The effect of stapes fixation on hearing results in tympanosclerosis treated by mobilization.

We aimed to investigate the effect of stapes fixation on hearing results in patients who underwent mobilization surgery due to tympanosclerosis (TS). Seventy-nine patients were retrospectively analyzed and divided into two groups. Forty-four (55.7%) patients with mobile stapes were classified as group 1, and 35 (44.3%) patients with fixed stapes were classified as group 2. Improvement of the air-bone gap (ABG) to become less than 20 dB and the pure-tone average (PTA) by at least 10 dB postoperatively were accepted as success criteria. The PTA and ABG levels were significantly improved in both groups. The pre- and post-operative PTAs were 46.57 ± 15.55 and 25.84 ± 15.47 dB, respectively, in group 1 (p = 0.001). The pre- and post-operative PTAs were 55.64 ± 12.69 and 36.20 ± 14.47 dB, respectively, in group 2 (p = 0.001). The pre- and post-operative ABG levels were 35.36 ± 10.53 and 16.91 ± 8.54 dB, respectively, in group 1 (p = 0.001). The pre- and post-operative ABG levels were 41.68 ± 8.78 and 22.20 ± 10.03 dB, respectively, in group 2 (p = 0.001). A gain ≥10-dB in the PTA in groups 1 and 2 was found in 34 (77.2 %) and 23 (65.7%) patients, respectively, and the difference between the groups was not significant (p = 0.684). The post-operative AGB in groups 1 and 2 was less than 20 dB in 32 (72.7%) and 21 (60%) patients, respectively, and the difference between the groups was not significant (p = 0.733). No significant negative effect of stapes fixation on post-operative hearing results in TS was detected. Successful results can be obtained with a mobilization procedure, even if the stapes is fixed.

Comparison of KTP, Thulium, and CO2 laser in stapedotomy using specialized visualization techniques: thermal effects.

High-speed thermal imaging enables visualization of heating of the vestibule during laser-assisted stapedotomy, comparing KTP, CO2, and Thulium laser light. Perforation of the stapes footplate with laser bears the risk of heating of the inner ear fluids. The amount of heating depends on absorption of the laser light and subsequent tissue ablation. The ablation of the footplate is driven by strong water absorption for the CO2 and Thulium laser. For the KTP laser wavelength, ablation is driven by carbonization of the footplate and it might penetrate deep into the inner ear without absorption in water. The thermal effects were visualized in an inner ear model, using two new techniques: (1) high-speed Schlieren imaging shows relative dynamic changes of temperatures up to 2 ms resolution in the perilymph. (2) Thermo imaging provides absolute temperature measurements around the footplate up to 40 ms resolution. The high-speed Schlieren imaging showed minimal heating using the KTP laser. Both CO2 and Thulium laser showed heating below the footplate. Thulium laser wavelength generated heating up to 0.6 mm depth. This was confirmed with thermal imaging, showing a rise of temperature of 4.7 (±3.5) °C for KTP and 9.4 (±6.9) for Thulium in the area of 2 mm below the footplate. For stapedotomy, the Thulium and CO2 laser show more extended thermal effects compared to KTP. High-speed Schlieren imaging and thermal imaging are complimentary techniques to study lasers thermal effects in tissue.

[A new method for the fixation of sound-conducting elements of the middle ear during ossiculoplasty].

The objective of the present work was to estimate the possibilities of the application of platelet-enriched plasma as a filtering material for ossiculoplasty. The results of surgical interventions on 120 patients presenting with chronic suppurative otitis media are reported. All the patients underwent closed-type sanation surgery (differential atticoanthrotomy) including either complete or partial restoration of the sound conduction mechanism in the middle ear. Platelet-enriched plasma was applied into the tympanic cavity of 55 patients as a fixing material for the reconstruction of the chain of the auditory ossicles. Ossiculoplasty without additional fixation was performed in 65 patients comprising the control group. The results of the study indicate that a clot of platelet-enriched plasma may be a good fixing material for the reconstruction of the entire chain of auditory ossicles and can be used for all types of ossiculopasty.

Stapedotomy with incus vibroplasty - A novel surgical solution of advanced otosclerosis and its place among existing therapeutic modalities - Hungarian single institutional experiences.

