Absent pyramidal eminence and stapedial tendon associated with congenital stapes footplate fixation: Intraoperative and radiographic findings.

OBJECTIVE: Report an association between congenital stapes footplate fixation (CSFF) and radiological absence of the pyramidal eminence and stapedial tendon. PATIENTS: Children and adults with intraoperatively confirmed CSFF and an absent stapedial tendon. INTERVENTIONS: Computed tomography (CT); exploratory tympanotomy with stapedotomy. MAIN OUTCOME MEASURES: Absence of a pyramidal eminence and stapedial tendon aperture identified on preoperative CT that was confirmed intraoperatively. RESULTS: Eight patients with intraoperative confirmation of CSFF and absent stapedial tendon were retrospectively identified. The average preoperative bone conduction and air conduction pure tone averages were 19.6 dB (SD 15.6 dB) and 55.9 dB (SD 23.6 dB), respectively. The average air-bone gap was 36.3 dB (SD 17.9 dB) preoperatively. In the seven patients who underwent preoperative CT, all were consistently identified to have an absent or hypoplastic pyramidal eminence and absent stapedial tendon aperture at the pyramidal eminence. In six cases, the stapedial footplate appeared normal, while in one case the footplate appeared abnormal which correlated with severe facial nerve prolapse observed intraoperatively. All eight cases underwent exploratory tympanotomy and demonstrated intraoperative stapes footplate fixation, absent stapedial tendon and either absent or hypoplastic pyramidal eminence, which correlated with preoperative CT findings. CONCLUSIONS: This study identifies a clinically pragmatic association between an absent pyramidal eminence identified on high-resolution CT and the diagnosis of CSFF. In a condition that otherwise generally lacks distinctive radiological features, the absence of a pyramidal eminence on CT in a patient with nonprogressive, congenital conductive hearing loss may strengthen clinical suspicion for CSFF.

The use of a surgical planning tool for evaluating the optimal surgical accessibility to the stapedius muscle via a retrofacial approach during cochlear implant surgery: a feasibility study.

PURPOSE: During cochlear implant (CI) surgery, visual detection of the stapedius reflex as movements of the stapes tendon, electrically elicited via the CI, is a standard measure to confirm the system's functionality. Direction visualization of the stapedius muscle (SM) movements might be more reliable, but a safe access to the small SM is not defined. A new surgical planning tool for pre-operative evaluation of the accessibility to the stapedius muscle (SM) during a cochlear implantation (CI) via a retrofacial approach was now evaluated. METHODS: A surgical planning tool was developed in MATLAB using an image processing algorithm to evaluate drilling feasibility. A flat-panel computed tomography (CT) combining a rotational angiographic C-arm units with flat-panel detectors (Dyna-CT) was used. In total, 30 3D Dyna-CT-based temporal bone reconstructions were evaluated by automatized algorithms, generating a series of trajectories and comparing their feasibility and safety to reach the SM via a retrofacial approach. The predictability of the surgical planning tool results was tested in 5 patients. RESULTS: The surgical planning tool showed that a retrofacial access to the SM would be feasible in 25/30 cases. Moreover, the evaluation of the predictability of the results obtained with the surgical planning tool conducted during 5 CI surgeries confirmed the results. Both the surgical planning tool and the results on SM accessibility via retrofacial approach during CI showed that this is safe and feasible only when the SM-exposed area was > 25% of its total, the distance between the SM and the facial nerve was > 0.8 mm, and the surgical corridor diameter was > 3 mm. CONCLUSION: The surgical planning tool seems to be useful for the pre-operative evaluation of the accessibility to the SM during a CI surgery via a retrofacial approach. Further prospective studies are needed to validate the results in larger cohorts.

Dyna-CT of the temporal bone for case-specific three-dimensional rendering of the stapedial muscle for planning of electrically evoked stapedius reflex threshold determination during cochlear implantation directly from the stapedius muscle via a retrofacial approach: a pilot study.

