[The application of endoscope and microscope in the stapes surgeries]

Objective:To compare the application of endoscope and microscope in all kinds of stapes surgeries. Methods:Fifty-nine stapes surgeries have been collected from April 2020 to May 2023 in Senior Department of Otolaryngology Head and Neck Surgery, Chinese PLA General Hospital, Chinese PLA Medical School. Hearing level, hospital stay post-operation, times of hospital visit post-operation, etc. have been compared between the endoscopic group and microscopic group. Patients who were failed to place the stapes prosthesis because of the poor exposure of the oval window have been analyzed. Results:Otosclerosis was the most common diagnosis in both groups. There was 1（1/23） middle ear malformation in the endoscopic group and 5（5/36） middle ear malformations in the microscopic group. There were 2 Van Der Hover syndromes and 4 Treacher Collins syndromes in the microscopic group. In the endoscopic group ABG of 10 ears（43.5%） ≤ 10 dB, and ABG of 21 ears（91.3%） ≤20 dB.In the microscopic group ABG of 13 ears（41.9%） ≤ 10 dB, and ABG of 28 ears（90.3%） ≤ 20 dB. There was no statistic difference between 2 groups. Times of hospital visit post-operation in the endoscopic group was less than in the microscopic group（P<0.01）. There was no facial palsy, tympanic perforation or profound sensorineural hearing loss in both groups. Conclusion:Endoscope is more suitable for patients who are evaluated with no severe stapes malformation, or less manipulation of drilling the bone. It could also reduce the hospital visit post-operation. Patients with narrow ear canal or severe middle ear malformation are recommended to perform the surgery with microscope, because it provides the chance of manipulation with 2-hands of surgeons.

Classification of Wideband Tympanometry by Deep Transfer Learning with Data Augmentation for Automatic Diagnosis of Otosclerosis

Otosclerosis is a common disease of the middle ear leading to stapedial fixation. Its rapid and non-invasive diagnosis could be achieved through wideband tympanometry (WBT), but the interpretation of the raw data provided by this tool is complex and time-consuming. Convolutional neural networks (CNN) could potentially be applied to this situation to help the clinicians categorize WBT data. A dataset containing 135 samples from 80 patients with otosclerosis and 55 controls was obtained. We designed a lightweight CNN to categorize samples into the otosclerosis and control. Receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.95 0.011, and the F1-score was 0.89 0.031 (r=10). The performance was further improved by data augmentation schemes and transfer learning strategies (AUC: 0.97 0.010, F1-score: 0.94 0.016, p<0.05, ANOVA). Finally, the most relevant diagnostic features employed by the CNN were assessed via the activation pattern heatmaps. These results are crucial for the visual interpretation of WBT graphic outputs which clinicians use in routine, and for a better understanding of the WBT signal in relation to the ossicular mechanics.

[Use of the Carina active middle ear implant in otosclerosis patients]

Patients with otosclerosis can suffer from different grades of combined hearing loss. In addition to surgery (stapedectomy), conventional hearing aids can be used in the treatment of otosclerosis. In cases of severe conductive components in addition to sensorineural hearing loss, treatment with normal hearing aids can be difficult or impossible. In these patients, implantable hearing systems such as cochlear implants represent a possible alternative. The totally implantable Carina middle ear system can be used in patients with even high-grade sensorineural hearing loss. Based on two exemplary cases, the option of using the Carina system in otosclerosis patients and post-implantation results are reported.

Osteoprotegerin gene polymorphisms and otosclerosis: an additional genetic association study, multilocus interaction and meta-analysis

BACKGROUND

Otosclerosis (OTSC) is among the most common causes of a late-onset hearing loss in adults and is characterized by an abnormal bone growth in the otic capsule. Alteration in the osteoprotegerin (OPG) expression has been suggested in the implication of OTSC pathogenesis.

METHODS

A case-control association study of rs2228568, rs7844539, rs3102734 and rs2073618 single nucleotide polymorphisms (SNPs) in the OPG gene was performed in a Tunisian-North African population composed of 183 unrelated OTSC patients and 177 healthy subjects. In addition, a multilocus association and a meta-analysis of existing studies were conducted.

RESULTS

Rs3102734 (p = 0.013) and rs2073618 (p = 0.007) were significantly associated with OTSC, which were predominantly detected in females after multiple corrections. Among the OPG studied SNPs, the haplotypes A-A-C-G (p = 0.0001) and A-A-C-C (p = 0.0004) were significantly associated with OTSC in females. Multilocus association revealed that the SNPs: rs2073618 in OPG, rs1800472 in TGFβ1, rs39335, rs39350 and rs39374 in RELN, and rs494252 in chromosome 11 showed significant OTSC-associated alleles in Tunisian individuals. In addition, meta-analysis of the rs2073618 SNP in Tunisian, Indian and Italian populations revealed evidence of an association with OTSC (OR of 0.826, 95% CI [0.691-0.987], p = 0.035).

CONCLUSIONS

Our findings suggest that rs3102734 and rs2073618 variants are associated with OTSC in North African ethnic Tunisian population. Meta-analysis of the rs2073618 in three different ethnic population groups indicated an association with OTSC.

Mid-term evaluation of perioperative i.v. corticosteroid treatment efficacy on overall and audiological outcome following CO2 laser stapedotomy: a retrospective study of 84 cases

Purpose

Our aim was to determine whether perioperatively administered corticosteroid treatment has any beneficial effect on the outcome of stapes surgery, with special regard to the audiological results and early postoperative morbidity.

