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Background: This paper evaluates endoscopic stapedotomy from the perspectives of a group of 3 surgeons, each of whose experience in endoscopic and microscopic stapedotomy is 3 years and more than 12 years, respectively. Methods: Thirty-four patients clinically diagnosed with stapedial otosclerosis were alternately assigned for unilateral, microscope- and endoscope-assisted stapedotomy following the selection criteria given. Results were evaluated with predetermined epidemiologic, preoperative, perioperative, and postoperative outcome parameters. Results: The microscope group had 12 ears with otosclerosis and the endoscope-assisted group 14. Ears found to have conditions other than otosclerosis at surgery, and patients lost to follow-up were excluded. Apart from the operative time, the difference in the results of none of the parameters was statistically significant in the two groups. The average operative times for microscope- and endoscope-assisted stapedotomy were 63 minutes and 86.5 minutes, respectively, the difference being statistically significant ( P < .001). Conclusions: From the perspectives of otologists in differential positions in the learning curve for microscope- and endoscope-assisted stapedotomy, there were no statistically significant differences between the two procedures in the execution of the steps to achieve "adequate surgical exposure" and in postoperative outcomes, except for operative time., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Placing a middle ear prosthesis is considered a key competency for the general otolaryngologist, but surgeons struggle to obtain and maintain this skill. The current study aims to characterize pre-coronavirus disease 2019 trends in stapedectomy and ossiculoplasty., Study Design: Database review., Setting: Tricare beneficiaries are treated at civilian and military facilities., Methods: The Department of Defense beneficiary population of more than nine million persons per year was reviewed for patients undergoing either stapedectomy or ossiculoplasty between 2010 and 2019, identified by the current procedural terminology code., Results: A total of 3052 stapedectomies and 7197 ossiculoplasties were performed. Over the 10-year study period, stapedectomy decreased by 23%, with an average annual rate of -2.7% per year (Pearson r = -.91, P = .0003). Ossiculoplasties declined by 18%, an average annual rate of -1.9% (r = -.8, P = .006). In combination, cases declined by 20%, an average annual rate of -2.2% (r = -.87, P = .001)., Conclusion: While declines in stapedectomy surgery have been well reported, here we show steady declines in ossiculoplasty as well. If these trends continue, more cochlear implantations may be performed annually than stapedectomy and ossiculoplasty combined, with cochlear implantation likely to overtake ossicular chain surgery in the near future. These changes in surgical volume have a direct implication on resident education and general otolaryngology expectations after graduation. Strong consideration should be made to replace "Stapedectomy/Ossiculoplasty" as resident key indicator with "Cochlear Implantation," a more professionally meaningful skill., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Purpose: To evaluate stapedotomy learning curve with cumulative summation methodology using different success criteria (ie, air-bone gap [ABG] ≤10 dB, ABG ≤15 dB, restoration of interaural symmetry, or hearing threshold gain >20 dB), and to assess patient characteristics influencing or modifying the learning curve., Methods: Retrospective chart review of primary and revision stapedotomy cases performed by surgeon 1 (S1, n = 78) and surgeon 2 (S2, n = 85)., Results: Using the classic criterion for a successful stapedotomy (ABG ≤10 dB), patients with preoperative ABG >34 dB were associated with unsuccessful procedures (S1 P = .02; S2 P = .07). Revision surgery was associated with unsuccessful outcomes (S1 P = .005; S2 P = .0012). Cumulative summation plots using different criteria did not show a linear trend of association between stapedotomy success and number of operations, but preoperative characteristics of the patients who underwent stapedotomy significantly influenced the plots. Cumulative summation plots showed an initial increasing tendency with improving results, but when ear surgeons got more skilled, they operated on more complex cases (ie, patients with higher preoperative ABG or revision stapedotomy) and they could not meet the success criteria., Conclusions: Cumulative summation plots do not seem useful to evaluate the stapedotomy learning curve, as they do not correctly deal with heterogeneous case series. The increasing complexity of the stapedotomy patients during the surgeons' career impacts on the outcome of stapedotomy and confounds the evaluation of the growing skills of the surgeon. Stapedotomy audiological success rates are strongly influenced by the success criteria used.

