Comparison of Outcomes with the Use of Different Heat-Activated Crimping Prostheses in Stapedotomy.

OBJECTIVE: To determine differences in failure rate and hearing outcomes of a completely encircling heat-activated crimping prosthesis (SMart 360°) compared to partially encircling prosthesis (SMart). STUDY DESIGN: Retrospective chart review. SETTING: Private neurotology tertiary referral center. PATIENTS: Patients who underwent stapedotomies performed by the senior authors from 2008 to 2019 using the SMart prosthesis and SMart 360° prothesis. INTERVENTIONS: Stapedotomy operations with placement of a SMart or SMart 360° prosthesis. MAIN OUTCOME MEASURES: Incidence of early failure requiring revision surgery. Differences in preoperative air-bone gap (ABG) compared to postoperative ABG at 3 months, 1 year, and 2 years after surgery. RESULTS: A total of 228 stapedotomies were performed (SMart n = 48 and SMart 360° n = 180). Mean preoperative ABG for SMart and SMart 360° were 26.15 and 29 dB, respectively. The mean difference in ABG for the SMart at 3 months, 1 year, and 2 years were 17, 18, and 11 dB, respectively. The mean difference in ABG for the SMart 360° at 3 months, 1 year, and 2 years were 20, 20, and 19 dB. ABG differences at 3 months (p = 0.10) and 1 year (p = 0.36) were not statistically different. The failure rate for the SMart prosthesis was 12.5% and for the SMart 360° 2.2% (p = 0.002). CONCLUSIONS: There were no statistically significant differences in ABG changes for SMart compared to SMart 360°. The Smart 360 corrects the problem with early failure seen with the Smart prosthesis. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Determination of most efficacious stapes prosthesis. LEARNING OBJECTIVE: Which stapes prosthesis produces better hearing results with fewer failures. DESIRED RESULT: To disseminate information necessary to choose the best stapes prosthesis for patients. LEVEL OF EVIDENCE: Level III. INDICATE IRB OR IACUC: 2022-029-agh.

[Analysis of the efficacy of fiber laser stapes fenestration in the treatment of 58 cases of otosclerosis and ossicular malformation].

Objective: To explore the surgical efficacy of conductive deafness caused by otosclerosis and ossicular malformation with 980 nm fiber laser stapedial floor fenestration. Methods: Data of 58 patients (ears) who were diagnosed with conductive deafness caused by otosclerosis (49 ears) and ossicular malformation (9 ears) treated by 980 nm Diode laser small-fenestra stapedotomy were retrospectively analyzed. Air conduction (AC) thresholds, bone conduction (BC) thresholds, and air-bone gap (ABG) at 0.5, 1, 2, 4 kHz pure tone frequencies were compared before and 3 months after surgery, and the advantages and precautions of 980 nm fiber laser were summarized. Paired t-test (SPSS 26.0 software) was use to analyze the listening data. Results: Fiber optic laser stapes fenestration and artificial stapes implantation were successfully completed in all 57 cases (ears), the hearing of another one patient (ear) with floating malformation of detachment of stapedial floor was lower than that before surgery. Preoperative at 0.5, 1, 2, 4 kHz frequencies of AC thresholds, BC thresholds, and ABG were (65.4±9.7) dB, (27.2±8.9) dB, and (38.2±9.8) dB respectively. Postoperative 3 months at the same frequency of AC thresholds, BC thresholds, and ABG were (42.1±11.3) dB, (26.9±6.6) dB, and (15.2±9.1) dB. Preoperative and postoperative of AC threshold and ABG were statistically significant at 0.5, 1, 2, 4 kHz (t value was 13.270 and13.948, both P<0.01), and yet the BC threshold was not statistically significant before and after surgery at the same frequency (t=0.418, P>0.05). Conclusions: 980 nm fiber laser stapes floor fenestration is an effective treatment for conductive deafness caused by otosclerosis and ossicular malformation.

Comparing the Quality of Life and Hearing Thresholds Following Stapedectomy Versus Laser Stapedotomy with NiTiBOND Piston.

