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

Hearing Results, Quality of Life, Patient Satisfaction, and Postoperative Complications of Day-case Versus Inpatient Stapes Surgery for Otosclerosis in Adults: A Randomized Controlled Trial

Objective

To investigate the effect of day-case stapes surgery on hearing results, quality of life, patient satisfaction, and complications rates, compared with inpatient stapes surgery.

Study Design

A single-center, nonblinded, randomized controlled trial in a tertiary referral center.

Methods

One hundred twelve adult patients planned for primary or revision stapes surgery were randomly assigned to either the day-case or inpatient treatment group. The effect on hearing outcomes (primarily), hearing benefits, quality of life, patient satisfaction, postoperative complications, and causes of crossover or readmission (secondarily) were assessed using auditory evaluations, questionnaires, and patients' charts over a follow-up period of 1 year.

Results

Audiometric measurements and postoperative success rates were not different between the inpatient and day-case group. There were no statistically significant differences between both groups regarding the overall quality of life (QoL) (HUI3), disease-specific QoL (GHSI), change in postoperative health status (GBI), and postoperative complications rate. We found a high patient satisfaction toward the day-case approach. Six patients allocated to the inpatient group requested same-day discharge. Of the day-case patients, there was a crossover rate to inpatient care of 38% (20 patients), mainly due to postoperative nausea and vomiting (25%), vertigo (20%), or dizziness (40%).

Conclusion

We found no significant differences in outcomes of audiometric measurements, QoL, patient satisfaction and postoperative complications following day-case, and inpatient stapes surgery. Therefore, stapes surgery in a day-case setting seems to be a feasible approach in terms of postoperative outcome, safety, and desirability when taking patient selection and surgical planning into account. Besides this, the familiarity with a day-case approach of both patient and the surgical team, will increase the acceptance and feasibility of day-case stapes surgery.

Wideband Acoustic Absorbance in Otosclerosis: Does Stapedotomy Restore Normal Tympanic Cavity Function?*

Introduction Otosclerosis is characterized by the fixation of the stapes to the oval window, thereby impairing acoustic signal absorbance. A commonly used surgical technique for improving hearing in cases of otosclerosis is stapedotomy. However, it is unclear whether this surgery restores all the physical characteristics of the tympano-ossicular system.

Objective To evaluate the tympano-ossicular system in individuals with fenestral otosclerosis pre and poststapedotomy using wideband tympanometry.

Method A total of 47 individuals and 71 ears were assessed. The subjects were divided into three groups: presurgery otosclerosis; postsurgery; and a control group of normal-hearing adults. A handheld tympanometer with a wideband module (226–8,000 Hz) was used to take measurements at ambient pressure and under pressurized conditions. The level of statistical significance adopted was p ≤ 0.05.

Results Acoustic absorbance at 226 Hz was low for all groups. At frequencies in the range 630 to 5,040 Hz, each group had a characteristic absorbance curve, allowing them to be distinguished from one another. In the presurgery group, absorbance values were below normal levels, with energy absorbance below 10%. Low energy absorbance was most evident at 1,000 Hz in the presurgery group, but this was not observed in the postsurgery group. Although there was an improvement in hearing, the surgery failed to restore the tympano-ossicular system to normal.

Conclusion Wideband acoustic absorbance proved able to differentiate normal ears and otosclerotic ears pre and postsurgery, under both ambient pressure and pressurized conditions.

Estimated Costs Associated With Management of Otosclerosis With Hearing Aids vs Surgery in Europe

IMPORTANCE

Surgery and hearing aids have similar outcomes in terms of hearing acuity but differ in terms of cost, aesthetics, and patient quality of life. The cost-effectiveness and budget impact of otosclerosis treatments have never been studied in Europe.

OBJECTIVES

To compare the estimated mean costs per patient over 10 years of surgery vs hearing aids for the treatment of otosclerosis and to estimate the budget impact of an increase in the proportion of patients receiving surgical treatment.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation analyzed French and European epidemiological data on the surgical management of symptomatic otosclerosis and compared them with data from the literature to build economic models. The analysis was conducted in January 2021.

EXPOSURES

Two care pathways were considered in the treatment of otosclerosis, either hearing aid or surgery.

MAIN OUTCOMES AND MEASURES

Costs were studied over 10 years using Markov models of the 2 care pathways (hearing aid vs surgery). The budget impact analysis was performed over 5 and 10 years, assuming a 1-percentage point yearly increase in the proportion of patients receiving surgical treatment.

