Stapedectomy in profound cochlear loss

Stapes Surgery in Far-Advanced Otosclerosis

INTRODUCTION

Surgical treatment of patients with far-advanced otosclerosis (FAO) has not yet been standardized. Patients with FAO are the candidates for stapes surgery or cochlear implant (CI). Although many surgeons consider stapes surgery as the first choice, other authors prefer CI because of the excellent hearing results.

OBJECTIVE

The authors discuss their experience in the treatment of patients with FAO, potentially candidates for CI, who underwent stapedotomy.

MATERIALS AND METHODS

Eleven adult patients with FAO underwent stapedotomy from 2006 to 2016. Pure-tone average (PTA) between 0.5-1-2-3 kHz and speech perception test with hearing aids were determined before and after stapedotomy.

RESULTS

The results show a statistically significant improvement in air condition threshold (PTA) and satisfactory results with regard to speech recognition in 9 (81.8%) cases. Postoperative results are not influenced by the type of stapedotomy prosthesis employed and do not change during follow-up (3 years).

CONCLUSIONS

The authors suggest first performing stapes surgery in patients with FAO and reserving CI in case of failure.

Comparison of the efficacy of cochlear implantation and stapes surgery in far advanced otosclerosis: a meta-analysis study

OBJECTIVE

This study is to compare the hearing outcomes and complications of stapes surgery and cochlear implantation (CI) in patients with far-advanced otosclerosis (FAO).

DATA SOURCES

A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of science and Cochrane Library was conducted in June 2021 for articles in the literature till this year.

STUDY SELECTION

Studies are published in English language, conducted on human subjects, concerned with comparison of CI and stapes surgery in the management of FAO, not Laboratory study and not Opinion study. The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA).

DATA EXTRACTION

Twenty-six studies were included with 334 patients in CI group and 241 patients in stapes surgery group. Comparison between both groups was done in terms of postoperative complications, audiological outcomes, rete of revision surgery and patients' satisfaction rate.

RESULTS

Postoperative complications rate was significantly lower in CI (13.6%) than stapes surgery (18.6%). CI had a significantly lower rate of revision surgery (8.1%) than stapes surgery (16.4%). CI had a better mean for pure tone average (29.1 dB) than stapedectomy (52.3 dB) while stapes surgery had a higher mean for recognition of monosyllables and disyllables than CI. CI had significantly higher satisfaction rate than stapes surgery.

CONCLUSION

Both Stapes surgery and CI are reliable treatment options for FAO with close success rates. Statistics of CI are greater than stapes surgery and CI has a consistent improvement in audiometric outcomes in comparison to stapes surgery.

Cochlear Implantation in Advanced Otosclerosis: Pitfalls and Successes

Purpose of Review

This review will highlight recent outcome-based evidence guiding decision making for cochlear implantation in advanced otosclerosis, related complications, and technical surgical considerations in otosclerosis and the obstructed cochlea.

Recent Findings

Cochlear implantation in advanced otosclerosis results in consistent, excellent auditory outcomes with improvement in both objective speech recognition scores and subjective quality of life measures. Facial nerve stimulation may occur at higher rates in otosclerosis cochlear implant recipients. Cochlear implantation in the setting of luminal obstruction in osteosclerotic patients may be managed with altered surgical technique to achieve successful auditory improvements. Pre-operative imaging with high resolution CT or MRI may help anticipate intraoperative challenges and post-operative complications in cochlear implantation.

Summary

Cochlear implantation is an established, successful treatment for profound hearing loss in advanced otosclerosis. Surgeon knowledge of outcomes, complications, and potential surgical challenges is important to appropriately counsel patients regarding auditory rehabilitation options in advanced otosclerosis.

Hearing Aid Treatment in Patients with Mixed Hearing Loss. Part I: Expected Benefit and Limitations after Stapes Surgery

OBJECTIVE

The purpose of the present study was to determine the fraction of patients with mixed hearing loss who can or cannot expect benefit from power hearing aids (HAs) after stapes surgery.

