Cochlear implantation outcomes in patients with far advanced otosclerosis.

OBJECTIVES: To compare hearing outcomes in patients with far advanced otosclerosis (FAO) undergoing cochlear implantation to an age-matched group of controls, to describe the effects of cochlear ossification on hearing, and to review the adverse effects of implantation in patients with FAO. HYPOTHESIS: Hearing performance in patients with FAO after cochlear implantation is comparable to similarly treated postlingually deafened adults without FAO. Ossification or retrofenestral otosclerosis does not predict poor hearing outcomes. Modiolar-hugging technology reduces postoperative facial nerve stimulation. STUDY DESIGN: Retrospective chart review. SETTING: Academic neurotologic tertiary referral center. PATIENTS: Thirty patients with FAO, who metaudiological criteria for cochlear implantation, were compared to 30 age-matched controls, postlingually deafened by non-otosclerotic causes. MAIN OUTCOME MEASURES: Audiometric pre- and postoperative speech reception threshold, word, and sentence scores were analyzed. The presence of retrofenestral findings on computed tomography or intraoperative cochlear ossification were noted. RESULTS: In the FAO group, radiographic abnormalities were noted in 26.4% of patients. Intraoperative ossification requiring drillout was seen in 29.4% of patients. None developed postoperative facial nerve stimulation. There was no difference between the FAO and control groups in the mean short-term and long-term postoperative speech reception threshold, word, and sentence scores (P = .77). The presence of radiographic abnormalities did not predict hearing outcome. Intraoperative cochlear ossification was not associated with worse short-term word and sentence scores (P = .58 and 0.79, respectively), and for the long-term hearing outcome (P = .24). CONCLUSIONS: In patients with FAO, effective and safe hearing rehabilitation can be accomplished with cochlear implantation.

Latent demand for the bone-anchored hearing aid: the Lippy Group experience.

OBJECTIVE: The usefulness of the bone-anchored hearing aid (BAHA) for conductive and mixed hearing losses and recently for single-sided deafness has been well documented. Less clear is the number of patients who might benefit from the BAHA and how many would be interested in having the surgery. The purpose of this investigation is to examine these latter issues from the perspective of an otology practice. STUDY DESIGN: Retrospective review. SETTING: Private otology practice. PATIENTS: Approximately 44,000 patient records were reviewed. On the basis of this review, 617 patients were sent a letter describing the BAHA and explaining that they might be candidates. One hundred sixty-two of these patients made an appointment to be evaluated for the BAHA. METHODS: Patients who responded to the BAHA letter underwent an otologic and audiological evaluation to confirm their candidacy. The BAHA surgery and device were described, and interested patients tried the BAHA test band in the office. Patient responses to the BAHA were noted. RESULTS: Approximately 1.4% of the cases reviewed (617/44,000) were considered to be potential BAHA candidates. One hundred forty-six of the 162 patients who scheduled a BAHA evaluation were confirmed to be candidates. After seeing and learning about the BAHA, 92% of the verified candidates wanted to try the BAHA test band. Most patients who tried the test band (92%) liked the BAHA, and nearly a third (30.6%) had BAHA surgery. Patients with conductive or mixed hearing loss who tried the test band were more likely to have BAHA surgery than those with single-sided deafness (45.8% versus 27.3%). The major limiting factor was infrequent or inadequate insurance coverage for the procedure or device. CONCLUSIONS: Although the percentage of patients in an otology practice who could benefit from the BAHA is small, finding and alerting potential BAHA candidates are worthwhile.

Topical otic antibiotics: clinical cochlear ototoxicity and cost consideration.

OBJECTIVE: Determine the incidence of clinical cochlear ototoxicity in routine use of Cortisporin after ventilation tube placement. Cost differential between use of Cortisporin and fluoroquinolone agents was evaluated. METHODS: A retrospective review of 500 patients was performed. Cortisporin otic suspension was used for 5 days following ventilation tube insertion. RESULTS: Testing following surgery indicated a sensorineural hearing loss (SNHL) in 19 (2.1%) ears. The SNHL existed prior to the surgery and there was no deterioration in the hearing postoperatively. The total cost for our study group who used Cortisporin was $15,500. If Floxin had been prescribed the cost would have been $45,000. Had Ciprodex been prescribed, the cost would have been $49,500. CONCLUSION: Our study demonstrates no clinical cochlear ototoxicity in children who received Cortisporin following ventilation tube placement. The cost differential for prescribing fluoroquinolone drops is significant. EBM RATING: C-4.

