Total Stapedectomy Research Articles

Revision stapes surgery.

This paper reports on the analysis of 332 otosclerosis revision operations. The results have been evaluated with reference to the type of the procedure at primary surgery, the alleged cause of failure and the applied technical solution. The need for revision surgery was found higher after primary total stapedectomy (3.4 per cent) than after partial stapedectomy (2.2 per cent) or stapedectomy (two per cent). The reason for revision varied according to the originally applied technique eg a migrated piston, a too short piston and a lateralized graft are almost exclusively found after total stapedectomies. The median hearing gain after revision of stapedectomy and partial stapedectomy was higher (20 dB and 18 dB respectively) than that after revision surgery for total stapedectomy (12 dB), but significantly lower than hearing gain after primary surgery (32 dB). Revisions yielded better results in the case of primary interventions with the use of a piston or pistonwire than in the case of primary interventions with a wire-type prosthesis. The risk for sensorineural loss (one per cent) was not higher than in primary surgery.

Hearing Results in Otosclerosis Surgery after Partial Stapedectomy, Total Stapedectomy and Stapedotomy

Hearing results in a consecutive series of 407 patients with otosclerosis undergoing primary stapes surgery were analysed (437 operated ears). Partial stapedectomy was performed in 70 ears (16%), total stapedectomy in 205 ears (47%), in both groups using the House steel wire prosthesis on fascia in the oval window. The remaining 162 ears (37%) underwent stapedotomy using the Fisch 0.4 mm teflon-platinum piston. No case of cochlear loss (>15dB) occurred in the total series. The comparison between the three groups one year postoperatively showed that the air-bone gap was smaller for partial and total stapedectomy for all frequencies except 4 kHz. The air-bone gap was calculated as the difference between the preoperative bone conduction and the postoperative air conduction thresholds. Partial and total stapedectomy also showed larger improvements of bone conduction thresholds compared with stapedotomy for all frequencies but 4 kHz. At the 3-year follow-up, the hearing gain for all frequencies (250-8000 Hz) was larger for partial and total stapedectomy. Yet, when comparing the decline of hearing from 1 to 3 year postoperatively, the hearing gain achieved with partial and total stapedectomy seemed to deteriorate at a higher rate, which was considered to be caused by impaired sensorineural function. Our results show that in the short-term perspective partial or total stapedectomy can still compete for better hearing results even at higher frequencies, but stapedotomy seems to yield more stable hearing results over time and should therefore be considered as the method of choice.

The phenomena of time coincidence of change-point periods in different derivations of EEG

Analysis of indications for stapes revision surgery in patients qualified for the secondary procedure at the Otosurgery Dept. Medical University of Lodz.25 cases of stapes revision surgery out of the 385 total treated surgically otosclerosis cases are discussed.In group A (patients after total stapedectomy) the following indications for the secondary surgical procedure were observed: 12 cases – platinum wire prosthesis displacement with ossicular chain discontinuity; 3 cases – perichondrium or adipose tissue atrophy; 2 cases of incudo-stapedial joint luxation. Group B was composed of 8 patients after stapedotomy (teflon piston operation, 0.6 mm).1. The most common indication for the stapes revision surgery in patients after total stapedectomy were prosthesis displacement and necrosis of the long crus of the incus. 2. Obliteration of the stapes footplate after small fenestra operation was observed in our material to be the most frequent indication for the secondary stapes procedure.

Statistical analysis of otosclerosis surgery performed by Jean Marquet.

The early and long-term hearing results of 1,681 primary otosclerosis operations performed by the same surgeon, Jean Marquet, were reviewed retrospectively and analyzed with very strict statistical standards. Significantly better short- and long-term results were achieved with the stapedotomy technique compared to total stapedectomy, mainly at the higher frequencies (4 and 8 kHz) important for speech discrimination. Whatever technique was used to open the footplate (micropick, microdrill, or laser), no statistical audiometric difference could be found. The results were equal whether or not the stapedial tendon was preserved. Perioperative problems like pronounced oozing, difficult anatomic relationships, and accidental perilymph aspiration could affect hearing at higher frequencies. The calibrated hole technique was equally as good as conventional oval window sealing in sealing of the fenestra to prevent fistula. The stapedotomy technique was found the safest, having fewer complications.

