Complications In Stapes Surgery

Assessment of the ability of the radiological incudo-stapedial angle to predict the stapedotomy technique type: a prospective case-series study

PURPOSE

This study aimed to propose a radiological classification of the incudo-stapedial angle by preoperative high-resolution computed tomography (HRCT) images and to highlight its importance for predicting the use of reversal-steps stapedotomy (RSS) rather than the traditional non-reversal technique.

METHODS

We included 83 candidates for stapedotomy operation. Two physicians measured the radiological incudo-stapedial joint angle in the preoperative HRCT. According to this measurement, the radiological incudo-stapedial joint was classified into three types: obtuse, right, and acute. In addition, this radiological classification was correlated with the intraoperative use of the stapedotomy technique, either reversal or non-reversal.

RESULTS

The RSS technique was used in forty-two (97.7%) cases with an obtuse angle and twenty-six (89.7%) with a right angle. At the same time, the traditional non-reversal technique was used in all patients with an acute angle. The three groups differed significantly regarding the method used for stapedotomy (P value < 0.001). Moreover, Spearman's correlation coefficient revealed a significant correlation between the used technique and the radiological type of the incudo-stapedial angle (P value < 0.001).

CONCLUSIONS

This prospective study proposed a preoperative radiological classification of the incudo-stapedial angle. This classification was significantly correlated with the type of stapedotomy technique. The RSS technique was feasible in most cases with an obtuse and right radiological incudo-stapedial angle. In contrast, the non-reversal method was used in all patients with an acute radiological incudo-stapedial angle. This radiological classification could predict the choice for the stapedotomy technique with an accuracy of 95.18%, a sensitivity of 73.33%, and a specificity of 100%.

Endoscopic Stapes Surgery: Pearls and Pitfalls

The endoscopic approach to stapes surgery affords unique advantages but is not without its specific challenges. The following reviews the equipment and surgical steps required to perform endoscopic stapes surgery safely and effectively, highlighting tips and potential points of failure through a series of case examples.

Gusher in stapes surgery: a systematic review

OBJECTIVE

The aim of this study is to perform a systematic literature review on the occurrence of gusher during stapes surgery, to understand its surgical management and outcomes.

METHODS

The PRISMA standard was applied to identify English, Italian or French-language studies, related to stapes surgery and mentioning gusher or perilymphatic leak. Full-texts lacking information on the management of gusher and/or the post-operative hearing outcome were excluded.

RESULTS

Twenty-four articles were eventually included. Seventy-six patients were involved in the qualitative synthesis. The management of gusher mostly consisted in covering the oval window and/or filling the tympanic cavity, with absorbable and autologous graft materials. Packing of the external auditory canal was reported in 51 patients (67%). Gusher was related to complete/profound loss of hearing in 25% of the cases and to a worsening of hearing function in 31% of patients. In 19% of patients an improvement in hearing tests was reported; in 28% the hearing function was unchanged. Post-operative vestibular symptoms were reported in 7 patients, and were mainly mild and transient. The absence of vestibular symptoms was underlined in 9 cases, while in 79% of the patients the authors did not provide information.

CONCLUSION

The unexpected occurrence of gusher during stapes surgery represents a relevant issue for the otologic surgeon. Its management most commonly consists in plugging the oval window and the tympanic cavity. In most of the cases, a stapes prosthesis could be positioned. The results on hearing and vestibular functions are widely variable.

Stapes surgery preserving the superstructure of stapes (Takagi's stapedotomy) in otosclerosis: A retrospective study of 24 consecutive cases

OBJECTIVE

The aim of this study was to evaluate the hearing outcomes and complications of stapedotomy in which the stapes superstructure was preserved (Takagi's stapedotomy). In this surgical approach, the lenticular process of the incus rather is removed, than the superstructure of the stapes.

METHODS

A single-center retrospective observational study was performed. We included all patients having Takagi's stapedotomy for otosclerosis between January 2005 and April 2016. Both primary and revision stapes surgery were included. We evaluated audiometric outcomes and surgical complications.

