Revision surgery in otosclerosis--operative findings in 186 patients

Recurrence of conductive hearing loss after stapes surgery: a narrative review

Among the functional failures of stapes surgery is recurrent conductive hearing loss, which can occur after a variable period of hearing improvement, from days/months up to many years after surgery. The most common cause of recurrent conductive hearing loss is prosthesis displacement, while fibrous adhesions or stapedotomy hole/oval window re-obliteration due to otosclerosis, occur less frequently. High resolution computed tomography plays an important role in the identification of the cause of hearing loss recurrence. Parallel to this, intra-operative exploration of the middle ear is crucial to confirm the cause of failure and address its treatment, possibly restoring hearing. While generally worse than after primary surgery, hearing outcomes after revision stapes surgery have improved thanks to advancements in pre-operative assessment, intra-operative view and technical refinements.

Rates of Sensorineural Hearing Loss and Revision Surgery After Stapedotomy: A Single-institution Experience Using the Nitinol Prosthesis

Background

Historically, stapedectomy complication rates are quoted as 1% profound postoperative sensorineural hearing loss (SNHL), 5%-10% nonprofound SNHL, and 5%-10% revision surgery.

Objective

We sought to reassess rates of post-stapedotomy complications based on our experience using contemporary surgical technique.

Methods

A retrospective case series was carried out at an academic tertiary referral center. Adult patients undergoing stapedotomy from 2013 to 2020 were included. Primary outcomes were rates of hearing loss and revision surgery. Rates of dizziness, tinnitus, dysgeusia, and proportions of patients who achieved air-bone gap (ABG) closure at 8-12 weeks postoperatively were also assessed.

Results

Four hundred sixty-eight stapedotomies in 399 patients with a median follow-up duration of 99 days (range, 11-5134) were reviewed. One patient (0.21%) suffered profound SHNL and 15 (3.20%) patients suffered nonprofound SNHL. The revision rate for stapedotomies from our institution was 4.49% (21 total revision surgeries). In 277 operations (59.19%), the patient had closure of the ABG within 10 dB. A further 132 (28.21%) had closure of the ABG between 10 and 20 dB. Air pure-tone audiometry scores improved by an average of 25.03 dB. Eighty-three (17.74%) patients complained of postoperative dizziness, which resolved by the time of the first follow-up appointment in all but 26 (5.56%). Seventeen patients (3.63%) complained of tinnitus, and 22 (4.70%) complained of dysgeusia.

Conclusions

SNHL, complications, and revision rates for stapedotomy in the modern era may be substantially lower than those currently presented to patients based on classic techniques and historical data.

Persistent and recurrent conductive deafness following stapedotomy

Background:

Stapedotomy produces the best hearing results of any otological operation. However, in a small number of cases the air–bone gap is not successfully closed, or conductive hearing loss recurs.

Objective:

To investigate the proportion of cases in the senior author's series which required revision surgery and to determine the medium to long term success rate of surgery, taking into account the results of revision surgery.

Methods:

Review of a series of 233 primary stapedotomy operations and 100 revision procedures carried out by one surgeon over a 20-year period.

Results:

Closure of the air–bone gap to within 10 dB was achieved in 80 per cent of cases following the primary procedure. Fifteen per cent of patients developed a recurrence of conductive hearing loss. When the results of revision surgery were taken into account, the proportion of ears with a mean air–bone gap of less than 10 dB was 86 per cent. However, of the patients undergoing revision surgery, air–bone gap closure to within 10 dB was only achieved in 52 per cent of cases.

Conclusion:

The best chance of obtaining a successful outcome in stapedotomy is to achieve this for the first procedure. However, revision surgery does increase the medium to long term success rate.

Failures in stapedotomy for otosclerosis

OBJECTIVE

To review the results of 78 revision stapedotomies, determining the causes of failure and the predictors of surgical success.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Seventy-eight operations were performed in a tertiary referral center on 72 patients between 1995 and 2005. Indication for surgery was recurrent or persistent conductive hearing loss.

