Ganancia auditiva en pacientes intervenidos de cirugía del estribo por otosclerosis / Hearing gain in patients undergoing stapes surgery for otosclerosis

Introducción y objetivo: La otosclerosis es una causa de hipoacusia en jóvenes, con mayor frecuencia en mujeres. La cirugía del estribo es un procedimiento correctivo ampliamente aceptado, con el advenimiento de la tecnología y cambios en la técnica, surge la interrogante de si existen diferencias entre ellas. Objetivo: Evaluar si existen diferencias en la ganancia auditiva entre técnicas y abordajes de las cirugías del estribo en pacientes con otosclerosis Método: Se recabaron variables demográficas, clínicas y quirúrgicas. Se aplicó estadística descriptiva. Se empleó prueba U de Mann-Whitney para variables numéricas, así como Kruskal Wallis para comparación diferencias en tres o más grupos. Se consideró significativo un valor de p ≤ a 0.05. Resultados: Entre los años 2020 y 2023 se realizaron 55 cirugías de estribo por otosclerosis, de las cuales 20 se tuvieron que excluir. De 35 cirugías en 31 pacientes, la media de edad de 41.16 ± 8.64 años, 77.4% fueron mujeres, el 51.4 % fueron en el oído derecho; se presentaron comorbilidades en el 25.7%, las complicaciones 5 presentaron hipoacusia, el 88.6 % de los procedimientos se encontró un cierre satisfactorio de la brecha aérea y ósea. No se presentaron diferencia entre las técnicas de la cirugía de estribo y resultados audiológicos postquirúrgicos p=0.872, ni con el tipo de abordaje de visualización p=0.636. Discusión: Nuestros resultados son similares a lo que encontraron algunos autores, no obstante, aún sigue existiendo incertidumbre sobre la mejor técnica. Conclusiones: No se encontraron diferencias estadísticamente significativas en cuanto a la ganancia auditiva con el abordaje de visualización y el tipo de procedimiento en el estribo para la colocación de la prótesis. (AU)

Introduction and objective: Otosclerosis is a cause of hearing loss in young people, more frequently in women. Stapes surgery is a widely accepted corrective procedure, with the advent of technology and changes in technique, the question arises as to whether there are differences between them. Objective: To evaluate whether there are differences in hearing gain between techniques and approaches of stapes surgeries in patients with otosclerosis. Method: Demographic, clinical and surgical variables were collected. Descriptive statistics were applied. The Mann-Whitney U test was used for numerical variables, as well as the Kruskal Wallis test to compare differences in three or more groups. A p value ≤ 0.05 was considered significant. Results: Between 2020 and 2023, 55 stapes surgeries were performed for otosclerosis, of which 20 had to be excluded. Of 35 surgeries in 31 patients, mean age 41.16 ± 8.64 years, 77.4% were women, 51.4% were in the right ear; Comorbidities were present in 25.7%, 5 complications presented hearing loss, in 88.6% of the procedures a satisfactory closure of the air-bone gap was found. There was no difference between stapes surgery techniques and postsurgical audiological results p=0.872, nor with the type of visualization approach p=0.636. Discussion: Our results are similar to what some authors found, however, there is still uncertainty about the best technique. Conclusions: No statistically significant differences were found in terms of hearing gain with the visualization approach and the type of procedure in the stapes for placement of the prosthesis. (AU)

A Review of Surgical Nuances and Outcomes of the Reverse Stapedotomy.

The stapes surgery has evolved through different eras of technical and technological development. The current standard of care is creating a stapedotomy with piston placement, and both these aspects have multiple variations and show well-established technological advances. The conventional technique has been fairly standardized,and it offers gratifying results to both the surgeon and the patient. To overcome certain procedural risks and potential complications, the reversal of steps technique was developed and streamlined by Ugo Fisch in the early 1980s. Since its beginning, the technique has been adopted by various centers, and surgical outcomes have been demonstrated to be at par with the conventional technique, with a reduced risk of complications. The aim of the present review is to detail the various surgical nuances and outcomes of this particular technique in a comprehensive narrative manner.