RESULTS

Twenty-four patients who underwent stapedotomy preserving superstructure were included in this study. The postoperative air-bone gap at 1year postoperatively was ≤10dB in 66.7% of patients and ≤20dB in all cases. In longer follow-up period, elevation of the air-bone gap was not observed over the 5 postoperative years in available cases. The postoperative air-bone gap was ≤10dB in 72.2% at 3years and 81.8% at 5years postoperatively.

CONCLUSION

Takagi's stapedotomy restore ossicular conduction without the removal of superstructure of stapes. The air-bone gap did not get worse in long-term follow-up, although audiometric results would be unsatisfactory. Further larger studies are needed to evaluate the efficacy and safety of Takagi's stapedotomy.

Cerebrospinal fluid leak during stapes surgery: Gushing leaks and oozing leaks, two different phenomena

Cerebrospinal fluid (CSF) leak is an uncommon event that can occur during stapes surgery. Such leaks can be classified as gushing leaks (stapes gushers) and oozing leaks. A stapes gusher is a massive flow of CSF through the perforated footplate that fills the middle ear suddenly, while an oozing leak is a slower and less profuse flow. We conducted a retrospective, observational, multicenter study of 38 patients-23 men and 15 women, aged 23 to 71 years (mean: 47)-who had experienced a CSF leak during stapes surgery. Patients were divided into various groups according to the type of surgical procedure performed and the type of postoperative complications they experienced. Audiometric and clinical evaluations were carried out pre- and postoperatively. Correlations among surgical variations (total or partial stapedectomy, placement of a prosthesis), hearing outcomes, and the incidence of postoperative complications (postoperative CSF leak and vertigo) were studied. Our statistical analysis revealed that gushing leaks and oozing leaks result in different degrees of hearing impairment and different rates of complications. We recommend that an individual approach be used to manage these complications.

Early Postoperative Imaging of the Labyrinth by Cone Beam CT After Stapes Surgery for Otosclerosis With Correlation to Audiovestibular Outcome

BACKGROUND

Sensorineural complications of stapes surgery are rare but potentially serious. Imaging is usually performed to identify an underlying cause, such as excessive intravestibular penetration of the prosthesis or pneumolabyrinth suggesting perilymphatic fistula. Unfortunately, there is very little data in an unselected series of uneventful patients.The aim of this study was to analyze the depth of prosthesis penetration within the vestibule and the rate of pneumolabyrinth the day or the day after the procedure by performing a cone beam computed tomography of the temporal bone in a cohort of unselected patients, and to correlate imaging findings to clinical outcome.

METHODS

A prospective monocentric study was conducted in a tertiary referral medical center. A cone beam computed tomography was performed in 80 consecutive patients having undergone stapes surgery for otosclerosis, the day or the day after the procedure. Penetration length and location of the prosthesis within the vestibule, as well as presence or absence of a pneumolabyrinth, were recorded, and compared with clinical data (vertigo, nystagmus, hearing measurement).

RESULTS

Pneumolabyrinth was found in 15% of the patients. The mean penetration length of the prosthesis within the vestibule was 1 mm (0-1.9 mm). No serious complication occurred during the study period. No correlations were found when comparing imaging findings to clinical outcome.

CONCLUSION

Our results do not support empirically insights into detrimental effects of postoperative pneumolabyrinth or too long prosthesis after stapes surgery. Further studies are needed to better understand the causes of postoperative complications of stapes surgery.

Dizziness, malpractice, and the otolaryngologist

PURPOSE

To assess malpractice claims related to the management of dizziness in otolaryngology in order to improve care and minimize the risk of litigation.

MATERIALS AND METHODS

This is a retrospective review of the LexisNexis "Jury Verdicts and Settlements" database. All lawsuits and out of court adjudications related to the management of dizziness by otolaryngologists were collected. Data including patient demographics, plaintiff allegation, procedure performed, and indemnities were analyzed.