The purpose of this study was to examine the quality of life (QoL) and hearing thresholds of patients who underwent 2 types of stapes surgery. A retrospective cohort study was performed comparing stapedotomy with NiTiBOND prostheses (n=20) and stapedectomy with autogenous cortical bone columella (n=20), applying the Glasgow Benefit Inventory (GBI) and the Hearing Handicap Inventory for Adults outcome measures with hearing thresholds. Univariate comparative statistical methods were applied. The stapedotomy cohort had significantly better values of Social Support Score of the GBI as compared to the stapedectomy cohort (P=.016). No statistically significant difference was detected between the groups in the pre- and postoperative audiological results and the further QoL measures. Apart from the excellent postoperative audiological results of the different types of stapes surgeries, stapedotomy with NiTiBOND prostheses seems to be superior as regards QoL over stapedectomy applying autogenous cortical bone columella.

Modified stapes surgery for otosclerosis: An evaluation of auditory results and postoperative complications.

BACKGROUND: The senior author Shiao, had introduced a modified version of the traditional stapes surgery, called minimally traumatic stapes surgery (MTSS), and explored its effectiveness in reducing postoperative vertigo. However, MTSS exhibited no significant breakthrough in terms of audiometric results. Building upon the original MTSS through slight modifications and the use of the Medtronic Big Easy ® Piston as the prosthesis, this study evaluates a refined version of the original MTSS technique. In particular, this research sought to investigate the impact of this refined approach on hearing outcomes and postoperative complications among patients diagnosed with otosclerosis. METHODS: This research comprehensively examined the medical records of individuals diagnosed with otosclerosis who underwent MTSS. The postoperative outcomes assessed encompassed hearing outcomes and the occurrence of any new complications. RESULTS: Overall, 95 patients diagnosed with otosclerosis (comprising 106 affected ears) underwent MTSS. Significant improvements in both the average air conduction threshold (40 ± 16.82 dB after vs 60 ± 14.56 dB before surgery; p < 0.0001) and average air-bone gap (11.99 ± 7.24 dB after vs 29.65 ± 9.47 dB before surgery; p = 0.003) were observed after the surgery. Conversely, no significant change in the average bone conduction threshold was observed after the procedure (28 ± 13.81 dB after vs 29 ± 12.31 dB before surgery; p = 0.149). Among the 106 affected ears, 102 showed postoperative air-bone gap measurements <20 dB, indicating an impressive 96.2% overall hearing improvement. Notably, only a few postoperative complications were observed, including vertigo, chorda tympani injury, facial weakness, and a slight hearing deterioration. CONCLUSION: The refined MTSS technique promoted significant postoperative hearing improvements with minimal complications. This approach showed potential for addressing the surgical challenges in Asian patients with otosclerosis, emphasizing the importance of further research on this advanced procedural method.

Stapedotomy Versus Cochlear Implantation for Far Advanced Otosclerosis: Insights From a Patient With Matched Preoperative and Postoperative Function.

OBJECTIVE: To examine patient preference after stapedotomy versus cochlear implantation in a unique case of a patient with symmetrical profound mixed hearing loss and similar postoperative speech perception improvement. PATIENTS: An adult patient with bilateral symmetrical far advanced otosclerosis, with profound mixed hearing loss. INTERVENTION: Stapedotomy in the left ear, cochlear implantation in the right ear. MAIN OUTCOME MEASURE: Performance on behavioral audiometry, and subjective report of hearing and intervention preference. RESULTS: A patient successfully underwent left stapedotomy and subsequent cochlear implantation on the right side, per patient preference. Preoperative audiometric characteristics were similar between ears (pure-tone average [PTA] [R: 114; L: 113 dB]; word recognition score [WRS]: 22%). Postprocedural audiometry demonstrated significant improvement after stapedotomy (PTA: 59 dB, WRS: 75%) and from cochlear implant (PTA: 20 dB, WRS: 60%). The patient subjectively reported a preference for the cochlear implant ear despite having substantial gains from stapedotomy. A nuanced discussion highlighting potentially overlooked benefits of cochlear implants in far advanced otosclerosis is conducted. CONCLUSION: In comparison with stapedotomy and hearing aids, cochlear implantation generally permits greater access to sound among patients with far advanced otosclerosis. Though the cochlear implant literature mainly focuses on speech perception outcomes, an underappreciated benefit of cochlear implantation is the high likelihood of achieving "normal" sound levels across the audiogram.

Endoscopic-Assisted Cochlear Implantation in Far Advanced Otosclerosis.