Trend in otolaryngological surgeries in an era of super-aging: Descriptive statistics using a Japanese inpatient database.

OBJECTIVE: To reveal the age distribution and capture the longitudinal trend in otolaryngological surgeries performed in Japan, where society is rapidly aging. METHODS: Using the Diagnosis Procedure Combination database, we extracted data on patients who were hospitalized and underwent any type of otolaryngological surgery in departments of otolaryngology or head and neck surgery from fiscal year 2007 to fiscal year 2013. Type of surgery, patient's age, and fiscal year were compared. We categorized >200 types of surgeries into eight specialties: ear surgery, functional endoscopic sinus surgery (FESS), other types of paranasal surgery (except for malignancy), head and neck cancer surgery, benign tumor surgery, upper airway surgery (including pharynx and larynx), removal of foreign body, and other. RESULTS: In total, 558,732 patients were included. The proportions of patients in each age category formed two peaks in middle age and in children aged ≤9years. The proportion of all surgeries made up by FESS, other paranasal surgery, benign tumor surgery, and head and neck cancer surgery gradually increased with age, forming a peak in patients in their 60s. The proportion of ear surgery was highest in patients aged ≤9years (34.0% of all surgeries, mostly myringotomy and transtympanic ventilation tube insertion) and formed a gradual peak in patients in their 60s (mostly tympanoplasty). The proportion of upper airway surgery (tonsillectomy and adenoidectomy) was highest in patients aged ≤9years (25.3% of all surgeries). The proportion of foreign body removal was highest in patients aged ≤9years (52.2% of all surgeries) and increased slightly with age. In 2013, compared with 2007, those aged 65-74 years and ≥75years made up a larger percentage of patients undergoing each specific surgery, including tympanoplasty, stapedectomy/stapedotomy, FESS, head and neck cancer surgery, pharyngolaryngectomy, total/subtotal glossectomy, thyroid lobectomy, parotidectomy (for a benign tumor), submandibular gland resection, tonsillectomy, and vocal fold polypectomy. CONCLUSION: The age distribution of otolaryngological surgeries varied by specialty. We found an increased proportion of patients aged 65-74 and ≥75years in most specific surgeries.

The Stapes Prosthesis: Past, Present, and Future.

Since the original carved Teflon stapes over vein graft, stapedectomy prostheses have undergone evolution. Prostheses shapes, materials, and surgical techniques for placement have reflected advances in biomaterials and surgical tools. The variability in prostheses has reflected alternative techniques of stapedectomy and stapedotomy and differing strategies for attachment to the incus. Although many iterations of stapes prostheses have been proposed, excellent results can be achieved with various prostheses designed to rest on tissue grafts in stapedectomy techniques or pass through the footplate in stapedotomy techniques when used by surgeons experienced with technique details specific to the selected prosthesis.

[Current concepts in the surgical management of otosclerosis]. / Aktuelle Aspekte zur chirurgischen Therapie der Otosklerose.

Otosclerosis can be of viral origin and in 25-50% of cases a familiar accumulation can be seen. Typically patients develop a progressive middle ear hearing loss which starts in young adulthood and which can affect one as well as both ears in up to 80% of cases. The surgical procedures of choice are stapedotomy and stapedectomy. Complications of surgery are persistent vertigo, secondary facial nerve palsy and the most severe complication is deafness in up to 1% of the cases. Even if the operation risks are low, the alternative use of a hearing aid must be offered in the initial consultation. A new technique of stapes surgery is laser-assisted stapedotomy. Necrosis of the incus process with dislocation of the prosthesis is the most common finding which necessitates stapes revision surgery. The aim of this article is to present the current scientific concept, diagnostics and therapy of otosclerosis with an emphasis on surgical treatment options.

[Optical coherence tomography in middle ear surgery]. / Optische Kohärenztomographie in der Mittelohrchirurgie.

