3/157 patients (1.9%) showed a sensorineural threshold reduction of ≥20 dB HL, but a significant air-bone gap improvement was observed (mean closure of 18.36 dB HL, P -lt; .0001). The endoscope promotes a concrete description of tympanic FN anatomy, and endoscopic stapes surgery appears to be a safe and viable option when dehiscent or prolapsed FNs reduce the footplate's exposure.

Comparison of Uncomfortable Loudness Level in Stapedotomy with or without Stapedial Tendon Preservation

Background: Otosclerosis is one of the commonest diseases of the ear mostly involves the otic capsule. Most often otosclerotic foci appear in stapes region leading to stapes fixation, predominantly affect the adolescence female. The most common presenting symptom of clinical otosclerosis is conductive deafness. The mainstay of treatment for otosclerosis is surgery. Surgical options include stapedectomy, stapedotomy with or without stapedial tendon preservation. The latter being is the procedure of choice. Aim: The aim of this study is to compare the outcome of uncomfortable loudness level in stapedotomy with or without stapedial tendon preservation. Methods: A prospective observational study was conducted in the Department of Otolaryngology-Head & Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka for 18 months in patients with otosclerosis. Total 30 subjects were selected based on the inclusion and exclusion criteria. All patients were assessed pre-operatively by clinical examination, otoscopy and microscopic examination. Hearing was assessed by pure tone audiometry. Uncomfortable level and stapedial reflex threshold were tested in all cases. The selected cases were placed into two groups. Stapedial tendon resection in Group-I and stapedial tendon preservation in Group-II. Post-operative follow up was done at 3 months and 6 months. Hearing and uncomfortable loudness level were evaluated with PTA during follow up by calculating the average of 500Hz, 1000Hz, 2000Hz and 4000HZ. The data were calculated manually. The statistical significance was set to P< 0.05. Results of the study were expressed as mean, standard deviation (± SD), frequency and percentages. Means and standard deviations were reported for continuous variables. Frequencies and percentages were reported for categorical variables. Unpaired Student’s t test was done to compare the continuous variables and Chi Square test was done to compare the categorical variables. Results: In this study preoperative average ABG for group I and group II were 35 ± 4.57 dB and 34 ± 4.17 dB respectively. In group I, post operative average ABG after 3 months and 6 months were 14 ± 3.7 dB and 13±3.3 dB respectively. Post operative average ABG after 3 months was 13 ± 5.7 dB and was 12 ± 4.4 dB for group II. But the hearing improvement between two groups was not statistically significant. In case of preoperative mean UCL was 95 ± 1.8 dB and 96 ± 2.5 dB for group I and group II respectively. Postoperative mean UCL after 3 months was 96 ± 3.57 dB and after 6 months was 99 ± 6.28 dB in group I. For group II, postoperative mean UCL after 3 months and 6 months was 107±4.2 dB and 113 ± 3.2 dB respectively. Here mean UCL was on average 11 dB higher for group II in 3 months and additional 6 dB improvement noted after 6 months, but show minimal change in group I. This finding was statistically significant. Conclusion: Preservation of the stapedial tendon is the choice in the surgical treatment of otosclerosis which helps to improve functional outcomes as well as to provide the more physiologic protection of middle ear. Postoperative discomfort threshold levels were increased in patients who had their stapedial tendon restored. Bangladesh J Otorhinolaryngol 2021; 27(2): 117-123

Stapedial reflex evaluation after preservation of stapedial tendon during stapedectomy

Background:Otosclerosis is one of the leading causes of conductive hearing loss with an intact tympanic membrane in adults. The stapedius tendon is routinely transected during stapes surgery. This study aimed to evaluate the success rates of stapedectomy with preservation of stapedial muscle tendon compared to stapedectomy without preservation of stapedial muscle tendon in the operative management of otosclerosis. Main text:This is a retrospective study. It was conducted in the Otorhinolaryngology Department, Faculty of Medicine, Zagazig University during the period from October 2018 to January 2021. The sample size is 36 cases were arranged into two groups the first group with preservation and the second group with cut of stapedial tendon and the size of each group is 18 cases. There was no significant difference between both groups in hearing improvement, but there was a significant difference between both groups in post-operative tinnitus improvement and acoustic reflex preservation.Conclusions: Preservation of the stapedial tendon in the surgical treatment of otosclerosis is associated with improvement in functional outcomes, as well as provide the patient with a stapedial reflex that had a primary protective effect against strong acoustic stimuli.Keywords: otosclerosis, stapedectomy, stapedial tendon.