OBJECTIVES: To evaluate the effectiveness of cochlear implantation (CI) in case of far advanced otosclerosis and to evaluate the value of using intraoperative otoendoscopy to facilitate the identification of the round window membrane and the scala tympani without the need to remove the posterior canal wall or to perform a subtotal petrosectomy. STUDY DESIGN: Retrospective case-series study. SETTING: Tertiary academic CI center. PATIENTS AND METHODS: This study was conducted on patients with far advanced otosclerosis who underwent endoscopic-assisted CI between January 2010 and June 2020 at the same CI center. The minimum follow-up period was 2 years after surgery. RESULTS: Fourteen patients were included in the study. Ten patients had undergone a previous stapedotomy. Electrode insertion in the scala tympani was successfully accomplished in all cases included in the study. There was a statistically significant improvement in pure-tone average and speech discrimination scores in all cases of the study group (p < 0.0001). There were no statistically significant differences in postoperative pure-tone average or speech discrimination scores between cases with and without cochlear ossification or between cases with and without a previous stapedotomy (p > 0.05). CONCLUSION: Endoscopic-assisted CI is an effective option for hearing restoration in patients with far advanced otosclerosis. Otoendoscopy can facilitate visualization and access to the scala tympani without the need to remove the posterior canal wall or to perform a subtotal petrosectomy.

Surgical decision-making in superior canal dehiscence syndrome with concomitant otosclerosis.

OBJECTIVE: The diagnosis and management of Superior Canal Dehiscence Syndrome (SCDS) with concomitant otosclerosis can be a challenge. Otosclerosis can mask SCDS symptoms and stapes surgery may reveal or exacerbate vestibular symptoms. Our aim is to present four cases of SCDS with concomitant otosclerosis and thereby informing the reader about the possibility of this dual occurrence and its implications for treatment. CASES: Four patients with SCDS and concomitant otosclerosis are presented. Two patients underwent surgical treatment for both SCDS and otosclerosis and two patients opted for conservative management. OUTCOMES: The main differences between surgically and non-surgically treated cases are the presence of autophony and pressure-induced vertigo and a more severe experience of symptoms in surgically treated cases. Surgically treated cases achieved a sizeable reduction in postoperative air-bone gap and resolution of vestibular symptoms. CONCLUSION: The subjective severity of symptoms in combination with shared decision-making is key in determining the appropriate treatment plan for SCDS and concomitant otosclerosis.

Audiometric and Vestibular Function after Classic and Reverse Stapedotomy.

Background and Objectives: Besides classical stapedotomy, reverse stapedotomy has been used for many years in the management of otosclerosis. Our study aims to investigate whether reversing the surgical steps in stapedotomy impacts vestibular function and hearing improvement. Materials and Methods: A cohort of 123 patients underwent either classic or reverse stapedotomy procedures utilizing a fiber-optic argon laser. Audiological assessments, following the guidelines of the Committee on Hearing and Equilibrium, were conducted, including pure tone average, air-bone (AB) gap, overclosure, and AB gap closure. Vestibular evaluation involved pre- and postoperative comparison of rotatory test parameters, including frequency, amplitude, and slow phase velocity of nystagmus. Results: The study demonstrated an overall median overclosure of 3.3 (3.3, 5.0) dB and a mean AB gap closure of 20.3 ± 8.8 dB. Postoperative median AB gap was 7.5 (7.5, 11.3) dB in the reverse stapedotomy group and 10.0 (10.0, 12.5) dB in the classic stapedotomy group. While overclosure and AB gap closure were marginally superior in the reverse stapedotomy group, these differences did not reach statistical significance. No significant disparities were observed in the frequency, slow phase velocity, or amplitude of nystagmus in the rotational test. Conclusions: Although not always possible, reverse stapedotomy proved to be a safe surgical technique regarding postoperative outcomes. Its adoption may mitigate risks associated with floating footplate, sensorineural hearing loss, and incus luxation/subluxation, while facilitating the learning curve for less experienced ear surgeons.

Measurement of stapes footplate thickness using ultra-high-resolution computed tomography: stapes axial plane correlates better with otosclerosis than lateral semicircular canal plane.