Objectives/hypothesis: To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy., Study Design: Retrospective study., Methods: This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment., Results: One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air-bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P > .05). No association between stapedotomy success and the increasing number of procedures was found., Conclusions: Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases., Level of Evidence: 4 Laryngoscope, 131:885-891, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Stapedectomy remains a joint key-indicator case with ossiculoplasty for otolaryngology residents in the United States. Yet, residents consistently report feeling inadequately prepared to perform stapes surgery following graduation. Applying recently described age- and sex-standardized incidence rates of surgically confirmed cases of otosclerosis to the US populace, upper and lower estimates of residents' case exposure to stapedectomy can be approximated. With this, uppermost projections estimate 6484 new cases of stapes surgery are performed annually nationwide. With approximately 1424 otolaryngology residents nationally, the average case exposure is 7.8 stapedectomies throughout their training, with upper and lower estimates of 17.1 and 4.2 cases, respectively. As such, proficiency in stapedectomy is no longer a realistic expectation for US graduating residents. This reality supports the removal of "stapedectomy" from the list of 14 key-indicator case requirements, leaving ossiculoplasty as its own key-indicator case, thereby reinforcing true competence in this fundamental procedure for the graduating otolaryngologist.

Objective: To identify costs and operative times for stapedotomy and evaluate factors influencing cost variation., Study Design: Case series with cost analysis., Setting: Multihospital network., Subjects and Methods: A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of all patients undergoing stapedotomy from 2013 to 2017. Subjects with additional procedures were excluded. Correlations between variable factors and cost were calculated by Spearman correlation coefficients. Audiometric and cost data were compared with a Mann-Whitney U test., Results: The study cohort included 176 stapedotomies performed by 23 surgeons at 10 hospitals. Mean ± SD patient age was 44.3 ± 17.4 years. Mean cut-to-close time was 61.1 ± 23.55 minutes. Mean total encounter cost was $3542.14 ± $1258.78 (US dollars). Significant factors correlating with increased total encounter cost were surgical supply cost ( r = 0.74, P < .0001) and cut-to-close time ( r = 0.66, P < .0001). Laser utilization ($563.37 ± $407.41) was the highest-cost surgical supply, with the carbon dioxide laser being significantly more costly than the potassium titanyl phosphate (KTP; $852.60 vs $230.55, P < .001). Additionally, the carbon dioxide laser was associated with a significantly higher mean total encounter cost than the KTP laser ($4645.43 vs $2903.00, P < .001) and cases where no laser was used ($4645.43 vs $2932.47, P < .001). There was no difference in mean total encounter cost between the KTP laser and cases of no laser use ($2903.00 vs $2932.47, P = .75)., Conclusions: Significant cost variation exists in stapes surgery. Surgical supply cost, specifically laser use, may be associated with significantly increased costs. Reducing variation in costs while maintaining outcomes may improve health care value.

Functional outcomes and complications in otosclerosis surgery are governed by the surgeon's experience. Thus, teaching the procedure to residents to guide them through the learning process as quickly as possible is challenging. Artificial 3D-printed temporal bones are replacing cadaver specimens in many institutions to learn mastoidectomy, but these are not suitable for middle ear surgery training. The goal of this work was to adapt such an artificial temporal bone to aid the teaching of otosclerosis surgery and to evaluate this tool. We have modified a commercially available 3D-printed temporal bone by replacing the incus and stapes of the model with in-house 3D-printed ossicles. The incus could be attached to a 6-axis force sensor. The stapes footplate was fenestrated and attached to a 1-axis force sensor. Six junior surgeons (residents) and seven senior surgeons (fellows or consultants) were enrolled to perform piston prosthesis placement and crimping as performed during otosclerosis surgery. The time required to perform the tasks and the forces applied to the incus and stapes were collected and analyzed. No statistically significant differences were observed between the junior and senior groups for time taken to perform the tasks and the forces applied to the incus during crimping and placement of the prosthesis. However, significantly lower forces were applied to the stapes by the senior surgeons in comparison with the junior surgeons during prosthesis placement (junior vs senior group, 328 ± 202.9 vs 80 ± 99.6 mN, p = 0.008) and during prosthesis crimping (junior vs senior group, 565 ± 233 vs 66 ± 48.6 mN, p = 0.02). We have described a new teaching tool for otosclerosis surgery based on the modification of a 3D-printed temporal bone to implement force sensors on the incus and stapes. This tool could be used as a training tool to help the residents to self-evaluate their progress with recording of objective measurements.

Objective: Comparing the endoscopic and microscopic approaches in stapes surgery, and establishing the surgical approach that allows better results in terms of visualization of the middle ear structures and aids assistant's training., Materials and Methods: Twenty-one residents from the first to the fifth year of training in Otolaryngology were enrolled in this prospective study. A questionnaire specifically designed to investigate the understanding of middle ear anatomy, the surgical steps, and a personal opinion about endoscopic stapes surgery was submitted to each resident., Results: Statistical differences between the endoscopic and microscopic approaches were evident about identification of stapes and long process of the incus (p=0.03) and stapes footplate and the oval window (p=0.03). No substantial difference between the two surgical approaches emerged regarding the visualization of the tympanic membrane and the other middle ear structures (p>0.5). A substantial difference in favor of the endoscopic approach emerged regarding the identification of the hole creation in the footplate of the stapes., Conclusion: Endoscopic stapes surgery could favor an easier understanding of the surgical technique for assistants in training with little knowledge of the anatomy and surgical steps.

