Systematic Review and Meta-analysis of Endoscopic vs Microscopic Stapes Surgery for Stapes Fixation

Taste Disorders After Middle Ear Surgery: Chorda Tympani Nerve Injury and Quality of Life

OBJECTIVE

To evaluate taste disorders after middle ear surgery, their modifying factors especially chorda tympani nerve injury or underlying otologic disease. We investigated consequences of taste disorders on quality of life.

STUDY DESIGN

Prospective cohort study.

SETTING

Monocentric study in tertiary care center.

METHODS

A total of 214 patients who underwent middle ear surgery were included. Data regarding taste disorders were collected by questionnaires over a 1-year follow-up period.

RESULTS

Taste disorders were reported in 42.7% at 10 days, in 23.3% at 4 months, and in 9.2% 1 year postoperatively. When the chorda tympani nerve was initially healthy, taste disorders were more frequent after its transection throughout the follow-up period. When it was involved in a cholesteatoma or inflammatory process, postoperative taste disorders were more frequent after nerve stretching. Postoperative discomfort in daily life was rated on the Likert scale at 3.5 out of 10. Dietary modifications were reported by 25.8% of patients, and mood alterations by 15% of patients.

CONCLUSION

Taste disorders are frequent after middle ear surgery although they mostly improve in the first months. When the CTN is healthy, cutting it leads to more taste disorders than stretching it, thus advocating its preservation to prevent these symptoms. However, in cases of pathological CTN, cutting this nerve, which is sometimes necessary to control the disease, is less likely to cause taste disorders than stretching it. These taste disorders are a source of discomfort and may present risks of dietary modifications and emotional impact.

Comparison of endoscopic and microscopic stapedotomy in the same patients: a prospective randomized controlled trial

PURPOSE

This study aimed to conduct a comparative analysis of audiological and postoperative clinical outcomes between the endoscopic and microscopic stapedotomy approaches.

METHODS

This study employed a randomized, controlled design. Twenty-seven patients with bilateral otosclerosis underwent stapedotomy in both ears, with randomized allocation of the surgical technique (endoscopic vs. microscopic) for the first operated ear. Air-bone gap (ABG) and ABG gain were measured at least 12 months postoperatively. Postoperative outcomes including pain (Visual Analog Scale-VAS), dizziness, early-term (day 1) and late-term (6 months) dysgeusia were evaluated. The Glasgow Benefit Inventory (GBI) assessed health-related quality of life at one month postoperatively, and operative time was measured.

RESULTS

This study compared endoscopic (n = 27 ears) and microscopic (n = 27 ears) stapedotomy for otosclerosis. Both groups achieved similar hearing improvement with no significant differences in pre-operative and post-operative bone/air conduction thresholds, ABG, and ABG gain (all p > 0.05). The endoscopic stapedotomy group demonstrated reduced postoperative pain (lower VAS scores, p < 0.001), lower early dysgeusia (3.7% vs. 33.3%, p = 0.005), shorter operative time (47.3 vs. 75.4 min, p < 0.001) and improved patient-reported outcomes (higher GBI score, p = 0.014) when compared to microscopic stapedotomy group. No significant differences were observed in postoperative dizziness or late-term dysgeusia between groups.

CONCLUSION

This study found similar hearing improvement with both endoscopic and microscopic stapedotomy for otosclerosis. However, the endoscopic approach showed advantages in reduced postoperative pain, early dysgeusia, and operative time, with improved patient-reported quality of life. These findings suggest endoscopic stapedotomy as a valuable alternative to the conventional microscopic approach.

A comparison between endoscopic and microscopic approaches for stapes surgery: experience of a tertiary referral center

PURPOSE

Otosclerosis is a common ear disease causing ankylosis of the stapedio-vestibular joint and conductive hearing loss. Stapedoplasty is the most advisable surgical solution. The restoration of hearing depends on the condition of the patient and the surgery itself. The aim of our work was to compare the surgical and audiological results of stapedoplasty performed with endoscopic versus microscopic technique.

METHODS

This is a retrospective study of 254 patients treated with stapedoplasty with a microscopic approach (91/254) or with an endoscopic approach (163/254) between 2014 and 2021 at our tertiary referral center. Statistical significance of differences between the two methods was determined using the Mann-Whitney test for quantitative variables and the Wilcoxon matched-pairs signed-rank test for repeated measures. Categorical variables were assessed with Fisher's exact test.

