Experimental in vivo fenestration of guinea pig cochlea using 2.79 Μm laser radiation

Erbium: Yttrium-Aluminum-Garnet Laser Application in Stapedotomy

OBJECTIVE: To assess clinical safety and efficacy of the erbium: yttrium-aluminum-garnet (Er:YAG) laser in the stapes surgery; to define and optimize parameters that render the procedure safe for the inner ear.

STUDY DESIGN: Retrospective study.

MATERIAL AND METHODS: A microscope-integrated Er: YAG laser stapedotomy was performed on 29 patients and a conventional stapedotomy on 41 patients. An early (within 1 to 3 days after stapes surgery) and late (at least 6 weeks) pure-tone bone-conduction threshold audiogram was obtained.

RESULTS: No statistically significant differences were found by Student's t test over all measured frequencies between pre- and postoperative bone-conduction thresholds in each group. There was no statistically significant difference for all frequencies between early (3 days) and late postoperative mean bone-conduction thresholds.

CONCLUSIONS: The results of our preliminary clinical study showed that erbium laser poses no risk to inner ear function. However, the lack of standardization obliges further investigation to establish safe clinical parameters of the Er:YAG laser.

EBM RATING: B-3

Mechanism study of laser cochleostomy-induced early hearing loss in a rat model

Hearing loss following laser-assisted ear surgery has been reported. However, the mechanism responsible for the hearing loss remains largely speculative. The aim of this study was to investigate the correlation between laser-induced hearing loss and changes in the number of hair cell ribbon synapses and ultrastructure in the cochlea. Laser cochleostomy was performed with a superpulsed carbon dioxide (CO2) laser at 2 and 5 W in Sprague-Dawley rats. Auditory brainstem responses (ABRs) were measured preoperatively and 2 days after surgery. The synapse numbers in apical and middle cochlear turns were quantified. Transmission electron microscopy was employed to further examine the subcellular changes in the cochlea. Click and tonal ABR threshold shifts in both 2 and 5-W groups displayed a frequency-dependent loss within the frequency range measured. Laser cochleostomy induced a significant decrease of synapse numbers in the middle turn in both groups (p < 0.05). Electron microscopy data indicated varying degrees of auditory nerve degeneration in both groups. Auditory nerve degeneration might contribute to laser-caused hearing loss even under low-energy laser cochleostomy. The high-energy laser-induced hearing loss was associated with more reduction of synapse number.

Advantages and dangers of erbium laser application in stapedotomy

Among different types of lasers, the erbium laser exhibits particularly favourable characteristics for ear surgery. Experiments with application of erbium laser pulses to the isolated stapes connected to an inner ear model confirmed that there was virtually no thermal effect to the inner ear liquid and that the border damage zone on the stapes footplate perforation did not exceed 5-10 microm. Erbium laser pulses, however, produce pressure waves due to the explosive ablation of tissue. Pulses of 10 to 17 J/cm2 producing pressure waves between 140 and 160 dB appear to be a limit for clinical application. With these criteria, an in-house built erbium YAG laser with a fiberoptic delivery device was used in 15 patients for stapedotomy. A special microhandpiece, where a zirconium fluoride fiber was connected to a quartz tip, was developed. In addition, three patients had stapedotomy with a commercially available Zeiss (Opmi TwinER) microscope equipped with a micromanipulator-operated erbium laser beam. One year after surgery, the air-bone gap was closed in all patients to within 20 dB between 0.5 and 3 kHz with only minor permanent bone conduction threshold losses (< 20 dB). However, we observed an immediate postoperative middle and high frequency loss of up to 75 dB on bone conduction threshold measurements 2 h after surgery, suggesting an acoustic traumatization by the erbium laser. This threshold shift recovered close to preoperative values within 6 h. These observations prompted us to discontinue the clinical use of erbium laser for stapedotomy until the problem of temporary acoustic traumatization is resolved.