Occasional stapes surgery--a Norwegian experience

Evaluation of Functional Outcomes after Stapes Surgery in Patients with Clinical Otosclerosis in a Teaching Institution

Introduction Otosclerosis is a primary disease of the temporal bone that leads to stapes ankylosis. Hearing loss is the main symptom. Treatment includes surgery, medical treatment, and sound amplification therapy alone or in combination.

Objective To evaluate the functional outcomes of patients with clinical diagnosis of otosclerosis undergoing primary stapes surgery in a teaching institution.

Method Retrospective descriptive study.

Results A total of 210 ears of 163 patients underwent stapes surgery. Of the 163 patients, 116 (71.2%) underwent unilateral surgery and 47 (28.8%) underwent bilateral surgery. Six of the 210 operated ears had obliterative otosclerosis. The average preoperative and postoperative air–bone gap was 32.06 and 4.39 dB, respectively. The mean preoperative and postoperative bone conduction threshold was 23.17 and 19.82 dB, respectively. A total of 184 (87.6%) ears had a residual air–bone gap <10 dB, and 196 (93.3%) had a residual air–bone gap ≤15 dB. Two patients (0.95%) had severe sensorineural hearing loss.

Conclusion Stapes surgery showed excellent functional hearing outcomes in this study. This surgery may be performed in educational institutions with the supervision of experienced surgeons.

Stapes surgery in residency - the ufpr clinical hospital experience

Surgery of the stapedius remains the established treatment for otosclerosis. Recent publications have showed that success in surgeries done by residents have decreased and hearing results are worse than those obtained by experienced otologic surgeons. Aim: To evaluate the experience of the otorhinolaryngology unit, Parana University, relative to stapes surgery done in the residency training program. Material and method: A retrospective study of 114 stapes surgeries done in the past 9 years in 96 patients. Audiometric results were analysed according to the Commitee on Hearing and Equilibrium guidelines and the Amsterdam Hearing Evaluation Plots. The improvement of the airway postoperative gap and thresholds were taken into account. Results: 96 patients were included, most of them female adults (67.7%) and white (93.7%). Stapedectomy was done in 50.9% of cases, mostly under local anesthesia and sedation (96.5%), using mostly the Teflon prothesis (37.7%). The surgical success rate was 50.88%, there was an 11.4% complication rate. Conclusion: Postoperative hearing gains considered as surgical success were inferior to published results in the literature, done by experienced surgeons.

The influence of measles vaccination on the incidence of otosclerosis in Germany

The pathologic process of otosclerosis is characterized by an inflammatory lytic phase followed by an abnormal bone remodeling at very specific sites of predilection. There is a clear genetic predisposition with about half of all cases occurring in families with more than one affected member. Females are affected more frequently than males with an approximate 2:1 ratio. N, H, and F measles proteins as well as measles virus RNA have been demonstrated in osteoblasts, chondroblasts, and macrophages of the inflammatory phase of the disease. These observations merely show an association between measles viruses and otosclerosis. In the present study, we tried to prove that there is a causal relationship: voluntary measles vaccination has been available in Germany since 1974. In the absence of official data, we reconstructed the rate of vaccination coverage between 1974 and 2004 using information from the Robert Koch Institute (RKI, Berlin) and from the literature. From the German Federal Office of Statistics, we received the data of 64,112 patients who had been hospitalized between 1993 and 2004 and in whom otosclerosis (ICD-9: 387; ICD-10: H80) had been confirmed. We calculated the effect of measles vaccination on the incidence of hospital treatments for otosclerosis in the period from 1993 to 2004 in Germany. For this purpose, we divided the female and male otosclerosis patients treated as inpatients each year in the observation period into two age groups: those up to 25 years, who had in most cases been vaccinated (designated below as "vaccinated patients") and those over 25 years who mostly could not have been vaccinated (designated below as "unvaccinated patients"). We calculated the incidence of otosclerosis requiring inpatient treatment for the two age groups in each year in the period of observation. For external validation of the study results, the same analysis was carried out in all patients who received inpatient treatment for otitis media in the same period. Between 1993 and 2004 the incidence of hospital treatments for otosclerosis decreased to a significantly greater extent in the vaccinated patients than in the unvaccinated patients. The decline is much greater in men than in women. A comparable effect cannot be demonstrated in patients with otitis media. The results indicate that measles vaccination in Germany has resulted in a significant reduction in the number of hospital treatments for otosclerosis in the vaccinated age groups. We conclude that there is a causal relationship between measles viruses and the development of otosclerosis.