PURPOSE: Evaluation of 3D Dyna-CTs to improve cochlear implantation (CI) planning and intraoperative electrically elicited stapedius reflex threshold (ESRT) measurements. METHODS: A prospective observational cohort study was performed. Anonymized data collection of Dyna-CTs and CI surgeries in which a retrofacial approach was implemented to access the stapedius muscle. 3D Dyna-CTs of 30 patients and the intraoperative confirmation of the predication in 5/30 patients during CI surgery were evaluated. Inter-rater reliability was also analyzed along with the predictive value of this evaluation. RESULTS: 36 representative structures of the middle and inner ear and 3D renderings of the Dyna-CTs were evaluated by four otoneurological surgeons. Fleiss' kappa values for the evaluation of the visibility were high (> 0.7) for most of the anatomical structures. The stapedius muscle was visible in 90% of the cases. Using the 3D data, the retrofacial access to the stapedius muscles was estimated as feasible in 86.7%. Fleiss' kappa value of the evaluation of the accessibility was 0.942. The intraoperative exploration of the stapedius muscle confirmed the preoperative prediction in all five selected patients (four patients with predicted accessibility and one patient with predicted inaccessibility). CONCLUSIONS: The use of Dyna-CT and 3D rendering is a helpful tool for preoperative planning of cochlear implantations and ESRT measurements from the stapedius muscle via the retrofacial approach.

Manubrio-incudo-stapedioplasty for reconstruction of Austin-Kartush type B ossicular defects.

OBJECTIVE: Manubrio-incudo-stapedioplasty functional outcomes were compared to those of other methods for reconstructing Austin-Kartush type B ossicular defects. METHODS: Forty-two patients underwent Austin-Kartush type B ossicular defect reconstruction using: manubrio-incudo-stapedioplasty (13 patients), an autologous incus (19 patients) or a titanium ossicular replacement prosthesis (10 patients). For manubrio-incudo-stapedioplasty reconstruction, the malleus head was removed, the manubrium was relocated posteriorly and the incus short process was placed on the mobile footplate. The manubrium was placed on the incus body groove and bone cement was applied to stabilise the manubrium-incus junction. Pre- and post-operative hearing thresholds were assessed. RESULTS: The air-bone gap decreased from 25.9 ± 6.0 dB to 12.3 ± 5.0 dB (p < 0.05) in the manubrio-incudo-stapedioplasty group. The hearing gain was 13.6 ± 5.2 dB for manubrio-incudo-stapedioplasty, 3.4 ± 14.2 dB with the autologous incus, and 3.3 ± 11.07 dB with the titanium ossicular replacement prosthesis. Hearing improvement was greater for manubrio-incudo-stapedioplasty compared to the other reconstruction methods (p < 0.05). CONCLUSION: Manubrio-incudo-stapedioplasty resulted in satisfactory hearing outcomes in patients with Austin-Kartush type B ossicular defects. This technique can be considered a stable, inexpensive and effective method to reconstruct Austin-Kartush type B ossicular defects.

[Recent surgical options for vestibular vertigo]. / Aktuelle operative Therapie des vestibulären Schwindels.

Vertigo is not a well defined symptom but a heterogenous entity diagnosed and treated mainly by otolaryngologists, neurologists, internal medicine and primary care physicians. Most vertigo syndroms have a good prognosis and management is predominantly conservative, whereas the need for surgical therapy is rare, but for a subset of patients often the only remaining option. In this paper, we describe the development of surgical therapy for hydropic inner ear diseases, Menière disease, dehiscence syndroms, perilymphatic fistulas, and benign paroxysmal vertigo. At the end, we shortly introduce the most recent development of vestibular implants. Surgical vestibular therapy is still indicated for selected patients nowadays when conservative options did not reduce symptoms and patients are still suffering. Success depends on the correct diagnosis and indication for the different procedures going along with an adequate patient selection. In regard to the invasiveness and the possible risks due to the surgery, in depth individual counselling is necessary. Ablative and destructive surgical procedures usually achieve a successful vertigo control, but go along with a high risk for hearing loss. Therefore, residual hearing has to be included in the decission making process for a surgical therapy.

Hammer sound elicited tinnitus in car body repair worker cured by stapedial tenotomy - A case report.

Abnormal auditory sensations or tinnitus caused by abnormal middle ear muscle contraction are extremely rare and uncomfortable for patients. A 67-year-old man who performed paint and body work for cars presented at our hospital with complaint of an audible and annoying abnormal sound that was synchronous with the striking of his hammer against the metal of the car body during his work. The patient reported that the sound was audible of left ear with a split-second delay after his hammer struck the metal. Preoperative subjective and objective testing failed to reveal any abnormal findings in our case. The patient's symptom was successfully cured by selective transection of the stapedius tendon. The characteristic nature of tinnitus with a split-second delay after striking the metal helped our diagnosis and method of intervention in this case.

Endolymphatic sac surgery versus tenotomy of the stapedius and tensor tympani muscles in the management of patients with unilateral definite Meniere's disease.