Does pregnancy affect otosclerosis?

OBJECTIVE: To evaluate the effect of pregnancy on the hearing of women with otosclerosis. STUDY DESIGN: A retrospective study of women who had undergone stapedectomy. The women were equally divided into two groups: one group with children and a control group without children. Air and bone conduction, as well as discrimination, were measured before and after stapedectomy in both groups. PATIENTS: Ninety-four women (47 with children and 47 without) were evaluated. Because many of the women had bilateral otosclerosis, the total number of ears studied was 128. RESULTS: Mean pure tone air and bone conduction thresholds were not worse in women with children versus those women without children. In fact, mean pre- and postoperative pure tone air and bone conduction thresholds from 500 Hz through 4,000 Hz in women with children were slightly but significantly better than women without children. There was no difference in discrimination scores between groups. Within the group with children, no significant correlation was found between number of children and hearing loss. Also, no correlation was found between breastfeeding and the amount of hearing loss. CONCLUSION: We found no adverse effect on hearing in otosclerotic women who had children compared with women without children. Even with increasing numbers of pregnancies, no deleterious impact was noted. Air conduction, bone conduction, and discrimination were not worse in women with children versus childless women. No significant correlation was found between the number of children and hearing loss, and neither did breastfeeding affect the amount of hearing loss.

Comparison of titanium and Robinson stainless steel stapes piston prostheses.

OBJECTIVE: Although stainless steel stapes prostheses have generally been considered magnetic resonance imaging safe, there is concern that this may change with the development of more powerful imaging systems. The objective of the study was to determine whether a titanium piston stapes prosthesis would be audiometrically and surgically equivalent to a Robinson stainless steel piston for stapedectomy. STUDY DESIGN: Retrospective chart review. SETTING: Private otology practice. PATIENTS: In all, 50 patients underwent stapedectomy with a Gyrus titanium piston prosthesis. These patients were matched on the basis of age and preoperative bone-conduction scores with patients who underwent stapedectomy with a Robinson stainless steel piston prosthesis. MAIN OUTCOME MEASURES: Audiometric results are analyzed, and surgical complications noted. RESULTS: There was no significant difference between groups in hearing improvement or postoperative air-bone gap. The mean four-frequency hearing improvement was 27.7 dB for the stainless steel group and 27.8 dB for the titanium group. The mean postoperative air-bone gap was 2.65 dB for the stainless steel group and 2.60 for the titanium group. Neither group had a surgical complication. CONCLUSION: The titanium stapes prosthesis is a good alternative to a stainless steel prosthesis.

Tympano-ossiculoplasty utilizing the Spiggle and Theis titanium total ossicular replacement prosthesis.

OBJECTIVE: Since 1993, titanium prostheses have been used in Europe as a biocompatible implant for ossicular reconstruction. More recently, the titanium ossicular prosthesis has become more widely available in the United States as a newer means of surgical restoration of hearing. We will review the hearing results of patients who have undergone tympano-ossiculoplasty using a titanium total ossicular replacement prosthesis (TOP). We will compare these results to our previously published results using the porous polyethylene TOP. METHODS: Retrospective review in a tertiary otologic practice. RESULTS: Eighteen patients underwent tympano-ossiculoplasty with a titanium TOP. Among these patients, 10 cases involved revision of a previously placed ossicular prosthesis. Hearing results showed that 16 of 18 patients (89%) had closure of the postoperative air-bone gap to within 20 dB, and the average air-bone gap improvement was 23 dB. The average follow-up time was 8 months (range, 2-21 months). The results of this initial evaluation compare favorably with the results that we obtained using a porous polyethylene TOP in which 67% of 133 patients closed the air-bone gap to within 20 dB. CONCLUSION: We have recently begun using the titanium TOP, which has resulted in improved postoperative hearing when compared with the porous polyethylene TOP. In the future, longer follow-up and increased patient numbers will strengthen our conclusions.

Stapedectomy revision in elderly patients.