OBJECTIVE: To delineate the advantages and steps of stapedotomy with incus vibroplasty, to assess the safety and efficacy of this method via the authors' experiences, and to overview the literature regarding other surgical options in advanced otosclerosis determining the place of stapedotomy with incus vibroplasty in the therapeutic range. METHODS: Four patients were enrolled in the study presenting severe mixed hearing loss of at least one side on pure tone audiometry. Based on complementary audiological examinations including stapedial reflex test and multifrequency tympanometry, all cases were suspected as advanced otosclerosis. Stapedotomy with incus vibroplasty - the combination of laser stapedotomy and simultaneous Vibrant Soundbridge implantation - was performed in each patient. Preoperative pure tone average, speech recognition thresholds and word recognition scores were compared to one-year postoperative free-field values with the implant switched on focusing on functional gain. RESULTS: Among 4 participants (3 females, 1 male) the mean age (SD) was 66 years (35). In three cases Nitinol, in one case NitiBond piston was inserted. One-year postoperative free-field functional gains were 30 dB, 34 dB, 42 dB and 51 dB, respectively. One-year postoperative free-field speech recognition thresholds were 45 dB, 45 dB, 49 dB and 50 dB, respectively, while word recognition scores were 70%, 70%, 70% and 75%, respectively. CONCLUSION: Postoperative results in our serie regarding pure tone average and word recognition score proved to be better than those found in the literature. Stapedotomy with incus vibroplasty - through sufficient air-bone gap closure and simultaneous sensorineural component management - seems to be a promising surgical solution in advanced otosclerosis, requiring further investigation.

Imaging of otosclerosis. / Bildgebung der Otosklerose.

BACKGROUND: Otosclerosis is an important cause of hearing loss and a widespread pathology in ENT medicine. Although a high diagnostic value of CT with impact on therapy is emphasized in the literature, the disease is seldom seen in the radiological routine diagnostics due to ENT findings often being diagnostic. Radiologists detect it rather more often in cases of unclear hearing loss or cochlear implant candidates. The findings may be very subtle. They require a target search and an optimal imaging technique. METHODS: This review article is based on a selective search of the literature in PubMed without any time frame restrictions as well as on the long clinical experience of the authors. RESULTS: The paper focuses on imaging aspects of otosclerosis: current role, advice for imaging technique, characteristic imaging signs, radiological differential diagnoses and findings after stapedoplasty. Pathology, clinical signs and therapeutic options are summarized briefly. CONCLUSIONS: With an optimal technique and sufficient radiological experience otosclerosis can be correctly diagnosed by imaging in a high percentage of cases. Radiology plays the key role in the diagnosis of retrofenestral otosclerosis. It can provide valuable information for the management of complications after stapedotomy. KEY POINTS: · X-ray cross-sectional imaging continues to be the method of first choice in the radiological diagnostics of otosclerosis. · With an optimal imaging technique and sufficient experience otosclerosis can be radiologically detected. · In complications after stapedoplasty, causes can be identified supporting the indication for a reoperation. CITATION FORMAT: · Kösling K, Plontke SK, Bartel S. Imaging of otosclerosis. Fortschr Röntgenstr 2020; 192: 745 - 753.

[Long term results stape surgery]. / Wyniki odlegle w otosklerozie.

For many years otosclerosis has been an interesting otologic problem in regard to pathological and clinical aspects. Many various conceptions of otosclerosis development which finally lead to the stapes immobility in the oval window were discussed. Resent genetic studies indicate that genetic factors as a cause of otosclerosis possibly in combination with other factors localize 3 genes responsible for otosclerosis to chromosom 15q25q-q26, 7q34-36, 6p21-22. The aim of the study was audiometric evaluation of 1380 patients out of 1716 stapes operations performed in years 1973-2004. Audiometric assessment for air and bone conduction was performed according to the European Academy of Otology and Neuro-Otology (EAO-NO) criteria. Postoperative air-bone gap 11-20 dB for speech frequencies (500, 1000, 2000, 4000 Hz) was obtained in 64.8% and in 28.9% was less than 10 dB. Postoperative air-bone gap (11-20 dB) recognized as a good result is determined by factors such as preoperative hearing loss, onset and duration of the disease, advanced and multiple otosclerotic foci, patient's age etc. Actually postoperative air-bone gap shows the improvement of air and bone thresholds obtained post stapedotomy versus preoperative air bone gap. In previous years an "over-closure" effect was taken into consideration. Hearing improvement post stapes surgery which included the "over closure" effect was obviously better. The authors indicate the necessity of standardization of audiometric results post ear surgery.

Shape-memory stapes prosthesis for otosclerosis surgery.