DESIGN

The audiological outcome of 374 stapes surgeries was used to calculate the patients' individual postoperative requirements in terms of gain and output of HAs. These requirements were compared to the available gain and output provided by state-of-the-art power HAs at 0.5, 1.0, 2.0, and 4.0 kHz. According to these comparisons, ears were divided into three groups. For G0, required gain and output lay within the corresponding technical limits of the HAs at all frequencies. In G1, one or both requirements could not be fulfilled at 1 frequency. G2 combined all ears where the requirements lay beyond the HA's technical limitations at 2 or more frequencies.

RESULTS

Stapes surgery resulted in an improvement of air-bone gap (ABG) in 84.5% of the cases by 15.7 dB on average. Based on pure-tone average (0.5, 1.0, 2.0, 4.0 kHz), 40.6% of all cases showed an ABG ≤10 dB. 44.9% of all cases did no longer need a HA after stapes surgery. A power HA would fulfill both audiological criteria at all 4 frequencies in 81.6% of cases that needed a HA postoperatively. However, 18.4% would not be sufficiently treatable at 1 or more frequencies (15.0% in G1, 3.4% in G2).

CONCLUSIONS

The present study identified a subset of patients with mixed hearing loss after stapes surgery that cannot be treated sufficiently with available power HAs. As the residual ABG is an important reason for this lack of treatment success, the advancement of alternative hearing devices that circumvent the middle ear, such as powerful active middle ear implants, is indicated.

Endoscopic approach for cochlear implantation in advanced otosclerosis: A case report

HYPOTHESIS

Ossification of the cochlea was once considered to be a contraindication for cochlear implantation. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. The endoscopic technique allows a direct approach to the round window and the cochlea, especially in remodeled labyrinth, allowing a better vision of scala tympani.

BACKGROUND

Tertiary referral ENT center.

METHODS

Between January 2011 and February 2015 three patients with far advanced otosclerosis with partial obliteration of the cochlea were selected and underwent endoscopic-assisted cochlear implantation.

RESULTS

In far advanced otosclerosis, endoscopy allowed a magnification of the anatomy of the round window, permitting the surrounding anatomical structures forming the anatomy of the niche to be identified, and avoiding a blind dissection. No postoperative complications were noted, in particular, no surgical site infection, no vertigo, and no facial nerve injuries. Implant activation was routinely performed 1 month after surgery. All monitoring till date has indicated that the external auditory ducts are well ventilated and there are no signs of extrusion.

CONCLUSIONS

Ossification may occur as a consequence of the pathology of meningitis, chronic otitis media, severe otosclerosis, autoimmune inner ear diseases, temporal bone traumas, and other diseases. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. Supported by a number of years of experience in the field of otoendoscopic surgery, we propose a technique for cochlear implantation under unfavorable conditions using endoscopic-assisted surgery, especially in advanced otosclerosis. This technique permits us to extend the indication for cochlear implantation, and in our opinion will reduce the morbidity associated with this surgical procedure.

Cochlear implantation outcomes in advanced otosclerosis

INTRODUCTION

Several studies support the use of cochlear implants (CI) in far-advanced otosclerosis (FAO).

MATERIAL AND METHODS

We compared our results of CI in patients with FAO and unknown origin hearing loss (UOHL) and our incidence of facial electrical stimulation and difficult insertion of the electrode bundle up to 3 to 5 years from surgery.

RESULTS

We found 17 patients with CI in FAO and UOHL. FAO patients achieved better results on the pure tone average (PTA) and recognition of monosyllables by GEE test (p=0.022; p=0.006), and particularly at 1 year on the PTA (p=0.002), at 6 months and a year in monosyllables (p=0.002; p=0.001), and at 6 months in disyllables (p=0.004). There were no differences toward complications.

CONCLUSION

In our experience, placement of CI in FAO has proven successful, with results comparable to other similar cohorts, and with low complications.

Very far-advanced otosclerosis: stapedotomy or cochlear implantation

CONCLUSION

Every patient with severe or profound hearing loss must have a temporal bone high-resolution computed tomography (CT) scan. Stapedotomy is a simple, safe and low-cost procedure compared with cochlear implantation and can provide very good results. This can justify our decision to propose stapedotomy at the initial treatment in patients with very far-advanced otosclerosis. In cases of hearing failure after stapes surgery, cochlear implantation is an option.

OBJECTIVE

This study aimed to find the best first intention treatment of very far-advanced otosclerosis.