OBJECTIVE: the objective was to determine the effectiveness of stapedectomy revision in patients 65 years of age or older. Although stapedectomy revision has been discussed in the literature, as well as primary stapedectomy surgery for elderly patients, we could find no study dedicated to stapedectomy revision in elderly patients. STUDY DESIGN: Retrospective. METHODS: One hundred twenty patients 65 years of age or older who had a stapedectomy revision between 1980 and 2001 were included. A randomly selected group of 120 patients younger than 65 years of age who had stapedectomy revision were included for comparison. Audiometric results were compared for the two groups. Surgical findings for each group are also discussed. RESULTS: The mean pure-tone average hearing improvement for each group was 17.6 dB. The success rate was 70.8% for the elderly group and 67.6% for the younger group. Surgical findings during revision in elderly patients were generally the same as those found for younger patients. CONCLUSION: Advanced age should not be seen as a contraindication to stapedectomy revision.

Total ossiculoplasty with footplate removal.

OBJECTIVE: We reviewed the results and management of cases in which total ossiculoplasty requires footplate removal. STUDY DESIGN AND SETTING: We conducted a retrospective review of 10 patients who underwent total ossiculoplasty with footplate removal between 1999 and 2002. These 10 patients represented 5.4% of those undergoing stapedectomy (n = 91) and ossiculoplasty (n = 93) during these years at a tertiary otologic referral center. RESULTS: A total of 10 patients were evaluated, with a mean 17-month follow-up. Closure of air-bone gap (ABG) to within 20 dB was achieved in 6 of 10 patients (60%). Mean postoperative ABG was 21.7 dB (500 to 4000 Hz) with an average 4-frequency pure tone improvement of 20.7 dB. Operative findings included extensive tympanosclerosis, partial obstruction of oval window by facial nerve, and changes from prior surgery. There were no patients with postoperative sensorineural hearing loss. CONCLUSIONS: The need to open the footplate in cases of total ossiculoplasty is uncommon. This may be accomplished with good improvement in hearing with minimal risk.

Stapedectomy in patients with a prolapsed facial nerve.

OBJECTIVE: We evaluated the method of stapedectomy and hearing results in patients who have 50% or more of the footplate covered by a prolapsed facial nerve. STUDY DESIGN: We conducted a retrospective review of 1497 primary stapedectomies performed between 1986 and 1995. METHODS: Twenty-eight patients had 50% or more of the oval window covered by a prolapsed facial nerve. Twenty-three patients in this group had adequate follow-up and their hearing results were compared with a matched control group of 50 patients with normal facial nerve anatomy. Also, facial nerve outcomes and any other complications are reported. RESULTS: In the patient group with facial nerve prolapse, closure of the postoperative air-bone gap to 10 dB or less was achieved in 19 of 23 (83%) ears and 16 of 20 (80%) ears at 6 months and 1 year, respectively. At 6 months and 1 year, the postoperative air-bone gap in 47 of 50 (94%) ears and 40 of 43 (93%) ears in the control group had closed to 10 dB or less. The average postoperative air-bone gap was 5.1 dB at 6 months and 6.8 dB at 1 year for the group with facial nerve prolapse. In comparison, the average postoperative air-bone gap in the control group was 3.5 dB and 3.9 dB, respectively. The difference in the hearing results for the 2 groups was not statistically significant. CONCLUSION: When the facial nerve covered at least 50% of the oval window, the poststapedectomy hearing results at 6 months and 1 year were similar to those of a matched control group of stapedectomy patients with a normal facial nerve course. There were no short- or long-term facial nerve complications in either group. In light of these results, we conclude that stapedectomy in patients with significant facial nerve prolapse can be performed safely with good hearing results.

Twenty-year review of revision stapedectomy.

OBJECTIVE: To evaluate surgical findings and techniques, patient management techniques, and audiometric results of 522 revision stapedectomies. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary otologic referral center. PATIENTS: A total of 522 revision stapedectomies over a 20-year period in Warren, Ohio, and Israel. The audiologic criterion for revision was an air-bone gap greater than 20 dB over the three-frequency range 0.5 to 2 kHz. RESULTS: Of the 522 revision cases, a total of 483 patients were operated on to improve hearing. The remainder of the patients were operated on for various other noted reasons. Closure of the air-bone gap to within 10 dB was achieved in 71% of patients (343 of 483). The mean pure-tone average improvement was 17.8 dB, with an average postoperative air-bone gap of 7.3 dB. The most common surgical findings were prosthesis malfunction at the oval window, incus, or both (58%). Since beginning the use of the Argon laser for surgical problems, the success rate has increased to 80%. A subgroup of 35 Argon laser revision stapedectomies resulted in a larger hearing gain (25.2 dB) and 91.4% closure of the air-bone gap to less than 10 dB. CONCLUSIONS: More than 70% of revision stapedectomy cases for hearing improvement have had successful closure of their air-bone gap. Since the introduction of the laser 5 years ago, the success rate has increased to 80%. In those specific cases where the laser was required, the success rate increased to 91.4%. Regardless of the revision technique, hearing results were the least successful when the incus could not be used for reconstruction.

