Arnold G. Schuring

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.

Practical Use of Total and Partial Ossicular Replacement Prostheses in Ossiculoplasty

The use of porous polyethylene total and partial ossicular replacement prostheses (TOPs and POPs) for ossicular reconstruction in middle ear surgery was retrospectively reviewed at the Warren Otologic Group, a tertiary referral center for otologic problems. Extrusion rates, lower than those previously reported, and improvement in hearing results were found in 250 cases. Follow‐up ranged from 6 months to 8 years. This paper details the optimal placement and relationships of the prosthesis, the interposed tragal cartilage, and the drum. Modifications to the prosthesis have increased stability and ease of reconstruction. The hearing results of both TOP and POP reconstruction, and comparison with the literature, will be presented. With TOPs, the air‐bone gap was closed to within 20 dB in 67% of cases. With POPs, similar results were obtained in 81% of cases.

Staging for Cholesteatoma in the Child, Adolescent, and Adult

A closed tympanomastoidectomy with subsequent staged surgical procedures leading to the excision of cholesteatoma was validated as described. All elements of staging with a 10-year experience of 354 patients are covered according to categories of child (0 to 9 years), adolescent (10 to 15 years), and adult. The child differed from the adolescent and adult in the following manner: More recurring cholesteatomas, greater ossicular necrosis, poorer hearing results, less aggressive residual cholesteatoma, and significantly poorer results with pars flaccida cholesteatoma than pars tensa cholesteatoma. After the end stage, 90% of the cases remained closed, with acceptable hearing in 60% of the patients.

A Postoperative Audiometric Evaluation of Cochlear Implant Patients

As the benefits of the cochlear implantation become more defined, many investigators hope that these devices can be offered to patients with a lesser degree of hearing loss. Accordingly, it is necessary to investigate the audiometric thresholds in the implanted ear after surgery. Preservation of the residual hearing after implantation would support the claims that surgery and the presence of a cochlear implant do not adversely affect the implanted ear.

Revision stapedectomy for incus erosion: Long-term hearing ☆ ☆☆ ★

One of the most common ossicular problems in revision stapedectomy is the eroded incus. Revision surgery has been reported as successful in 70% to 80% of cases at 1 year. Little is written about long-term results or the association of erosion with various prostheses. We evaluated 83 cases from 1 to 20 years, including multiple revisions. In 23 cases the erosion was seen at initial stapedectomy. Surgery was performed with the patient under local anesthesia, with the use of the Lippy modified prosthesis. Initial success was seen in 72% (41/57), satisfactory results in 90%, no change in 5%, and none worse. At 10 years, success had declined to 50% (7 of 14), with 80% satisfactory. The numbers for multiple revisions were lower. Success in nonrevision cases was 90% (21 of 23), dropping to 86% at 10 years, with satisfactory results in 100%. The type of prosthesis associated with erosion was a crimped wire in 34% (24 of 70), a plastic strut in 23%, and a Robinsion prosthesis in 17%. We conclude that the risk of incus erosion appears less with the Robinson prosthesis. The Lippy modified prosthesis yields good long-term results, particularly when erosion is seen at initial stapedectomy. Results worsen with subsequent revision.

Ossiculoplasty in canal wall down mastoidectomy

OBJECTIVE: The aim of this study was to evaluate the initial and longer term success of closing the air-bone gap (ABG) to 20 dB in ossiculoplasty with canal wall down mastoidectomy. METHODS: This study was conducted at a private otologic practice. Patients included those who underwent ossiculoplasty from 1989 to 1996 with canal wall down mastoidectomy, whether primary or revision (33 from a total of 387 tympanomastoidectomies). Outcome measures included ABG closure, long-term hearing stability, mastoid appearance, extrusion, and sensorineural hearing loss. RESULTS: Almost 64% of ABGs were closed to within 20 dB. The mean pure-tone average improvement was 12.3 dB. The mean PTA hearing decline in the years after surgery was slightly less than 1 dB/year. CONCLUSION: Hearing improvement with a stable long-term hearing result is possible with canal wall down mastoidectomy. The potential for hearing gain is greatest for patients having larger preoperative ABGs. (Otolaryngol Head Neck Surg 2000;123: 30-3.)

Short- and long-term results of stapedectomy in children.