Association Between Postoperative Vertigo and Hearing Outcomes After Stapes Surgery for Otosclerosis

During the postoperative period, most patients with otosclerosis report vertigo and/or nausea caused by interventions within the inner ear. The aim of this study was to evaluate both early and late vertigo associated with hearing improvement after stapes surgery for otosclerosis. The analysis included 170 patients admitted to the hospital undergoing their first surgery for otosclerosis. Audiological diagnostics, surgical techniques, and symptoms reported by the patients were all analyzed. A statistical correlation and an unfavorable influence of late, undesired symptoms, such as vertigo, nausea/vomiting, and nystagmus, on final hearing improvement after surgical treatment of otosclerosis were found. Prostheses that were too long or placed too deep within the inner ear space were the most frequent cause of both vertigo and lack of hearing improvement observed after stapedotomy. A significant negative influence on bone conduction thresholds, particularly at 2000 Hz, was associated with vestibular symptoms persisting for 7 days after the surgery. Symptoms of impaired bony labyrinth function after stapedotomy, persisting for more than 1 year, were associated with insufficient reduction of the air-bone gap and worse improvement in bone conduction thresholds at 1000 and 2000 Hz. The cause of both problems was related to a prosthesis that was too long or placed too deep in the inner ear during stapedotomy.

The Stapes in Otosclerosis: Osteoarthritis of an Ear Ossicle.

Otosclerosis is a pagetoid proliferation of bone remodeling, vascular proliferation, bone resorption and new bone formation in the tympanic region of the temporal bone. The resulting anklyosis of the stapes footplate as it articulates with the oval window is the most common cause of conductive hearing loss in young to middle aged, predominantly Caucasian individuals. The characteristic histologic features have been well documented by autopsy studies of the temporal bone. Although stapedectomy is the surgical treatment for otosclerosis, the stapes specimen may be submitted for gross examination only or not examined at all. A retrospective study of 73 stapedectomy specimens (2008-2019) not including the stapes footplate. Clinical features from the electronic medical record as well as standard histologic sections from surgical specimens were reviewed. Neither the stapedal head nor crura showed histologic features of otosclerosis. There was mild osteoarthritis affecting the head, possibly as a consequence of persistent ossicular vibration superimposed on the ankylosed rigidity. The most common changes were surface fissuring (65%), cartilaginous erosion (49%) and irregularity of the osteochondral interface (51%). An occasional osteophyte (8%) was observed. The ear ossicles, embryologically analogous to long bones of the extremities, develop via endochondral ossification and exhibit articular surfaces of hyaline cartilage. The present observations suggest that a consequence of otosclerotic ankylosis is osteoarthritis of the stapedal head. In this study, the histological features could not be correlated with the severity of hearing loss or duration of clinical disease.

A comparative study of results of stapedotomy and neo-stapedotomy as a surgical treatment for otosclerosis

<p class="abstract"><strong>Background:</strong> The aim of the study was to establish the usefulness of preservation of the stapedius tendon and the incudo-stapedial joint during the surgical procedure for the treatment of otosclerosis, to find out the advantages of neo-stapedotomy over standard stapedotomy and to compare the hearing improvement in neo-stapedotomy and stapedotomy.</p><p class="abstract"><strong>Methods:</strong> A prospective, randomised, controlled study with a sample size of 150 patients (ears) presented with pure conductive deafness, paracusis willisii and tinnitus was done. The patients were divided in to group A (n=60) &and group B (n=90), where neo-stapedotomy and standard stapedotomy procedure were performed respectively. Pure tone audiometry and tympanometry were done both pre and postoperatively. Speech discrimination score (SDS) and loudness discomfort levels (LDL) were measured at 3 months postoperatively. </p><p class="abstract"><strong>Results:</strong> Postoperative hearing improvement in both groups was almost identical. Improvement in middle ear compliance was marginally more in group A patients. Stapedial reflex could be elicited in 72 % of the patients in group A, but remained absent in group B, at 3 month post-operatively. The SDS became worse with more than 20 dB suprathreshold sounds in group B patients whereas it was maintained even with 80 dB in most patients of group A. Post-operative mean LDL for both pure tone and speech frequency in group A patients were higher than those in group B. </p><p class="abstract"><strong>Conclusions:</strong> The difference of SDS and LDL between two groups were statistically significant. Hence, neo-stapedotomy is a better procedure, as no postoperative pseudo-recruitment ‘rollover’ observed and also dynamic range of hearing increased.</p>