RESULTS

Of 21 cases meeting inclusion criteria, 17 were decided by a trial jury and four were resolved out of court. Jury verdicts favored the plaintiff 53% of the time and a payout was made in 57% of cases overall. Average payments were higher for jury verdicts in favor of the plaintiff ($1.8 million) as compared to out of court settlements ($545,000). Two-thirds of cases involved surgery, most commonly stapes surgery. Legal allegations, including physical injury, negligence, and lack of informed consent failed to predict the legal outcome.

CONCLUSIONS

Appropriate examination, testing, and referrals within a timely manner are crucial in the management of dizzy patients to avoid misdiagnoses. It is imperative that patients undergoing ear surgery are appropriately counseled that dizziness is a potential complication. The analysis of malpractice literature is complementary to clinical studies, with the potential to educate practitioners, improve patient care, and mitigate risk.

Post-stapedectomy granuloma: a devastating complication

OBJECTIVES

This paper reports three cases of severe post-stapedectomy granuloma, emphasising the variable presentation of this devastating complication and the challenges of its management.

METHODS

A retrospective review was conducted of three cases of post-stapedectomy granuloma requiring surgical debulking between 2010 and 2015. Clinical symptoms, serial imaging, histopathology and post-operative outcomes were considered.

RESULTS

Intra-operatively, extensive granulation tissue with erosion of the otic capsule was found. There was spread along the VIIth and VIIIth cranial nerves to the cochlear nucleus in one patient. Post-operative clinical improvement was demonstrable, corroborated by diminution of contrast enhancement on serial magnetic resonance imaging. Facial nerve function recovered, tinnitus amelioration was variable and some otalgia persisted. Post-operative complications included grade IV facial weakness and late Pseudomonas aeruginosa meningitis, which all resolved.

CONCLUSION

To the authors' knowledge, this paper reports the only case of post-stapedectomy granuloma tracking to the brainstem. Otalgia was present in all our cases, and may be deemed a red flag symptom of progressive bony destruction and otic capsule involvement. Although granuloma remains rare, it should be considered in any patient with worsening otological symptoms following stapes surgery.

[The application of stapedoplasty for the treatment of hearing loss in the patients suffering from obliterative otosclerosis]

This article presents the results of analysis of the data obtained during the examination and the surgical treatment of the patients presenting with the obliterative form of otosclerosis and suffering from hearing impairment with special reference to the intraoperative findings, technical aspects of stapedoplasty, and its effectiveness. A total of 14 patients (17 ears) were recruited for the participation in the present study including 10 women at the mean age of 38.8±6.2 years and 4 men (mean age 44.8±3.9 years). The duration of the hearing loss in the period preceding the surgical treatment in 7 (50%) patients was more than 8 years. According to the results of tonal threshold audiometry (TTA), the mean bone conduction (BC) threshold for conductive hearing loss in the frequency range from 0.5 to 4.0 kHz was 24.9±8.1 dB with the mean bone air gap (BAG) equaling 38±5.1 dB. Computed tomography (CT) of the temporal bones revealed grade 1 obliterative otosclerosis in 4 patients, grade II of the same condition in 6 patients, and grade III in 7 ones. These findings were confirmed intraoperatively. In 15 cases, stapedostomy was carried out with the use of the non-contact CO2 laser-based system, in the remaining cases a microdrill was employed. Five patients underwent laser-assisted piston stapedoplasty while in 11 others the stapes prosthesis was placed on the autovein. One patient was treated by the same method with the use of the autocartilaginous prosthesis. The functionally acceptable results within 1 year after the surgical intervention were obtained in all the treated patients with the mean bone air gap equaling 13.2±3.4 dB. The best outcome (the reduction of the BC threshold and BAG by 7 dB and 25.9 db on the average respectively within 1 year after surgery was achieved in the patients with grade III obliterative otosclerosis.

Round window otosclerosis: radiologic classification and clinical correlations

OBJECTIVE

To develop a radiologic classification of severity of round window involvement in otosclerosis and describe the impact of each class on hearing and outcome of stapes surgery.

