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Background: The aim of the study was to describe our initial experience with the high-definition three-dimensional (3D) exoscope for middle ear surgery versus the operating microscope. Methods: The study included 60 randomly chosen patients diagnosed with otosclerosis (n = 30) or chronic otitis media (n = 30) with a clinical indication for surgery. The primary measurement was the subjective estimation of quality of the visibility of the operating field provided by the 3D exoscope—VITOM-3D (Karl Storz, Tuttlingen, Germany) in comparison to the operating microscope. Results: All procedures, except for two (3.3%) converted to the microscope, were successfully completed using a 3D exoscope. In both stapedotomy and tympanoplasty, the exoscope was superior to the microscope during more superficial portions of the procedures. By contrast, in deeper areas of the middle ear, the exoscope provided significantly worse visibility, but usually not suboptimal. Both intraoperative bleeding and the narrow surgical field substantially reduced the visibility with the 3D exoscope in comparison to the microscope. Conclusions: Overall, our study shows that the 3D exoscope offers excellent, highly magnified, and well-illuminated high-definition images of the surgical field. However, our experience revealed several important limitations of this system, including decreased depth perception in deep areas of the tympanic cavity and reduced visibility in a difficult surgical field, with subsequent need to switch to an operating microscope in select cases.

To ascertain if wideband acoustic immitance (WAI) measurements are useful in assessing crimping status following stapedotomy.WAI measurements were obtained using the Mimosa Acoustics HearID system. Wideband chirp sound stimuli and a set of tone stimuli for nine frequencies between 0.2 and 6 kHz were used at 60 dB SPL. Five sets of measurements were performed on each temporal bone: mobile stapes, stapes fixation and stapedotomy followed by insertion of a tightly crimped, a loosely crimped and an uncrimped prosthesis.Eight fresh-frozen temporal bones were harvested from human cadaveric donors.At lower frequencies, up to 1 kHz, stapes fixation decreased absorbance. Compared to the baseline absorbance, absorbance with stapes fixation dropped by 6 to 17% in absolute terms from the baseline value (p = 0.027). Absorbance was not affected in higher frequencies (p = 0.725). Stapedotomy changed the absorbance curve significantly compared to the normal condition with an increase of absolute absorbance values by 6 to 36% around 0.25-1 kHz (p-value0.01). The crimping conditions did not differ from one another (p = 0.555).WAI is not useful in distinguishing between tightly crimped, loosely crimped and uncrimped stapes prostheses following stapedotomy.

Objectives/Hypothesis To evaluate the effect of crimping techniques in stapes surgery for otosclerosis patients measured by hearing outcomes on pure-tone audiometry. Data Sources PubMed, EMBASE, and the Cochrane Library. Methods A systematic search was conducted. Studies comparing the effect of different crimping methods on pure-tone audiometric results in patients undergoing stapes surgery for otosclerosis were included. Relevance and risk of bias were assessed. Absolute risks and risk differences, means and mean differences, and 95% confidence intervals were extracted or calculated for the primary and secondary outcomes, which were air-bone gap closure to 10 dB or less, mean postoperative air-bone gap, and postoperative sensorineural hearing loss. Results Twenty-two studies with moderate or high risk of bias were included for data extraction. Air-bone gap closure to 10 dB or less was assessed in 17 studies and mean postoperative air-bone gap in 20 studies. The hearing outcomes did not consistently favor one crimping method. However, the differences that were statistically significant were consistently in favor of heat crimping over manual and no crimping (difference in air-bone gap closure to 10 dB or less ranged between 22% and 42% in these studies and difference in mean postoperative air-bone gap between 2.8 dB and 7.4 dB) and in favor of manual crimping over no crimping (30% difference in air-bone gap closure to 10 dB or less and difference in mean postoperative air-bone gap between 2.6 dB and 6.0 dB). Conclusion Moderate to high risk of bias and inconsistent results characterize the current evidence.

Objectives/Hypothesis To prospectively evaluate hearing outcomes in children with otosclerosis undergoing primary stapes surgery. Study Design A nonrandomized, nonblinded, prospective case series. Methods Thirty-four consecutive pediatric patients who underwent 41 primary stapedotomies for otosclerosis in a tertiary referral center were included. Patients were included when there was evidence of otosclerotic stapes fixation and they had available postoperative pure-tone audiometry. Patients underwent primary stapedotomy with vein graft interposition and reconstruction with a regular piston, bucket handle prosthesis, or total ossicular replacement prosthesis. Hearing results were evaluated using pre- and postoperative four-frequency (0.5, 1, 2, and 4 kHz) audiometry. Air-conduction thresholds, bone-conduction thresholds, and air-bone gaps were measured. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months after surgery and at a yearly interval thereafter. Results Overall, a postoperative air-bone gap closure of 10 dB or less was achieved in 93% of cases and to within 20 dB in 98% of cases. Mean gain in air-conduction threshold was 23 dB for the entire case series, and mean air-bone gap closure was 23 dB. Postoperative sensorineural hearing loss, defined as changes in bone-conduction thresholds exceeding 10 dB, occurred in one case at last follow-up. The bone-conduction threshold deteriorated 13 dB in this case. Conclusion Primary stapedotomy is a safe and feasible treatment option in children with juvenile otosclerosis. Level of Evidence 4. Laryngoscope, 126:442-446, 2016.