ASSESSMENT OF PRESERVATION OF STAPEDIAL TENDON DURING STAPEDECTOMY FOR MANAGEMENT OF OTOSCLEROSIS

Background: Otosclerosis is one of the most common cause of progressive hearing loss in young adults. Otosclerosis is a primary disease of the otic capsule and middle ear ossicles just anterior to stapes footplate which is more specifically. Aim of the work: This study was to evaluate the success rates of stapedectomy with preservation of stapes suprastructure with stapedial muscle tendon compared to stapedectomy without preservation of stapedical muscle tendon in the operative management of otosclerossis. Patients & Methods: This study was conducted in Otorhinolaryngology Department, Faculty of Medicine, Zagazig University during the period from October 2018 to July 2019 on 18 patients with conductive hearing loss. Arranged into two groups, group I with preservation of stapedial tendon and group II with cut of stapedial tendon. Number of each group is 9 patients. Results: There is statistically insignificant difference between two groups as; regard pre and post-operative air conduction, bone conduction, air bone gap. The difference was statistically significant. There was statistically significant difference regarding air conduction of pre and postoperative group I and group II at all frequencies while it was insignificant at 8 KHz . There is statistically significant difference of air bone gap.Conclusions: Preservation of the stapedial tendon in the surgical treatment of otosclerosis is associated with improvement in functional outcomes, as well as provides the patient with stapedial reflex that had primary protective effect against strong acoustic stimuli.

Small Fenestra Stapedotomy Versus Large Fenestra Stapedectomy in Improving Hearing Ability in Patients with Otosclerosis: Our 10Years Experience.

The aim of this study was to review the experience with surgical treatment of otosclerosis over the last 10years at Amrita Institute of Medical Sciences and Research Centre and to compare it with reported outcomes. A total of 125 patients who had reported between January 2008 and June 2018 were selected for the study. The inclusion criteria for the study included the age group 15-60years, conductive hearing loss with intact tympanic membrane and an air-bone-gap (ABG) of more than 30dB. The exclusion criteria included patients below 15years of age and above 60years of age, patients with chronic otitis media and the cases of revision stapes surgery. Audiological evaluation was conducted prior to the surgery and post operative audiological evaluation was also performed after 1month to understand the difference in hearing. In all cases the same surgical technique was used, only the dimension of the foot plate removed varied. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) (version windows base system, SPSS Inc. Chicago IL USA) software. Mean age in years who underwent surgery is 37.8 ± 11.4 and duration of disease in months median 36months (range 1-120months). Of the 125 patients (42% males and 58% females), 73 patients underwent large fenestra stapedotomy, and 52 patients underwent small fenestra stapedotomy. There was significant improvement in the following hearing parameters studied (puretone average of air conduction thresholds-PTA, ABG) in both the groups after surgery. There was no significant difference between the small fenestra and large fenestra groups with respect to improvement in PTA and ABG. On comparison of SDS (pre and post surgery) statistically significant difference was noted only in small fenestra group. However, this difference of SDS was not significant in between group comparison (stapedotomy versus stapedectomy). In summary both techniques are safe and effective treatment for conductive hearing loss in otosclerosis patients. There appears to be no deleterious effects of either procedures on hearing function. Similar results can be obtained in experienced hands using either technique. The absence of serious complications makes it reasonable to perform stapes surgery in both ears in patients with bilateral otosclerosis with conductive hearing loss.

The role of endoscopic stapes surgery in difficult oval window niche anatomy.

The surgical treatment of otosclerosis can be challenging in case of anatomical abnormalities or variations of the oval window niche (OWN) area, as in very narrow OWN or in an overhanging facial nerve. The aim of the present study was to explore the role of endoscopic stapes surgery in cases with difficult OWN anatomy. Patients undergoing endoscopic stapes surgery from 2008 to 2017, which fulfilled the CT scan criteria for a "difficult" anatomical condition, according to the measurements and cut-off values defined in the literature, were retrospectively selected. The intraoperative endoscopic view of the anatomical details and surgical difficulties were analysed through the review of the operative videos. Finally, a statistical analysis of the relationship between endoscopic visualization of anatomical details and radiological measurements was carried out. Eighteen out of 205 patients (8.7%) were included in the study. The 94.4% of patients obtained an optimal endoscopic exposure and visualization of all the anatomical details considered in the study, during each step of stapes surgery. The OWN measurements (width, depth and facial-promontory angle) did not affect significantly the endoscopic surgical exposure of the footplate or any of the other anatomical details. The anatomic features of the oval window area which reduce the visualization in microscopic surgery, did not affect the surgical exposure in endoscopic stapes surgery. Patients having a difficult anatomy of the OWN can be treated safely with the endoscopic approach. In the case of a predicted "difficult anatomy", the endoscopic approach can be considered a viable option.