MATERIALS AND METHODS

This was a retrospective study and included 14 patients with non-measurable preoperative bone and air conduction thresholds and otosclerosis on temporal bone high-resolution CT scan. Stapes surgery followed by a well fitted hearing aid was the initial treatment in 11 patients and cochlear implantation in 7 patients, including 4 patients who had poor results after stapedotomy. Objective and subjective audiometric results were studied and compared between stapedotomy and cochlear implantation groups.

RESULTS

Objective and subjective results were statistically better in the cochlear implant group than in the stapedotomy group. However, four patients in the stapedotomy group had comparable results to the patients with cochlear implants.

Cochlear Implantation of Patients with Far-Advanced Otosclerosis

OBJECTIVE

This current single-subject, repeated-measures study was to describe our experience with 30 patients who had been diagnosed with "far-advanced otosclerosis" and who were included in our program of cochlear implants. We analyzed the history of the patients and their families before implantation, the surgical findings, and the performance over a follow up of 3 years.

MATERIAL AND METHODS

All patients met one or more of the after criteria: 1) previous surgical intervention as a treatment of their otosclerosis; 2) signs of pericochlear hypodensities in high resolution computed tomography (HRCT) scans; and 3) family precedents of otosclerosis. All underwent standard surgical cochlear implantation.

RESULTS

In 78% of the cases, a stapedectomy had previously been realized. Cochlear otosclerosis could be appreciated in HRCT in 78% of the patients. A family history of otosclerosis was found in 40%, and 33.3% of patients had familial precedents of nonfilial hypoacusis. The mean results in the two-syllable test were 20% preimplantation, 54% 6 months after implantation, and 52%, 62%, 54% at 1, 2, and 3 years after implantation. In the CID sentence test, they were in the order of 32% preimplantation and of 64% at 6 months, 66% after 1 year, of 68% after 2 years, and reaching 72% after 3 years. No complications related to the surgery were detected.

CONCLUSION

Patients diagnosed with far-advanced otosclerosis have a good prognosis with cochlear implantation comparable to that of other patients in whom postlingual implants are performed.

Cochlear Implantation in Cochlear Otosclerosis

OBJECTIVES/HYPOTHESIS

The objective was to correlate implant performance in cochlear otosclerosis to 1) matched control samples, 2) severity of otic capsule involvement, 3) prior ipsilateral surgery, and 4) programming issues.

STUDY DESIGN

Retrospective case controlled study.

METHODS

Study cohort comprised 30 individuals. Diagnosis was based on prior ear surgery (stapedectomy [n = 18] or fenestration [n = 2]) and/or pathognomonic radiological findings. High-resolution computed tomography images of the temporal bones were assessed by two radiologists and graded (range, 0-3) for the extent of otosclerosis. Operative records were reviewed. Performance, programming visits, and the number of electrode deactivations at 6 months and at 1 year after implantation were determined for the individuals with otosclerosis and compared with a group of matched control subjects. A within-group comparison correlating severity of otosclerosis to the above was carried out.

RESULTS

Implant performance in individuals with cochlear otosclerosis was not significantly different from those without. Previous surgery on the side of implantation did not alter performance. Programming difficulty as reflected in the number of visits and electrode deactivation for sound quality reasons were comparable. Deactivation for facial nerve stimulation occurred exclusively in otosclerotics with the most severe radiological disease (grade 3) and was only with non-modiolar hugging electrodes (n = 5). There was no observed difference between the radiological extent of otosclerosis and implant performance.

CONCLUSION

Individuals with severe otosclerosis considering cochlear implantation can be counseled to expect similar benefit to those without, regardless of whether prior surgery occurred on the side of implantation or of severity of otic capsule involvement. There is a significant risk of facial nerve stimulation in otosclerotics with grade 3 disease.

Cochlear Implantation in Otosclerosis

OBJECTIVE

The purpose of this study was to evaluate and compare the results obtained in a group of implanted otosclerotic patients with a group of cochlear implant (CI) patients not affected by otosclerosis.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Nine patients affected by profound sensorineural hearing loss caused by otosclerosis and nine patients affected by profound sensorineural hearing loss not caused by otosclerosis were evaluated.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURES

Preoperative imaging, intraoperative findings, postoperative facial nerve stimulation, and speech perception performance measures were performed and the data analyzed.