OBJECTIVES: The aim of this study was to determine the efficacy of a shape-memory alloy, Nitinol, as a component of an improved stapes prosthesis. STUDY DESIGN: Prospective laboratory and clinical study to develop a Nitinol stapes prosthesis. METHODS: Various diameters of Nitinol wire and temperature transition variants were analyzed with regard to ease of deformation, response to heating, and strength. The size and geometry of the closed hook was determined by measurement of 50 incus cadaver bones. Several heat sources for activating the shape memory were evaluated, including electrocautery, lasers, and warm water. Trial surgeries were then performed on human temporal bones in the laboratory. The closure characteristics of the Nitinol loop were studied. Magnetic resonance imaging (MRI) testing at 1.5 Tesla was performed to determine safety during MRI studies. Preliminary human subject trials were then instituted. RESULTS: In all cases, a low heat condition was ample to activate the shape memory characteristics of the hook and return it to a closed position after it had been opened. Laser power was generally set well below the power needed for removing bone. The Nitinol loop closed snugly around the incus with application to the top of the hook with a low temperature laser setting. Almost any heat source was effective. MRI testing at 1.5 Tesla showed no movement of the prosthesis. Preliminary results in human subjects showed excellent air-bone closure. The Nitinol loop holds uniform contact around the incus. CONCLUSIONS: The Nitinol piston greatly simplifies the stapedectomy procedure by taking the need for a hand operated instrument out of the surgeon's hands. Because of the nature of the Nitinol wire, it can never over-crimp. All these characteristics make the prosthesis advantageous for otosclerosis surgery.

Quality of life following small fenestra stapedotomy.

OBJECTIVES: A cross-sectional observational study was designed to evaluate patient satisfaction after stapedotomy. METHODS: Two validated questionnaires, the Psychosocial Impact of Assistive Devices Scale (PIADS) and the Hearing Handicap Inventory (HHI), were used to assess patients for whom audiometric data were available. RESULTS: The response rate was 79%. The PIADS score showed that 96% of patients reported an improvement in quality of life. The HHI score, however, showed that 32% of patients still experienced a marked degree of handicap after surgery. The HHI scores correlated positively with postoperative audiometric data, and the PIADS scores correlated positively with the degree of change in audiometric data. CONCLUSIONS: The results of this study support the role of small fenestra stapedotomy as a primary treatment for otosclerosis. The study also identifies a certain subpopulation of patients with residual handicap who may require further aural rehabilitation.

Numerical study of Hough technique in surgery of otosclerosis, using the finite element method.

PURPOSE: Otosclerosis is a metabolic bone disease of the otic capsule that can cause the stapes fixation, resulting in conductive hearing loss or, in a profound sensorineural deafness threshold. Surgery is one of the possible treatments for the otosclerosis. To repair small focus of otosclerosis in the anterior crus of the stapes, in 1960, Hough suggested the implementation of a technique in which part of the anterior crus is fractured and the stapes turned. As a result, the posterior crus of the stapes is the only connection with the inner ear. In this work, the outcome of Hough's surgical technique was simulated. METHODS: Based on computerized images, a finite element model of middle ear ossicles and tympanic membrane was created, as well as a model where the stapes has changed. The discretization of the tridimensional solid model was made using the ABAQUS software. The mechanical properties used were taken from the literature and adequate boundary conditions were applied. RESULTS: The results obtained with the Hough technique simulation were compared with a representative model of the normal ear, taking into account the displacements obtained on the central part of the stapes footplate and the maximum principal stress in the stapes crus. CONCLUSIONS: The results obtained are closer to the normal ear model, therefore Hough technique stands out as a good option to correct small focus of otosclerosis.

Symposium: Congenital anomalies of the middle ear. I. Epitympanic fixation of incus and malleus.

Epitympanic fixation of the incus and malleus may be surgically corrected by transcanal atticotomy and removal of the fixed incudomalleolar mass. Restoration of serviceable hearing has resulted in five of six cases by repositioning the natural incus or using a homograft incus.

Stapes fixation in chronic middle ear disease.

Rigid stapes fixation is not uncommonly found in chronic otitis media and can be caused by several conditions. Careful stapedectomy with some form of ossicular chain reconstruction is the treatment of choice, usually as a second stage procedure. Hearing results to date have been gratifying.

Triple ossicular fixation.

A technique for overcoming conductive deafness secondary to fixation of all three ossicles is described in detail. This procedure is also applicable to previously fenestrated ears.

Stapedectomy trends for the resident.

The diminishing number of cases of otosclerosis limits the training experience in stapes surgery during residency. Results are suboptimal. Closure of the preoperative air conduction to within 10 dB of bone conduction was obtained in only 64% of resident cases. Efforts to maximize experience and improve results include closer faculty supervision, use of one stapedectomy technique, and a prospective study of individual residents' performance.

Assessment of stapes mobility by use of a newly developed piezoelectric ceramic device. A preliminary experiment in dogs.

A piezoelectric device was developed for assessment of stapes mobility during middle ear surgery. The device comprises a pair of ceramic bimorph elements: one for activation of the stapes and the other to pick up the vibration as an electric output, which varies in accordance with the stapes mobility, ie, the inverse of the cochlear input impedance (Zsc). The device is compact and easily manipulated even in the narrow surgical field of the ear. However, the measuring range is restricted to between 1 and 10 kHz. Measurement of Zsc was conducted with this device in 5 ears of 5 dogs. The mean magnitude of Zsc increased with frequency in the range from 1 to 10 kHz: 0.95 megohm at 1 kHz and 8.8 megohms at 10 kHz. After fixation of the stapes with dental cement, the magnitude increased to more than 10 megohms, except at 1 kHz. The results suggest that the device is useful in detecting decreases in stapes mobility in patients with chronic otitis media.