RESULTS

The most common causes of failure were prosthesis displacement, incus necrosis, and oval window fibrosis. Postoperative air-bone gap was closed to within 10 dB in 54 percent of cases, and mean postoperative air-bone gap was 13.6 dB. Overclosure occurred in five percent of cases, sensorineural hearing loss in six percent of cases, and we had one postoperative dead ear. Success rates were higher in cases presenting prosthesis or ossicular malfunction than in cases with oval window problems. Hearing results did not differ if the prosthesis was crimped to either the malleus or the remnant of the long incudal process. Outcomes were similar for local or general anesthesia, and the nitinol piston did not significantly improve the hearing results.

CONCLUSION

Revision stapedotomy is less successful than primary procedure. Lessening the surgical trauma provides the most favorable results.

Revision Stapedectomy

Revision stapedectomy can be a technically demanding operation. The surgeon must be prepared for many pathologic conditions before revision stapes surgery. Appropriate preoperative patient counseling is a must. The best chance for hearing improvement is in those cases that have a delayed conductive hearing loss after primary stapedectomy. This article serves as a guideline for discussing the myriad possibilities that may be encountered during this type of revision stapedectomy. Indications for revision stapedectomy and general surgical guidelines for management of specific pathologic conditions are discussed. The material presented is based on literature review, the authors' personal experience, and a review of temporal bone studies relative to stapes surgery.

Success rate in revision stapes surgery for otosclerosis

OBJECTIVE

The aim of this study was to evaluate the hearing results of revision stapes surgery performed because of previously failed operations and to determine the causes of failure.

STUDY DESIGN

Retrospective review of revision stapes operations.

SETTING

Tertiary referral center.

PATIENTS

Sixty-three consecutive revision stapes operations were performed in 56 patients over a period of 12 years (1992-2004). The indication for revision surgery was recurrent or persistent air-bone gap greater than 20 dB after primary surgical treatment of otosclerosis of the oval window.

RESULTS

All patients were operated on to improve hearing. Sixty-three revision stapes operations resulted in closure of the air-bone gap to 10 dB or less in 52.4% of cases. The average postoperative air-bone gap was 13.1 dB, and the mean pure-tone average improvement was 12.9 dB. In six patients (9.5%), revision surgery produced no change in hearing, and in four (6.3%) the hearing decreased by 5 dB or more. In one patient, the operation resulted in a profound hearing loss. Prosthesis malfunction was the most common primary cause of failure (60.3%). The original prosthesis was replaced with a new one in 48 cases. In 30 of these (62.5%), closure of the air-bone gap to within 10 dB was achieved. In 15 cases, the prosthesis was not replaced, and in only four of these (26.7%), closure of the air-bone gap within 10 dB was obtained (p < 0.022).

CONCLUSION

Revision stapes surgery is less likely to be successful than the primary operation. Closure of the air-bone gap to within 10 dB was achieved in 52.4% of patients. The success rate was better in cases where the original prosthesis was replaced with a new one. The risk for decreased bone-conduction threshold does not seem to be higher than in primary surgery.

Delayed Vertigo after Stapes Surgery

OBJECTIVES

Stapes surgery restores partial or total hearing in almost 95% of cases, and in case of failure, revision surgery may often resolve the problem. Delayed vertigo is commonly related to perilymphatic fistula. The aim of this study is to report experience gained in revision stapes surgery in cases of delayed vertigo.

STUDY DESIGN

This is an intervention study, before-after trial; it includes follow-up between 12 and 84 months that was based on clinical history and audiometric evaluations.

METHODS

The work was carried out in the otologic surgery referral center of Piemonte in outpatient surgery. Nine patients (4 males and 5 females, between 43 and 60 years of age) who presented with delayed vertigo after stapes surgery were retrospectively reviewed. All nine underwent clinical history evaluation, pure tone audiogram, investigation of the vestibular system with a bithermal binaural caloric test, and fistula test. Vestibular tests were performed with electronystagmography recording. In all nine subjects, functional middle ear exploration was carried out by way of a transmeatal approach using local anesthesia. The demonstration of a perilymphatic leak was positive in only three (33%) cases, but the oval window region was filled with fibrin glue in all nine cases.