Methods

84 CO₂ laser stapedotomies performed in our institute between 2013 and 2018 were included in our investigation. All cases underwent preoperative and mid-term postoperative pure-tone audiometric evaluation. Vestibular complications were also evaluated. The cases were subdivided into two groups, 23 patients received perioperative i.v. methylprednisolone treatment (“S”) while the other 61 patients (“nS”) did not receive any adjuvant pharmacological therapy. The data were analyzed retrospectively using IBM SPSS Statistics.

Results

CO₂ laser stapedotomy proved to be a successful intervention with a significant improvement in ABG and AC thresholds as well. Long-term BC levels were significantly better compared to preoperative ones in the S group; however, in the nS group, no difference could be shown. Hearing and ABG gain were significantly superior in group S [28.1 dB (SD11.2) vs. 18.1 dB (SD 10.9) and 23.9 dB(SD 9.8) vs. 17.2 dB (SD 9.5), respectively].

Conclusion

No significant inner ear damage was detectable in the results of our CO₂ laser stapedotomy method; however, the positive effect of corticosteroid treatment could be demonstrated through the postoperative hearing levels. We found no statistical difference in early postoperative morbidity. According to our data, the routine administration of corticosteroids during stapes surgery could be an issue worthy of consideration. The effects of perioperative treatment vs that on the first day after surgery, and topical vs. systemic treatment could be the subject of further investigation in a prospective manner.

[The diagnostics and surgical treatment of the patients presenting with otosclerosis in the Primorye Territory]

The objective of the present study was to characterize the effectiveness of the audiological and radiological diagnostic techniques as well as the results of the surgical treatment of the patients presenting with otosclerosis based at the hospital clinic of the Pacific State Medical University. The analysis included 49 surgical interventions for stapedoplasty carried out on 42 patients during the period from 2015 to 2017. The tympanic form of the disorder was diagnosed in 51.02% of the cases, the mixed form I in 16.28%, and the mixed form II in 32.7%. The excellent results within two months after surgery were obtained in 87.2% of the treated patients, the good and satisfactory results in 8.72% and 4.08% of them respectively.

[Stapedo-Vestibular Ankylosis: Retrospective Study of Five Cases in São Tomé e Príncipe]

INTRODUCTION

Otosclerosis is a common form of conductive hearing loss characterized by abnormal bone remodeling exclusively in the otic capsule. The prevalence of otosclerosis varies in racial populations and is described as being rare in black African populations. In this paper we aim to report five cases of clinical, and surgically confirmed, otosclerosis in black individuals, in São Tomé and Príncipe.

MATERIAL AND METHODS

Since February 2011, Ear, Nose and Throat consultations and surgeries specialty have been carried out at Dr. Ayres de Menezes Hospital in cooperation with the project 'Health for all'. A retrospective analysis was undertaken of the records of all patients subjected either to stapedectomy or partial stapedectomy until February 2014. Information regarding clinical presentation, audiometric data and surgery reports was recorded.

RESULTS

Five adult patients underwent stapedectomy or partial stapedectomy. All of them presented with normal otoscopy, conductive or mixed hearing loss on audiogram and normal tympanometry with absent stapedial reflexes. None of the patients had signs of infection or history of head trauma. Three cases showed improvement in the air-bone gap after surgery. The other two were lost to follow-up.

DISCUSSION

We documented and surgically confirmed five cases of clinical otosclerosis in this population. A thematic review was carried out and concluded that, despite being described as a rare event in this race, available literature on this topic is not enough to state that there is lower prevalence of otosclerosis amongst the African population.

CONCLUSION

Even if not common, otosclerosis cannot be disregarded as a possible cause for conductive hearing loss among the population of São Tomé and Principe.

[The application of stapedoplasty for the treatment of hearing loss in the patients suffering from obliterative otosclerosis]

This article presents the results of analysis of the data obtained during the examination and the surgical treatment of the patients presenting with the obliterative form of otosclerosis and suffering from hearing impairment with special reference to the intraoperative findings, technical aspects of stapedoplasty, and its effectiveness. A total of 14 patients (17 ears) were recruited for the participation in the present study including 10 women at the mean age of 38.8±6.2 years and 4 men (mean age 44.8±3.9 years). The duration of the hearing loss in the period preceding the surgical treatment in 7 (50%) patients was more than 8 years. According to the results of tonal threshold audiometry (TTA), the mean bone conduction (BC) threshold for conductive hearing loss in the frequency range from 0.5 to 4.0 kHz was 24.9±8.1 dB with the mean bone air gap (BAG) equaling 38±5.1 dB. Computed tomography (CT) of the temporal bones revealed grade 1 obliterative otosclerosis in 4 patients, grade II of the same condition in 6 patients, and grade III in 7 ones. These findings were confirmed intraoperatively. In 15 cases, stapedostomy was carried out with the use of the non-contact CO2 laser-based system, in the remaining cases a microdrill was employed. Five patients underwent laser-assisted piston stapedoplasty while in 11 others the stapes prosthesis was placed on the autovein. One patient was treated by the same method with the use of the autocartilaginous prosthesis. The functionally acceptable results within 1 year after the surgical intervention were obtained in all the treated patients with the mean bone air gap equaling 13.2±3.4 dB. The best outcome (the reduction of the BC threshold and BAG by 7 dB and 25.9 db on the average respectively within 1 year after surgery was achieved in the patients with grade III obliterative otosclerosis.