RESULTS

Both techniques improved the hearing status of patients, with no statistically significant difference between them. There was also no statistically significant difference in reported complications between the two techniques. There is a statistical difference (p < 0.001) in operating time between the two techniques: the endoscopic technique had a mean operating time of 39 min versus 45 min for the microscopic technique.

CONCLUSIONS

The two techniques are comparable in terms of results and the choice depends on the surgeon's preferences and experience.

Brazilian Society of Otology task force - Otosclerosis: evaluation and treatment

OBJECTIVES

To review and provide evidence-based recommendations for the diagnosis and treatment of otosclerosis.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on otosclerosis were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: 1) Diagnosis - audiologic and radiologic; 2) Treatment - hearing AIDS, pharmacological therapy, stapes surgery, and implantable devices - bone-anchored devices, active middle ear implants, and Cochlear Implants (CI).

CONCLUSIONS

The pathophysiology of otosclerosis has not yet been fully elucidated, but environmental factors and unidentified genes are likely to play a significant role in it. Women with otosclerosis are not at increased risk of worsening clinical condition due to the use of contraceptives or during pregnancy. Drug treatment has shown little benefit. If the patient does not want to undergo stapedotomy, the use of hearing aids is well indicated. Implantable systems should be indicated only in rare cases, and the CI should be indicated in cases of profound deafness.

The utility and safety of diode laser in endoscopic stapes surgery

Objective

The advantages of laser stapedotomy are less trauma and more precise and minimally invasive techniques; however, the potential risk of overheating from the laser combined with the endoscope tip must be considered. This study aimed to assess the efficacy and safety of diode lasers for endoscopic stapes surgery.

Methods

A retrospective review of 56 patients with otosclerosis who underwent primary endoscopic stapedotomy with a diode laser from 2017 to 2020 was conducted. Demographic data, intraoperative findings, preoperative and postoperative audiological assessments, and postoperative complications were analyzed.

Results

There was no statistically significant difference between the preoperative and postoperative bone conduction thresholds. The mean postoperative air-bone gap (ABG) improved significantly compared to the preoperative ABG (4.07 vs. 35.43 dB, p < .001). The postoperative ABG closure within 10 dB at 6 and 12 months was achieved in 87.50% and 91.07% of patients, respectively. The postoperative pain scores at 4 and 24 h were 2.55 and 0.39, respectively. Immediate postoperative vertigo was reported in 12.50% of patients, with 100% complete recovery 2 months after surgery. The chorda tympani nerve was preserved in all the cases. Postoperative taste disturbances at 2 and 12 months were observed in 17.86% and 1.79% of patients, respectively.

Conclusion

The diode laser in endoscopic stapedotomy is a safe and effective technique that provides satisfactory hearing outcomes. Temporary taste disturbances during the early postoperative period are a concern. The handheld diode laser delivery system is suitable for an endoscopic approach and is an alternative armamentarium for the treatment of otosclerosis. Level of evidence: IV.

Juvenile otosclerosis and congenital stapes footplate fixation. A systematic review and meta-analysis of surgical outcomes and management

OBJECTIVE

Juvenile Otosclerosis (JO) and Congenital Stapes Footplate Fixation (CSFF) are rare ossicular chain disorders seen in the paediatric population and present with conductive hearing loss. Ongoing controversy exists regarding the role of surgical intervention in JO and CSFF given the poorer hearing outcomes and complications when compared with surgical intervention for adult otosclerosis. The objective of this study is to assess the published data on the surgical outcomes of JO and CSFF in order to guide clinicians and counsel patients on the various medical options for these disease entities.

METHODS

A systematic review of MEDLINE, EMBASE and Cochrane was performed with inclusion criteria of children with JO or CSFF and hearing outcomes following stapes surgery. Studies identified by the search were reviewed and assessed by two independent reviewers in line with the PRISMA guidelines.

RESULTS

464 articles were initially reviewed and 28 articles met inclusion in the systematic review and meta-analysis. A total of 810 ears (473 and 337 cases of JO and CSFF respectively) underwent stapes surgery. Average age at time of surgery for JO and CSFF was 14.3 and 10.2 years old respectively. The mean pre-operative Air-Bone-Gap (ABG) for JO and CSFF was 31.8 ± 5.2 dB and 39.4 ± 10 dB respectively. Following stapes surgery, the mean post-operative ABG for JO and CSFF was 9.6 ± 6 dB and 19.2 ± 12.5 dB respectively. Surgical success rate (defined as ABG <10 dB) was 81% for JO and 41% for CSFF. Mean ABG gain for JO and CSFF was 24.8 dB (95% CI: 18.6-33.1) and 22.6 dB (95% CI: 18.4-27.8) respectively. The reported number of dead ears was 4/473 (0.8%) for JO and 2/337 (0.6%) for CSFF. 23 cases (2.8%) reported sensorineural hearing loss (SNHL) >10 dB.