Promontory drilling in stapedectomy.

OBJECTIVE: Evaluate in stapedectomy the clinical outcome and audiometric results (particularly bone conduction) of drilling the promontory because of a narrow oval window niche. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center, private otology practice. PATIENTS: Twenty-five stapedectomy patients requiring promontory drilling who had surgery between 1995 and 2000. METHOD: A total of 25 patients were evaluated with a minimum 6-month follow-up. Only patients who required promontory drilling and who had complete preoperative and postoperative audiometric testing including bone conduction were included. Promontory drilling was performed with a skeeter drill to thin the promontory. Twenty-five stapedectomy patients who did not undergo promontory drilling were randomly selected from this same period as a comparison group. RESULTS: In addition to the narrow oval window niche, associated anatomical findings were facial nerve overhang in five patients and an obliterated footplate in three patients. Ninety-six percent of cases were successful (<10 dB postoperative air-bone gap). The one unsuccessful case was a strut over the mobile footplate that was later successfully revised. No patients suffered from intraoperative or postoperative tinnitus or vertigo. The mean 4-frequency (500-4,000 Hz) pure-tone average revealed slight improvement in bone conduction postoperatively. CONCLUSION: Drilling of the promontory in stapedectomy is required in only a small percentage of cases. Although audiometric results indicated the possibility of a slight amount of acoustic trauma from the drilling, the effect on hearing was minimal and not considered a contraindication to this procedure.

The use of cartilage in revision stapedectomy.

OBJECTIVE: To evaluate the incidence of stapedectomy patients who developed significant chronic ear disease resulting in reconstruction of the tympanic membrane with cartilage and concomitant revision stapedectomy. Audiometric results of this subgroup within revision stapedectomy are analyzed, and the salient features of the reconstruction method are discussed. STUDY DESIGN: Retrospective study of revision stapedectomy patients during the years 2003-2012. SETTING: Tertiary referral center. INTERVENTION: Cartilage tympanoplasty and revision stapedectomy. RESULTS: Seventeen patients (18 ears) of 144 revision stapes patients were studied who required cartilage tympanoplasty and revision stapedectomy. One-half underwent revision stapedectomy with a modified Lippy prosthesis (MLP), and one-half required a total ossicular prosthesis (TOP). The mean postoperative air-bone gap (ABG) was 11.1 dB with mean pure tone average (PTA) hearing improvement of 15.6 dB.The rate of ABG closure was 55.6% <10 dB and 38.8 % >10 dB and <20 dB. CONCLUSION: The number of patients requiring revision stapedectomy due to significant chronic ear disease is small. This paper discusses the management and successful outcome of these more difficult revisions.

Short- and long-term results of ossicular reconstruction using partial and total plastipore prostheses.

OBJECTIVE: To evaluate the short- and long-term success of using a plastipore prosthesis for partial and total ossiculoplasty (POP and TOP). Subtechniques for optimal hearing improvement are discussed. Literature review and comparison to the recent use of titanium prostheses is made. STUDY DESIGN: Retrospective review of partial and total ossiculoplasties. SETTING: Private practice tertiary otologic center. PATIENTS: A total of 152 patients who underwent ossicular reconstruction by the primary author greater than 3 years before this investigation with long-term results (mean, 4.3 yr) available for 83 patients. MAIN OUTCOME MEASURES: Preoperative and postoperative air and bone conduction thresholds and air-bone gap for pure tone averages for 4 frequencies. Percentage of patients achieving an air-bone gap (ABG) of less than or equal to 10 dB abd 20 dB. RESULTS: The percentage of patients closing their ABG to within 10 dB was 51.3% and 75% to within 20 dB short term. The mean PTA ABG for the POP patients was 11.9 and 15.8 dB for the TOP groups short term. For the long-term group, 41.7% of POP patients had 10 dB or lower ABG and 81.2% within 20 dB. In the TOP group, 20% had a PTA ABG of 10 dB or lower with 60% within 20 dB ABG long term. There were no patients with complication of significant sensorineural hearing loss. One extrusion occurred in this group of patients. CONCLUSION: Functional results with the POP and TOP plastipore prostheses were good postoperatively. Longer-term results also supported the use of these prostheses and techniques in that more than 53 months, our partial ossiculoplasty cases had a minimal air-bone gap worsening of only 1.7 dB. The total ossiculoplasty cases had a 6.3 dB air-bone gap decline, which is less than a 1.5 dB decrease per year.