Objective To evaluate the effect of piston diameter in primary stapedotomy for otosclerosis patients measured by hearing outcome. Data Sources PubMed, Embase, and the Cochrane Library. Review Methods A systematic search was conducted. Studies reporting original data on the effect of piston diameter on pure-tone audiometric results in patients undergoing primary stapedotomy for otosclerosis were included. Relevance and risk of bias of the selected articles were assessed. Studies with low relevance, high risk of bias, or both were excluded. Absolute risks and risk differences, means and mean differences, and 95% confidence intervals were extracted. Results Twelve studies with moderate to high relevance and moderate risk of bias were included for data extraction. Air-bone gap closure to 10 dB or less was assessed in six studies, the majority of which did not show a statistically significant or clinically relevant difference between two pistons with a different diameter. More importantly, the differences that were found were not consistently in favor of smaller-diameter pistons or larger-diameter pistons. Mean postoperative air-bone gap ranged from 3 dB in favor of a smaller-diameter piston to 3 dB in favor of a larger-diameter piston across four studies. Permanent sensorineural hearing loss was assessed in eight studies and occurred in only one study. In this study, no difference was found between a 0.4-mm-diameter piston and a 0.6-mm-diameter piston. Conclusion There is not sufficient evidence to support the superiority of the use of a larger-diameter piston compared to a smaller-diameter piston for primary stapedotomy in otosclerosis patients.

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.Il numero di interventi per otosclerosi è progressivamente diminuito nel corso degli ultimi 20 anni. Questa riduzione crea difficoltà sia al chirurgo esperto ma soprattutto a quello giovane che inizia il suo percorso di formazione. Abbiamo analizzato in maniera retrospettiva i risultati funzionali ottenuti dopo stapedotomia effettuati da un giovane chirurgo presso la Clinica Otorinolaringoiatrica del Policlinico “A. Gemelli” di Roma. La tecnica impiegata è quella della stapedotomia con laser CO

Otosclerosis is a localized disorder that is characterized by a deposition of abnormal sponge-like bone in the otic capsule. Fixation of the stapes footplate in the oval window niche results in a conductive hearing loss, which can be treated conservatively using hearing aids, or surgically in a procedure called stapedotomy. In stapedotomy, the stapes arch is removed and a small fenestration is made in the stapes footplate. A prosthesis is placed between the incus and the fenestration in the stapes footplate. Success percentages of primary stapedotomy range between 72 and 94%. The effect of prosthesis shaft diameter is one quality that has been the subject of research for the last few decades. Evaluation of the available literature revealed 12 cohort studies on this topic, the majority of which showed neither a statistically significant nor a clinically relevant difference between two prostheses with a different diameter piston. Two studies reached statistical significance and both of these studies favored the use of a larger-diameter piston with a difference in success of 31% and a difference in mean postoperative air-bone gap of 2 to 3 dB. The effects of different prosthesis shaft diameters were also evaluated in a temporal bone model. At midrange frequencies, between 500 and 4000 Hz, round window velocities increased by 2 to 3 dB using a 0.6-mm-diameter piston compared to a 0.4-mm-diameter piston. The use of a 0.8-mm-diameter piston led to a further increase in round window velocities of 2 to 4 dB. Prostheses can be crimped to the incus in various fashions. Some prostheses do not require crimping at all whereas others are crimped using manual force or heat. In a systematic literature search, 22 studies were identified that evaluated the effect of different crimping techniques on hearing outcomes. The differences in success and mean postoperative air-bone gap were not consistently in favor of one crimping method. However, the differences that were statistically significant were consistently in favor of heat crimping over manual and no crimping with differences in success between 22 and 53%, and differences in mean postoperative air-bone gap between 4 and 9 dB. Furthermore, the differences that were statistically significant were consistently in favor of manual crimping over no crimping with a 30% difference in success and a difference in mean postoperative air-bone gap between 3 and 6 dB. A substantial number of patients require revision stapes surgery because they suffer from a recurrent or residual conductive hearing loss following primary surgery. Surgical outcomes of revision surgery are less favorable than those of primary surgery with reported success percentages ranging between 40 and 80%. Furthermore, revision surgery is associated with a relatively high risk of postoperative sensorineural hearing loss of 1 to 8%. We developed an internally validated prediction model for success. Previous surgical technique, primary cause of failure leading up to revision stapes surgery and type of the prosthesis placed during revision surgery were associated with treatment success. We developed a similar model predicting sensorineural hearing loss following revision stapes surgery. Preoperative presence of vertigo, presence of oval window obliteration and type of the prosthesis placed during revision surgery were associated with postoperative sensorineural hearing loss. Prosthesis dislocation is a positive factor for success compared to other primary causes of failure. A diagnostic test that accurately assesses crimping status following stapes surgery may be helpful in diagnosing the primary cause of failure before revision surgery and thus in preoperative counseling of patients. We investigated the role of wideband acoustic immitance measurements in assessing crimping status following stapedotomy in a temporal bone model. Stapedotomy changed the absorbance curve significantly, but the crimping conditions did not differ from one another.