CONCLUSION

CSFF was associated with poorer hearing outcomes compared to JO, however both entities showed similar improvement in ABG post operatively. Counselling patients and their families on the surgical success rates and complications of JO or CSFF is an important part of the decision making process when deciding between a surgical option or conservative measures such as hearing aids.

Missed Radiological Diagnosis of Otosclerosis in High-Resolution Computed Tomography of the Temporal Bone-Retrospective Analysis of Imaging, Radiological Reports, and Request Forms

Objectives: Several studies reported low detection rates of otosclerosis in high-resolution computed tomography (HRCT), especially when the scans were reviewed by non-specialized general radiologists. In the present study, we conducted a retrospective review of the detection of otosclerosis in HRCT by general radiologists and the impact of inadequately filled radiological request forms on the detection rate. Methods: Retrospective analysis of hospital records, HRCT reports, and radiological referral notes of 40 patients who underwent stapedotomy surgery for otosclerosis. HRCT imaging data sets were retrospectively reviewed by a blinded experienced neuroradiologist, whose reading served as the gold standard. Results: General radiologists reading HRCT scans had an overall detection rate of otosclerosis of 36.1% in this cohort (13 of 36 available HRCT reports). The neuroradiologist had a much higher detection rate of 82.5% (33 of 40 cases). Interobserver agreement between the general radiologists and the subspecialist neuroradiologist was poor (Cohen’s kappa κ = 0.26). General radiologists missed the diagnosis in 15 of the 33 CT-positive scans, corresponding to a missed diagnosis rate of 45.4%. There was a highly significant association between a missed diagnosis and the lack of an explicitly mentioned clinical suspicion of otosclerosis in the request forms (Pearson’s chi-squared test, p < 0.005). Conclusion: The diagnosis of otosclerosis is frequently missed by radiologists on HRCT scans of the temporal bone in a clinical setting. Possible reasons include a relative lack of experience of general radiologists with temporal bone imaging as well as the failure of clinicians to unambiguously communicate their suspicion of otosclerosis.

The pre-chorda and post-chorda tympani approach in endoscopic stapes surgery based on the chorda tympani nerve classification

PURPOSE

In most stapes surgeries, the posterior ear canal is enlarged and a piston is inserted posterior to the chorda tympani nerve (post-chorda tympani approach; Post C). Although reports vary, some indicate that more than 60% of the patients experience lingual symptoms following surgery. Endoscopic surgery may permit an anterior approach to the nerve (pre-chorda tympani approach; Pre C). Herein, we propose a suitable approach for endoscopic stapes surgery based on the classification of the chorda tympani nerve.

METHODS

We retrospectively reviewed the medical records of 23 patients who underwent endoscopic stapes surgery at our institution between 2019 and 2021. The nerve classification previously reported, the modified nerve classification (attached long type is divided into Category 1: lenticular process is visible with 0° endoscope and Category 2: not visible), selected approach (Pre C or Post C), use of a 30° endoscope, and manipulation of the nerve (number of contacts and traction, with or without suction, with or without malposition or extension and amputation, and damage score) were evaluated.

RESULTS

The damage score was significantly lower in the Pre C group (p < 0.05); however, using this approach for all cases is not desirable owing to the high risk of damage to the nerve during posterior malpositioning.

CONCLUSION

The Post C should be used for the detached and attached long 1 types, while the Pre C with a 30° endoscope should be used for the attached long 2, attached short, ultrashort, and external auditory canal types.

Endoscopic vs. microscopic stapes surgery: An anatomical feasibility study

Objectives

To investigate the feasibility of the endoscopic approach vs. microscopic approach during stapes surgery, focusing on the visualization of the important anatomical structures of the middle ear, the volume of the resected scutum and chorda tympani (CT) injury.

Methods

Fresh frozen human cadaveric heads underwent two stapes surgeries using an operating microscope on one ear and an endoscope on the other ear. The surgeon documented the visualization of critical landmarks, as well as exposure and injury of the CT. The volume of resected scutum was evaluated using cone beam computed tomography scanning and three-dimensional imaging.