Studies have indicated that stapedectomy can be an effective procedure in children for correcting conductive hearing losses due to juvenile otosclerosis. However, because childhood otosclerosis is rare and children commonly choose to use hearing aids in lieu of undergoing surgery, little outcome data are available. The purpose of this retrospective study was to provide additional outcome data in both the short and the long term. Stapedectomies were performed on 47 children. Preoperative hearing results were compared with 6‐month postoperative hearing results. Hearing results for the children who had long‐term follow‐up (5 years or more) were compared with the 6‐month postoperative results. Stapedectomy was successful (postoperative air conduction pure‐tone average [PTA] within 10 dB of the preoperative bone conduction PTA) in 91.7% of the cases. The mean over‐closure of the preoperative bone conduction PTA by the postoperative air conduction PTA was 0.2 dB. The mean PTA hearing improvement was 32.8 dB. Results from the 21 children (28 ears) who had long‐term follow‐up indicated an average 0.7 dB/year PTA worsening from the 6‐month postoperative PTA. Results from this study provide additional evidence that stapedectomy can be an effective procedure for correcting conductive hearing losses due to juvenile otosclerosis.

Stapedectomy Revision Following Sensorineural Hearing Loss

This study analyzes 71 stapedectomies that resulted in a sensorineural hearing loss, followed by a revision stapedectomy on the suspicion of an oval window fistula. The cases were divided between two primary stapedectomy techniques: a stainless steel Robinson prosthesis on a vein graft and a wire prosthesis with Gelfoam. The major differences between the surgical findings of the two groups were the fistula rate with the wire prosthesis was 10 times that with the Robinson prosthesis; the wire prosthesis was longer than necessary in 21% of the cases in which it was used; there was no finding of excess length with the Robinson prosthesis; and after revision stapedectomy, dizziness was lessened in 20% of the patients in the Robinson prosthesis group, in 60% of those in the wire prosthesis group, and in 75% of those with fistula. Surgical directions are given for revision stapedectomy following a sensorineural hearing loss.

Prosthesis size in stapedectomy

Primary stapedectomies were performed on 60 patients with bilateral otosclerosis. Every patient had a 4 mm long Robinson prosthesis with a 0.4 mm wide shaft placed in one ear and a 4 mm long Robinson prosthesis with 0.6 mm wide shaft placed in the opposite ear. With the 0.4 mm wide prosthesis, 54 patients overclosed the air bone gap and 6 were within 10 dB of closing. With the 0.6 mm wide prosthesis, which was placed in the opposite ear, 51 patients overclosed their air-bone gap and 8 were within 10 dB of closing. We conclude that there is no statistical difference in hearing results between the 0.4 mm and the 0.6 mm wide Robinson prosthesis when they are used in a partial stapedectomy with a vein graft covering the oval window.

Partial ossicular reconstruction in children: A review of 62 operations†

Objective/Hypothesis: The published experience and audiometric results with ossicular reconstruction in children are limited. To better understand the role of ossiculoplasty in children, audiometric results were examined for partial ossicular reconstructions performed on a pediatric population. Study Design: Retrospective. Methods: Sixty‐two partial ossicular reconstructions performed on a pediatric population were reviewed for audiometric results, prosthesis extrusion rates, and mechanisms of failure at revision. Comparison of techniques and prosthesis types: porous polyethylene partial ossicular replacement prosthesis (POP), Schuring ossicle cup (SOC), and modified Robinson prosthesis (MRP) were also evaluated. Follow‐up ranged from 6 to 72 months. Results: Six‐month hearing results showed postoperative air‐bone gaps less than or equal to 20 dB in 77% of cases. Successful results at 1 and 2 years were retained in 66% and 63% of cases, respectively. Results for POPs at 1 and 2 years were 78% and 89%. Results for SOCs at 1 and 2 years were 61% and 55%. The overall extrusion rate was approximately 3%. Conclusions: These results compare favorably with those from other, mostly adult, studies. Comparison of prosthesis types revealed generally stable long‐term results with few significant differences. Success with ossiculoplasty in children can be obtained by applying the same principles and approach to ossicular reconstruction as used in adults. Ossicular reconstruction in children remains a secondary goal after establishing a safe, dry, and stable ear. A discussion of techniques and comparative literature review are presented. Laryngoscope, 108:1674–1681, 1998