BACKGROUND, AIMS: Stapes footplate thickness measurement using ultra-high-resolution CT has been described only in the lateral semicircular canal plane. The purpose of this study was to compare stapes footplate thickness between the lateral semicircular canal and stapes axial planes in patients with otosclerosis compared to controls. MATERIAL AND METHODS: We performed a retrospective single-center study of patients undergoing high-resolution temporal bone CT. Two radiologists measured stapes footplate thickness in both the lateral semicircular canal and stapes axial planes. RESULTS: Between February 2020 and October 2022, we collected 81 ears from 49 patients (75% of women; mean age 51.22 ± 16.6 years, 17 otosclerosis, and 64 controls). In the stapes axial plane, there was a significant anterior thickening in otosclerosis patients (Reader 1: 0.52 ± 0.12 [0.3-0.7] vs. 0.41 ± 0.08 [0.3-0.6], p = 0.001; Reader 2: 0.54 ± 0.06 [0.5-0.7] vs. 0.39 ± 0.08 [0.2-0.6], P < 0.001) compared to controls. These differences were not significant using the lateral semicircular canal plane. CONCLUSION: The stapes footplate was thickened at its AC in otosclerosis patients using only the stapes axial plane. SIGNIFICANCE: We propose to use the stapes axial plane instead of the lateral semicircular canal plane when analyzing the stapes.

Interest of computer tomography in the study of prognostic factors of otosclerosis.

BACKGROUND: Otosclerosis is a primary osteodystrophy of the otic capsule that causes stapedo-vestibular ankylosis. Its diagnosis is suspected on the basis of clinical and audiometric elements, basically in the presence of conductive hearing loss with a normal eardrum. The CT-scan is an essential examination for the preoperative evaluation of otosclerosis. The aim of our study was to evaluate the use of CT-scanning in predicting the functional outcome of otosclerosis surgery by correlating postoperative audiometric results and preoperative CT findings. METHODS: We conducted a retrospective study at the ENT Department in association with the Medical Imaging Department of our hospital, over a period of 8 years, from January 2014 to December 2022 and involving 90 patients (104 ears). RESULTS: The average age of our patients was 40 years with extremes ranging from 22 to 61 years. We noted a sex ratio of 0.38. The preoperative CT-scan showed signs of otosclerosis in 87% of the cases and infra-radiological forms in 13% of the cases. Veillon stage II was the most frequent radiological stage encountered with a percentage of 48%. A good audiometric evolution, defined by a closure of postoperative Air Bone Gap (ABG ≤ 20 dB) and by an improvement of Bone Conduction (BC gain ≥ 0), was recorded in 86 cases (82.7%) for ABG and in 84 cases (80.8%) for BC gain. Scanographic predictive factors of poor postoperative outcome for ABG and BC gain were: advanced stages (Veillon stage III and IV), endosteal effraction, and round window involvement. According to multivariate analysis, only the extent of otosclerotic foci was directly and independently associated with the postoperative audiometric outcome. CONCLUSION: The CT-scan is an essential examination in the preoperative evaluation of otosclerosis. It allows a positive diagnosis to be made and evaluate the extension of otosclerosis. Moreover, thanks to the analysis of the extent of the otosclerosis foci, mainly by the Veillon classification, the CT-scan allows to predict the postoperative audiometric prognosis.

Otic Capsule Demineralization and Hearing Outcome of Stapes Surgery for Osteogenesis Imperfecta in Comparison With Otosclerosis.

OBJECTIVE: To assess the location/number of otic capsule demineralization and hearing outcomes of stapes surgery (SS) for osteogenesis imperfecta (OI) compared with otosclerosis (OS). PATIENTS: This study included 11 and 181 consecutive ears from 6 and 152 patients with OI and OS, respectively. INTERVENTIONS: Demineralization loci observed as hypodense area of the otic capsule were examined using high-resolution computed tomography. All patients underwent SS. MAIN OUTCOME MEASURES: Locations of the hypodense areas were classified into the anterior oval window, anterior internal auditory canal, and pericochlear area. The location/number of hypodense areas and preoperative/postoperative hearing parameters were correlated. Postoperative hearing outcome was evaluated 12 months after surgery. RESULTS: Hypodense area was more frequently observed in OI (9 of 11 ears [81.8%]) than in OS (96 of 181 ears [53.0%]), with significant differences. Multiple sites were involved in 81.8% OI and 18.8% OS patients, showing significant differences. Preoperative air conduction (AC), bone conduction, and air-bone gap (ABG) were 48.9 ± 17.8, 28.0 ± 11.3, and 20.7 ± 8.4 dB, respectively, in OI and 56.2 ± 13.5, 30.5 ± 9.9, and 26.4 ± 9.7 dB, respectively, in OS, demonstrating greater AC and ABG in OS than in OI. Postoperative AC (31.3 ± 20.5 dB), ABG (10.6 ± 10.0 dB), and closure of ABG (12.1 ± 4.7 dB), that is, preoperative ABG minus postoperative ABG of OI, were comparable to those of OS (AC, 30.9 ± 13.3 dB; ABG, 7.0 ± 7.4 dB; closure of ABG, 20.1 ± 11.6 dB). CONCLUSION: OI ears showed more severe demineralization of otic capsule than OS ears. However, favorable hearing outcomes could be obtained through SS for OI and OS ears.