KTP laser fine fenestra stapedotomy with vein graft interposition in the surgical management of otosclerosis.

Otosclerosis is an hereditary disease of bone derived from the embryonic otic capsule. The exact aetiopathogenesis remains unclear. It can be associated with significant disability due to hearing impairment. Medical and surgical treatments, with varying degrees of effectiveness and complication rates, are available. The surgical method for the correction of the conductive hearing loss associated with otosclerosis continues to undergo technical refinement with the aim of improving results and minimising complications. The surgical technique of fine fenestra stapedotomy is well established. Here, we describe a new modification of this technique involving the use of a KTP laser. Based on the retrospective review of the results and complication rates of over 200 consecutive cases, we would like to recommend the technique of KTP laser fine fenestra stapedotomy in the surgical management of otosclerosis.

Congenital conductive hearing loss.

Congenital conductive hearing loss due to ossicular deformities can be treated by either rehabilitation with a hearing aid or surgical reconstruction. We present the results of exploratory tympanotomy performed in a large paediatric otolaryngology centre in 67 patients with non-serous congenital conductive hearing loss. Forty-two children had malformation of one or more ossicles without fixation of the stapes, and 19 had fixed stapes. In 26 cases, the surgeon decided not to perform surgical correction. Seven operated patients were lost to follow-up. As a group, 47 per cent of the patients who underwent reconstruction showed no significant benefit from surgery, with post-operative air-bone gaps (ABG) greater than 30 dB. Assessment of the results by pathology showed that 64 per cent of the patients with mobile stapes had an air-bone gap within 30 dB compared to only 33 per cent of the patients with fixed stapes. One patient sustained severe sensorineural loss after the procedure. Considering that exploratory tympanotomy is a relatively minimal, benign procedure but that findings during exploration may exclude the option of reconstruction (in 39 per cent of our patients), we suggest exploring the ear, but in a more realistic, informed way.

Stapedectomy--past and present.

Surgical technics for bypassing ankylosis of the stapes in the management of otosclerosis gradually evolved; modifications were prompted by problems which were revealed by the ongoing audits carried out by earlier surgeons. Auditing of performance must remain an integral part of any otologist's work. The natural history of otosclerosis should be taken into account so that a patient may be fully informed of treatment alternatives available. Stapedectomy will remain a most effective operation which can be recommended with confidence, provided the surgeon has acquired the skill to perform it properly. It is now accepted that many ear, nose and throat surgeons are neither physically nor temperamentally capable of this task and should not perform stapedectomy.

Stapes mobilization in otosclerosis.

We performed a retrospective chart study (including surgeon's notes and audiometric results) and an analysis of the archival temporal bones from a patient who had undergone surgery for stapes mobilization in both ears. The stapes footplate was submerged into the vestibule on the right (as a complication of surgery) and absent on the left. One interesting finding was that the patient's hearing had improved on the right despite the presence of the depressed footplate and that the air-bone gap had widened on the left despite the absence of complications on that side.

[Stapedectomy and micro-stapedotomy in the treatment of otospongiosis. A comparative study]. / Stapédectomie et micro-stapédotomie dans le traitement de l'otospongiose. Etude comparative.

This is a comparative study of 622 patients undergoing either stapedectomy or stapedotomy for otosclerosis. 379 underwent stapedectomy, which in the majority of cases employed interposition of the posterior crus of the stapes into a venous graft placed over the newly created fenestra. The results of this technique are compared with 243 microwindow stapedotomies performed since 1976. For all patients a minimum of 5 years had elapsed between surgery and evaluation of outcome. In some instances, this time period was 20 years. One month post-surgery the closure of the air-bone gap was more frequently superior with stapedectomy, particularly in the low frequencies. The degree of an incidence of overclosure was comparable for both techniques. However, at 4,000 Hz, bone threshold levels deteriorated more usually following stapedectomy. The air-bone gap widened progressively over the proceeding years post-stapedectomy. This was in contrast to the effect seen during the same period after stapedotomy, namely a narrowing of the air and bone threshold levels. Additionally a progressive loss of bone thresholds was noted after the latter technique. The incidence of sudden total deafness, either immediate or delayed, was less than 1% for both procedures. Even after 15 years or more poststapedectomy, the air-bone gap (13 dB average) and bone thresholds remained stable. Revision surgery was necessary in 8% of stapedectomies and in 4% stapedotomies. However, the post-operative follow up period is much shorter for the latter.