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Data and Picture Interpretation Stations: Cases 1–45
Published in Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar, ENT OSCEs, 2023
Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar
Stapes surgery, commonly known as ‘stapedectomy’ is a treatment for otosclerosis and any other cause of stapes fixation. The middle ear is entered by lifting the tympanic membrane. The bony scutum may then be widened for greater access, aiming to preserve the chorda tympani which lie in the same plane. After confirmation of stapes fixation by testing ossicular chain mobility, then incudostapedial joint is divided. The stapedius tendon is then divided, followed by the posterior crus of the stapes suprastructure. The stapes suprastructure is then downfractured and removed. A hole is then made in the stapes footplate. Typically this might measure 0.4–0.6mm. Prosthesis is placed onto the long process of incus and passes through the footplate fenestration. This then restores the conduction of sound from the tympanic membrane all the way through to the inner ear. Risks to explain in the consent process include: dead ear, worsening or failure to improve hearing, infection, bleeding, dizziness, tinnitus, altered taste, facial palsy, perilymph leak, prosthesis failure and tympanic membrane perforation.
Otosclerosis
Published in R James A England, Eamon Shamil, Rajeev Mathew, Manohar Bance, Pavol Surda, Jemy Jose, Omar Hilmi, Adam J Donne, Scott-Brown's Essential Otorhinolaryngology, 2022
Stapedectomy was first described by John Shea in 1956. This involves removing the fixed stapes and placing a piston from the incus to the vestibule. The basic technique Shea described remains in place. However, refinements have taken place over the last 60 years, and the main modification of the technique is to perform a small stapedotomy rather than removing the whole stapes footplate. This has reduced the risk of total sensory hearing loss and probably improved high-frequency hearing results. There are many piston designs but with little to choose between them. A larger piston diameter should theoretically give better hearing, but the differences are small. Most surgeons use a piston with a diameter between 0.4 and 0.6 mm. There are a variety of methods of removing the stapes superstructure and performing the stapedotomy. Cutting the stapes crura with a laser reduces the risk of stapes dislocation when removing the superstructure. Many surgeons use a laser when performing the stapedotomy, but there is no good evidence to favour laser over microdrill or hand trephine. If the incus is eroded the piston can be secured using bone cement. If the residual incus long process is very short or dislocated a malleostapediopexy can be performed in which a piston is placed from the malleus handle to the stapedotomy. Whilst not as good as standard stapedotomy, excellent results can still be achieved with this technique.
Case 42
Published in Simon Lloyd, Manohar Bance, Jayesh Doshi, ENT Medicine and Surgery, 2018
Simon Lloyd, Manohar Bance, Jayesh Doshi
Hearing rehabilitation options always include standard hearing aids. In this case, consideration should strongly be given to stapedotomy to close the air-bone gap followed by hearing aids. This would allow much better function with the hearing aids. The third option is cochlear implantation. At this level of hearing, this might well be considered if hearing is not satisfactory with hearing aids even after stapedotomy or stapedectomy. Another possible option is to drive the inner ear with a middle ear driver such as the CODACS™ driver from Cochlear Corp, which bypasses the footplate with a stapedotomy.
Prognostic factors for duration of vertigo after stapes surgery via a time-to-event analysis
Published in Acta Oto-Laryngologica, 2021
Atsushi Fukuda, Keishi Fujiwara, Shinya Morita, Kimiko Hoshino, Hiroko Yanagi, Yuji Nakamaru, Akihiro Homma
Overall, 35 primary ears (26 with otosclerosis and nine with congenital stapes fixation) from 31 patients (eight ears in seven men and 27 ears in 24 women) were enrolled in this study (Table 1). Two ears were excluded due to a history of idiopathic sudden sensorineural hearing loss on the other side. There were no exclusions due to an episode of vertigo/dizziness previously. The median age of the patients was 48 years (range: 12–73). The median follow-up period after surgery was 41 months (range: 12–63). There were six (17.1%) ears with a history of stapes surgery in the opposite ear. Four of these six ears underwent stapedotomy at our hospital, while the other two had undergone stapedotomy at other hospitals previously. The median period between the stapes surgery in the first ear and the next stapes surgery in the opposite ear was 1.5 years (range: 0–22). The median operation time was 120 min (range: 75–248). A 4.0-mm prosthesis was used in two (5.7%) ears and a 4.5-mm prosthesis was used in 33 (94.3%) ears. A total of 25 (71.4%) ears had covering around the site of piston insertion in the footplate.
The clinical characteristics of otosclerosis and benefit from stapedotomy: our experience of 48 patients (58 ears)
Published in Acta Oto-Laryngologica, 2019
Jing Xie, Ling-Jun Zhang, Na Zeng, Yun Liu, Shu-Sheng Gong
Audiological improvement is the primary benefit of stapes surgery but we evaluated a range of probable predictive factors for successful surgery. All operations were performed by the same skilled surgeon. A recent review considered the short- and long-term hearing outcomes of stapedotomy and stapedectomy procedures. Stapedotomy was associated with better high-frequency improvement [5]. Another consideration is the size of the prosthesis, where 0.4 mm and 0.6 mm are the most popular sizes representing small and large fenestrations, respectively. Although the latter may be associated with a better success rate (67%) than the former (58%), no high-quality trails have been conducted to validate this claim [5,18]. In addition, advocates for smaller prostheses believe that less trauma and better plasticity can be achieved with smaller units. We used a 0.4 mm prosthesis for all cases at our center; the success rate in the current study was 71.43% (20/28) based on the average ABG at four frequencies (0.5, 1, 2, and 4 kHz).
Distorted sound perception and subjective benefit after stapedotomy – a prospective single-centre study
Published in International Journal of Audiology, 2019
David Bächinger, Christof Röösli, Rahel Kesterke, Adrian Dalbert, Dominik Péus, Dorothe Veraguth, Flurin Pfiffner, Alexander Huber
Stapedotomy is a well-established surgical procedure replacing a pathologically immobile stapes with a piston prosthesis (Fisch 1982). By far the most common underlying cause of an immobile stapes is otosclerosis, a condition affecting up to 4 in 1000 individuals in Caucasian populations (Ealy and Smith 2011). Otosclerosis is characterised by the stapes footplate’s becoming fixed by pathological bone remodelling of uncertain aetiology (Ealy and Smith 2011) causing a conductive hearing loss. If the disease affects the stapes, then the preferred treatment is stapedotomy, a safe and successful procedure restoring sound conduction. Stapedotomy is usually considered successful if the air-bone gap (ABG) is substantially reduced (≤10 dB) with air conduction (AC) thresholds better than 30 dB hearing level (HL) (Smyth and Patterson 1985). The ABG closures in large-scale studies are reported to be ≤20 dB in 98% and ≤10 dB in 95% of patients (Vincent et al. 2006; Kisilevsky et al. 2010).