The role of cVEMPs and vHIT in the evaluation of otosclerosis and its eventual vestibular impairment: preliminary findings

The role of cVEMPs and vHIT in the evaluation of otosclerosis and its eventual vestibular impairment: preliminary findings.

OBJECTIVES

Otosclerosis is one of the most common causes of hearing loss in adults, with a prevalence of 0.3% to 0.4% in Caucasians. Vestibular symptoms may occur, with an incidence ranging between 5% and 57% of patients. The aim of our study is to evaluate the vestibular function and its eventual changes after stapes surgery in patients affected by otosclerosis.

METHODS

Prospective case-control study. Twenty patients (17 females; age range 33-58; mean age 44) who underwent surgery for otosclerotic disease between April 2012 and February 2014 were prospectively studied. These patients underwent preoperative and postoperative audiological tests. Furthermore, vestibular function was evaluated using the cervical evoked myogenic potentials test (cVEMPs) and video head impulse test (vHIT), preoperatively and postoperatively. A case-control study was also performed. Quantitative and statistical analysis of patients' vestibular function was carried out both before and after stapes surgery.

RESULTS

The means of the vHIT gains in the case group were 1.03 on the right side and 1.01 on the left side. A significant difference between case and control groups was seen, with a lower left gain registered in the control group. No cases with a gain of less than 0.8 were found in either group. Moreover, a significant postoperative reduction in P1/NI amplitude was seen in patients complaining of postoperative dizziness or vertigo.

CONCLUSIONS

These findings indicate a probable traumatic saccular impairment in patients with vestibular symptoms. However, a longer follow-up may help in understanding the behaviour of cVEMPs in post-stapes surgery vertigo.

Otosclerosis: Incidence of Positive Findings on High-Resolution Computed Tomography and Their Correlation to Audiological Test Data

Objectives:

Computed tomographic (CT) scanning with slices of 1 mm or more has not been sufficient to demonstrate otosclerotic foci in most cases to date.

Methods:

We investigated the validity of CT scans with a 0.5-mm cubical scan technique, with and without planar reconstruction, and correlated these findings with audiological data. Forty-four temporal bone CT scans from 30 patients with conductive or mixed hearing loss were evaluated.

Results:

Otosclerotic foci were visualized in 74% of the cases. With reconstruction at the workstation, the sensitivity increased to 85%. Whereas in fenestral otosclerosis a correlation was found between the size of the focus and the air-bone gap, no correlation was seen between the size of the focus and bone conduction thresholds with cochlear involvement. Otosclerotic foci in patients treated with sodium fluoride were smaller than those in patients without treatment. This finding may indicate a beneficial effect of sodium fluoride on otosclerotic growth.

Conclusions:

High-resolution CT scans are a valid tool that can be used to confirm, localize, and determine the size of clinically suspected otosclerotic foci.

[High-resolution CT with multi-planar reformation in diagnosis of stapedial otosclerosis]

OBJECTIVE

To evaluate the value of HRCT with multi-planar reformation (MPR) in the diagnosis of otosclerosis.

METHODS

138 ears in 129 patients with otosclerosis confirmed by surgery were evaluated retrospectively, using the MPR image along stapes as standard image, and 132 normal ears were collected as the control group.

RESULTS

In the otosclerosis group, HRCT-MPR was positive in 108 ears, suspicious positive in 12 ears, and negative in 18 ears.In the control group, HRCT-MPR was positive in 4 ears, suspicious positive in 9 ears, and negative in 119 ears. The sensitivity for HRCT-MPR was 87.0% and the specificity was 90.2%. However, with 2 mm axial CT alone, the sensitivity was only 47.8%.The positive findings were mainly fenestral foci which related to stapes.

CONCLUSIONS

HRCT-MPR showed high rate of sensitivity and specificity.We recommend the MPR image along stapes as standard image for otosclerosis diagnosis.

Towards quantitative diagnosis of ossicular fixation: Measurement of stapes fixations using magnetically driven ossicles in human temporal bones

CONCLUSION

Information on the degree of stapes fixation can be found by measuring the ratio of stapes to umbo and stapes to incus velocity.

OBJECTIVES

To evaluate a method of quantifying ossicular fixation in an ear with elevated tympanic membrane.

METHOD

Measurements were made on four fresh-frozen human temporal bones. After elevating the tympanic membrane, a small magnet was attached to the manubrium and an electromagnetic excitation coil was used to vibrate the ossicles. The vibration response of the umbo, the tip of the incus long process, and the posterior crus of the stapes were measured before and after partially fixing the footplate with luting cement.

RESULTS

The velocities at the different measurement points were unequally affected by the fixation. The difference in the velocity ratio between different points provides an indication of the degree of footplate fixation.