RESULTS

Otosclerosis patients showed signs of cochlear ossification both on high-resolution computed tomography scans and intraoperatively. The incidence of facial nerve stimulation was higher in the otosclerosis group, three out of nine, and was generally related to the use of electrical stimulation from the Nucleus 22 cochlear implant. Psychophysical and speech perception measures did not show significant differences between the two groups, despite some otosclerosis patients showing increased electrical thresholds and comfort levels and slightly poorer speech perception performance scores.

CONCLUSIONS

Patients with otosclerosis who have progressed to profound hearing loss derive significant benefit from cochlear implants; however, an increased risk of cochlear ossification and facial nerve stimulation has to be taken in account during preoperative counseling. The advance in imaging techniques, CI technology and the possibility to stimulate precise regions of the cochlea with lower intensities make it possible for the surgeons and audiologists to readily and successfully manage these complications as they arise.

Management of far advanced otosclerosis in the era of cochlear implantation

OBJECTIVE

To evaluate issues pertaining to cochlear implantation in patients with far advanced cochlear otosclerosis.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary care referral center.

PATIENTS

Eight adult patients (18 years of age or older) referred for management of profound hearing loss, the cause of which was determined to be otosclerosis.

INTERVENTION

Cochlear implantation with multichannel cochlear implant device.

MAIN OUTCOME MEASURES

Benefit from cochlear implant as measured by CID sentence scores, incidence and management of facial nerve stimulation, and technical issues pertaining to cochlear implantation in this patient population.

RESULTS

All patients demonstrated significant improvement in auditory function as measured by performance on CID sentence scores and ability to engage in telephone conversation. Facial nerve stimulation was present in two of eight patients and was managed with deactivation of the stimulating electrodes. Ossification in the basal turn of the cochlea, detected on preoperative computed tomography, necessitated placement of the electrode into the scala vestibuli in two patients and use of a thinner electrode (Nucleus 24) in a third patient.

CONCLUSION

Patients with profound hearing loss secondary to otosclerosis derive excellent benefits from cochlear implantation. Surgical implantation may be complicated by ossification of the cochlea, which can be detected on preoperative computed tomography. Electrode activation may be complicated by facial nerve stimulation, which can be addressed with programming strategies.

Critical evaluation of deafness

OBJECTIVE

The purpose of this study is to investigate the clinical aspects of profound hearing loss (PHL) and their significance for defining deafness.

METHODS

The audiological data were reviewed from 3660 patients who were evaluated in the Otolaryngology Clinic at Louisiana State University in Shreveport, LA, over a 5-year period. The medical charts from the patients were also reviewed for the information of medical diagnosis, surgical records and radiological findings.

RESULTS

There were 34 patients identified with bilateral PHL or deaf, 177 patients with unilateral PHL and 123 patients with borderline PHL. Congenital hearing loss and unknown-cause hearing loss in this series were predominant with 267 cases (79.9%). A surgical management was indicated in 39 cases (11.7%) including middle ear infection, ossicular chain abnormalities and auditory nerve/brainstem tumors.

CONCLUSION

This study suggests that audiometrically PHL should be thoroughly evaluated to detect reversible or remediable conditions by surgical and medical approaches. The diagnosis of deafness should be confirmed by an integration of the audiological data and medical documents including surgical and radiological findings. Aural rehabilitation program should be designed for deaf patients with varied etiology and degree of residual peripheral hearing sensitivity following medical clearance.

Stapedectomy for far-advanced otosclerosis

Patients with far-advanced otosclerosis (FAO) may appear to be suffering from profound sensorineural hearing loss and are frequently directed to cochlear implantation programmes. In order to avoid such misdiagnosis, FAO should be considered in patients with non-measurable bone-conduction levels and air-conduction levels exceeding 85 dB. Specific clues can lead the clinician to suspect otosclerosis as the aetiology of hearing loss. A review of eight patients (nine ears) with FAO who underwent stapedectomy from 1985-1995 reveals that six of the eight (75 per cent) who had been unable to use a hearing aid preoperatively obtained serviceable hearing with a hearing aid after surgery. This confirms that cochlear implantation is not the best treatment for all profoundly deaf patients; some are better off with stapedectomy.