Кохлеарная имплантация при отосклерозе с IV степенью тугоухости и глухотой

The article presents a literature review devoted to such pathology as otosclerosis with severe hearing loss and deafness. The article describes in details this pathology, research methods, analysis of statistical data and different methods of surgical treatment of otosclerosis with degree IV hearing loss, as well as their results. The article describes the present-day methods of diagnostics and differential diagnostics with other pathologies in the preoperative period in otosclerosis with severe hearing loss and deafness. The experience of various authors in preoperative preparation of patients with otosclerosis with severe hearing loss in cochlear implantation (CI). The detailed analysis of each CI technique, complexity and complications (intraoperative and postoperative), which significantly affects the results of rehabilitation in cochlear implantation in patients with otosclerosis with degree IV hearing loss and deafness. The problem of intraoperative diagnosis of this pathology remains unsolved. The authors suggest various ways of registration of reflexes, however, they are not effective in stapes ankylosis or after stapedoplasty. The article points out the unsolved problems in this pathology that need further development to improve the results of rehabilitation after CI.

A Prospective Study of Efficacy of Small Fenestra Stapedotomy at a South Asian Center

Abstract Introduction The best surgical treatment for otosclerosis is stapedotomy. Various methods are used for creating fenestra, including manual pick, laser, and Skeeter drill. In India, despite several studies on the hearing outcomes of otosclerosis surgery, there exist few studies on small fenestra stapedotomy performed using a microdrill. Hence, we designed this study with the objectives of examining the demographic profile, hearing improvement after surgery, anatomical variations encountered at surgery, effect of microdrill use on bone conduction (BC), and postoperative complications of small fenestra stapedotomy. Methods A prospective study was conducted for 63 patients of otosclerosis. Stapedotomy was performed by the same surgeon on all patients by a transcanal approach under local anesthesia. Small fenestra stapedotomy was performed using Skeeter microdrill. The study proforma included sociodemographic profile, clinical history, examination, audiometry, surgical details, and postoperative findings. Descriptive statistics was used to analyze the data. Results Our study demonstrated a male preponderance (58.7%) over females (41.3%). Of the study population, 31.7% reported a family history of otosclerosis, whereas nine (14.28%) individuals had a history of measles. All four different types of footplates were identified. Most of them were either type 1 (52.4%) or 2 (34.9%). In most cases, the diameter was 0.4 mm (96.8%), a majority of the cases having either 4.25 (22.2%) or 4.5 mm (63.5%) long piston. After stapes surgery, the mean ABG reduced from 39.48 (±9.17) to 13.89 (±7.99) dB. The mean worsening in postoperative BC was only 3.035 dB. Use of microdrill caused only a slight and statistically insignificant decline in BC. Anatomical variation of a narrow oval window niche may require drilling of the bone. In practice, this drilling does not adversely affect the BC of the patient. Some facial nerve variation (partially overhanging facial nerve and exposed facial nerve) may be encountered, but it does not affect the facial nerve function or hearing improvement. On rare occasions, facial paresis may occur on the fifth to sixth postoperative day, even without facial nerve handling. This can be managed conservatively with oral steroids with favorable results. Taste alterations are seen even when the chorda handling is minimal. Complaints are most common in the first few weeks after surgery. Over a 6-month period, only 5% of the patients who underwent surgery were found to have altered taste sensation. Conclusion Microdrill-assisted small fenestra stapedotomy, performed under local anesthesia, with placement of a 0.4-mm Teflon piston for patients with otosclerosis produces excellent results. The complication rates are low, and the surgery has a positive impact on the patient's hearing.

CHIRURGICZNE LECZENIE OTOSKLEROZY U 5-LETNIEGO CHŁOPCA – STADIUM PRZYPADKU

Otosclerosis is most often diagnosed in adults, especially women. It is much less common in children and even rarer in boys. The aim of this paper is to present the case history and results of surgical treatment of a 5-year-old boy with bilateral conductive hearing loss and tinnitus. Results of surgical treatment show mean air-bone closure of 25 dB and cessation of tinnitus. Surgical treatment for otosclerosis is recommended regardless of the patient’s age. Additional motivations for surgical intervention in children are: severe progressive hearing loss, tinnitus, and rising bone-conduction threshold.