The application of optical coherence tomography (OCT) in middle ear surgery has a high diagnostic potential, especially for intraoperative evaluation of the cause of stapes fixation, intraoperative assessment of the morphology of the stapes footplate in revision stapes surgery, and as an orientation guide in cochlear implantation in congenital anomalies. OCT displays the middle and inner ear structures precisely. This technology enables the surgeon to use this information for further specification of the intraoperative modus operandi. Considering our own in vivo and ex vivo investigations and animal experiments, potential areas of application can be defined: visualization of the oval window niche in revision stapesplasty and reconstructive middle ear surgery, as well as during explorative tympanotomy for intraoperative assessment of perilymph fistula, and demonstration of structures of the exposed but not opened inner ear.

Time trend analysis of otological procedures performed in England, 1989 to 2005.

OBJECTIVE: To observe trends in the number of major otological procedures performed in England, in the context of advances in the understanding of disease. METHODS: The data used were obtained from the Hospital Episode Statistics statistical database, published by the UK Department of Health, for England, 1989 to 2005. Specific otological procedures were identified using the Classification of Surgical Operations and Procedures system (fourth revision) of the Office of Population, Censuses and Surveys. Trend analysis of different procedures was performed using exponential smoothing (using the Statistical Package for the Social Sciences version 13 software). RESULTS: Our study did not confirm any reduction in the number of surgical procedures performed for cholesteatoma or otosclerosis. We noted a sharp decline in the number of endolymphatic sac surgical procedures performed, probably attributable to the increased use of intratympanic therapy. CONCLUSION: The number of major otological procedures (other than endolymphatic sac surgery) was consistent over the period examined. The generally perceived reduction in the number of procedures performed by individual surgeons may be due to a dilutional effect. This can only support the need for subspecialisation, particularly regarding the training of junior surgeons.

Stapedectomy: demographics in 2006.

OBJECTIVE: To evaluate whether the performance of stapes surgery by residents during residency has decreased during the last 40 years, and if so, whether such a decrease has impacted the number of general otolaryngologists performing stapedectomy in the private practice setting. STUDY DESIGN: Survey questionnaire of members of the American Academy of Otolaryngology-Head and Neck Surgery. METHODS: A short questionnaire was mailed to 1,700 members of the American Academy of Otolaryngology-Head and Neck Surgery. Data collected included age, year of residency graduation, fellowship (if any), practice setting, geographic location, number of stapedectomies performed in residency, and number of stapedectomies performed currently. RESULTS: Seven hundred fifty-six (44%) of 1,700 surveys were returned; 558 (74%) of 756 respondents did not complete a fellowship and were included in the general otolaryngologist group. Overall, 41% of general otolaryngologists are performing stapes surgery. There was a significant decline in the number of resident stapedectomies performed between 1960 and 1986; since 1986, this number has plateaued to an average of 8 to 9 (self-reported) cases per resident. More recent graduation from residency trended toward decreased inclination to do stapedectomy, although the result was not statistically significant. Increasing number of stapedectomy cases performed in residency correlated with an increased likelihood of performing the operation in practice. CONCLUSION: Despite a decreasing case volume of stapes surgery in residency, stapedectomy remains an operation performed by general otolaryngologists.

Importancia del láser en la técnica quirúrgica de la otosclerosis y sus resultados / Importance of laser in the surgical technique of otosclerosis and its results

Los autores plantean la utilización del láser en la cirugía. Se revisa la literatura, en la que se encuentran autores que nos hablan de las ventajas que supone la utilización de este instrumento. También se recogen nuevas tendencias en la cirugía del estribo. Se plantea la enseñanza de la cirugía de la otosclerosis, con diferentes criterios. Se refuerza la idea de que es dificil mejorar los rendimientos auditivos, ya que los que se obtienen con técnicas clásicas son excelentes, pero si que se mejora la comodidad y se disminuyen los riesgos

The authors bring up the matter of the usefulness of laser in otosclerosis surgery. They set out some advantages of laser utilization. A bibliografic review is done and some important authors are found explaining the advantages of this instrument. Some new tendencies on stapes surgery are presented. Teaching on otosclerosis surgery problems are stated, with some different criteria. The idea that improvement of audiologic results in stapes surgery is not easy is strengthened, because the results obtained with the classic techniques are excellent, but some of these methods increase the surgical comfort and reduce the potential risks to the patient

Stapes surgery in the United States.

