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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.

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.

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.

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.)

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.

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.

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.