Evolution Of Techniques Of Stapedectomy From The Total Stapedectomy: TO THE SMALL FENESTRA STAPEDECTOMY

No consensus exists among surgeons about how much of the footplate to remove in stapes surgery. By comparing ideal cases with identical surgical techniques, it may be possible to select an optimal amount of the stapes footplate to remove. This article details the evolution of techniques of stapedectomy from the total stapedectomy to the small fenestra stapedectomy.

Change of bone conduction thresholds by total footplate stapedectomy in relation to age

Introduction: The influence of age on threshold changes of bone conduction after stapedectomy has not been thoroughly studied. Improvement of the Carhart notch by stapes surgery might be related to age as well as an increase in cochlear sensitivity to surgical trauma. Patients and Methods: A retrospective study on the outcome of stapedectomy was undertaken. The results of surgery performed on 387 ears in 315 patients for otosclerosis between 1962 and 1989 were obtained. Stapedectomy, performed by a single surgeon, consisted of total stapedectomy, seal of the oval window with tragal perichondrium, and insertion of a free tragal cartilage graft. Results: Analysis of bone conduction changes with stapedectomy shows an average improvement of 5 to 6 dB at 0.5, 1, and 2 kHz with best improvement at 2 kHz. At 4 kHz a mean decrease of 4 dB is recognized. The improvement of bone conduction at 2 kHz is 12 dB in patients younger than 30 years compared with 4 dB in patients older than 60 years ( P < .05). The youngest group was improved by 2 dB at 4 kHz, whereas the oldest group deteriorated by 5 dB ( P < .05). Age relationship was apparent in all 4 frequencies. Concluslons: With increasing age there is less improvement in bone conduction at 0.5, 1, and 2 kHz with correction of the Carhart notch and more deterioration at 4 kHz. The cochlear sensitivity to surgical trauma increases with age. In younger patients the preoperative bone conduction levels do not reflect the true cochlear reserve. Patients younger than 40 years of age might profit more from a partial or total footplate removal in stapedectomy, as this better corrects the Carhart notch. Patients older than 40 years of age might profit more from a stapedotomy as this better preserves high frequencies.

Mechanics of the middle ear in otosclerosis and stapedoplasty.

Seventy-three otosclerotic patients, 138 subjects who had undergone stapes surgery (50 total stapedectomies, 43 stapedotomies with stapedius tendon section and 45 stapedotomies with stapedius tendon preservation) and 70 normal controls were investigated by susceptance multiple frequency tympanometry. The aims were to evaluate the efficiency of this procedure in diagnosing otosclerosis and to assess the resonance properties of middle ears undergoing different types of stapedectomy. Tympanometry was performed using sweep frequencies ranging from 226 to 2,000 Hz for each pressure step of 12.5 daPa (pressure range from -500 to 400 daPa). The resonance frequency of the system was evaluated by identifying the "W" morphology of susceptance tympanograms. The results of the present investigation indicate that stapes surgery abnormally reduces the stiffness of the tympano-ossicular system. This phenomenon is limited by preservation of the stapedius tendon, which confers a significant degree of stiffness on the conductive system.

The influence of age on the results of stapedectomy.

In a retrospective study, we investigated the results of 384 stapedectomies performed between 1962 and 1989. The purpose was to determine the possible influence of age on the postoperative functional result. The operative technique uniformly consisted of a total stapedectomy, seal of the oval window with perichondrium and replacement of the stapes by a free tragal cartilage graft. The audiometric data at 0.5, 1, 2, and 4 kHz were compared. The patients were divided into five groups based upon chronological age: under 30, 30-40, 41-50, 51-60, over 60 years. Although the preoperative airbone gap (ABG) increased with age at all frequencies, and thus the chance for surgery to improve the ABG, the youngest group showed the best improvement in ABG (P less than 0.05). Using a technique with total removal of the footplate, bone conduction thresholds improved in the frequencies up to 2 kHz. At 4 kHz, they deteriorated in the four oldest groups. The greatest improvement in bone conduction thresholds occurred in the youngest group of patients (P less than 0.05), with a parallel decline in age and postoperative results occurring. The causes of these differences are not yet clear, although spontaneous recovery and greater resistance to operative trauma in the younger age groups might be of influence.

