Small fenestra stapedotomy using a fiberoptic hand-held argon laser in obliterative otosclerosis.

Obliterative otosclerosis has been a challenge since the advent of stapes surgery. "Drill-out" procedures have had a generally poorer prognosis than conventional stapes surgery because of excessive bleeding, acoustic trauma from the burr, and reclosure of the oval window by otosclerosis. In this report, we describe our early experience using a hand-held fiberoptic argon laser for small fenestra stapedotomy in 10 cases of obliterative otosclerosis. Closure of the air-bone gap to within 10 dB was seen in 100% of the patients. There was no significant sensorineural hearing loss, vertigo, or facial weakness. Argon-laser stapedotomy using a hand-held fiberoptic system is a safe and effective alternative to drill-out stapedotomy in cases of obliterative otosclerosis.

Robot-assisted stapedotomy: micropick fenestration of the stapes footplate.

OBJECTIVE: Micropick fenestration of the stapes footplate, a difficult step in stapedotomy, was selected for trials evaluating the potential for robotic assistance (RA) to improve clinical measures of surgical performance. STUDY DESIGN: In a surgical model of stapedotomy, we measured accuracy of fenestration to a desired point location and force applied to the stapes footplate. Performance variables were measured for 3 experienced and 3 less-experienced surgeons. RESULTS: RA significantly reduced the maximum force applied to the stapes footplate. For fenestration targeting, RA significantly improved accuracy for less-experienced surgeons and significantly worsened targeting for more-experienced surgeons. CONCLUSIONS: RA significantly improves performance for micropick fenestration in a surgical model of stapedotomy. For certain tasks, RA differentially affects performance for users of different experience levels. CLINICAL SIGNIFICANCE: These are the first results showing quantitative improvements in performance during simulated ear surgery using RA and differential effects of RA on performance for users of different experience levels.

Capturing thermal, mechanical, and acoustic effects of the diode (980 nm) laser in stapedotomy.

INTRODUCTION: The diode laser, with a wavelength of 980 nm, has promising characteristics for being used for the fenestration during stapedotomy. It is known that at this wavelength absorption in pigmented tissues is high, and absorption in water is relatively low compared with medical lasers in the infrared, making it theoretically an applicable laser for stapes surgery in patients with otosclerosis. Another important advantage is that, with respect to other lasers, this device is relatively inexpensive. Despite the potential advantages, the available literature only shows limited reports of this laser being used in stapes surgery. The present article evaluates the thermal, mechanical, and acoustic properties of the diode laser during stapes surgery. METHODS: For the mechanical effects, high-speed imaging with a frame rate up to 4000 f/s (=250 µs resolution) was performed in an inner ear model. For thermal effects, the high-speed Schlieren technique was used. Acoustics were recorded by a hydrophone, incorporated in the model. Pulse settings were 100 ms, 3 W, which are the same settings used during stapes surgery. RESULTS: The application of the diode laser resulted in limited mechanical and thermal effects. Impulse noise was low with an average of 52 (SD, 7.8) dB (A). Before carbonization of the tip of the delivery laser, fiber enhances ablation of the footplate. CONCLUSION: The 980-nm diode laser is a useful tool for laser-assisted stapedotomy in patients with otosclerosis. Mechanical, thermal, and acoustic effects are limited and well within the safety limits.

Physical characteristics of various lasers used in stapes surgery.

The invention of modern small-fenestra stapedotomy procedures using a piston-type prosthesis resulted in a remarkable hearing improvement and at the same time in a reduction of complications compared to conventionally performed stapedectomies. These procedures, however, still contain unpredictable risks such as uncontrolled stapes fracturing, luxation of the stapes or creating a floating footplate, which all can cause hearing loss or even deafness. The worldwide use of the small-fenestration techniques led to the observation that most cases of sensorineural hearing loss occurring after surgery were due to intraoperative trauma to the inner ear, most commonly during footplate manipulation. This led to the use of lasers in otological surgery as a possible tool for precise noncontact cutting of bone without any drill vibration. Today, argon, KTP, CO(2) and Er:YAG lasers are clinically used in middle ear surgery. Each laser has its characteristic interaction process with bone with its specific advantages and disadvantages. Therefore, it is not surprising that there are conflicting and controversially discussed experimental and clinical reports. The purpose of this study was to comprehensively compare the physical processes underlying the laser-tissue interaction of the different laser systems in view of safety and efficacy in order to enhance the ability to perform safe minimally invasive surgery on the stapes footplate.

Microdrill versus perforator for stapedotomy.

The purpose of this study was to compare the hearing results of performing stapedotomy using either a microdrill or a perforator. Two groups of patients, otherwise similar, were followed up for at least 2 years after the stapedotomy. It was possible to create 0.8 mm fenestra in 91.6% of our patients. There was no significant difference between the two groups in hearing results. The results showed a continuous improvement in the first 6 post-operative months after which the hearing stabilized. In our hands, the microdrill has not proved to be more traumatic than the perforator to the inner ear.