RESULTS

Over 10 years, the estimated mean cost per patient was significantly lower in the surgery group compared with the hearing aid group (€3446.9 vs €6088.4; mean difference, -€2641.5; 95% CI -€4064.8 to -€1379.4 [US $3913.4 vs US $6912.4; mean difference, -US $2999.0; 95% CI, -US $4614.9 to -US $1566.1]). Increasing surgical treatment by 1 percentage point per year for 10 years would lead to overall savings of €1 762 304 (US $2 000 798) in France, with an increase of €1 322 920 (US $1 501 952) at 10 years for the public health insurance system and a decrease of €3 085 224 (US $3 502 750) at 10 years for patients and private health insurers. Sensitivity analyses showed that these results were robust.

CONCLUSIONS AND RELEVANCE

These results suggest that in France, treating otosclerosis surgically is slightly less expensive over 10 years than using hearing aids, when considering all payers. The proposed models developed in this study could be adjusted to perform the same analysis in other countries.

Audiologic Outcomes of Footplate Drillout for Obliterative Otosclerosis

OBJECTIVE

To evaluate the audiologic outcomes of microdrill fenestration for obliterative otosclerosis compared to traditional stapedotomy technique.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients undergoing stapedotomy for otosclerosis.

MAIN OUTCOME MEASURES

Patients were separated into groups that underwent either microdrill or laser fenestration based on intraoperative severity of disease. Audiologic outcomes and complications were compared between the two groups.

RESULTS

There were 588 ears in 519 patients that were evaluated. There was a significant postoperative improvement in pure tone average, air-bone gap, and mean bone conduction thresholds for both the obliterative and nonobliterative group (p < 0.001). There was no significant difference in the pre- or postoperative hearing status between the two groups. There was no significant difference in complications between the two groups, including no cases of postoperative profound hearing loss in the drill fenestration group.

CONCLUSIONS

Audiologic outcomes are similar between microdrill fenestration and laser fenestration for otosclerosis. Pure tone average, air-bone gap, and mean bone conduction thresholds all improved postoperatively and were similar between groups.

Revision Stapedotomies: the Role of Periprosthetic Scar Tissue Formation in the Development of Unsatisfactory Hearing Results after Stapedotomy

Introduction  Revision stapes surgeries are difficult to perform, and their audiological results are inferior to primary surgeries.

Objective  Our goal was to identify the most common and most influential postoperative reasons that cause persistent air-bone gap (ABG) after the primary surgery. Our focus was concentrated on the mechanical dysfunctions in the middle ear, with special regard to postoperative adhesion formation.

Methods  We performed a retrospective case series study with 23 cases that underwent revision stapedotomies.

Results  A significant improvement was seen in ABG and air conduction levels after surgery. The periprosthetic adhesion formation was seen in 65% of the cases, and it was the primary cause behind the unsatisfactory hearing result in 30% of cases. There was no significant difference in the level of persistent ABGs after the primary surgery, in case of the intratympanic adhesion presence, compared with the presence of other surgical failures. Concerning hearing and ABG gain after revision surgery, the non-inferiority of the negative effect associated with adhesion was shown compared with the other reasons.

Conclusion  The revision stapedotomy is an efficient treatment option in case of persistent ABG. Periprosthetic adhesions are the most common intratympanic reasons for compromised audiological outcomes after stapedotomy.

Adhesion formations have the same negative effect on ABG development as any other surgical failure, and the revision could be more challenging in these cases. These findings highlight the use of the most atraumatic surgical technique and preservation of intact intratympanic mucosa during middle ear surgery.

Hearing Results in 151 Primary Stapedotomies for Otosclerosis: The Effects of Using Different Audiologic Parameters and Criteria on Success Rates

OBJECTIVE

To describe the 151 hearing results of primary stapedotomy for otosclerosis using different criteria of success rates.

DESIGN

Retrospective case series of 151 patients with a diagnosis of otosclerosis and operated on by the same surgeon with the same technique, using a CO2 laser. Patients with revision surgery were excluded. The audiometric data were extracted from the patient files and divided into three groups: early postoperative follow-up (<1 mo after surgery), mid-term follow up (between 1 mo and 1 yr), and late postoperative follow-up (>1 yr).

RESULTS

The postoperative air-bone gap (ABG) was 10 dB or less in 45.2% in the mid-term follow up. For this same follow-up, ABG closure less or equal than 20 dB was achieved in 95.6% of cases. The lower percentage of patients with a postoperative ABG closure of less than or equal to 10 dB can be due to the high rate of bone conduction (BC) overclosure of 15.65%. The functional success described as an air conduction (AC) threshold less than or equal to 30 dB was achieved in 52.2% of patients. The mean speech reception threshold (SRT) in the mid-term follow up was 27.4 dB. The analysis of the data according to the Amsterdam Hearing Evaluation Plots (AHEPs) shows a success rate of 87% at early follow-up.