STUDY DESIGN

Retrospective chart review with radiologic review of computed tomographic scans.

SETTING

Hospital and private otolaryngology clinics.

PATIENTS

We reviewed computed tomographic scans of 930 ears with clinical otosclerosis; 121 (13%) had round window involvement, with no pericochlear involvement in 41 of these-the primary subjects of the study. A control group consisted of 15 ears with stapedial otosclerosis.

MAIN OUTCOME MEASURES

Round window involvement was classified into 5 groups from isolated round window edge hypodensity (RW-I) to overgrowing obliteration with possible extension to the cochlea (RW-V). Hearing measures included 4-frequency pure-tone average air conduction, bone conduction, and air-bone gap (ABG).

RESULTS

Of the 41 ears, 17.1%, 31.7%, 34.1%, and 17.1% were classified as RW-I to RW-IV, respectively. Patients with RW-I and RW-II otosclerosis, compared with the controls, showed no statistically significant differences in preoperative hearing or in ABG after stapes surgery. Patients with RW-III otosclerosis had significantly poorer hearing and a larger postoperative ABG (mean, 15 dB) than controls and groups RW-I and RW-II, whereas the RW-IV group showed the most severe hearing loss and poorest surgical outcome (all p's ≤ 0.001).

CONCLUSION

The proposed classification for round window otosclerosis is a valuable clinical tool that can help in decisions regarding, and counseling about, stapes surgery. Classes RW-I and RW-II have no clinical impact. Patients with RW-III otosclerosis may have a mild residual gap after surgery; those with RW-IV have dramatically poorer results.

Iatrogenic injury of the chorda tympani: a systematic review

Objective:

To review the currently available literature on iatrogenic injury of the adult chorda tympani.

Design:

Systematic literature review.

Method

Five electronic databases and one search engine were used to access available English language literature on the chorda tympani, focusing on iatrogenic injury.

Results:

The chorda tympani is most often injured during middle-ear surgery, after which at least 15–22 per cent of patients experience symptoms, mostly changes in taste and dryness of the mouth. Numerous factors influence whether injury to the chorda tympani causes symptoms, including the extent of injury, type of surgery, age of the patient, anatomical variables and subjective adaptation. Although most patients experience gradual symptomatic recovery, complaints can be persistent and troublesome.

Conclusion:

Care should be taken to preserve the chorda tympani during middle-ear surgery, and to warn patients pre-operatively about this potential complication. This is particularly important if surgery is bilateral.

Depth of stapes prosthesis in the vestibule: baseline values and correlation with stapedectomy outcome

CONCLUSION

Deeper protrusion of the prosthesis into the vestibule does not correlate with worse postoperative hearing outcome.

OBJECTIVES

To establish baseline values for the depth of the stapes prosthesis in the vestibule after stapedectomy and to investigate a possible correlation between the relative prosthesis depth (actual depth expressed as a percentage of the vestibule depth) and the hearing results.

METHODS

This was a prospective case study. Sixteen patients underwent stapedectomy and were examined by high-resolution CT of the temporal bone during the first week after surgery. They then underwent audiometric follow-up at specified intervals during the first postoperative year. The actual depth of the prosthesis in the vestibule, its relative depth, and correlations between the relative depth and postoperative hearing results (at 1 week, 1 month, and 1 year) or postoperative complications (prolonged vertigo and sensorineural hearing loss) were measured.

RESULTS

The actual depth of the prosthesis in the vestibule (mean +/- SD) was 2.39 +/- 0.42 mm (range 1.83-3.39 mm). The depth of the prosthesis relative to the depth of the vestibule was 52 +/- 9.74% (range 41.3-74.2%). In general, deeper protrusion of the prosthesis into the vestibule did not correlate with a worse hearing outcome. On the contrary, the correlation between prosthesis depth and better hearing results was positive at several frequencies.

