John Oates

Surgical findings and long-term hearing results in 3,050 stapedotomies for primary otosclerosis: a prospective study with the otology-neurotology database.

Objective: To evaluate with a new otologic database the results of primary stapes surgery for otosclerosis with up to 14 years of follow-up in a consecutive series of 2,525 patients operated on by the same surgeon with the same technique (stapedotomy and vein graft interposition) and to provide online access to the complete data of this study for the reviewers. To study the effect of specific operative findings (obliterative otosclerosis and simultaneous malleus ankylosis) and age at the time of surgery on the long-term outcome. Study Design: Prospective clinical study using a new computerized otologic database. Setting: Tertiary referral center. Patients: Two thousand five hundred twenty-five patients who underwent 3,050 stapedotomies for otosclerotic stapes fixation were enrolled in this study from January 1991 to December 2004. Separate analyses were made for two unique pathologies (92 cases of obliterative otosclerosis and 19 cases of simultaneous malleus ankylosis) diagnosed during surgery and for patients in two age brackets (≤18 yr [28 patients] and ≥65 yr [302 patients]). Intervention: Stapedotomy with vein graft interposition and reconstruction with either a Teflon piston, a bucket handle prosthesis, or a total prosthesis. Main Outcome Measures: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were all assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 14 years. Results: Overall, the postoperative ABG was closed to 10 dB in 94.2% of cases. The mean four-frequency postoperative ABG was 1.7 dB compared with 25.6 dB preoperatively. The mean four-frequency bone-conduction thresholds were unchanged postoperatively. A significant postoperative sensorineural hearing loss (SNHL; >15 dB) was seen in 0.5% of cases in this series. Postoperative ABG was achieved to within 10 dB in 95% of cases of obliterative otosclerosis and in 64.7% of cases of simultaneous malleus ankylosis. A significant postoperative SNHL (>15 dB) was seen in 4.8% of cases of obliterative otosclerosis and was not observed in any cases of simultaneous malleus ankylosis. Postoperative ABG was achieved to within 10 dB in 93.5% of cases in the pediatric series and in 94.5% of cases in the senior series. A significant postoperative SNHL (>15 dB) was seen in 0.7% of cases in the senior group but was not observed in the children. Conclusion: Using a new otologic database, our series confirms that stapedotomy with vein graft interposition for otosclerotic stapes fixation is a safe and successful treatment for long-term hearing improvement. The deterioration in hearing with time after stapedotomy did not exceed the rate of hearing loss because of presbyacusis. Therefore, argon laser stapedotomy with vein graft interposition is our preferred surgical technique in the treatment of otosclerosis. Obliterative otosclerosis and simultaneous malleus ankylosis may be encountered during stapedotomy. Our study shows that reasonable success rates can still be expected in these situations. Stapedotomy results in the elderly and in children are comparable to those obtained in patients of other groups of age undergoing surgery for otosclerosis without an increased risk for complications.

Stapedotomy for tympanosclerotic stapes fixation: is it safe and efficient? A review of 68 cases.

Objective Performing stapedotomy in cases of tympanosclerotic stapes fixation is controversial. The procedure is traditionally considered to carry a high risk of postoperative sensorineural hearing loss. The aim of this study was to report the hearing results in surgically treated cases of stapes fixation. Study Design A retrospective review of tympanosclerosis of the oval window with stapes fixation. Setting The study was performed at the Jean Causse Ear Clinic in Clombiers, France. Patients Sixty-five patients who underwent surgery for tympanosclerotic stapes fixation between January 1992 and October 1999. Intervention Stapedotomy with vein graft interposition and reconstruction with a Teflon piston, or a total prosthesis in cases of incudal erosion. Main Outcome Measures Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap, bone conduction threshold, air conduction threshold, and Glasgow Benefit Plot were measured. Results Postoperative air-bone gap closure to within 10 dB was achieved in 39% of cases. An air-bone gap less than 20 dB was obtained in 70% of cases. Significant postoperative improvement of air conduction thresholds, more than 20 dB, was found in 46% of cases. The postoperative bone conduction thresholds were unchanged in 92% of cases. No significant sensorineural hearing loss was seen in this series. Conclusion This series demonstrates that safe and successful stapedotomy is possible if certain rules are respected.