OBJECTIVE: A contemporary analysis of trends in the surgical management of otosclerosis in the United States is presented. DATA SOURCES: U.S. population demographics were obtained from the U.S. Census Bureau. Surgical case data was obtained from publications of the National Center for Health Statistics. Physician population statistics are published by the American Medical Association. DATA EXTRACTION: Available estimates for otologic operations are interpreted according to clinical setting used for data acquisition and surgical practice patterns. Linear regression of included data defines trends in operations performed. Population statistics are used to define changes in the incidence of surgical cases. CONCLUSIONS: The number of stapedectomy cases has declined over the past 30 years. During this same interval, the U.S. population (including the white population) and the number of surgeons has increased. This indicates that the incidence of surgical otosclerosis is declining. Although the true etiology of the decline is uncertain, widespread immunization for measles is a plausible hypothesis.

Management of otoscierosis--an Irish perspective.

The last 30 years have seen a gradual change in the management of otosclerosis. The aim of this study is to evaluate the current practice amongst Irish otolaryngology consultants by a questionnaire and to compare it with the practice currently followed in Great Britain. Thirty-eight responses (67.9%) were available for analysis. The overall trend is towards centralisation with a reduction in the number of surgeons undertaking stapes surgery (39%). The majority of consultants (67%) who undertake stapes surgery would operate for a unilateral conductive loss and 67% would undertake bilateral stapes surgery. Stapedotomy is the only operation performed (100%) with none of the consultants performing partial or total stapedectomies.

The future of stapedectomy--the Singapore problem.

Concern has been expressed in the recent literature regarding the problem of a dwindling number of stapedectomy cases and an increasing number of surgeons trained to do this operation. In Singapore, the problem is made worse by the very low incidence of this disease in its main ethnic groups of Chinese and Malays who together make up more than 90 per cent of the population. We report here an audit of 47 ears that underwent stapedectomy in a teaching hospital over a six-year period. The hearing results for consultants and surgical trainees were compared. Closure of the air-bone gap to within 10 dB was obtained in 64 per cent of Consultants' cases and 68 per cent of trainees' cases. These results fall short of the 90 to 95 per cent figure reported by experts in this procedure and only comparable to the less satisfactory results of several series recorded by residents in North America. We conclude that the unsatisfactory results arise from the small number of surgical cases available for each surgeon to improve and maintain his skills in a technically demanding procedure. It is proposed that such cases be directed to those pursuing otology as a subspecialty rather than all otolaryngologists in general.

Current practice of stapedectomy in Great Britain.

Since the introduction of stapedectomy with reconstruction of the ossicular chain to Great Britain, many modifications in practice have taken place. The changes include patient selection, operative technique and the type of prosthesis used, as well as the number of operations performed yearly. The aim of this study is to attempt to establish the actual practice among British otolaryngology consultants by means of a simple questionnaire. Two hundred (50.3%) forms were analysed anonymously. The study confirms the decrease in the number of operations performed annually, the absence of centralization for this type of surgery in Great Britain and also demonstrated the trends towards stapedotomy and the practice of bilateral surgery amongst younger consultants.

'Collective stapedectomy' (an approach to the numbers problem).

The results of a first series of fifty stapedectomies, using newly adopted 'Fisch stapedotomy technique' are presented and contrasted with 'world results' and results of leading otologists. The essential points in the evolution of stapes surgery are outlined. In the light of the small number of deaf otosclerotics the philosophy of who should be performing stapes surgery and who should be trained to perform it, is discussed. The title 'Collective Stapedectomy' denotes personal system of collecting patients from the waiting list in batches and operating on each stapedectomy batch in consecutive fashion.

Stapes surgery: implications for training.

The worldwide decline in surgery for otosclerosis had been reflected by a similar pattern here in Great Britain. Unless we are prepared to accept poorer results than have formerly been achieved, we will have to adopt measures to ensure that the skills of stapes surgery are transferred to the next generation of surgeons. Using the results of our experience, at the Queen Elizabeth Hospital, over the past 18 years, I have examined the implications for surgical training and for the management of future patients with otosclerosis.