Improvement in Hearing and Incidence of Complications Following Three Types of Stapes Surgery

We reviewed the records of 80 patients who had undergone stapes surgery over the past 10 years and who had been followed for more than 6 months at Nagoya University Hospital. They were divided into three groups: those who received total stapedectomy using a wire loop (29), those who received a large fenestra stapedotomy using a 0.6 mm Teflon wire piston (39), and those who received a small fenestra stapedotomy using a 0.3 mm Teflon piston (12). The decline in the air conduction threshold and closure of the air-bone (A-B) gap were used as indices of postoperative improvement in hearing. The postoperative elevation of bone conduction threshold at 4 and 8 kHz was used as an index of inner ear damage caused by the surgery. The postoperative hearing improvement at four speech frequencies between the three types of stapes surgery did not differ significantly. At 4 and 8 kHz, postoperative bone conduction was elevated significantly in the patients who received total stapedectomy as compared with those who underwent a large or small fenestra stapedotomy.

Hearing Gain after Stapedotomy, Partial Platinectomy, or Total Stapedectomy for Otosclerosis

The differences in hearing gain 1 year after stapedotomy, partial platinectomy, or total stapedectomy for otosclerosis were studied separately at 0.5, 1, 2, 4, and 8 kHz with the data available from 311 consecutive primary operations performed between 1980 and 1982 in the University of Nijmegen Department of Otorhinolaryngology. Three groups of patients were matched for age, sex, clinical type of otosclerosis, and type of 0.6-mm all-Teflon piston. The hearing gain for air conduction was significantly better by an average of 7.4 dB for all frequencies combined after either stapedotomy or partial platinectomy compared to total stapedectomy.

Chondrogenic potential of tragal perichondrium: A cause of hearing loss following stapedectomy

Tragal perichondrium is a widely used tissue seal in the oval window following stapes surgery. Autogenous and easily accessible, it is a suitable substance to cover the vestibule in total stapedectomy, and to seal around the prosthesis in small-fenestra stapedotomy. The incidence of complications from the use of perichondrium in this manner is exceedingly low. We report a case where tragal perichondrium in the oval window resulted in the proliferation of cartilage. The cartilage displaced the stapes prosthesis, resulting in a conductive loss. Although the chondrogenic potential of perichondrium is known, we are not aware of other reports implicating this as a cause of failure in stapes surgery. The pertinent clinical and experimental literature regarding chondrogenesis is reviewed. This information suggests that the formation of cartilage from perichondrium in the oval window might be influenced by mechanical trauma and tissue orientation.

Small fenestra Stapedectomy (S.F.S.) or Stapedotomy—A. review

Stapedectomy opration has withstood the test of time and is now a standard operation for the last 3 decedes Different methods of Stapedectomy performed are : (1) Total Stapedectomy (L.F.S.); (2) Partial Stapedectomy : and (3) Small fenestra Stapedectomy (S.F.S.) or Stapedotomy. The immediate success rate is practically same in all the above techniques, but it has been observed that incidence, of inner ear hazards are less in S. F. S. compared to L.F.S. in delayed and long term post-operative period. Incidence of perilymph fistula is practically nil in case of S.F.S. compared to 4% in L. F. S. In overall long term result the success rate of Stapedectomy appears to be better (94%) in S. F. S. compared with 86% in L. F. S.

Stapedectomy in residency training.

The number of new patients with otosclerosis seen by the average otolaryngologist has declined over the past several years. As a result, a controversy has arisen regarding the ability to train residents adequately in the technique of stapedectomy. In this regard, we have analyzed 44 consecutive stapedectomies performed by senior residents, under direct faculty supervision, at the University of California, San Francisco. All procedures were total stapedectomies, performed under local anesthesia, utilizing either wire-vein or wire-perichondrium technique. Four of the ears required footplate or promontory drilling. Closure to within 10 dB of the preoperative bone conduction, averaged over the speech frequencies of 500, 1000, and 2000 Hz, was achieved in 75% of ears, and closure to within 20 dB in 93% of ears. In no patient was hearing made worse. While there were no permanent complications, self-limited problems occurred in 9% of the procedures. Despite a declining caseload of otosclerotic ears in residency programs, it is possible to train residents safely in stapes surgery, given a program of consistent technique and close faculty supervision.

Poor high frequency results following total stapedectomy—Theoretical considerations

Theoretical considerations behind the lack of satisfactory improvement at high frequency of 4000 Hz, 6000 Hz and 8000 Hz are discussed. A small fenestra and a correct fitting prosthesis seems to be giving better high frequency results.