Otosclerosis 3: the surgical management of otosclerosis

The surgical management for otosclerosis has evolved from stapes mobilisation to total extraction of the footplate, the so called 'stapedectomy', to a small hole in the stapes footplate, the 'stapedotomy'. The aim of stapes surgery is to restore the vibration of fluids within the cochlear canal. Revision stapedectomy should be approached with caution. Stapedectomy can lead to some minor and other more serious complications.

Reliability of high-resolution CT scan in diagnosis of otosclerosis

OBJECTIVE

To assess the reliability of high-resolution computed tomographic scan (HRCT scan) for the diagnosis of otosclerosis and to determine its usefulness to predict hearing deterioration and surgical difficulties.

STUDY DESIGN

Prospective study.

SETTING

Tertiary reference center.

PATIENTS

Two hundred nine ears (200 patients) presenting progressive conductive hearing loss with normal tympanic membrane, abnormal stapedial reflex, and scheduled for stapes surgery. The mean age was 47.3 years.

INTERVENTION

All patients underwent HRCT scan before surgery (slice thickness of 0.6 to 1 mm). Stapedotomy was performed in 99% of cases.

MAIN OUTCOME MEASURES

High-resolution computed tomographic scan results were categorized as positive, doubtful, or negative. We classified a CT scan as positive for otosclerosis when a hypodense focus was seen around the otic capsule. Preoperative and postoperative air- and bone-conduction thresholds were collected.

RESULTS

Of 209 HRCT scans, 84.2% were classified positive, 8.6% doubtful, and 7.2% negative. In all patients with positive CT scan, otosclerosis was confirmed in surgery. Among 15 negative cases, we found 4 minor malformations and 1 fracture of the stapes. Footplate incidents (mobilized, floating, or fractured footplate; 5.3%) occurred significantly more frequently when an HRCT scan was negative or doubtful (p = 0.05). Mean preoperative air-bone gap was 27.7 dB (standard deviation, 10). Mean postoperative air-bone gap was within 10 dB in 65% and within 20 dB in 92% of cases. Greater than 10 dB deterioration of bone-conduction thresholds occurred in 2% of cases. Mean preoperative and postoperative bone-conduction thresholds were significantly lower in cases of round window obliteration, pericochlear, or internal auditory canal hypodensities (p < 0.005 and p < 0.0001, respectively).

CONCLUSION

In our series, the sensitivity of HRCT scan to otosclerosis was 95.1%. Hypodense otosclerotic foci were mostly localized at the anterior part of footplate. Negative or doubtful cases were associated with the highest incidence of stapes footplate complications. Foci involving otic capsule, internal auditory canal, or round window led to a significantly higher risk of sensorineural hearing loss.

Fisch's reversal steps stapedotomy: when to use it?

OBJECTIVE

To determine that the use of Fisch's reversal steps stapedotomy is recommended only when the visible portion of the footplate is blue in all its points before removing the stapes superstructure.

STUDY DESIGN

Prospective study.

MATERIALS AND METHODS

This study started on January 2007 and ended on June 2007, when the statistical data reached significance. Fifty patients with otosclerosis were examined. Four otosclerosis were excluded from the study following the exclusion criteria indicated by Fisch (obliterative otosclerosis and narrow oval niche). Finally, 46 otosclerosis patients were considered for the study. For all patients, stapedotomy procedures using the reversal steps technique by Fisch were planned. The study group was divided into 2 groups (A and B) on the basis of the footplate color before removing the stapes superstructure. Group A included otosclerosis with blue footplate (n = 34). Group B included otosclerosis with white footplate (n = 12). We estimated whether the reversal steps stapedotomy proposed by Fisch significantly avoids incus complications (luxation and subluxation) and stapes footplate complications (luxation and fracture) both in blue and white otosclerosis.

MAIN OUTCOME MEASURES

Footplate color, incidence of complications.

