Second ear stapedectomy--a continued controversy

Second Ear Stapedectomy

A long-term follow up of a personal series of 79 second ear stapedectomies indicates that the procedure can be undertaken with minimal complications. No bilateral dead ears or vestibular disasters have occurred. The results were satisfactory in 87.5% of ears, and bilaterally symmetrical hearing with an air-bone gap of 30 dB or less was achieved in 24% of patients. Whilst the established dictum that only one ear should be operated upon should not be abandoned, the results reported in this paper may encourage the more experienced to operate on the second ear at a later date in carefully selected cases.

Bilateral Stapedectomy: Association between First- and Second-Ear Surgical Findings and Their Effects on the Second-Ear Outcome

Objectives: We assessed the association between first-ear and second-ear surgical findings in patients undergoing second-ear stapedectomy for bilateral otosclerosis and the impact of such findings on the audiometric outcome of the second ear.

Methods: A retrospective chart review of all stapedectomy patients who underwent stapes surgery by one of two surgeons in a single tertiary referral institution from 1962 to 2001 was performed, and those patients who underwent bilateral stapedectomy were identified. Patient demographic data, surgical findings, procedure performed, and preoperative and postoperative audiometric data were recorded.

Results: A total of 459 patients (918 ears) underwent bilateral stapedectomy for bilateral otosclerosis during the study period, of whom 426 had complete data for analysis. The finding of a white or obliterated footplate in the second ear was significantly higher if the first ear had this disease manifestation (p < .001, χ2 test). The association between a second drill-out's being performed and a drill-out in the first operation was significant (p < .001, χ2 test). Statistical analysis identified that those who underwent a drill-out procedure had a 2.9-fold increase in unsuccessful outcome in comparison to those who did not have a drill-out (odds ratio, 2.89; 95% confidence interval, 1.41 to 5.89). Facial nerve anomalies were infrequently encountered, affecting only 23 patients, of whom 3 had bilateral abnormalities. The finding of an overhanging or dehiscent facial nerve in the second ear was significantly more likely if such an abnormality was identified during the first procedure (23% versus 2.5%; p = .005, Fisher's exact test).

Conclusions: Second-ear hearing results are poorer in those who require a drill-out of this ear, and this is more likely to be required if a drill-out was required in the first ear, regardless of a successful outcome of the first procedure. Patients should be aware of the reduced likelihood of success in these cases and be counseled regarding risks and benefits of second-ear surgery based, in part, on the findings from the first ear. This study confirms that bilateral advanced footplate obliteration and overhanging or dehiscent facial nerves may be anticipated in patients found to have these abnormalities during first-ear stapedectomy.

Balance after stapedotomy: analysis of balance with computerized dynamic posturography

OBJECTIVES

The aim of this study was to investigate vestibular symptoms and their effect on the balance in otosclerosis patients undergoing stapedotomy operations.

DESIGN & SETTING

Prospective study at an academic tertiary referral centre.

PARTICIPANTS

Thirty-three patients undergoing stapedotomy were included in the study.

MAIN OUTCOME MEASURES

Sensory organisation test (SOT) protocol of computerized dynamic posturography was used to analyse the balance in patients preoperatively, in the first postoperative week and the first postoperative month. Postoperative vestibular symptoms were analysed with a grading system. Audiograms were obtained preoperatively and 1 month after the operation.

RESULTS

Preoperatively, all patients were asymptomatic when considering the vestibular system; however, eight of them got low SOT scores on vestibular examination. Postoperatively 82% of the patients had vestibular complaints in variable severity. In the first week, all but one patient become asymptomatic. This patient recovered by the end of postoperative second week. However, a significant drop in SOT scores was encountered at the first week testing (Student's T-test, P = 0.001). One month after the operation, all patients were asymptomatic and SOT scores recovered at least to preoperative level. Neither patient characteristics, nor audiological findings were found to be correlated with vestibular changes.

CONCLUSION

Stapedotomy causes a temporary balance loss in a high percentage of patients which then recover to their former levels in the first postoperative month.

Simultaneous bilateral stapes surgery

CONCLUSIONS

The patients recovered from the surgery as after unilateral surgery. The success rate for hearing improvement was good both subjectively and objectively, and this was also displayed in the quality of life. According to our study, simultaneous bilateral stapes surgery can be performed safely in selected patients with bilateral conductive hearing loss.

OBJECTIVES

Otosclerosis is bilateral in the majority of patients. In this study we evaluated the outcome of simultaneous bilateral stapes surgery.

SUBJECTS AND METHODS

Eighteen patients suffering from bilateral otosclerosis or osteogenesis imperfecta were prospectively included. After operation, hearing and vestibular function were followed by audiometry and visual feedback posturography (VFP). Patients estimated their hearing gain, the intensity of vestibular symptoms and quality of life score with a questionnaire during the follow-up period of 1 year.

RESULTS

The mean improvement in pure-tone average (PTA) air conduction (PTA-AC) was 18 dB (range 1-41 dB). The mean air-bone gap (AB-GAP) diminished from 22 dB (range 10-41 dB) to 7 dB on both sides (range 0-18 dB). The mean preoperative score of 2.3 for hearing improved significantly to 4.1 (p<0.001). Vestibular symptoms were mild and temporary. The VFP was not permanently impaired in any of the patients. The quality of life score improved significantly from 3.4 to 1.3 postoperatively (p<0.001).