Autogenous cartilage—Perichondrium stapes replacement prosthesis

An inexpensive autogenous cartilage—perichondrium-complex prosthesis (SRP—Stapes Replacement Prosthesis), constructed from the tragal cartilage, which is easily and readily available under local anesthesia, for replacing the stapes after total stapedectomy, is presented. It provides a good oval window seal and an excellent ‘canoe’-‘mast’ sound transmitting mechanism. The postoperative improvement in hearing is as good as and comparable to that following other available methods. Being an autogenous prosthesis there is no rejection or immune reaction in the internal ear leading to sensorineural deafness. It is superior to the other techniques in-so-far as (a) there is no possibility of the SRP perforating into the inner ear leading to sensorineural deafness and (b) there is no chance of pressure necrosis of the incus since there is no jeopardy to the blood supply to the bone.

Silastic implants in the ears of cats.

Silastic was examined in experiments on cats in order to determine its inertness in the ear and to assess its possible usefulness in middle ear and oval window surgery. The results indicated that properly prepared Silastic sheeting is inert in the meso-tympanum and may have a useful part to play in tympanoplasty by promoting regeneration of mucosa and lessening of adhesions. Its usefulness in the confined spaces of the attic was less certain. Silastic sponge inserted after total stapedectomy provided inadequate protection of the internal ear and was associated with a high incidence of cochlear degeneration. Insertion of a Silastic piston after a stapes footplate fenestration was likewise associated with severe internal ear damage.

Management of the ossicles in tympanoplasty. Consideration of techniques.

In many situations of tympanoplasty, it is difficult to maintain or reestablish ossicular continuity while at the same time achieve adequate exposure for removal of disease. Methods of assessing and treating the ossicles in tympanoplasties Types I, III and IV are discussed. A special situation occasionally occurs where the ossicles are normal and intact in the presence of extensive middle ear disease. A technique can be used which affords a wide middle ear exposure. It consists of removing and subsequently replacing an anterior canal skin flap, drum, malleus and incus as a “unit”. In addition, special situations requiring Type V tympanoplasty using a total stapedectomy approach are discussed.

THE STAINLESS STEEL PISTON. SURGICAL INDICATIONS AND RESULTS.

In recent months much attention has centered on the use of piston-shaped prosthetic devices constructed of Teflon, steel, and Teflon-steel in surgery for clinical otosclerosis.^1,2The surgical philosophy determining the use of these prostheses differs with the clinical experience of the surgeon. It is the intent of this paper to review the development of one of these prosthetic devices (the stainless steel piston), to discuss the indications and surgical technique employed in its use, and to present the clinical data accumulated after one-and-a-half year's experience. <h3>Development of the Stainless Steel Piston</h3> The present use of this prosthetic device can be more fully appreciated if a study of 401 consecutive total stapedectomies followed for a two-year period is briefly reviewed. The operative technique employed in these cases was, with minor variations, the classical wire technique as originally described by Dr. H. F. Schuknecht.³Previously enumerated surgical principles concerning stapedectomy

A NEW STAPEDECTOMY PROSTHESIS.

The prosthesis is designed as a substitute for the stapes bone following total stapedectomy for otosclerosis. It consists of a metal prosthesis of SMO 316 stainless steel, having at one end a loop for attachment to the incus and, at the other, a piece of dry Gelfoam. The diameter of the steel prosthesis is 0.004 inches, and the shaft is made in lengths of 4, 4.5, and 5 mm. The Gelfoam, which has been firmly knotted to the prosthesis, measures 3×2 mm in size. Dr. Howard House appears to have demonstrated adequately that the tissue membrane which replaces the Gelfoam is adequate protection against bacterial invasion of the inner ear. The insert is removed from the sterile package, and the Gelfoam is grasped in the tips of the gloved thumb and forefinger. Two or three drops of Ringer's, or similar solution, is placed on the Gelfoam with a medicine dropper,

IRRIGATION OF OPEN VESTIBULE IN STAPES SURGERY. A CLINICAL AND EXPERIMENTAL STUDY.

Postoperative cochlear loss and recession of hearing due to bony closure of the oval window are the two major problems in stapes surgery today, just as they were in the days of classical fenestration. Although most authors report a higher incidence of cochlear problems in total stapedectomy procedures than in those in which the vestibule is opened less widely, there is little agreement as to other factors responsible for cochlear losses in stapes surgery. Shambaugh and Takahara, 1 in a study in 1955 of cochlear pathology after fenestration, found a significantly higher incidence when bleeding into the fenestra was greater and when infection of the postoperative cavity was noted. House 2 noted an increase in the incidence of cochlear losses after stapes operations when organisms were cultured from the middle ear during surgery. He also suggested that the use of Gelfoam rather than tissue grafts to close the oval window