Results

We performed endoscopic stapes surgery in 10 ears and microscopic stapes surgery in 11 ears. A stapes prosthesis was placed in all ears. The volume of bony scutum resection was significantly lower in the endoscopic group (median = 2.20 mm³, IQR = 4.17) than in the microscopic group (median 13.25 mm³, IQR = 8.71). No scutum was removed in two endoscopic ears, while scutum was removed in all microscopic ears. The endoscopic and microscopic group had similar CT injury.

Conclusions

This study showed that the endoscopic stapes surgery procedure is feasible and might be less invasive than microscopic stapes surgery. Future clinical prospective and functional studies will be needed to support our findings.

“Hot” vs “Cold” endoscopic stapes surgery: a matched case–control study

Purpose

To compare hearing results and complication rates between two groups of patients operated on by endoscopic stapes surgery (ESS) for otosclerosis, either with CO2 fiber laser or microdrill.

Methods

A case–control study was performed. All consecutive cases of CO2 fiber laser ESS operated at a single center during the period 2017–2020 (case group) were matched to a control group of patients operated by traditional technique, according to year of surgery, preoperative mean air–bone gap, sex and age. Audiological data from preoperative and postoperative examinations and complication rates were compared.

Results

46 cases were included. Mean operative time was significantly longer in the laser cohort (65 min) than in the drill one (45 min) (p = 0.003). Similar results were found in the two groups regarding the mean postoperative BC-PTA. The high-frequency bone conduction resulted significantly higher in the laser group (p = 0.002), suggesting an overclosure effect in the laser group. Consistently, a significant improvement of the BC-PTA threshold at 2000 Hz postoperatively was found in the laser group (p = 0.034). The postoperative AC-PTA significantly improved in both groups at all frequencies (p < 0.05), except for the AC threshold at 8 kHz. Similar rates of complications were found in the two groups.

Conclusion

This study is the first to compare hearing results and complications between CO2 fiber laser and microdrill in ESS. Our results demonstrated similar functional outcomes between the two groups, confirming ESS as safe and effective, regardless of the technique used.

Patient-Reported Postoperative Pain and Numbness: Applications for Endoscopic vs. Microscopic Ear Surgery

Background: Transcanal endoscopic ear surgery (TEES) avoids a postauricular incision, which has been shown to minimize pain and numbness. Our objective is to assess how much patients value minimizing pain and numbness relative to other postoperative otologic outcomes. Methods: Cross-sectional anonymous surveys were distributed to otolaryngology clinic patients in a tertiary care center. Patients were instructed to rate how much they value various outcomes when undergoing hypothetical ear surgery on a scale of 0 (not important) to 10 (very important). Results: 102 patients responded. Ten percent of survey respondents were Spanish-speaking. Outcomes of the highest importance included hearing (mean 9.3; SD 1.9), staff friendliness (8.9; 1.8), numbness (8.3; 2.4), and pain (8.1; 2.5). Outcomes of moderate importance included time spent under anesthesia (7.0; 3.2), scar visibility (6.3; 3.5), incision size (5.5; 3.4), incision hidden in the ear canal (5.4, 3.9), and surgery cost to the hospital (5.1; 3.9). In linear regression analysis, increasing age was associated with decreased value placed on incision size (p < 0.001) and scar visibility (p < 0.001). Conclusion: Patients placed a high value on minimizing pain and numbness after ear surgery, nearly as much as a good hearing outcome. These patient-centric outcomes are important in justifying the minimally invasive approach of TEES.

Endoscopic and Robotic Stapes Surgery: Review with Emphasis on Recent Surgical Refinements

Purpose of Review

Stapes surgery has been established as the gold standard for surgical treatment of conductive hearing loss in otosclerosis. Excellent outcomes with very low complication rate are reported for this surgery. Recent advances to improve surgical outcome have modified the surgical technique with endoscopes, and recent studies report development of robotical assistance. This article reviews the use of endoscopes and robotical assistance for stapes surgery.

Recent Findings

While different robotic models have been developed, 2 models for stapes surgery have been used in the clinical setting. These can be used concomitant to an endoscope or microscope. Endoscopes are used on a regular base regarding stapes surgery with similar outcomes as microscopes. Endoscopic stapes surgery shows similar audiological results to microscopic technique with an advantage of less postoperative dysgeusia and pain. Its utility in cases of revision surgery or malformation is emphasized.

Summary

Endoscopic stapes surgery is used on a regular basis with excellent outcomes similar to the microscopic approach, while reducing surgical morbidity. Robotic technology is increasingly being developed in the experimental setting, and first applications are reported in its clinical use.