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.

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.

Balance after stapedectomy: the measurement of spontaneous sway by posturography

Sway was measured by static posturography in 25 patients undergoing stapedectomy, 16 first-side and nine second-side operations. Measurements were taken pre-operatively and at 1 week and 6 months after surgery, 25 age-matched controls were also tested. In both the first and second side groups, sway was greater at 1 week after surgery than pre-operatively when relying on vestibular function alone (P = 0.01 first-side, 0.05 second-side, 0.01 both sides taken together). By 6 months, sway measurements were no longer significantly different from pre-op or control values. Thus, it appears that there is a measurable increase in patients' sway following stapedectomy but this is well compensated by visual and proprioceptive information, and resolves fully with time. Patients undergoing a second side stapedectomy do not appear to fare worse than those undergoing first-side surgery.

Long-term results of bilateral stapedectomy

Bilateral stapedectomy was performed in 122 cases of bilateral otosclerosis at Ulleval Hospital between 1960 and 1978. Ninety-six patients (192 ears), or 79 per cent, were re-examined in 1980. The long-term results showed that the air/bone gap was closed to within 10 db. in 142 ears (74 per cent). Twenty-four patients (25 per cent) used a hearing aid at the time of the examination, mainly because of presbyacusis. Deafness or serious sensori-neural loss ascribed to the operation was found in 21 ears (11 per cent). Immediate deafness occurred in three ears (1.5 per cent), and in seven ears (3.7 per cent) the patient became deaf later. Eleven ears (5.8 per cent) had marked sensori-neural losses, but with some speech comprehension. None of the patients had bilateral deafness, but one patient was deaf in one ear, with a sensori-neural loss of 80 db. in the other. Eleven patients (13 ears) who had undergone previous stapediolysis or crurotomy, were treated as a separate group, and their results were compared with those obtained in the other patients. We have also tried to find out if there is any difference between the long-term results of surgery in the first and in the second ear.

Recent and future trends in the management of otosclerotic conductive hearing loss

The protection of cochlear function following stapedectomy has emerged as the major problem in the surgical treatment of otosclerosis. Both immediate and delayed sensorineural losses continue to occur in spite of refinements of technique. The frequency and extent of these complications has been investigated by prospective and retrospective studies of the author's patients. It has been concluded that the size of the footplate fenestration plays a major role in the outcome, both immediately, and in the long term. Revision operations are necessary when initially good results rapidly deteriorate, both to resolve complications such as perilymphatic fistulae and also to restore function. Although second ear operations are usually worthwhile, they should be performed only when certain specific criteria have been met. The expected duration of unaided hearing gain, although often adequate when a standard large fenestra operation is performed, is considerably prolonged by restricting the size of the footplate to less than half its total area. For reasons unknown, bone conduction thresholds appear to be better, eventually, in operated as compared to unoperated ears.

Stapedectomy and the Labyrinthine Reaction in the Contralateral Ear

Exploring the relationship between stapedectomy and the labyrinthine reaction in the contralateral ear in 45 stapedectomized otosclerotic patients, the authors concluded that good operative results can be expected if the ear not operated on demonstrates hyperfunction after surgery, whereas there will be either a partial increase in hearing or no hearing gain when there is hypofunction of the opposite labyrinth.

Eighteen years experience in stapedectomy. The case for the small fenestra operation

The postoperative findings in almost 800 stapedectomized ears were analyzed to evaluate the proposition that complication rates in stapedectomy were affected by the size of footplate fenestration. It was concluded that small fenestra stapedectomy (diameter 0.4 mm) provided similar hearing gains to those achieved with standard techniques, that articulation problems occurred to a similar extent as with wire loop prostheses, and that there was a significantly lower incidence of a) fistual and b) immediate and delayed severe sensorineural hearing loss than with any other technique. There was also significantly less deterioration in bone conduction thresholds at 4 kHz after three years postoperatively. The incidence of severe immediate sensorineural loss in large fenestra stapedectomy (half or more of footplate removed) was significantly influenced by factors such as age, preoperative bone conduction thresholds and oval window pathology. A retrospective analysis provided no information which might predict oval window pathology. Additional information gained from the analysis indicated that with all types of stapedectomy, bone conduction did not deteriorate significantly more rapidly in the operated as compared to the unoperated ear, whereas in unoperated ears, deterioration in bone conduction was significantly greater in ears with mixed hearing losses than when the loss was purely sensorineural. It was concluded that small fenestra stapedectomy was currently the operation of choice because with it, the threat of cochlear dysfunction both immediately, and in the long term, was significantly less.

Otosclerosis surgery

Results of otosclerosis surgery using the stapes footplate removal with various types of reconstruction are reported in 456 ears (360 patients). Primary success was obtained in around 95% while 83% retained their improvement over the years. The posterior crus on fascia has become the preferred method because of its stability and relative lack of inner ear complications. Inner ear damage is mostly due to perilymph fistulae, which should be promptly recognized and repaired, since revision after the ear has become deaf does not restore hearing. Some late inner ear losses may be due to reactions to foreign material introduced with the graft. Bilateral operations should not be done if the first operation was difficult or caused vertigo for several days.