Revision Stapedotomy : Operative Findings and Hearing Results. A Prospective Study of 652 Cases From the Otology-Neurotology Database

Objective: To identify the causes of failure of primary stapes surgery and to evaluate the hearing results of revision stapes surgery in a consecutive series of 652 cases. Study Design: Prospective nonrandomized clinical study. Setting: Tertiary referral center. Patients: Six hundred thirty-four patients who underwent 652 consecutive revision stapes operations from April 1992 to December 2007 were enrolled in this study. Main Outcome Measures: Preoperative and postoperative audiometric evaluation using conventional audiometry, namely, air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds, were assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 15 years. Results: The most frequently identified reason for primary surgery failure was incus erosion (27.6%) and prosthesis displacement (18.2%). The postoperative ABG was closed to 10 dB or less and 20 dB or less in 63.4 and 74.6% of cases, respectively. The mean 4-frequency postoperative ABG was 11.5 dB as compared with 28 dB preoperatively (mean difference, 16.5 dB; 95% confidence interval [CI], 15.1-17.9 dB, p < 0.0001). The mean 4-frequency postoperative air-conduction thresholds were 45.7 dB compared with 58.7 dB preoperatively (mean difference, 13 dB; 95% CI, 11.4-14.6 dB, p < 0.0001). The mean 4-frequency postoperative bone-conduction thresholds were 34 dB compared with 30.6 dB preoperatively (mean difference, −3.5 dB; 95% CI, −4.4 to −2.5 dB, p < 0.0001). A significant postoperative sensorineural hearing loss (>15 dB) was observed in 2.9% of cases in this series. Conclusion: Improvement of a conductive hearing loss after initial unsuccessful primary or revision stapes surgery can be accomplished with further revision but is occasionally modest.

The Learning Curve in Stapes Surgery and Its Implication to Training

Objective: To identify the stapedotomy learning curve of two U.K. otolaryngologists.

Ossiculoplasty with Intact Stapes and Absent Malleus: The Silastic Banding Technique

To report an original method of ossicular reconstruction with intact stapes and absent malleus. Ossiculoplasty is performed with a total ossicular replacement prosthesis positioned from the stapes footplate to the under-surface of the tympanic membrane, using a Silastic banding technique to stabilize the prosthesis. Study Design: A prospective study of ossicular reconstruction using the Silastic banding technique. A consecutive series of cases with intact stapes superstructure and missing malleus handle (Austin-Kartush Group C) is presented. Setting: One tertiary referral center. Patients: Ninety-nine patients who underwent total ossicular reconstruction with Silastic banding technique were enrolled in the study from January 2000 to December 2002. Interventions: Ossiculoplasty with total ossicular replacement prostheses with Silastic Rubber Band for chronic otitis media and non-inflammatory disease. Main Outcome Measures: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap, bone-conduction threshold, and air-conduction threshold were assessed. Postoperative audiometry was performed at the 6th, 9th, 12th, 18th, 24th, and 36th months. Results: Overall, a postoperative air-bone gap closed to within 10 dB was achieved in 61.5% of cases. An air-bone gap smaller than 20 dB was obtained in 77% of cases. Postoperative improvement of air-conduction thresholds by at least 20 dB was found in 51% of cases. There was no case of postoperative sensorineural hearing loss. One case of extrusion of the prothesis was seen (1%). Conclusion: Stabilizing the total ossicular replacement prosthesis with the Silastic banding technique when performing ossicular reconstruction is a safe, effective method when the stapes supra-structure is present and the malleus absent.

Traumatic fracture of the stapes suprastructure following minor head injury.

Traumatic fracture of the stapes occurs rarely following head injury. Ossicular dislocation is more commonly encountered. When present, stapes fractures are usually associated with an underlying temporal bone fracture. A higher incidence has been reported in childhood, possibly because of the greater flexibility of the skull in this age group. This report highlights the fact that these fractures can be associated with a relatively minor head injury. This possibility should be kept in mind when evaluating patients, especially children, who have a persistent conductive deafness of more than 30 dB with an intact tympanic membrane following any form of head injury. An exploratory tympanotomy with appropriate ossicular reconstruction, as described in this case, can yield excellent results.

KTP versus CO2 laser fiber stapedotomy for primary otosclerosis: results of a new comparative series with the otology-neurotology database.