RESULTS

At follow-up, vertigo was resolved in all cases with revision surgery, even though perilymph leak was positive only in three cases.

CONCLUSION

From the results obtained, we feel that exploration of the middle ear should be always carried out in cases of delayed vertigo after stapes surgery with suspected perilymphatic fistula.

Short- and long-term results of stapedotomy and stapedectomy with a teflon-wire piston prosthesis

We analyzed the results of 604 cases of primary stapes surgery performed between 1974 and 1997 with replacement of the stapes by a 0.6- or 0.8-mm Schuknecht Teflon-wire piston. At long-term follow-up (1 to 21 years; mean, 7 years), the residual air-bone gap was 10 dB or less in 79% of the cases. The hearing results and postoperative complications were comparable to those reported by authors who used the same evaluation criteria. Although the aim of the surgery was to perform a small stapedotomy with a narrow footplate perforation (0.8 mm), a large stapedotomy or a stapedectomy was performed in 134 cases (22.2%) because of surgical or anatomic conditions. Our results show that the larger footplate perforations allowed a better correction of the air-bone gap at the lower frequencies. The ears with larger perforations did not show a higher incidence of sensorineural hearing loss.

A review of 308 cases of revision stapedectomy

OBJECTIVE/HYPOTHESIS

Identify causes of primary and revision stapedectomy failure in 308 patients, assess whether these are different based on source of initial surgery, and evaluate hearing results in revision stapedectomy to improve outcome.

STUDY DESIGN

Retrospective, nonrandomized chart review of patients undergoing revision stapedectomy in a referral otology practice in a large metropolitan region.

MATERIALS AND METHODS

Intraoperative findings, preoperative and postoperative revision stapedectomy air and bone conduction pure-tone averages, speech discrimination scores, postoperative air-bone gaps, complications, and repeated revisions were noted in 308 patients.

RESULTS

Leading causes of primary stapedectomy failure included dislocated prosthesis (24.4%), inadequate prosthesis length (14%), long process resorption (14%), and fibrous adhesions (13.6%). Revision stapedectomy air-bone gaps were less than 10 dB in 80% and greater than 30 dB in 6.8% of cases. Increased sensorineural hearing loss occurred in 0.8% of revision stapedectomy cases. Five of seven cases of vertigo associated with primary stapedectomy resolved after revision surgery.

CONCLUSION

Revision stapedectomy by experienced surgeons is highly effective in attaining successful air-bone gap closure in 80% and improved closure in 84.8% of operative cases. Risk of vertigo and/or sensorineural hearing loss was not any higher in this patient population when compared with reports of primary stapedectomy.

Revision stapedectomy: intraoperative findings, results, and review of the literature

Seventy-four revision stapedectomies performed consecutively over 10 years (1986 to 1995) were reviewed retrospectively. The most common intraoperative findings were incus erosion, prosthesis displacement, and oval window closure. Incus erosion was more frequently associated with multiple revisions. The postoperative results were reported using the conventional method (postoperative air minus preoperative bone) as well as the guidelines recently published by the American Academy of Otolaryngology--Head and Neck Surgery (postoperative air minus postoperative bone), with success rates of postoperative air-bone gap closure to within 10 dB after revision surgery of 51.6% and 45.6%, respectively. Patients with persistent conductive hearing loss (large residual air-bone gaps) after primary stapedectomy had poorer postrevision hearing results. Sensorineural hearing loss (defined as a drop in bone pure-tone average of more than 10 dB) occurred in four cases (5.4%). The number of revision surgeries, variations in operative techniques using laser or drill, and the ossicle to which the prosthesis was attached did not statistically affect the postoperative air-bone gaps. These results were compared with previously published data.