Cochlear otospongiosis etiology, diagnosis and therapeutic implications

First, the authors discuss the most valuable way to correlate specific morphological changes encountered in cochlear otospongiosis with sensorineural hearing loss. They think that biochemical factors may be responsible for this association of cochlear otospongiosis and histopathologic changes, and they explain their enzymatic concept resulting from experimental findings and cyto-clinical relationship. Second, the authors analyze clinical, audiometric and X-Rays investigations enabling the diagnosis of cochlear otospongiosis, in its pure pereceptive form as well as in the perceptive component added to the conductive loss in far-advanced mixed audiometric types in surgical otospongiosis. They present two typical cases of cochlear otospongiosis: one combines clinical history, audiometric test and post mortem investigations;-the other shows the passage from a pure cochlear otospongiosis to a secondary stapedial fixation, ten years later, thus confirming by audiometric data and by stapedectomy the otospongiotic etiology of this previous pure sensorineural loss. Finally, they insist upon the great interest of establishing an early diagnosis in cochlear otospongiosis on account of its therapeutic implication, particularly from the enzymatic point of view.

Skull vibration-induced nystagmus test in unilateral superior canal dehiscence and otosclerosis: a vestibular Weber test

CONCLUSIONS

The skull vibration-induced nystagmus test (SVINT) acts as a vestibular Weber test and reveals a vibration-induced nystagmus (VIN), elicited mainly on the vertex location, with a horizontal or torsional component beating more often toward the side of the lesion in superior canal dehiscence (SCD) than in otosclerosis (OS). In SCD, the VIN vertical component is most often up-beating. These results suggest more a global vestibular contribution than the sole stimulation of the superior semicircular canal.

OBJECTIVES

This study aimed to evaluate the possible occurrence of nystagmus during SVINT in unilateral conductive hearing loss related to SCD or OS.

METHODS

The slow-phase velocities (SPVs) of the VIN horizontal, torsional, and vertical components were recorded in patients with a unilateral otologic lesion (17 SCD, 38 OS) and 12 control subjects. Vibratory stimulations (60 Hz, 100 Hz) were applied on the vertex and on each mastoid.

RESULTS

In SCD, VIN was observed in 82% of patients with a primarily torsional, horizontal, and vertical (up-beating) component in 40%, 30%, and 30%, respectively. Horizontal and torsional components beat toward the side of the lesion more often than in OS. Higher SPVs were observed after vertex stimulation. In OS, VIN was sparse with low amplitude and was not systematically lateralized to a specific side.

Absent stapedial reflex: otosclerosis or middle ear tumor?

We present an unusual case in which a patient diagnosed as having otosclerosis on the basis of clinical and audiologic findings actually had a middle ear facial nerve schwannoma. To the best of our knowledge, this is the first reported case in English literature in which a facial nerve schwannoma presented with conductive deafness of gradual onset and absent stapedial reflex with a normally functioning facial nerve. We also include a review of the literature.

[A case of congenital (juvenile) otosclerosis]

The present paper reports a case of congenital (juvenile) otosclerosis. This pathology is known to occur in 10% of the patients and cause severe hearing impairment. Precise diagnostics of the activity and extent of the otosclerotic process based on the results of functional multispiral computed tomography (MSCT) enables the practicing surgeons to identify indications for the surgical intervention, choose the adequate method and time for its performance, and make prognosis of its outcome. This inference is confirmed by the clinical observation described in this communication.

Incus augmentation with glass ionomer cement in primary and revision stapes surgery

In stapedotomy, augmentation of the long process of the incus is necessary when the structure is too short or thin or when the bone has been eroded to the point that it is not possible to satisfactorily attach a piston prosthesis to it. One substance that has been used to augment the long process is glass ionomer cement (GIC). GIC is a dental bone cement that is finding new uses in otologic procedures. We conducted a retrospective study of 10 stapedotomies (6 primary and 4 revision cases) that included the use of GIC to augment an insufficient long process. In all 10 cases, surgery was successful and without complication. A comparison of pre- and postoperative audiometry revealed significant improvements in mean air-conduction threshold and air-bone gap following surgery. Our findings suggest that GIC is safe and effective in augmenting the long process of the incus during both primary and revision stapedotomy.

Otosclerosis among patients with dizziness

OBJECTIVE

The objective of this study was to identify patients with otosclerosis and to characterize its clinical presentation among patients examined at our hospital with vertigo as the primary and most distressing symptom.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary medical center.

PATIENTS

This study involved 40 patients suffering from dizziness and diagnosed with otosclerosis.

METHODS

At inclusion, the clinical status, as well as auditory (pure tone hearing level and speech audiometry, impedancemetry) and vestibular function (bedside, nystagmography, caloric test and rotator chair testing) were assessed. The results were analyzed using parametric and non-parametric tests, and the chi2 test.

RESULTS

The clinical presentation was diverse: 12 patients with Menière's syndrome (30%); 11 patients with spontaneous recurrent vertigo without hearing fluctuation (27.5%); 13 patients with positional vertigo (32.5%); 3 patients with chronic unrelapsing imbalance (7.5%); and 1 patient with acute unilateral vestibulopathy (2.5%). There was a lag between the detection of hearing loss and the beginning of vertigo attacks or imbalance in all patients. When measured through bone conduction, hearing loss was significantly different in patients with Menière's disease, spontaneous recurrent vertigo and positional vertigo.

CONCLUSIONS

Dizziness, although frequent in patients with otosclerosis is rarely a cause for specific clinical assessment. There is a lag between the patient's perception of hearing loss and the initiation of vestibular symptoms, and it is not associated with any specific clinical disorder Otosclerosis can be found as any one of the most common vestibular disorders and in general, vestibular function tests reveal a more severe vestibular dysfunction than in the idiopathic forms.

LEVEL OF EVIDENCE

2A.