RESULTS

The footplate fenestration had not caused fractures or luxation of footplate in both groups. The fracture of the anterior crus had caused 5 footplate complications (2 luxations and 3 fractures) in Group B, but none in Group A. This difference was significant. In Group A, we had no subluxation/luxation of the incus. In Group B, we had 3 incus subluxations. This difference was significant.

CONCLUSION

The use of Fisch's reversal steps stapedotomy is recommended only when the visible portion of the footplate, before removing the stapes superstructure, is blue in all its points, that is, "blue otosclerosis," because only in this case that the original idea of Fisch avoids incus and footplate complications. When the visible portion of the footplate, before removing the stapes superstructure, is white in all or in most of its points, that is, "white otosclerosis," the reversal steps technique by Fisch is not recommended because it does not avoid incus luxation/subluxation and footplate complications (fracture and luxation of the anterior half).

Simultaneous bilateral stapes surgery--a pilot study

CONCLUSIONS

The short-term postoperative results of bilateral stapes surgery were satisfactory. Hearing results between the two ears were comparable and there was no increased complication risk for the second ear. The results are encouraging, although a larger series and longer follow-up time are needed to confirm them.

OBJECTIVE

The purpose of our study was to evaluate the preliminary outcome of simultaneous bilateral stapes operation.

PATIENTS AND METHODS

Eight patients suffering from bilateral otosclerosis and one from osteogenesis imperfecta were prospectively included in the pilot study. Both ears were operated under general anesthesia by the same surgeon. Inclusion criteria were mean conductive hearing loss of 15 dB or more at frequencies 0.5-4.0 kHz and negative Rinne fork test (256 Hz) on both sides. Patients with mean thresholds for sensorineural hearing over 40 dB or other otoneurological diseases or medications were excluded. Pure tone audiogram was performed 3 months after the operation.

RESULTS

The air-bone gap diminished from 28 (range 19-41) to 10 (range 4-23) dB in the first ear and from 24 (range 16-40) to 8 (range 3-19) dB in the second. Four patients experienced mild, temporary dizziness during rapid head movements, but that resolved fully. No patient suffered significant sensorineural hearing loss.

Akute Komplikationen in der Mittelohrchirurgie

Stapes surgery is remarkably different from regular middle ear surgery. The inner ear space has to be opened and the risk of postoperative deterioration of hearing and deafness is much higher. Peculiarities involve submerged parts of the foot plate into the vestibulum, the overhanging facial nerve with or without bony covering, bleeding from the mucosa, and problems involving the chorda tympani. Labyrinthine reactions during or post surgery are common. Important is the question of whether or when the piston should be removed. Rare cases such as a gusher with a wide connection between perilymph and CSF space are a major challenge in stapes surgery.

[Realistic early and late results after otosclerosis surgery and presentation of a technique involving almost no complications]

Although the modern technique of otosclerosis surgery introduced by John Shea on 1st May 1956 has already been used throughout the world for almost fifty years it has not been possible to bring in line the differing opinions of surgeons concerning the optimum operation technique, the problems of the fenestration of the footplate, material and form of stapes replacement prosthetics and kind and place of their anchoring on the incus. Moreover, there is considerable disagreement among surgeons on a realistic evaluation of the findings of early and late results. During the last few decades otosclerosis surgery has become the hallmark of modern ear surgery and has been practiced in very highly specialized departments as well as in outpatient departments. The author, who has been very active in otosclerosis surgery since 1959-since 1979 with a modified personal technique-, wishes to prove that it is both meaningful and essential to modify the operation technique further, which is based on his own experiences and on more than 100 international publications. In this paper he presents his modified method, which has been tested on 1800 ears since 1979, as well as the results, achieved in this way.

Apert syndrome and hearing loss with ear anomalies: a case report and literature review

Acrocephalosyndactyly Type I, or Apert syndrome is a congenital disorder characterized by craniosynostosis and syndactyly. When hearing loss occurs, it is usually bilateral and conductive, often attributable to congenital stapes fixation. In determining treatment, the risk of gusher with stapedectomy becomes an important consideration. We present an adult with Apert syndrome and hearing loss, with particular emphasis on a progressive conductive component in one ear. Surgical exploration failed to reveal any definite middle ear abnormality and no stapedectomy was performed. A theory on the pathogenesis of the conductive loss in our patient follows a brief review of the literature on gusher in patients with ear malformations.