This study aims to compare the outcomes of patients with Meniere's disease submitted to either endolymphatic mastoid shunt (ES) or tenotomy of the stapedius and tensor tympani muscles (TSTM). This is a retrospective chart review of patients treated with ES or TSTM between 2000 and 2010 and followed up for at least 12 months. The main outcomes were represented by: (1) vertigo class, hearing stage and functional level according to the American Academy of Otolaryngology-Head and Neck Surgery criteria; (2) adjustment of dizziness handicap inventory (DHI) and (3) complete and substantial vertigo control using the Kaplan-Meier survival method. Sixty-three patients met the inclusion criteria: 34 underwent ES and 29 TSTM. The baseline demographic characteristics, the hearing stage, the functional level, the DHI and hearing levels were not different between the two groups. No significant difference in vertigo class was demonstrated: 66 % of TSTM patients attained class A compared to 44 % in the ES group (p = 0.14). Kaplan-Meier survival curves specific to class A showed significant differences, favoring TSTM (log-rank test, p = 0.022). TSTM patients demonstrated significantly improved functional level (p = 0.0004) and improved DHI scores (p = 0.001). Eight ES patients (25 %) demanded a second surgical attempt compared to none in the TSTM. Aural fullness was significantly improved in TSTM group (p = 0.01), while the difference in tinnitus improvement was non-significant. Hearing preservation was significantly better in TSTM group (p = 0.001). TSTM is a safe surgical procedure, with significant vertigo control rates, and important hearing preservation rates. More patients and longer follow-up are needed to support our preliminary findings.

Three-dimensional temporal bone reconstruction from histological sections.

OBJECTIVE: To produce a high-resolution, three-dimensional temporal bone model from serial sections, using a personal computer. METHOD: Digital images were acquired from histological sections of the temporal bone. Image registration, segmentation and three-dimensional volumetric reconstruction were performed using a personal computer. The model was assessed for anatomical accuracy and interactivity by otologists. RESULTS: An accurate, high-resolution, three-dimensional model of the temporal bone was produced, containing structures relevant to otological surgery. The facial nerve, labyrinth, internal carotid artery, jugular bulb and all of the ossicles were seen (including the stapes footplate), together with the internal and external auditory meati. Some projections also showed the chorda tympani nerve. CONCLUSION: A high-resolution, three-dimensional computer model of the complete temporal bone was produced using a personal computer. Because of the increasing difficulty in procuring cadaveric bones, this model could be a useful adjunct for training.

[Stapedoplasty in a HIV-infected patient].

This paper reports an observation illustrating the possibility of the successful surgical treatment of otosclerosis in a HIV-infected patient presenting with acquired immunodeficiency syndrome (AIDS) and positive response in the test for hepatitis C. The authors used the results of multispiral computed tomography (MSCT) of the temporal bones as a basis for the prediction of the outcome of the surgical intervention taking into consideration specific primary manifestations of HIV infection as well as immunological and virlogical responses to anti-retroviral therapy.

Tenotomy of the stapedius and tensor tympani muscles reduces subjective dizziness handicap in definite Meniere's disease.

CONCLUSION: Tenotomy is a promising surgical alternative with a high reduction in dizziness handicap in the short and long term. OBJECTIVES: To investigate the immediate and the long-term effect of tenotomy of the stapedius and tensor tympani muscles on subjective dizziness as measured by the Dizziness Handicap Inventory (DHI). METHODS: A retrospective follow-up study of 42 patients with definite, unilateral Meniere's disease (19 males, 23 females, average age = 58.1 ± 14.1 years) had undergone tenotomy under general anesthesia through an endaural approach. Pre- and postoperative DHI values were compared for all patients, with postoperative follow-up ranging from 6 months to 9 years. Additionally, results were divided into three postoperative subgroups (A = 0-3 years, B = 3-6 years, C = 6-9 years). RESULTS: A statistically significant reduction of 48 DHI points, from a median preoperative DHI = 52 to DHI = 4 postoperatively, was noted (p < 0. 001). In all, 40/42 patients reported a reduction of dizziness handicap, while in 33/42 the difference was > 12 points. A statistically significant reduction of DHI scores was noted (A = 60, B = 34, C = 33) in all subgroups. It was also noted that the higher the preoperative DHI score, the greater the subjective success of the surgery.

Intra- and postoperative electrically evoked stapedius reflex thresholds in children with cochlear implants.