Otosclerosis 1: the aetiopathogenesis of otosclerosis

Otosclerosis is a bone dystrophy localised to the inner ear and the stapes footplate. Otosclerosis is a frequent cause of deafness in adults. The patient with otosclerosis typically presents with a history of slowly progressive conductive or mixed hearing loss that is usually bilateral and often asymmetric, usually between the ages of 15 and 45 years. The disease is characterised by alternating phases of bone resorption and formation. The majority of studies on families with otosclerosis suggest an autosomal dominant mode of inheritance with incomplete penetrance.

[Cochlear otosclerosis: 3 cases report and literature review]

OBJECTIVE

To investigate the clinical features in cochlear otosclerosis.

METHOD

Three cases with cochlear otosclerosis in our hospital from March 2007 to October 2008 were reported and the relevant literatures were reviewed. All the cases were confirmed the diagnose by temporal bone high-resolution CT scan (HRCT).

RESULT

The chief complaint when visited was recurrent episodic vertigo or equilibrium disturbance with progressing hearing loss in all cases. Two ears in 2 cases were simple sensorineural deafness and considered the pure cochlear otosclerosis. Others were mixed deafness with the descent of bone conduction in different extent. The characters in HRCT: the low density area could be seen in different areas of the otic capsule, the pericochlear lucency or double-ring effect were the typical signs.

CONCLUSION

The diagnosis of cochlear otosclerosis is considered in the insoluble sensorineural deafness and the mixed deafness with vestibular symptoms and chronic hearing loss history. Temporal bone HRCT plays an important role in the clinical diagnosis of cochlear otosclerosis.

Nystagmus induced by bone (mastoid) vibration in otosclerosis: a new perspective in the study of vestibular function in otosclerosis

BACKGROUND

The aim was to explore vestibular responses to bone vibration-induced nystagmus (BVIN) during bed-side examination in patients with otosclerosis and conductive hearing loss. It is assumed that vibration of the mastoid (at 100 Hz) stimulates all vestibular end organs (semicircular canals and otolith structures). Previous studies described oculomotor responses to vestibular activation by vibratory stimulus. Stimulation of individual semicircular canals produces eye movement in the plane of the stimulated canal. Vibratory stimulation of otolith structures (utricular macula) produces changes in ocular torsional position. Otosclerosis is responsible for conductive hearing loss and symptoms such as dizziness and vertigo. Diagnosis is usually by a combination of family medical history, conductive hearing loss pattern, absence of air-VEMP, and CT scan of the temporal bone.

MATERIAL/METHODS

Eye movements of patients diagnosed with otosclerosis and conductive hearing loss were recorded in complete darkness. These oculomotor responses to long-lasting unilateral vibratory stimulation applied to the mastoid surface were evaluated and the patterns of vertical, torsional, and horizontal eye velocity and eye position were measured by three-dimensional computerized infrared video oculography.

RESULTS

Mastoid vibration evoked responses in all cases, mostly demonstrating excitation of the affected side. In all cases, three-dimensional infrared video oculography showed mostly horizontal nystagmus directed with the slow phase to the healthy side.

CONCLUSIONS

Three-dimensional analysis of BVIN in patients with otosclerosis and conductive hearing loss may be appropriate in evaluating the vestibular function and altered immittance related with this clinical entity. This promises to be an interesting new field of research.

How to eliminate air-bone gaps audiometrically: use too much masking

The excessive, indiscriminate use of masking during measurements of pure-tone bone-conduction thresholds can reduce or eliminate air-bone gaps. This may result in an abnormal, audiometrically induced bone-conduction threshold shift and suggest to the otologist the need for auditory brainstem response testing and/or magnetic resonance imaging. A case is presented in which the inappropriate use of the masking plateau method resulted in a reduction of the air-bone gap in an ear with a mild conductive hearing loss. The audiometric Weber test should be used in these cases, and nonmasked bone thresholds should be used to determine the actual level of the cochlear reserve.

Blood flow to the promontory in cochlear otosclerosis

OBJECTIVE

To investigate Schwartze sign with measurements of blood flow to the promontory in patients with cochlear otosclerosis.

DESIGN

Prospective clinical study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Five patients with cochlear otosclerosis and five control subjects. Significant decalcification around the cochlea was observed by computed tomography (CT) in patients with cochlear otosclerosis. However, no recognizable lesion was observed at the oval window in two patients. One patient had mixed hearing loss and four patients had sensorineural hearing loss without an air-bone gap.

MAIN OUTCOME MEASURES

The relationship between CT findings and the presence or absence of Schwartze sign was investigated. Blood flow to the promontory was measured through the tympanic membrane using laser speckle flowgraphy and laser Doppler flowmetry.

RESULTS

The Schwartze sign correlated significantly with otosclerotic lesions invading the promontory. Patients with otosclerosis exhibited elevated and pulsating blood flow to the promontory with the Schwartze sign.

CONCLUSIONS

Computed tomography demonstrated that cochlear otosclerosis can exist without the oval window lesion. Schwartze sign can be used as a sign of the otosclerotic invasion to the promontory. The reddening of the Schwartze sign is likely due to increased blood flow.

Déhiscence du canal semi-circulaire antérieur mimant une otospongiose: intérêt de l'imagerie

OBJECTIVES

To emphasize the role of computerized tomography (CT) in the etiologic work-up of stapes surgery failure.

