Stapes Surgery Outcomes: The Practice of 35 Years

115 Introduction Otosclerosis is a hereditary disorder of the otic capsule that is autosomal dominant with incomplete penetrance. In fact, otosclerosis is the primary otospongiosis of the labyrinthine capsule. At the early stages of the disease, a slight decrease in air conduction is detected by pure tone audiogram. However, in advanced cases with the development of sensorineural hearing loss, mixed-type hearing loss can be seen. Autoimmunity and measles are blamed to be the causes of this disease (1, 2). There is no difference in the incidence of histological otosclerosis between males and females. But, clinical otosclerosis is more common in females (3). The prevalence in races is different, and it is more common in Caucasians. The prevalence is about 6.4% in Europe and North America. But, symptomatic stapes fixation is in about only 3 in 1000 persons (4). Otosclerosis is mostly seen at young and middle age. With the increase in data and new diagnostic techniques, the diagnosis of otosclerosis can be made in early age, even in childhood. Although the hearing loss begins mostly in the third decade, the histologic changes begin in puberty and even in early childhood. Stapedial fixation begins in early age in juvenile otosclerosis. In 15.1% of patients with stapedectomy, complaints begin under the age of 18 years; the research about the therapy of juvenile otosclerosis is insufficient (5). Otosclerosis is very rare in children, and stapedectomy in this group is controversial (2). There is no medical therapy for otosclerosis (5, 6). But, for the treatment of hearing loss in otosclerosis, research has been made since the first stapedectomy trial of Kessel in 1876 and Miot’s stapes mobilization. There have been many periods of tha stapes surgery, such as fenestration by Holmgren, Sourdille, and Lempert, and stapes mobilization by Rosen in 1953. In 1958, Shea proposed stapedectomy, which included the removal of the stapes, closure of the window with a thin slice of connective tissue, and the implantation of a prosthesis from the incus to oval window. This technique continues with minor modifications. Even in more advanced cases, stapedotomy is more popular, and a prosthesis is used. Since the early 1980s, to minimize damage to the inner ear during the operation, various types of lasers have also been used (7). Methods Although there were 1247 stapedectomy cases who were operated on in our center and analyzed retrospectively, the data of 327 cases were achieved. The data were evaluated according to age, gender, preoperative and postoperative hearing thresholds, type of surgery, type of prosthesis used, early and late complications, and need for revisions. There were 190 (58%) female patients and 137 (41.9%) male patients. The age was ranging between 11-70 years, and the mean age was 39. Stapes surgery in our clinic has been made by a transmeatal incision under local anesthesia in the large majority. Ear ossicular chain mobility was checked by taking the nerve chorda tympani forward after entering the middle ear. If the malleus and the incus were mobile and there was no mobility in the stapes, stapedectomy was performed. After removing the stapes suprastructure, a small fenestra at the base of stapes was opened. After the required measurements, a Teflon piston was cut and placed between the stapedotomy fenestra and the incus long arm. To close the remnant of the fenestra, sawdust obtained from the stapedial bone was filled around the hole. Of the 199 patients having preand postoperative hearing tests, the mean value of 500, 1000, 2000, and 4000 Hz air-bone thresholds was taken. This procedure was performed for both the preoperative and postoperative periods. To evaluate the success of the operation, the air-bone conduction gap averages were obtained for preoperative and postoperative bone. The data was evaluated via SPSS 18 (Statistical Package for the Social Sciences 18, Chicago, Illinois, United States). Informed consent of all cases was obtained pre-operatively, as their surgical information might be used for the literature without giving any personal information. Ethics committee approval was obtained from the Hacettepe University Medical Faculty Ethics committee, which was enumerated as GO14/457. Results Among the 1247 cases, 327 stapedectomy surgeries with information that could be achieved at our clinic between 1964-2001 were examined retrospectively. There were 190 (58.1%) female patients and 137 (41.9%) male patients. Their ages ranged between 11-70 years; the average age was 39. Also, 155 cases were operated on in the left ear versus 172 on the right. Four patients had previous surgery at another clinic. Three patients received NaF treatment. The average air-bone conduction gap was 30.5 dB (SD±5.42 dB) in preoperative audiograms. Preoperative ipsilateral reflexes were as follows: at the opposite site in 53.8% of cases, negative in 45.8% of cases, and positive in 0.4% of the cases. When preoperative contralateral reflexes were evaluated, 98.7% of them were negative, 0.4% of them were reversed, and in 0.9%, the on-off phenomenon was observed. Opposite ear hearing was as follows: 117 (44.5%) patients had otosclerosis follow-up; 62 (23.5%) of them had stapedectomy; 1 (0.3%) had total hearing loss; 2 (0.7%) used a hearing aid; and 81 (30.8%) were identified with normal hearing. Through the cases, 321 operations (98.1%) were under local anesthesia, and 6 (1.8%) were performed under general anesthesia. A transmeatal incision was used in 325 (99.4%) cases, and an endaural incision was used in 2 (0.6%) cases. Also, 234 operations (71.6%) were performed by specialists, and 93 (28.4%) were performed by resident doctors. CO2 laser surgery was used in 5 cases. Further, 66 (20.2%) of the cases were stapedectomy, and 261 (79.8%) were stapedotomy. A Teflon piston was used in 298 (98%) surgeries, wire Teflon was used in 5 (1.6%) surgeries, and a homograft bone was used in l case (0.3%). The prosthesis diameter was 0.6 mm in 178 (54.4%) cases, 0.8 mm in 148 (45.2%), and 0.4 mm in 1 (0.3%) case. The length of the prosthesis was ranging between 3.5-5 mm; the most widely used were as follows: 3.5 mm (2.2%), 3.75 mm (9.9%), 4 mm (28.7%), 4.5 mm (25%), 4 , 25 mm (20.4%), 4.75 mm (5.6%), and 5 mm (5.2%). In closing the oval window fenestra around the piston, stapes sawdust was used in 65.8% of cases, external ear sawdust was used in 0.9%, and Gelfoam and sawdust were used in 33.2% of cases. A vein greft was never used. Otosclerosis type in surgery was as follows: annular in 123 (41.2%), anterior in 44 (14.8%), biscuits in 3 (1.6%), diffuse in 109 (36.5%), obliterative in 18 (5.5%), and tympanosclerosis in l (0.3%) patient. The round window reflex was normal in 325 (99.4%) of 327 cases and otosclerotic in 2 cases (0.6%). The facial canal was open and prolapsed to the oval window in 6 patients (2.2%). During the operation, 40 (12.2%) patients encountered complications. These complications were incus luxation in 5 (1.5%), floating footplate in 10 (3.1%), chorda tympani injury Turk Arch Otolaryngol 2014; 52: 115-20 Hanci et al. The Results of Stapes Surgery 116