High fluence in laser stapedotomy aggravates transient subjective dizziness.

BACKGROUND: Laser fenestration in stapedotomy has thermal effect to the vestibule. AIMS/OBJECTIVES: To evaluate the role of energy density (fluence) in the severity of postoperative vestibular symptoms. MATERIALS AND METHODS: The retrospective chart-review study included 84 patients with otosclerosis that underwent primary laser stapedotomy. Surgical outcomes, including nystagmus, and subjective vestibular symptoms during one-month follow-up, were compared between potassium titanyl phosphate (KTP) and CO2 laser. According to this study and literature, we assessed the relationship between laser parameters and the incidence of persistent vestibular symptoms lasting more than one week after surgery. RESULTS: The KTP and CO2 laser group included 48 and 36 patients, respectively. Fluence was different between the KTP (637 J/cm2) and CO2 (141 J/cm2) laser (p < .001). The KTP group showed gradual decrease in dizziness during one-month observation period, while the CO2 group exhibited a steep recovery curve in the first postoperative week (9 and 4 d of duration, respectively). The incidence of persistent vestibular symptoms was correlated with both fluence (r = 0.80, p = .01) and spot size (r = -0.74, p = .01). CONCLUSIONS AND SIGNIFICANCE: Appropriate setting of parameters with lower fluence is desirable for the efficiency and safety of laser stapedotomy.Abbreviations: ABG: air-bone gap; SD: standard deviation.

Microdrill Versus Diode Laser in Endoscopic Stapedotomy: A Comparative Study.

BACKGROUND: Microdrill and diode laser are two different methods used in endoscopic stapedotomy for otosclerosis. These two methods have not been compared in endoscopic stapedotomy. AIMS/OBJECTIVES: To analyze the differences between microdrill and diode laser in endoscopic stapedotomy for otosclerosis. MATERIALS AND METHODS: This is a randomized clinical trial; patients with otosclerosis were randomly divided into microdrill group (group A: n = 69) and diode laser group (group B: n = 62). Differences between the two groups were then compared. RESULTS: The preoperative air-bone gap (ABG) was 25.40 ± 10.88 dBHL in group A and 24.84 ± 12.23 dBHL in group B, with no significant between-group difference ( p > 0.05). The postoperative ABG in group A was 13.27 ± 9.91 dBHL versus 11.79 ± 10.82 dBHL in group B, and there was no significant difference between the groups ( p > 0.05). The surgical time in group B (64 ± 31.23 minutes) was significantly longer than that in group A (48 ± 25.62 minutes) ( p = 0.02). There were no significant between-group differences in basic patient-related data, preoperative air conduction (AC), preoperative bone conduction (BC), postoperative AC, distribution of postoperative ABG, preoperative ABG at different frequencies, and postoperative ABG at different frequencies. There was also no significant between-group difference in the average bleeding volume or number of patients with postoperative dizziness. CONCLUSION AND SIGNIFICANCE: The postoperative improvement in hearing level in the two group was equivalent, but group A had the advantage of a shorter operation time. LEVEL OF EVIDENCE: 4.

Cochlear Otosclerosis and Secondary Hydrops (Ménière's Syndrome).

ABSTRACT: This article discusses a case of cochlear otosclerosis leading to secondary hydrops and near-complete hearing loss. Histopathological examination revealed advanced multifocal otosclerosis in both temporal bones, with specific focus on cochlear invasion and significant bone resorption. The severity of the case ruled out surgical intervention due to the risk of further hearing loss. The article emphasizes the challenges in managing otosclerosis-related hydrops and highlights the potential use of advanced imaging techniques for diagnosis. The study underscores the complexity of otosclerosis-induced hearing loss, contributing to the understanding of this pathology and its impact on auditory function.

[The application of endoscope and microscope in the stapes surgeries].