MATERIAL AND METHODS

Helical high resolution CT scan of the temporal bone with axial and coronal views and multiplanar reconstructions was performed in a patient who had undergone unsuccessful stapedectomy.

RESULTS

CT scan demonstrated a well located prosthesis, the absence of the radiological hallmarks of otosclerosis, and revealed a superior semicircular canal dehiscence (SSCD). The diagnosis of SSCD was retrospectively considered accountable for the preoperative clinical and audiometric presentation that had mimicked otosclerosis.

CONCLUSION

CT is the diagnostic test of choice in elucidating stapes surgery failure (with persistent or recurrent conductive hearing loss), whereas SSCD should be systematically considered among its causes.

Three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging findings in a patient with cochlear otosclerosis

A 51-year-old man had progressive hearing loss over more than 15 years. He had bilateral sensorineural hearing loss (SNHL). Computed tomography (CT) showed extensive bilateral demineralization of the cochlear capsule, which is characteristic of diffuse cochlear otosclerosis. Three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) of magnetic resonance imaging before enhancement revealed high signals in the cochlea and vestibule. Postcontrast 3D-FLAIR revealed enhancement of the basal turn of the left cochlea. This is the first published case of the breakdown of the blood-labyrinth barrier in a patient with cochlear otosclerosis. Our findings suggest that the breakdown of the blood-labyrinth barrier is associated with a part of SNHL in cochlear otosclerosis.

Is it possible to predict diffuse obliterative otosclerosis preoperatively by audiologic examination

Patients with diffuse obliterative otosclerosis have more extensive footplate pathology than annular cases. As a result of this more skill is required for diffuse otosclerosis cases, and postoperative hearing results are usually worse than annular cases. In this retrospective study we compared the preoperative audiological features of annular and diffuse otosclerosis patients. The subjects were 60 patients with conductive hearing loss who had undergone stapedectomy. Annular and diffuse groups were comprised of 30 patients each. Annular otosclerosis was defined as the footplate pathology involving the annular ligament only, where the footplate of the stapes is very thin and retains its bluish color. On the other hand diffuse, obliterative otosclerosis was defined as the pathology involving the whole footplate and also in some cases extending beyond the confines of the annular ligament. In each group preoperative air- and bone-conduction levels at 125-6000 Hz and 500-4000 Hz were noted respectively. Average air-bone gap for the obliterative otosclerosis group was 37.5 dB; the same value for the annular group was 23.8 dB (p<0.05). The gap characteristics of the audiogram were different for the two groups. The annular group had an air-bone gap which was nearly constant for all the frequencies. In the diffuse otosclerosis group, the air-bone gap was more prominent in the low frequencies and it decreased at higher frequencies. No difference was noted in bone-conduction thresholds, and Carhart notch between the two groups. This study demonstrated that a large air-bone gap in patients with conductive hearing loss may be a sign of diffuse obliterative otosclerosis. This may warn the surgeon that a more challenging surgery is possible, and the patient may have a less favorable hearing result. Therefore, in the presence of a large air-bone gap, it may be appropriate to inform the patient of the strong possibility of diffuse otosclerosis.

Otosclerosis of the incus

OBJECTIVE

To report a case of a patient with otosclerosis of the incus.

PATIENTS

A 61-year-old woman with a progressive hearing loss on her left ear and a computed tomographic scan of the temporal bone revealing an expansible lesion of the incus.

INTERVENTIONS

The ossicle was removed by using a transtympanomastoid approach; the ossicular chain was reconstructed using a titanium partial ossicular replacement prosthesis.

MAIN OUTCOME MEASURE

The diagnosis of the disease was obtained by means of histopathologic examination of the specimen.

RESULTS

The patient obtained a good postoperative hearing result. The histopathologic examination of the specimen documented an otosclerosis of the incus.

CONCLUSION

Otosclerotic involvement of the middle ear ossicles, apart from footplate, was very rarely mentioned. Most subjects were incidentally diagnosed postmortem by means of examination of specimens from temporal bone collections. The diagnosis and treatment of a patient with otosclerosis of the incus is exceptional; however, otosclerosis should be considered in the differential diagnosis of expansible lesions of the ossicles.

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.

Revision stapes surgery

We present the results of our revision stapes operations from 1989 to 2004 (n = 217). Long-term follow-up was performed in the first 135 cases. Eighteen of these patients were revised because of inner ear symptoms, predominantly within the first year. One hundred and sixteen cases underwent revision surgery due to conductive hearing loss, on average after 10.6 years. One patient was operated because of dysgeusia. In 1999, we first described inner ear damage after implantation of gold prostheses. Therefore, we developed a titanium implant that was initially investigated in cell culture and subsequently tested in a clinical trial. We report on the most frequent causes that led to revision surgery such as adhesions, prosthetic problems, erosions of the long process of the incus, or refixation of the footplate, and on the different surgical techniques. In a first series of patients with a conductive hearing loss, a significant hearing improvement of 69.4% of these cases was obtained. However, this result very much depends on the selection of cases. There was no case of additional sensorineural hearing loss. Since 1999, we had mainly used titanium implants for replacement in stapes revision surgery. In a second series, a significant hearing improvement of 76.2% was found. One patient with a platinum Teflon implant had to be revised because of vertigo and conductive hearing loss which was observed during MRI.