Over the last 20 years, the number of stapes operations performed has decreased steadily. This inadequate exposure to stapes surgery poses problems for both trainees and trainers. We retrospectively reviewed the outcomes of stapedotomy performed by a young physician at the ENT Clinic of the "A. Gemelli" Hospital of Rome. We used the technique of "one-shot" CO2 Laser stapedotomy using a titanium-Teflon piston. For data analysis, we considered the audiograms obtained 24 hours preoperatively and at the last follow-up examination (mean 45 months). Air conduction (AC) and bone conduction (BC) PTA were calculated for 0.25, 0.5, 1, 2 and 4 kHz thresholds. Air bone gap (ABG) were obtained from ACPTA and BCPTA. Postoperative hearing gain was calculated from the ABG before the operation minus the ABG at late follow-up examination. Analysis of outcomes did not show a clear endpoint for the learning curve; complete closure of the ABG was obtained in a large number of patients at the beginning followed by patients who showed a higher ABG. Fortunately, we did not observed any "dead ear". The study supports a learning curve in stapes surgery, but the results can vary widely among surgeries with excellent results followed by others that are not fully satisfactory. Stapes surgery should not be one of the first ear surgeries performed by a young otologist due to the functional outcome expected by patients and the lack of necessary surgical skills., (© Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.)

Endoscopic surgery of the middle ear is progressively gaining the interest of otologists, as technological advances have overcome some of its main drawbacks. The long learning curve required to master this technique, urges the search for models to practice it. After the validation of sheep's ear as a proper training model for microscopic stapedectomy, our objective is to demonstrate its adequacy for practicing stapes surgery but performed through a fully endoscopic approach. Endoscopic stapedectomy was performed by two surgeons in 40 sheep ears (20 specimens each). To analyze the effects of the learning curve on surgical success, complication rates and surgical time reduction, the sample was divided in two groups: group 1 being the first ten procedures of each surgeon, and group 2 the second set of stapedectomies. The impact of the operated side and the resection of the chordal spine were also studied. No statistically significant differences were found considering the operated side. A statistically significant improvement in some of the surgical steps was demonstrated comparing both groups and also after the resection of the chordal spine. Mean surgical time declined from 38 to 31.5 min (p < 0.05). Using this model for endoscopic stapedectomy, a learning curve was objectively demonstrated, along with other subjective appreciations such as improvement in depth perception and one-hand instrument handling. We believe that sheep ear is an optimal model for endoscopic middle ear surgery, as it allows for the acquisition of the skills required to master this technique.

In this article, a new surgical model for evaluating telemanipulators used in middle ear surgery is presented. The purpose of this work was to develop an evaluation and training system which imitates a typical surgical task of middle ear surgery and which can easily be repeated in order to get significant result. The abstract task can be performed manually or by means of a microsurgical telemanipulator and guaranties stable experimental conditions between different subjects at any time. As a task the stapedotomy was chosen, due to the high demands in positioning and in applying forces to the delicate structures in the middle ear. The manual and telemanipulated performance of 15 ENT surgeons and 17 medical students was compared using this evaluation and training system.

Hypothesis and Background: Stapedectomy is a surgical technique that requires progressive training. The external and middle ear of sheep have a close resemblance to the human and have been previously used as surgical training models. In our project we describe the anatomy of the middle and external ear in sheep focusing on surgical landmarks and technique in order to determine whether the sheep's ear is an adequate model for stapedectomy training., Materials and Methods: We reviewed the literature on sheep anatomy and use of sheep as an otologic surgical model. Macroscopic sections as well as temporal bone computed tomography were obtained. Stapedectomy was performed on 40 sheep, using 4 mm platinum piston prosthesis, by first year residents., Results: Most of the structures in the sheep's middle ear are similar to those in humans although their size is about two thirds smaller. Incus long process is shorter, thicker, and closer to the malleus body, making the piston insertion and adjustment more difficult. The median surgical time of stapedectomy was reduced from 70 (52.5-100.3) minutes to 39.5 (35.5-48) minutes after completing training. There was also a reduction in rate of complications (flap disruption, incus dislocation, and footplate mobilization)., Conclusion: Sheep ears constitute a cheap, easy to obtain and anatomically adequate model for stapedectomy training.