CONCLUSIONS

The success rate is mainly dependent on the definition and criteria as a measure of success. An analysis of the evolution of the BC is mandatory to avoid a false positive success rate when the ABG closure is used. Therefore, the use of the AHEPs would acquire additional information. The hearing outcome has also been based on the speech audiometry and the number of patients achieving an AC less than or equal to 30 dB as a more realistic measure of success. Our series confirms good long term hearing results achieved in stapedotomy surgery with the CO2 laser.

Binaural squelch effect in unilateral otosclerosis surgery: comparison of speech intelligibility in noise before-after surgery

PURPOSE

We aimed to evaluate the speech intelligibility benefit in noise provided by stapedotomy in the treatment of unilateral otosclerosis.

METHODS

We enrolled adults suffering from unilateral conductive hearing loss and followed them up until 9 months after surgery. The patients underwent a free field speech hearing evaluation using the French Matrix test before and after stapedotomy. Speech material was sent to the front of the patients (S0) and noise was presented either at the front (N0), or at the operated ear (N-90) or at the non-operated ear (N + 90). The speech intelligibility benefit in noise was assessed by comparing Squelch effect (SE), Head shadow effect (HS) and Binaural redundancy (BR) before and after surgery. SE was measured as the difference in speech reception thresholds (SRT) between S0N + 90 situations before and after surgery, HS as the difference in SRT between S0N + 90 and S0N-90 situations, and BR as the difference in SRT between S0N0 situations before and after surgery. In addition, two quality of life's questionnaires were completed by patients to evaluate their discomfort.

RESULTS

Among 25 patients, 19 were followed up during 9 months, 4 were excluded and 2 were lost for the following-up. Stapedotomy provided a restoration of SE of 3.7 dB SNR (p < 0.001) and a BR gain of 1.8 dB SNR (p < 0.001). HS did not show any statistical variation after surgery (p = 0.077). Finally, the questionnaires showed a residual hearing discomfort.

CONCLUSION

Stapedotomy provided a binaural benefit with the restoration of the SE and BR but which remained lower than in the normal-hearing population.

TRIAL REGISTRATION

The 07/02/2018 on Clinical.Trial.Gouv: NCT03587792.

Otosclerosis: Experience With Stapes Surgery

Introduction Otosclerosis is a disorder in which the footplate of the stapes is replaced by an abnormal bone, thereby affecting sound transmission to the inner ear at the level of the oval window. The solution to this condition is to reestablish this mechanism back to normal via the ossicular chain to the inner ear. The aim of stapes surgery is to improve the hearing level to thresholds appropriate enough to obviate the need for hearing aid. The hearing improvement achieved after surgery often lasts for many years. The purpose of the current study was to review our experience and find out the rate of success related to hearing outcomes after stapedotomy. Methods The patients who were operated for otosclerosis between January 2000 and December 2010 at Aga Khan University Hospital, Karachi, Pakistan were included in the study. The charts were reviewed to collect clinical data regarding stapes surgery. The values of speech reception threshold (SRT) were recorded, and the preoperative and postoperative means were compared with a t-test. The bone conduction (BC) and air conduction (AC) thresholds were evaluated at 0.5 kHz, 1.0 kHz, 2.0 kHz, and 3.0 kHz. The preoperative and postoperative means of air-bone gap (AB-gap) were compared with a t-test. The descriptive frequency was calculated to evaluate postoperative AB-gap in individual patients; patients were grouped with a difference of 10 dB of AB-gap. The SPSS Statistics software (IBM, Armonk, NY) was used for statistical analysis. Results A total of 46 patients were included in the study. There were 15 males and 31 females. The mean age was 35 years (range: 20-56). Thirty-three patients had bilateral otosclerosis; two patients had surgery for both ears, taking the total number of ears operated to 48. The mean preoperative AB-gap was 39, while the mean postoperative AB-gap was 11. The means were compared with a t-test and a p-value of <0.05 was considered significant. The means of preoperative and postoperative SRT were 56.25 and 24.27 respectively. Both means were compared with a t-test, and a p-value of <0.05 was considred significant. Postoperatively, 34 ears had AB-gap of 10 dB (70.8%), 11 (22.9%) had within 20 dB, and three (6.3%) had within 30 dB. Conclusions The success rate related to hearing outcomes in patients operated for otosclerosis was excellent and comparable to that found in the current literature. The wide AB-gap noticed in the majority of our patients may represent a delayed presentation to otolaryngologists, which requires further evaluation.