OBJECTIVES: The aim of this study was to investigate whether there is a significant correlation between intra- and postoperative electrically evoked stapedius reflex thresholds (eSRTs) in children with cochlear implants. METHODS: Sixty-five pediatric cochlear implant users were included in this study. All patients had congenital prelingual hearing loss. The round window approach was used in all patients. The eSRTs were intraoperatively measured using the 1st, 3rd, 6th and 12th electrodes of the cochlear implant. The measurements taken during the first fitting of the device were taken again one month after surgery. We used paired-sample t-tests to determine the correlation between intra- and postoperative eSRTs. RESULTS: The eSRT analysis revealed a statistically significant difference between the intra- and postoperative thresholds. A correlation analysis did not reveal any correlation between intra- and postoperative eSRTs. CONCLUSION: Intraoperative eSRT measurements were unable to predict early postoperative eSRTs.

A scanning electron microscopic study of crimping of stapedial prostheses.

OBJECTIVE: The aim of this study was to evaluate, through the Scanning Electron Microscopy, the loop closure of four types of stapedial prostheses and to compare the different systems of crimping to the long process of the incus. MATERIALS AND METHODS: Four types of stapedial prostheses (one platinum-teflon, two different titanium and one nitinol-teflon pistons) were inserted in 40 specially prepared temporal bones simulating the in vivo stapedotomy procedure. Two pistons were crimped by single manual manoeuvre with a McGee microforceps; the remainders were self-retained and thermal-crimped, respectively. All the specimens were evaluated through the Operative Microscopy and the Scanning Electron Microscopy. RESULTS: Through the Operative Microscopy, all prostheses apparently achieved a correct adhesion to the long process of the incus; on the contrary the Scanning Electron Microscopy study demonstrated some limits of the manual crimping and the different coupling with the ossicular chain of each type of stapedial prosthesis. CONCLUSION: A complete adhesion of the prosthetic loop cannot be obtained because of the irregular profile of the incus at the site of attachment of the stapedial prosthesis. Consequently, on the basis of the morphological analysis with Scanning Electron Microscopy, in the surgical practice, the preference could be given to the stapedial prostheses that achieve greater contact such as the self-retaining and thermal crimping pistons compared to the standard sized prostheses considered.

Intraoperative electrically evoked stapedius reflex thresholds in children undergone cochlear implantation: round window and cochleostomy approaches.

OBJECTIVES: To study the best electrically stimulation in cochlear implant surgery with round window (RW) and Promontory cochleostomy approaches with electrically evoked stapedius reflex thresholds (ESRT) intraoperatively. METHODS: Thirty-nine children underwent CI surgery were included for this study. The surgical procedures consisted of RW and Promontory cochleostomy. ESRT for each 1st, 3rd, 6th and 12th electrodes (E) were determined. Statistical evaluation was done for the comparison of the thresholds and duration times for both groups. RESULTS: The duration times of ESRT for E1, E3, E6 and E12 electrodes was shorter in RW group compared with the Promontory group (p<0.05). The statistical evaluation of ESRT measurements of E1, E3, E6 found p<0.001 and E12 electrode p<0.05 in RW group. ESRT measurements were recorded at lower threshold in the RW group compared with the Promontory group. CONCLUSION: The duration of electrically stimulation thresholds were shorter in RW group. ESRT measurements were recorded at lower threshold in the RW group compared with the Promontory group. RW insertion offers best electrically stimulation relative to electrode insertion via a promontory cochleostomy.

Fístula perilinfática traumática: entidad otorrinolaringológica poco frecuente / Traumatic perilymphatic fistula: a rare otorhinolaryngological entity

La fístula perilinfática corresponde a una patología infrecuente en la práctica otorrinolaringológica diaria. Esta puede tener un origen congénito, de aparición espontánea o más frecuentemente postraumática, presentando habitualmente la triada clínica de hipoacusia, tinnitus y vértigo. A continuación se presenta el caso clínico de una paciente de 50 años atendida en el Servicio de Otorrinolaringología del Hospital Clínico de la Universidad de Chile, ingresada por un cuadro con clínica compatible, de inicio súbito luego de una perforación timpánica traumática autoinferida.

Perilymphatic fistula is an infrequent pathology in standard otorhinolaryngological practice. Fistulas of this sort may be of congenital, spontaneous or, more frequently post traumatic origin, normally presenting with the clinical triad of hearing loss, tinnitus and vertigo. The case of a 50 year old patient presenting with clinically compatible symptoms of sudden appearance after a self-infringed traumatic tympanic perforation is discussed.