Comparison of Videonystagmography and Audiological Findings after Stapedotomy; CO2 Laser vs Perforator.

Various types of laser, microdrill, and perforator are effectively used in the surgical treatment of otosclerosis. However, they have certain disadvantages along with advantages. The aim of this study was to evaluate the effects of carbon dioxide (CO2) laser and perforator stapedotomy techniques on audiological outcomes and postoperative vestibular functions via videonystagmography (VNG). This prospective and randomized clinical study was conducted in an academic tertiary medical center. Sixty-nine patients diagnosed with otosclerosis who underwent stapedotomy were enrolled in this study. Patients were divided into two groups based on the technique used in stapedotomy: CO2 laser and perforator. Postoperative hearing gain and VNG findings were the main outcome measures. Subsequently, the two study groups were compared for analysis. The preoperative air-bone gap was 32.7±8.9 decibel (dB) in the study population and it was improved to 12.9±8.4 dB after operation. There were no differences in VNG findings and vertigo symptoms between the laser and perforator groups at postoperative day 2. There was no significant gain difference regarding the air conduction, bone conduction, and air-bone gap between the two groups (p=0.294, p=0.57, and p=0.37, respectively). Both CO2 laser and perforator stapedotomy have successful audiological outcomes with no difference in postoperative vestibular disturbance.

Surgery for Otosclerosis: Results on 508 Patients

Objective: The objective of our paper is to evaluate the hearing results after surgical treatment of otosclerosis from a retrospective analysis of 649 procedures performed by the same surgeon (484 stapedotomies, 69 total stapedectomies, 26 partial stapedectomies, and 70 revisions). We also evaluated the hearing improvement in patients with far-advanced otosclerosis. Method: We conducted a retrospective study on 649 operations performed on 508 patients between 1998 and 2005. The approach was endoaural under local anesthetic. Audiological evaluation has been performed according to the Committee on Hearing and Equilibrium–AAO-HNS guidelines. Results: We found results better after stapedotomy than stapedectomy with a postoperative ABG within 10 dB in 89.67% after stapedotomy, in 85.51% after total stapedectomy, and in 84.62% after partial stapedectomy. Stapedotomy was most reliable in the variation of the BC for high tones; we had a worsening of BC in 17.56% after stapedotomy and in 21.74% after stepedectomy. After revision surgery the outcomes were worse than primary surgery, with an ABG within 10 dB in 85.36% after revision of stapedotomy and in 82.76% after revision of stapedectomy. In far advanced otosclerosis, we obtained a mean postoperative ABG within 10 dB in 86.32%. Conclusion: This study confirmed stapes surgery allows for a good restoration of hearing function in a high percentage of cases with slightly better results after stapedotomy. Time of surgery is fundamental for recovery of hearing function since the outcomes are better in patients without sensorineural hearing loss.

Functional hearing results in patients with otosclerosis before and after stapedotomy

Surgical treatment of otosclerosis with stapedotomy leads to the improvement of subjective and objective problems in patients with otosclerosis. A prospective study included patients who had been treated surgically at the Department for Ear, Nose and Throat in Novi Sad in the period from September 2006 to September 2007. On the basis of the appropriate diagnostic procedures, 33 patients were diagnosed with otosclerosis. Functional hearing was assessed before and after surgery by means of pure tone audiometry. The comparison of functional results before and after surgery revealed no changes in pure tone average of bone conduction threshold (average hearing threshold for hearing range), whereas pure tone average of air conduction and pure tone average of the gap showed statistically significant improvement. The results of this study demonstrated the applicability of stapedotomy as a method for successful management of otosclerosis. This way of examination offers a new perspective on patients' health, which should be defined as a physical, psychosocial and social well-being, and not only the absence of a disease itself.