Objective To compare the 3-month postoperative hearing results after laser stapedotomy using a flexible potassium titanyl phosphate (KTP) or CO2 laser fiber in patients with primary otosclerosis. Study Design Prospective nonrandomized clinical study. Setting Tertiary referral center, 862 stapedotomies were performed in 818 study patients between November 2006 and July 2011. Methods Otosclerotic stapes fixation was treated with flexible KTP laser fiber in 410 patients (431 stapedotomies) and with flexible CO2 laser fiber in 408 patients (431 stapedotomies). Their preoperative and postoperative audiometric results were compared. Logistic regression analyses were performed to evaluate the main effect of laser fiber type and the effect after adjustment for independent predictors of a postoperative air-bone gap (ABG) 10 dB or lower. Results In the KTP laser group, the mean postoperative ABG was 4.3 dB compared with 3.1 dB in the CO2 group (difference, 1.1; 95% confidence interval, 0.4–1.9). In 90.4% of the patients in the KTP group, the postoperative ABG was 10 dB or lower, as compared with 96.5% in the CO2 group. The mean postoperative ABG at 4 KHz was 5.4 dB with KTP and 2.2 dB with CO2 (difference, 3.2; 95% confidence interval, 2.2–4.2). Sensorineural hearing loss was reported by 1 patient with KTP laser (0.3%) and by none with CO2 laser. “Type of laser” and “sex” were independent predictors of ABG 10 dB or lower. The chance to achieve a postoperative ABG 10 dB or lower for male subjects is 95%, when treated with CO2 laser and 85% when treated with KTP laser. For female subjects, these chances are 97% and 94%, respectively. Conclusion The use of the CO2 laser fiber may be associated with better hearing results than the KTP laser fiber, regarding the ABG closure within 10 dB.

Malleus relocation in ossicular reconstruction: managing the anteriorly positioned malleus: results in a series of 268 cases.

Objective: The objective of this study was to report an original method of malleus relocation allowing for better placement of both partial and total prostheses in ossicular reconstruction. Study Design: We conducted a retrospective review of clinical and audiometric findings. Setting: A tertiary referral center. Materials and Methods: This is a study of 268 patients who underwent ossiculoplasty surgery from October 1997 to October 2000 for chronic otitis media, noninflammatory disease, and otosclerosis revision. Malleus relocation with total and partial ossicular replacement prostheses was used in all cases. Audiometric assessment included pre- and postoperative audiometric evaluation using conventional audiometry. Air–bone gap, bone-conduction thresholds, and air-conduction thresholds were measured. Results: A postoperative air–bone gap closed to within 10 dB was achieved in 56% of cases. An air–bone gap smaller than 20 dB was obtained in 78% of cases. Postoperative improvement of air-conduction thresholds superior to 20 dB was found in 41.5% of cases. The postoperative bone-conduction thresholds were unchanged in 98% of cases. One case of total postoperative sensorineural hearing loss was seen in this series (0.4%). Extrusion of the protheses was not observed in this series. Follow up ranged from 6 to 36 months (mean, 12.4 months). Conclusion: This study shows that malleus relocation is a safe and efficient technique for ossicular reconstruction. The ideal position of the relocated malleus allows easier and more stable placement of middle ear prostheses.

A nonrandomized comparison of potassium titanyl phosphate and CO2 laser fiber stapedotomy for primary otosclerosis with the otology-neurotology database.

To compare short‐term hearing results in patients undergoing laser stapedotomy for primary otosclerosis using either the flexible potassium titanyl phosphate (KTP) or CO2 laser fiber.

Ossiculoplasty in intact stapes and malleus patients: a comparison of PORPs versus TORPs with malleus relocation and Silastic banding techniques.

Objectives: To compare hearing results in patients undergoing ossiculoplasty using either partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) with Silastic banding and malleus relocation techniques in cases with malleus and stapes both present and mobile. Study Design: Prospective nonrandomized clinical study. Setting: Tertiary referral center. Methods: Five hundred eighty-five patients undergoing ossiculoplasty were enrolled in this study from April 1991 to May 2010. Comparative analyses were made between a group of 304 patients who underwent ossiculoplasty with partial prosthesis positioned from the malleus to the stapes head and 281 patients who underwent ossiculoplasty with total prosthesis positioned from the malleus to the stapes footplate. Preoperative and postoperative audiometric evaluation using conventional audiometry, that is, air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were assessed. Results: In the PORP group, the mean postoperative ABG was 13.1 dB compared with 8.9 dB in the TORP group, (95% confidence interval [CI], 2.2-6.2 dB; p ≤ 0.001). Fifty-four percent of patients from the PORP group had a postoperative ABG of 10 dB or less, compared with 68.9% in the TORP group (mean difference, 14.6%; 95% CI, 6%-23%; p < 0.001). The postoperative ABG was closed to within 20 dB in 70.4% of cases in the PORP group compared with 86.9% in the TORP group (mean difference, 14.5%; 95% CI, 10%-23%; p < 0.001). Conclusion: In patients with an absent incus and intact stapes and malleus, ossicular reconstruction with TORP combined with our malleus relocation and Silastic banding technique results in significantly better hearing outcomes compared with reconstructions with PORP.