Pneumolabyrinth: A Late Complication of Stapes Surgery

As temporal bone imaging techniques continue to improve, it is likely that we will see an increase in the detection of pneumolabyrinth. Several mechanisms have been proposed to explain how air enters the labyrinth. A small number of authors has reported an association between pneumolabyrinth and temporal bone fractures, perilymphatic fistulae, and displaced stapes prostheses. In this article, we describe a new case of pneumolabyrinth that was seen as a late complication of stapes surgery, and we summarize what is known about this rare condition.

The other ear: findings and results in 1,800 bilateral stapedectomies

OBJECTIVES

To determine the incidence of middle ear abnormalities in patients with bilateral otosclerosis, which could potentially affect successful stapedectomy, and the rates of success in these patients, including the chance of overclosure in the second ear.

STUDY DESIGN

Retrospective case review of operative and audiologic records.

SETTING

Private otology practice.

PATIENTS

One thousand eight hundred patients underwent 3,600 primary stapedectomies for bilateral otosclerosis.

INTERVENTION

Analysis of perioperative and follow-up audiograms with associated operative findings, including obliterative otosclerosis and solid footplates, dehiscent or overhanging facial nerve, narrow oval window niche, promontory overhang, and ossicular fixation or malformation.

MAIN OUTCOME MEASURES

Audiologic stapedectomy success was determined as overclosure or closure of preoperative air-bone gap to less than 10 dB at 1 year or more of follow-up.

RESULTS

The rate of finding any abnormality was 25%. Abnormalities present bilaterally were found in 135 patients (7%), with otosclerosis requiring an oval window drillout as the most common finding (41%), followed by dehiscent or overhanging facial nerves (25%). Success in patients with abnormalities was 78% overall, with bilateral overclosure in 40%.

CONCLUSIONS

Abnormal middle ear findings during stapedectomy occur in a significant percentage of patients. Reasonable rates of success and overclosure can still be expected, but this is somewhat finding-specific. The predictive value of these findings, the associated rates of success with potential impact on surgical counseling, and planning for the "other ear" are discussed.

CT evaluation of prosthetic ossicular reconstruction procedures: what the otologist needs to know

Postoperative otologic evaluation of patients who have undergone ossicular reconstruction is often difficult. However, thin-section computed tomography (CT) can help determine the type of prosthesis used for reconstruction and adequately assess for complications that may be causing postoperative conductive hearing loss. A variety of prostheses may be used in ossicular reconstruction (eg, stapes prosthesis, incus interposition graft, Applebaum prosthesis, Black oval-top prosthesis, Richards centered prosthesis, Goldenberg prosthesis) and can usually be identified at CT by their shapes and locations. Several causes of prosthetic failure are readily demonstrated at CT, including recurrent cholesteatoma and otitis media, formation of granulation tissue or adhesions, and various mechanical problems (eg, subluxation, dislocation, extrusion, fracture, bending). Perilymphatic fistula can be difficult to identify at CT but may be suggested by the presence of pneumolabyrinth, unexplained middle ear effusion, or fluid accumulation within the mastoid air cells. The presence of soft tissue within the oval window niche 4-6 weeks following surgery may indicate poststapedectomy granuloma or fibrosis. Familiarity with the normal and abnormal CT appearances of ossicular prostheses will enable the radiologist to assist the otologist in identifying patients in whom revision surgery is most appropriate.