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW

The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis?

RECENT FINDINGS

A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients.

SUMMARY

Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Stapedectomy

OBJECTIVE

To evaluate whether the performance of stapes surgery by residents during residency has decreased during the last 40 years, and if so, whether such a decrease has impacted the number of general otolaryngologists performing stapedectomy in the private practice setting.

STUDY DESIGN

Survey questionnaire of members of the American Academy of Otolaryngology-Head and Neck Surgery.

METHODS

A short questionnaire was mailed to 1,700 members of the American Academy of Otolaryngology-Head and Neck Surgery. Data collected included age, year of residency graduation, fellowship (if any), practice setting, geographic location, number of stapedectomies performed in residency, and number of stapedectomies performed currently.

RESULTS

Seven hundred fifty-six (44%) of 1,700 surveys were returned; 558 (74%) of 756 respondents did not complete a fellowship and were included in the general otolaryngologist group. Overall, 41% of general otolaryngologists are performing stapes surgery. There was a significant decline in the number of resident stapedectomies performed between 1960 and 1986; since 1986, this number has plateaued to an average of 8 to 9 (self-reported) cases per resident. More recent graduation from residency trended toward decreased inclination to do stapedectomy, although the result was not statistically significant. Increasing number of stapedectomy cases performed in residency correlated with an increased likelihood of performing the operation in practice.

CONCLUSION

Despite a decreasing case volume of stapes surgery in residency, stapedectomy remains an operation performed by general otolaryngologists.

Stapes Surgery in the United States

OBJECTIVE

A contemporary analysis of trends in the surgical management of otosclerosis in the United States is presented.

DATA SOURCES

U.S. population demographics were obtained from the U.S. Census Bureau. Surgical case data was obtained from publications of the National Center for Health Statistics. Physician population statistics are published by the American Medical Association.

DATA EXTRACTION

Available estimates for otologic operations are interpreted according to clinical setting used for data acquisition and surgical practice patterns. Linear regression of included data defines trends in operations performed. Population statistics are used to define changes in the incidence of surgical cases.

CONCLUSIONS

The number of stapedectomy cases has declined over the past 30 years. During this same interval, the U.S. population (including the white population) and the number of surgeons has increased. This indicates that the incidence of surgical otosclerosis is declining. Although the true etiology of the decline is uncertain, widespread immunization for measles is a plausible hypothesis.

Audit of stapedectomy results in a district general hospital

We report a series of 100 stapes operations performed for otosclerosis. The problems in reporting the results of stapedectomies are discussed. The audit showed a difference in the measured results between two consultants. As a result, the consultant with the worse outcome chose to stop operating on patients with otosclerosis. The advantages and disadvantages of a single surgeon performing all the cases are discussed. We advocate a central registry of all surgeons performing stapes surgery to allow periodic national comparative audits.

Audit of stapedectomy results in a teaching hospital

The number of stapedectomies performed annually has declined since 1963. Also, surgery has become available at an increasing number of centres, resulting in a further fall in the number of such operations performed in teaching hospitals. Several studies have suggested benefit might be gained, both by patients and by otology as a speciality, from limiting training to post-graduates who show an aptitude for otology, and concentrating surgery in a small number of specialized centres. We report a series of 179 patients who had stapedectomy performed for otosclerosis in a teaching hospital. We have retrospectively compared the audiological outcome and complication rates for consultants and surgical trainees. For the two groups, there is no significant difference in postoperative hearing levels and complication rates are similar. Our success rate is comparable to other major series. We conclude that stapedectomy is a safe procedure to teach adequately experienced and supervised trainees.

Stapes surgery: implications for training

The worldwide decline in surgery for otosclerosis had been reflected by a similar pattern here in Great Britain. Unless we are prepared to accept poorer results than have formerly been achieved, we will have to adopt measures to ensure that the skills of stapes surgery are transferred to the next generation of surgeons. Using the results of our experience, at the Queen Elizabeth Hospital, over the past 18 years, I have examined the implications for surgical training and for the management of future patients with otosclerosis.