Unlabelled: Stapes surgery is one of the approaches indicated to treat conductive hearing loss secondary to otosclerosis. The procedures requires skill and experience from the surgeon and is part of medical residency training., Aims: To assess which type of prosthesis (Teflon or metal/steel) presents the best results in surgeries performed by residents and the incidence of complications., Materials and Methods: we retrospectively assessed 189 interventions that counted on the active participation of resident physicians, and we compared the two types of prosthesis used. Audiometric results were analyzed following the guidelines from the Committee on Hearing and Equilibrium and also according to the Amsterdam Hearing Evaluation Plots., Results: Bone-air gap reduced in an average value of 21.90 dB (p<0.05) after the surgery in the group that received the Teflon prosthesis and 21.37 dB (p<0.05) in the group that received the mixed prosthesis, and gain in SRI was of 22.33 and 26.10 dB (p<0.05), and the air-bone gap was below 20 dB in 80.6% and 85.04%, respectively., Conclusions: We did not see differences in the audiometry and in the incidence of complications when we compared the type of prosthesis used. We believe it is valid to continue teaching this procedure in medical residency training programs, regardless of the type of prosthesis.

Objectives: To demonstrate that 1) recent graduates of training programs in otorhinolaryngology-head and neck surgery are less likely to recommend/perform stapedectomy than more senior otolaryngologists; and 2) when surgery is recommended, referral is most commonly made to an otologist/neurotologist., Study Design: Survey of 500 regional otolaryngologists pertaining to their treatment of patients with hearing loss secondary to otosclerosis., Methods: Otolaryngologists in community practice were provided with written surveys pertaining to their treatment of otosclerosis., Results: Data were obtained from 179 general otolaryngologists treating adults and children in solo or group private practices in our geographic region. The majority (66%) diagnosed one to five new cases per year. Ten percent of surgeons graduating in the 1970s, 25% graduating in the 1980s, 50% graduating in the 1990s, and 90% of graduates in the 2000s never performed stapedectomy as part of their practices (P < .001). Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do this surgery. A trend toward greater use of hearing aids for the treatment of otosclerosis was seen in more recent graduates (P < .08). When surgery was recommended, otologists/neurotologists received the majority of referrals (75%) from the practitioners surveyed., Conclusions: Stapedectomy is performed and recommended less often by more recent graduates of otolaryngology training programs. Training requirements for both general otolaryngologists and neurotologists may need modification given current practice patterns for stapes surgery.

To determine the usefulness of sheep cadaver ear as a complementary model for training of stapedectomy at residency programs, 2 of our 4 year residents were included in the study and each operated 20 sheep ears. All routine steps of stapedectomy operation were performed, and their success and complication scores were recorded. Performance of residents for stapedectomy and teflon piston placement in sheep ears were evaluated by the authors. Success of both residents improved progressively. Success and complications were impressively better in the second 10 ears than the initial 10 for each resident. Both residents had better outcomes in last 10 ears. Sheep cadaver ear is an excellent model for stapedectomy training in residency and helps to improve surgical skills. We offer sheep cadaver ear training model especially in the countries where obtaining human cadaver temporal bone is difficult.

Unlabelled: Surgery of the stapedius remains the established treatment for otosclerosis. Recent publications have showed that success in surgeries done by residents have decreased and hearing results are worse than those obtained by experienced otologic surgeons., Aim: To evaluate the experience of the otorhinolaryngology unit, Parana University, relative to stapes surgery done in the residency training program., Material and Method: A retrospective study of 114 stapes surgeries done in the past 9 years in 96 patients. Audiometric results were analysed according to the Committee on Hearing and Equilibrium guidelines and the Amsterdam Hearing Evaluation Plots. The improvement of the airway postoperative gap and thresholds were taken into account., Results: 96 patients were included, most of them female adults (67.7%) and white (93.7%). Stapedectomy was done in 50.9% of cases, mostly under local anesthesia and sedation (96.5%), using mostly the Teflon prosthesis (37.7%). The surgical success rate was 50.88%, there was an 11.4% complication rate., Conclusion: Postoperative hearing gains considered as surgical success were inferior to published results in the literature, done by experienced surgeons.