Resultados auditivos de estapedostomías en platinas complicadas / Hearing results on stapedostomies in complicated platens

La estapedostomía es una alternativa de tratamiento quirúrgico de la otoesclerosis altamente eficaz y con resultados estables a largo plazo. Uno de los factores que puede condicionar una peor ganancia auditiva postoperatoria es la presencia de alteraciones significativas en la platina del estribo. Se incluyen en este estudio pacientes con otoesclerosis que fueron sometidos a estapedostomía entre los años 2000 a 2005 y en los cuales se constató la presencia de platina obliterada o flotante. Se compararon los valores auditivos pre y postoperatorios con un grupo de referencia constituido por pacientes sometidos a estapedostomía en el mismo período con platina azul. Se incluyeron 14 pacientes, sin diferencias en edad y género con respecto a los controles. No existieron diferencias estadísticamente significativas entre los grupos en cuanto a umbrales de vía ósea, aérea ni diferencia óseo-aérea. No se presentaron complicaciones en esta serie. Estos resultados demuestran que una técnica quirúrgica apropiada, junto a la experiencia del equipo quirúrgico hacen de la estapedostomía una alternativa exitosa en este tipo de pacientes.

[Results of stapedotomy in the cases of "floating footplate"]. / Wyniki stapedotomii w przypadkach "plywajacej plytki".

One of the problems in the stapes surgery is the floating footplate. The frequency of incidence of this complication is 2% to 5.8% of all operations. The authors present the results of stapes operations in a group of 28 cases (2.5%) from all the 1120 operations, in which the surgeon experienced a floating footplate. The hearing results were evaluated on the base of the average gain of air-conduction thresholds and air-bone gap levels at 500, 1000, 2000 and 3000 Hz. The improvement of hearing we observed in 24 patients, 4 patients heard worse.

Does it make sense to preserve the stapedial muscle during surgical treatment for otosclerosis?

Our study aimed to show whether it is useful to preserve the stapedial muscle during the surgical treatment of otosclerosis. The study was carried out on 67 patients with tympanoscopic evidence of otosclerosis. In group A (34 patients) the stapedial muscle was intra-operatively preserved as follows: the stapedial suprastructure with preserved muscle tendon was transpositioned onto the longer arm of the incus and secured with a wire loop. The mean uncomfortable level for sounds was measured after surgery and the results of group A patients were compared with those obtained in group B (33 patients, who underwent standard surgery). One month after surgery, in group A patients, the cochleostapedial reflex was evoked in 21 patients (61.8 per cent) and two months later in 32 patients (94.1 per cent). One month after operation, in group A patients the mean uncomfortable level was 108.8 dB, while three months later it increased to 114.1 dB. In group B, the relevant values were 97.8 dB one month after surgery, and 98.0 dB three months later. Our presumption that stapedial muscle preservation is necessary has been proved by the fact that the patients with the preserved muscle had a higher noise discomfort threshold.

[Hearing status after stapedectomy with preservation or cutting of stapedius tendon]. / Stan sluchu po stapedotomii z zachowaniem lub z przecieciem sciegna miesnia strzemiaczkowego.

The authors analysed the influence of preservation or cutting of stapedius tendon during stapedotomy on postoperative hearing improvement. The material analysed was 110 operated ears, which were divided into two egual groups considering preservation or cutting of stapedius tendon. All operations were performed by the same surgeon using stapedotomy with tarflen prothesis. In all cases before and after operation there was performed tonal audiometry within a range from 0.5 to 4.0 kHz, speech audiometry with indication of speech reception threshold using mono-syllable test. The comparison of operation results did not show significant statistical differences between the studied groups of operated ears.

[Electrophysiological study of cochlear damage in early otosclerosis and after stapedial surgery]. / Estudio electrofisiológico del daño coclear en la otoesclerosis precoz y tras cirugía estapedial.

Otoesclerotic patients usually have neurosensorial hearing toss in addition to a predominantly conductive impairment, but there is no universally accepted explanation for this abnormality. The bone conduction threshold in tonal audiometry is accepted as a test of cochlear function. An early evaluation of damage to the cochlea arid acoustic nerve after surgery was made by studying 99 ears with BERA and latency/intensity curves to test cochlear function. We concluded that early damage was present. Postoperative cochlear damage was found in spite of successful surgery, but it was no greater than the damage present before surgery.