Objective:To compare the application of endoscope and microscope in all kinds of stapes surgeries. Methods:Fifty-nine stapes surgeries have been collected from April 2020 to May 2023 in Senior Department of Otolaryngology Head and Neck Surgery, Chinese PLA General Hospital, Chinese PLA Medical School. Hearing level, hospital stay post-operation, times of hospital visit post-operation, etc. have been compared between the endoscopic group and microscopic group. Patients who were failed to place the stapes prosthesis because of the poor exposure of the oval window have been analyzed. Results:Otosclerosis was the most common diagnosis in both groups. There was 1（1/23） middle ear malformation in the endoscopic group and 5（5/36） middle ear malformations in the microscopic group. There were 2 Van Der Hover syndromes and 4 Treacher Collins syndromes in the microscopic group. In the endoscopic group ABG of 10 ears（43.5%） ≤ 10 dB, and ABG of 21 ears（91.3%） ≤20 dB.In the microscopic group ABG of 13 ears（41.9%） ≤ 10 dB, and ABG of 28 ears（90.3%） ≤ 20 dB. There was no statistic difference between 2 groups. Times of hospital visit post-operation in the endoscopic group was less than in the microscopic group（P<0.01）. There was no facial palsy, tympanic perforation or profound sensorineural hearing loss in both groups. Conclusion:Endoscope is more suitable for patients who are evaluated with no severe stapes malformation, or less manipulation of drilling the bone. It could also reduce the hospital visit post-operation. Patients with narrow ear canal or severe middle ear malformation are recommended to perform the surgery with microscope, because it provides the chance of manipulation with 2-hands of surgeons.

The effect of local dexamethasone on stapedotomy surgery outcomes in patients with otosclerosis.

BACKGROUND: Some studies have shown a positive effect of systemic corticosteroid on hearing results after stapedotomy, but its side effects can limit its routine administration. AIM: The aim of this study was to investigate the effect of local dexamethasone on the results of stapedotomy surgery. MATERIAL AND METHODS: Fifty two patients undergone stapedotomy surgery for otosclerosis involved. In the case group after stapedotomy we fulfilled the middle ear with dexamethasone and then the placement of the prosthesis was done. In the control group after stapedotomy we did not use dexamethasone in the middle ear. RESULTS: Gender, age, nausea, vomiting, postoperative vertigo and nystagmus did not significantly differ between the groups. A significant difference was observed in tinnitus rate between two groups. In the case group ABG decrease was higher and bone conduction thresholds improved at frequencies of 1000, 2000, and 4000 three months after surgery. CONCLUSION: Since local dexamethasone had a positive effect on the results of stapedotomy surgery, it can be used instead of systemic corticosteroids to reduce the side effects and increasing surgery's success rate. SIGNIFICANCE: If local dexamethasone had a positive influence on the results of stapedotomy surgery, it can be used instead of systemic corticosteroids to reduce the side effects and increasing surgery's success rate.

The effect of piston diameter in primary stapes surgery on surgical success.

PURPOSE: To evaluate the effect of piston diameter in patients undergoing primary stapes surgery on audiometric results and postoperative complications. METHODS: A retrospective single-center cohort study was performed. Adult patients who underwent primary stapes surgery between January 2013 and April 2022 and received a 0.4-mm-diameter piston or a 0.6-mm-diameter piston were included. The primary and secondary outcomes were pre- and postoperative pure-tone audiometry, pre- and postoperative speech audiometry, postoperative complications, intraoperative anatomical difficulties, and the need for revision stapes surgery. The pure-tone audiometry included air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2 and 3 kHz. RESULTS: In total, 280 otosclerosis patients who underwent 321 primary stapes surgeries were included. The audiometric outcomes were significantly better in the 0.6 mm group compared to the 0.4 mm group in terms of gain in air conduction (median = 24 and 20 dB, respectively), postoperative air-bone gap (median = 7.5 and 9.4 dB, respectively), gain in air-bone gap (median = 20.0 and 18.1 dB, respectively), air-bone gap closure to 10 dB or less (75% and 59%, respectively) and 100% speech reception (median = 75 and 80 dB, respectively). We found no statistically significant difference in postoperative dizziness, postoperative complications and the need for revision stapes surgery between the 0.4 and 0.6 mm group. The incidence of anatomical difficulties was higher in the 0.4 mm group. CONCLUSION: The use of a 0.6-mm-diameter piston during stapes surgery seems to provide better audiometric results compared to a 0.4-mm-diameter piston, and should be the preferred piston size in otosclerosis surgery. We found no statistically significant difference in postoperative complications between the 0.4- and 0.6-mm-diameter piston. Based on the results, we recommend always using a 0.6-mm-diameter piston during primary stapes surgery unless anatomical difficulties do not allow it.