Objective: To identify the 'stapedotomy' learning curve of 2 UK otolaryngologists., Study Design: A retrospective review of the outcome of the first 100 stapedotomy operations by each surgeon. Included in the study was a postal survey of the incidence of stapes surgery by UK otolaryngologists., Setting: Two tertiary referral centres., Patients: All ears in which primary stapedotomy was performed for otosclerosis. Non-otosclerotic cases and malleus stapedotomy cases were excluded., Intervention: One surgeon used the technique of small fenestra stapedotomy with either a Teflon wire or titanium piston, but without vein graft interposition, whilst the second employed the technique of stapedotomy with vein graft interposition, and a Teflon piston., Main Outcome Measures: The first 100 stapes operations performed by each surgeon were subdivided into consecutive groups of 10. Using a postoperative air-bone gap of 20 dB or better as a definition of 'success', the 'success rates' of each group were plotted on graphs - the learning curves. The end point of the learning curve was defined as the point 'where the curve reaches its plateau'., Results: The learning curves of both surgeons included 70-80 operations. Both surgeons had one 'dead ear' in their first 15 cases. The postal survey showed that some trainers only perform a small number of stapes surgeries, whereas some otolaryngologists who regularly perform stapedotomies were not trainers., Conclusions: This is a mismatch of trainers and trainees in stapes surgery. If the current trend of decline in stapes surgery continues, it will take many years for some otolaryngologists to complete their learning curves.

This paper is a review of concepts and methods presented as a tribute to a great pioneer and teacher, Harold Frederic Schuknecht. His book entitled Stapedectomy, published in 1971, is based on past experience of '6,200 stapedectomy operations over a period of 13 years' and on experience gained from teaching the procedure to numerous residents and fellows. His concepts are still valid and represent a solid base for teachers and students of this elegant but precarious procedure.

Unlabelled: The number of patients with stapes otosclerosis compared to the number of otorhinolaryngologists has declined over the past several years. As a result a controversy has arisen in the literature, whether or not stapes surgery should be included in residency programs., Aim: the objective of the present study is to evaluate the results and complications of estapedotomies performed by residents between January, 1997 and January, 2000, and consequently study the feasibility of including estapedotomies in residency programs. STUD DESIGN: retrospective review of prospectively collected audiometric data., Materials and Methods: fifty charts of patients that were submitted to a total of 51 primary stapedotomies were reviewed mainly for complications and audiological results., Results: there was closure of the air-bone gap within 10 dB HL in 70.5% of ears and closure to within 20 dB HL in 86.3% of ears. There was one ear with total hearing loss (2%)., Conclusion: From the results and complications seen in the present study, and analyzing papers from the literature, it is possible to conclude that stapedotomy is a procedure that can be included in residency programs, if there are surgical cases for the residents.

Purpose of Review: The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis?, Recent Findings: A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients., Summary: Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Complications following stapedectomy are the most common cause of litigation involving otological cases in the USA. Manipulation and placement of the prosthesis during a stapedectomy may have a profound effect on the final hearing results. Concerns have been raised over the reduced number of cases, training of residents, and the maintenance of the necessary skills to achieve consistently good results. Temporal bone dissection is an important adjunct to developing the required skills to perform stapedectomies. However the reduced availability of specimens limits their use for teaching or practising the procedure. In order to circumvent these problems an inexpensive and easily constructed middle-ear simulator has been developed based on materials readily available in any ENT ward. It is believed that this might help trainees develop the necessary skills to master the procedure.

Until recently the practice of otological procedures on cadaver temporal bones was a common occurrence in otolaryngology departments. The difficulty in acquiring specimens has led to alternative techniques which involve artificial and computer-aided models. This article looks at the present situation in these rapidly developing areas and describes an artificial model developed by the senior author for training in middle-ear procedures.

The number of new patients with otosclerosis seen by the average otolaryngologist has declined over the past several years. As a result, a controversy has arisen regarding the ability to train residents adequately in the technique of stapedectomy. In this regard, we have analyzed 44 consecutive stapedectomies performed by senior residents, under direct faculty supervision, at the University of California, San Francisco. All procedures were total stapedectomies, performed under local anesthesia, utilizing either wire-vein or wire-perichondrium technique. Four of the ears required footplate or promontory drilling. Closure to within 10 dB of the preoperative bone conduction, averaged over the speech frequencies of 500, 1000, and 2000 Hz, was achieved in 75% of ears, and closure to within 20 dB in 93% of ears. In no patient was hearing made worse. While there were no permanent complications, self-limited problems occurred in 9% of the procedures. Despite a declining caseload of otosclerotic ears in residency programs, it is possible to train residents safely in stapes surgery, given a program of consistent technique and close faculty supervision.

Controversy exists regarding the appropriateness of offering all residents training in stapes surgery due to dwindling case loads in residency programs nationally. A recent study indicated poorer results for stapes surgery performed by residents than results obtained by practicing otologists. One hundred consecutive stapedectomies performed by residents over a three-year period at our institution were reviewed retrospectively, with the objective of determining whether these results should be generalized.