Is there an ototoxicity risk from Cortisporin and comparable otic suspensions? Distortion-product otoacoustic emission findings.

The purpose of this investigation was to use distortion-product otoacoustic emission (DPOAE) testing to address the issue of possible ototoxicity from the use of neomycin/polymyxin B/hydrocortisone otic suspension following tympanostomy tube placement. We retrospectively reviewed our clinical records and identified 36 children (52 ears) who had met our three study criteria: (1) unilateral or bilateral placement of transtympanic ventilation tubes, (2) treatment for 3 to 5 days with neomycin/polymyxin B/hydrocortisone drops, and (3) postoperative evaluation by DPOAE testing. We identified another set of 36 children (52 ears) who had not received these drops and who had not undergone tube placement but who had been evaluated by DPOAE testing to serve as a control group. We found no significant differences in DPOAE amplitudes between the treatment and control groups. These findings are consistent with decades of clinical experience indicating that neomycin/polymyxin B/hydrocortisone otic suspension is safe when used responsibly.

Hearing results in reconstructing the damaged incus with varying lengths of the modified Lippy prosthesis.

OBJECTIVE: Evaluate success of reconstructing the damaged incus in otosclerotics and chronic ear disease with the use of the modified Lippy prosthesis. Maintaining ossicular continuity is critical in optimizing sound transfer particularly when there has been incus erosion of varying degrees. Our hypothesis was that the varying lengths of the Lippy modified prosthesis would allow for reconstruction of the incus with very good results. PATIENTS: Clinical records were reviewed from 1998 to 2009. Fifty-four patients requiring incus reconstruction with the modified Lippy prosthesis were evaluated. INTERVENTION: Analysis was done of type of surgery, varying lengths of incus erosion and lengths of prostheses used. Audiometric outcomes were evaluated with respect to length of prosthesis and type of surgery performed. MAIN OUTCOME MEASURES: Audiometric evaluation of 4 frequency closure to within 10 dB air-bone gap (ABG). RESULTS: Audiometric results for the 54 patients revealed a mean postoperative ABG of 7.8 dB with mean follow-up of 7.4 months. Closure of ABG within 10 dB was achieved in 74.1% of patients, and 96.3 % achieved closure within 20 dB. Long-term follow-up at 51 months for a subset of 15 patients demonstrated a mean postoperative ABG of 15.5 dB. No relation was found between prosthesis length and ABG at both the initial and long-term postoperative evaluation. CONCLUSION: Incus erosion presents a significant challenge in middle ear reconstruction. The otologic surgeon must be prepared to perform incus reconstruction whether in otosclerosis or in chronic ear surgery. Knowledge in use of the modified Lippy prosthesis enables the surgeon to deal with varying degrees of incus necrosis yielding very good hearing results.

High body mass index as a risk factor for skin overgrowth with the bone-anchored hearing aid.

OBJECTIVES: To identify whether an increased body mass index (BMI) predisposes patients to more soft tissue problems after placement of a Bone-Anchored Hearing Aid implant. PATIENTS: We retrospectively reviewed 88 adult patients who met criteria for inclusion in the study. RESULTS: Ten (11.4%) of the 88 patients had significant soft tissue reaction requiring excision, revision of the skin graft, or placement of a longer abutment (8.5 mm). Of these 10 patients, 4 required placement of a longer abutment, whereas 4 underwent revision skin grafting. All 10 patients had scar excisions in the office. Of the 10 patients, 9 were considered obese with a BMI of 30 lb/in or greater. One patient was considered overweight with a BMI of 28.1 lb/in. The mean BMI for those patients with significant soft tissue reactions was 34.2 lb/in. The mean BMI for patients with no reaction or minor reactions was 27.6 and 27 lb/in, respectively. No patient lost an implant due to soft tissue reaction during the follow-up period. CONCLUSION: Our study demonstrates that after Bone-Anchored Hearing Aid surgery, most patients (78/88, 88.6%) had no soft tissue reaction or had only a mild reaction that was easily treated. However, there are a definite percentage of patients who may develop significant scarring over time. This study identified a significant relationship between obesity (BMI > 30 lb/in) and extensive soft tissue reaction around the implant site.