The influence of postoperative tissue formation on sound transmission after stapes surgery

In the surgical treatment of otosclerosis, the coupling between the stapes prosthesis and the long process of the incus is critical. After surgery, connective tissue and mucosa may grow over the coupling area and thereby influence the sound transmission properties of the incus–prosthesis interface.It was the hypothesis of this study that tissue ongrowth in the incus–prosthesis interface has little influence on sound transmission following stapes surgery. The goals of the study were to: (1) investigate the extent of postoperative tissue ongrowth over the stapes prosthesis; (2) objectively evaluate intra- and postoperative sound transmission properties of revision stapes surgery and compare the findings to those from primary surgery; (3) quantify the influence of ongrown tissue on sound transmission after stapes surgery.A group of 10 patients undergoing revision stapes surgery was investigated with audiological evaluations and intraoperative laser Doppler interferometry, and with scanning electron microscopy of the explanted incus with its adherent prosthesis in 6 patients. Results were compared to a group of patients undergoing primary otosclerosis surgery and temporal bone experiments.Results indicated that tissue grows over the prosthesis, as identified in all specimens. Sound transmission properties were evaluated intraoperatively (i.e., incus mobility and prosthesis-fixation quality), and found to correlate well with the functional hearing results. Ongrowing mucosa in the incus–prosthesis interface had only a minimal effect on sound transmission properties and cannot compensate adequately for insufficient prosthesis fixation. Therefore, it is essential that the stapes prosthesis is properly fixed during primary otosclerosis surgery.

Surgical treatment of otosclerosis in medical residency training

The number of patients with stapes otosclerosis compared to the number of otorhinolaryngologists has declined over the past several years. As a result a controversy has arisen in the literature, whether or not stapes surgery should be included in residency programs. the objective of the present study is to evaluate the results and complications of estapedotomies performed by residents between January, 1997 and January, 2000, and consequently study the feasibility of including estapedotomies in residency programs. STUD DESIGN: retrospective review of prospectively collected audiometric data. fifty charts of patients that were submitted to a total of 51 primary stapedotomies were reviewed mainly for complications and audiological results. there was closure of the air-bone gap within 10 dB HL in 70.5% of ears and closure to within 20 dB HL in 86.3% of ears. There was one ear with total hearing loss (2%). From the results and complications seen in the present study, and analyzing papers from the literature, it is possible to conclude that stapedotomy is a procedure that can be included in residency programs, if there are surgical cases for the residents.

Surgical treatment of otosclerosis in elderly patients

Objective The aim of this study was to analyze hearing results of stapes surgery in otosclerotic patients older than 65 years. Study design Among 473 primary stapedectomies, 16 were performed in patients over 65 years old and were retrospectively reviewed. Hearing results were compared with those of a randomly selected group of 16 patients younger than 65 years old. Results Improvement in hearing (closure of the air-bone gap to <20 dB) was achieved in all of the cases, and closure of the air-bone gap to less than 10 dB occurred in 87.5% at 1 month and in 81.8% at the last evaluation (mean follow-up, 19.5 months). Hearing results were similar in elderly and younger patients. Conclusion and significance Stapes surgery is an effective procedure in elderly patients with otosclerosis to avoid hearing aid use or to facilitate hearing aid fitting.

Long-term results in otosclerotic patients operated by stapedectomy or stapedotomy

Stapedectomy and stapedotomy are the techniques currently used in the surgical treatment of otosclerosis. During the period 1977-81, a total of 60 consecutive patients were subjected to surgery for otosclerosis according to the method of Schuknecht (Gelfoam and wire prosthesis). Another 55 consecutive otosclerotic patients were operated on during 1987-91with stapedotomy, according to the method advocated by Fisch (Fisch-type piston). Independent of the surgical technique used, the maximal hearing gain was obtained 1 year after surgery. In the frequency range 0.5-3 kHz, the mean value of the averaged pure tone thresholds improved from 52 to 28 dB in the stapedectomy group and from 57 to 26 dB in the stapedotomy group. In the frequency range 4-6 kHz, the subjects' hearing was not significantly improved in the stapedectomy group, whereas the subjects' hearing in the stapedotomy group improved from 61 to 44 dB. Per- and postoperative complications were low in both groups, except for one patient in the stapedectomy group who experienced the serious complication of a deaf ear after surgery.

Laser stapedotomy technique

The surgical treatment of otosclerosis has been one of the most successful operations in any surgical field and an exciting chapter in otologic surgical history. The use of the laser to remove the superstructure of the stapes and to create the footplate fenestra represents the latest in the continuum of refinements in making the procedure safer and with reduced morbidity. In laser stapedotomy there are many details and nuances that make the procedure more successful for all levels of technical expertise. This communication describes surgical preparation of the patient and the surgeon, and the operative technique currently employed by the author in the laser stapedotomy procedure. It provides a highly graphic depiction of the steps in the procedure along with a description of specific instrumentation employed in each step. Management of special circumstances such as overhanging facial nerve, narrow niche, obliterated and floating footplates are discussed.