A checklist for surgical exposure in stapes surgery: how to avoid misapprehension

The goal of middle ear exploration in stapes surgery is to identify impairments of function along the entire ossicular chain. The endaural approach with an extended tympanomeatal flap and an almost routinely performed anterosuperior canalplasty allow adequate exposure to identify the anterior malleal ligament and process (1), the inferior incudomalleal joint (2), the entire stapes including the pyramidal process (3), and the round window niche (4). With this checklist at hand the otologic surgeon can define the exact location of the hearing impairment and choose the proper technique for hearing reconstruction in primary and revision surgeries.

Superior semicircular canal dehiscence mimicking otosclerotic hearing loss

A puzzling aspect of middle ear surgery is the presence of an air-bone gap in a small number of cases with no apparent cause. We believe that some of these cases are due to unrecognized superior semicircular canal dehiscence (SSCD). We have now gathered experience from 20 patients with SSCD presenting with apparent conductive hearing loss without vestibular symptoms. All affected ears had SSCD on high-resolution CT scan. The common findings in these patients were: (1) the air-bone gaps occurred in the lower frequencies below 2,000 Hz, and ranged from 10 to 60 dB; (2) bone conduction thresholds below 2,000 Hz were sometimes negative (-5 dB to -15 dB); (3) the acoustic (stapedial) reflex was present; (4) measurement of umbo velocity by laser Doppler vibrometry showed slight hypermobility of umbo motion; (5) the vestibular-evoked myogenic potential response was present, with thresholds that were abnormally low, and (6) the middle ear was normal at exploratory tympanotomy, including normal mobility of the ossicles and a patent round window niche. We have investigated the mechanism of the air-bone gap due to SSCD using a theoretical framework, clinical research data and an animal model (chinchilla). Our research supports the hypothesis that SSCD introduces a 'third' window into the inner ear which produces the airbone gap by (1) shunting air-conducted sound away from the cochlea, thus elevating air conduction thresholds, and (2) increasing the difference in impedance between the scala tympani and scala vestibuli, thus improving thresholds for bone-conducted sound.

Case report: Meniere's disease and otosclerosis—Different outcomes of the same disease?

The etiologies of Meniere's disease and otosclerosis are largely unknown. An association between these two diseases has been proposed on both a clinical and histopathologic basis but the causal relationship is controversial. In this paper we report two families in which both otosclerosis and Meniere's disease are inherited as independent phenotypes suggesting that the two diseases represent different outcomes of the same mutation. Thus the Meniere's disease occasionally seen in otosclerotic patients might not be caused by otosclerosis, but rather by a molecular defect leading to endolymphatic hydrops and/or clinical otosclerosis.

Bilateral congenital ossicular chain disruption mimicking otosclerosis

A rare case of bilateral congenital ossicular chain disruption whose history and findings mimicked those of otosclerosis is reported. A 54-year-old male consulted us for slowly progressing hearing loss. Audiogram showed bilateral intermediate mixed hearing loss. The stapedial reflex was negative and the tympanogram was normal A-type. Based on the diagnosis of otosclerosis, stapes surgery was planned for the left side. Surgical findings revealed normal mobility of the stapes and a small disruption at the incudostapedial joint with connection of intact mucosa. The disruption was repaired with auto-bone columella. The patient's hearing improved after surgery. The surgery for the other side was performed successively, and similar ossicular disruption was observed. The mechanisms of findings that misled the preoperative diagnosis are discussed.

Phenotype-genotype correlations in otosclerosis: clinical features of OTSC2

As part of the GENDEAF consortium, a European multi-centre otosclerotic database is under construction to collect the clinical data of as many otosclerotic patients as possible. Otosclerosis represents a heterogeneous group of heritable diseases in which different genes may be involved regulating the bone homeostasis of the otic capsule. The purpose of the GENDEAF otosclerosis database is to explore the otosclerotic phenotype more in depth. Subtle phenotypic differences otherwise not visible, may become statistically relevant in a large number of patients. Their identification can lead towards the discovery of new genes involved in the pathway of abnormal bone metabolism in the human labyrinth. As soon as one of the otosclerotic genes is identified, it would allow us to identify genotype-phenotype correlations. From other deafness genes, it is know that different mutations in the same gene may cause similar phenotypes of varying severity. Also the variability in treatment outcomes after surgery or fluoride therapy may result not only from differences in practice or surgical skill among physicians, but also on the nature of the underlying disorder. Screening large numbers of patients would make it possible to undertake clinical trials comparing different treatments. Identifying a genetic susceptibility would allow us to dissect out possible environmental factors that prevent the expression of clinical otosclerosis in those that carry the mutated gene and yet retain normal hearing.

Audiological evaluation of patients with otosclerosis

Even though the diagnosis of otosclerosis is confirmed definitively during surgery, preoperative diagnosis and determination of the indication for surgery are made based on audiological evaluation. Audiological tests should firmly establish a conductive component to hearing loss. The measurement of pure-tone air and bone conduction thresholds has limitations that prevent an accurate diagnosis based solely upon these test results. Such limitations include general variability of threshold measurements, individual variations of tests in the bone conduction mode, and complex interactions between changes of middle ear mechanics and threshold. Objective audiometric tests should be added because of these uncertainties. The presence of otoacoustic emissions effectively excludes a diagnosis of otosclerosis. Standard clinical immittance measurements are used to confirm (or exclude) otosclerosis, the typical pattern being a normally shaped tympanogram and absent stapedial reflexes. Multifrequency tympanometry adds little information. Aside from establishing a preoperative diagnosis, audiological evaluation provides quantification of hearing loss, upon which the indication for surgery is based. Moreover, it lays the foundation for evaluation of surgical success and outcome measures. For both of these aims, speech audiometric tests such as a speech reception threshold should be included in the preoperative audiological evaluation of patients with otosclerosis.