Stapedectomy in military aircrew

Stapedectomy in military aircrew is generally considered to be the end of an aviation career. Perilymphatic fistulae, prosthesis dislodgement, and perforation of the vestibule are recognized complications of stapedectomy. Consequently, barotrauma, G forces, and otherwise hostile conditions and their effects on the poststapedectomy ear are usually cited as reasons for grounding. Data supporting such a restrictive policy, however, are limited. This study examined the aeromedical outcome of 16 U.S. Air Force aircrew members who returned to flight duty after stapedectomy between 1965 and 1992. Selected patients were subjected to centrifuge and altitude chamber testing before they returned to flight duty. No episodes of sudden hearing loss or vestibulopathic conditions have occurred in the entire study group. Guidelines for surgical technique, reconstruction materials, and postoperative aeromedical testing are proposed for evaluating selected stapedectomy patients before their return to flight status.

Success in surgery for otosclerosis: hearing improvement and other indicators

PURPOSE

This retrospective study investigates the general outcome and subjective impression of patients who have undergone surgery for otosclerosis. Postoperative complaints and complications, as well as hearing results, are also reported.

MATERIALS AND METHODS

Questionnaire and audiomeric results of 246 stapes surgery patients (270 operations) were studied.

RESULTS

Hearing results showed a mean improvement in pure-tone average of 26 dB and air-bone gap closure to within 10 dB in 214 cases (79%). No serious complications or profound sensorineural hearing loss occurred. Patients were generally pleased with surgery, and subjective evaluation of benefit corresponded with objective audiometric result. However, a variety of complaints, such as vertigo, tinnitus, loud noise intolerance, pain, chorda tympani symptoms, and sound distortion problems, were reported. Most of these symptoms correlated significantly with the patients' subjective opinion of the surgical outcome.

CONCLUSION

Patients as well as surgeons consider hearing improvement as the main indicator of success in surgery for otosclerosis. However, postoperative symptoms and complaints can be expected in a certain percentage of patients. Because these can influence the general outcome of surgery, the ear surgeon should try to painstakingly refine his technique in an effort to minimize their sources. They should also be discussed in preoperative patient counseling.

Hearing loss as a complication of stapes surgery

During a 10-year period (1984-1994) 1229 stapes operations for otosclerosis were performed at our respective institutions by experienced surgeons well trained in the various techniques. Procedures included 691 stapedectomies, 234 small-fenestrae stapedotomies, and 304 revision operations. These primary and revision cases resulted in 20 ears with severe sensorineural hearing loss or anacusis noted during the immediate postoperative period. This article will critically evaluate those procedures that resulted in profound hearing loss and attempt to determine possible reasons for this occurrence. It is hoped that these data will allow surgeons to identify before and/or during surgery patients at risk for development of this complication and therefore decrease the overall morbidity rate of this exacting procedure.

Post-stapedectomy reparative granuloma: a misnomer

The pathophysiology of so-called 'reparative granuloma' occurring after stapedectomy has not been determined and universally accepted management of this rare complication has not yet been established. A case is presented in which a mass developed in the middle ear after the use of a fat/wire prosthesis in a stapedectomy. Histological assessment revealed nonspecific granulation tissue and fat necrosis. It is suggested that 'reparative granuloma' is a misnomer as there is no microscopic evidence in this case nor in the literature of granulomatous formation. The condition may follow stapedectomy or stapedotomy. Furthermore, the name leads to confusion with a different condition, giant cell reparative granuloma, which involves the jaws and rarely the temporal bone. An alternative name, 'Stapes surgery induced granulation tissue' (SSIG) is therefore suggested for this condition.

Large vestibular aqueduct syndrome and stapes fixation

An abnormally large vestibular aqueduct has a well recognized association with inner ear anomalies and it has been assumed previously to be a variant of a Mondini type of deformity (Shuknecht, 1980; Emmett, 1985). The sole radiological finding in some patients with progressive sensorineural loss has been a large vestibular aqueduct (Valvassori and Clemis, 1978; Valvassori, 1983), which is now accepted as a separate clinical entity, i.e. the large vestibular aqueduct syndrome (LVAS). A case is presented which is believed to be the first reported with unilateral LVAS and stapes fixation and also the first stapes gusher described in association with LVAS.