How does stapes surgery influence severe disabling tinnitus in otosclerosis patients?

Tinnitus is a common symptom in otosclerosis patients. Many papers have been written about tinnitus outcome after stapes surgery. However, none has attempted to quantify the intensity of the symptom pre- and postoperatively in order to evaluate the influence of surgery on the degree of annoyance caused by tinnitus. Severe disabling tinnitus (SDT) is defined by Shulman as a symptom severe enough to disrupt the patient's routine and to prevent him from performing his daily tasks. We have studied 48 consecutive otosclerosis patients by means of a visual analogue scale measuring tinnitus intensity before and after stapes surgery. We have accepted tinnitus as severe and disabling when the symptom score was 7 or above in a visual analogue scale from 1 to 10. Of 19 patients with preoperative SDT, 10 reported complete remission and 7 reported significant improvement. Two patients had no change and none reported worsening of tinnitus after stapes surgery. We conclude that stapes surgery can improve SDT significantly in 90% of otosclerosis patients and is very unlikely to make the symptom worse.

Stapes surgery in the elderly

Thirty-eight patients aged 70 years and older submitted to stapedectomy by the same surgeon were identified and their clinical records retrospectively reviewed. The comparison group consisted of 38 patients belonging to a younger age group (less than 70 years old) who were randomly selected from patients operated with the same technique in or around the same period. Although the success rate, defined as a postoperative air-bone gap within 10 dB, was lower in the older group (71%) than in the younger group (92%), stapedectomy remains an effective surgical procedure also in the elderly.

Sofia profile plot: a new graphical approach to present the changes of hearing thresholds with time

After pure-tone audiometry, we have several sequences of threshold values. Usually, a multiple-line plot is used to present and compare data between measurements by overlaying them in a single graph. Calculation of air-bone gap and pure-tone average is widely accepted as an approach to simplify statistical handling of these data. The aim of this report was to introduce the Sofia profile plot using as examples different otosclerotic cases. This plot provides a simple way to visually present several pre- and postoperative hearing thresholds. Individual data points (pure-tone average and some other thresholds) are presented by marks in two-dimensional space. The vertical axis represents the time line and starts with the first threshold evaluation. The horizontal scale is used to mark hearing levels in decibels -- the right ear on the left of the vertical axis and the left ear on the right. The Sofia profile plot was developed especially for otosclerotic patients and permits the unambiguous marking of the onset of any individual unilateral or bilateral event (e.g. operation, revision, tinnitus) and thus to visually inspect its impact on hearing levels.

Distortion product otoacoustic emissions in otosclerosis: intraoperative findings

The aim of the study was to investigate changes in middle ear dynamic characteristics caused by both otosclerosis and stapes surgery (platinotomy, prosthesis positioning, ossicular chain maneuver) and to evaluate distortion product otoacoustic emissions (DPOAEs) before and following surgery. The study included 15 patients (12 women, 3 men; mean age 51 years; range 32-69 years) with advanced otosclerosis. All the patients were evaluated with the use of pure-tone audiograms (preoperatively, 5 and 30 days after surgery), stapedial reflexes (preoperatively), and DPOAE recordings (preoperatively, at the end of surgery, and 5 and 30 days after surgery). Changes in the hearing thresholds and in the DPOAE amplitudes were compared. Preoperative tests showed conductive hearing loss, with a mean air-bone gap of 36.6 dB HL ranging from 0.25 to 1 kHz, and no stapedial reflexes were detected. DPOAEs were not measurable preoperatively, and they were detected only in 2 patients at the end of surgery, with low amplitudes in a narrow frequency range. No significant changes occurred in DPOAEs 5 days postoperatively. A month after surgery, improvement in conductive hearing loss was observed; the mean air-bone gap from 0.25 to 1 kHz was 12.9 dB HL, whereas the higher frequencies were still affected by the disease. DPOAEs increased in amplitude in 4 patients, but this was not significant. It remains unclear why DPOAEs are not detected despite a subjective hearing improvement and a sufficiently closed air-bone gap at least in middle and low frequencies. The results of our study show that DPOAEs cannot replace behavioral threshold tests; they may only be included in a battery of tests for a complete clinical follow-up for efficiency monitoring after stapes surgery.

Imaging of postoperative sensorineural complications of stapes surgery: a pictorial essay

Sensorineural hearing loss and/or vertigo are rare but severe complications of stapes surgery for otosclerosis, ranging from 0.2 to 3%. Management of such complications depends on the underlying cause: intravestibular protrusion of the prosthesis, perilymph fistula, labyrinthitis, and reparative granuloma extending into the vestibule. Surgery is mandatory in cases of intravestibular prosthesis or of persistent perilymph fistula. In cases of suppurative labyrinthitis or reparative granuloma extending into the vestibule, prognosis is usually poor, despite aggressive medical therapy or revision surgery. CT scan or magnetic resonance imaging can frequently help to determine the cause of the inner ear complication of stapedectomy. Demonstrative cases are presented to illustrate the prominent place of imaging in managing sensorineural complications of stapes surgery.