The aim of this study is to perform a systematic review and meta-analysis of observational studies in which hearing outcomes after primary stapes surgery have been reported. After the surgical procedure, the effectiveness of stapes surgery using nickel titanium (Nitinol) or other prostheses were systematically compared and evaluated using a meta-analytic method. A systematic search for articles before January 2017 in Embase, Medline and Cochrane Library databases was conducted. Only articles in English were included. Inclusion criteria for qualitative synthesis consisted of a population of otosclerosis patients, intervention with primary stapes surgery using the Nitinol heat-crimping prosthesis compared with other type of stapes stapedotomy prostheses, and hearing outcome. Inclusion criteria for quantitative analysis consisted of application of audiometry guidelines of the American Academy of Otolaryngology Head and Neck Surgery Committee on Hearing and Equilibrium for evaluation of conductive hearing loss. A postoperative air-bone gap (ABG) ≤ 10 dB was considered effective. A bias assessment tool was developed according to Cochrane guidelines. To evaluate the mean age of the samples we used the chi-square test. Of the 4926 papers identified through the electronic database search (3695 in Pubmed/Cochrane and 1231 in Embase), 540 studies matched the selection criteria (436 in Pubmed/Cochrane and 104 in Embase) after application of filters and elimination of duplicate articles. After analysis of the title and abstract, 459 were excluded (396 in Pubmed/Cochrane and 63 in Embase). Of the remaining 81 papers, 74 were excluded according to the study selection criteria. A total of seven eligible studies with 1385 subjects, consisting of 637 in the Nitinol group and 748 in the non-Nitinol group, were included in our study. There were statistically significant differences in the effectiveness of stapes surgery between the Nitinol and non-Nitinol prostheses; the data showed a combined odds ratio (OR) of 2.56 (95% CI 1.38-4.76, p = 0.003). There were no statistically significant differences in the mean pre-operative age between Nitinol and non-Nitinol prostheses (p = 0.931). Our results suggest that the effectiveness of Nitinol was higher than non-Nitinol prostheses, with superiority of the number of patients with ABG ≤ 10 dB. © 2018, Pacini Editore S.p.A. All rights reserved. publishersversion published

ObjectiveThis study aimed to compare the hearing results of two different stapedotomy techniques used in the clinic at different time points.MethodsAn endoscopic surgery group (group 1; n = 37) were compared retrospectively with a microscopic surgery group (group 2; n = 57). A small fenestra and Teflon piston technique were used in all patients. Bone cement was used for fixation between the prosthesis and incus in the endoscopic group only. Bone conduction threshold and air–bone gap were used as the comparison parameters.ResultsThe pre-operative air–bone gap was 31.26 dB in group 1 and 32.51 dB in group 2. The post-operative air–bone gap was 8.93 dB in group 1 and 14.28 dB in group 2. There was a significant difference between the groups in post-operative air–bone gaps. There was no significant difference between the groups in post-operative bone conduction thresholds.ConclusionThe endoscopic technique using bone cement fixation was better for closing the air–bone gap.

Objective Using a contact-free laser technique for stapedotomy reduces the risk of mechanical damage of the stapes footplate. However, the risk of inner ear dysfunction due to thermal, acoustic, or direct damage has still not been solved. The objective of this study was to describe the first experiences in footplate perforation in cadaver tissue performed by the novel Picosecond-Infrared-Laser (PIRL), allowing a tissue preserving ablation. Patients and intervention Three human cadaver stapes were perforated using a fiber-coupled PIRL. The results were compared with footplate perforations performed with clinically applied Er:YAG laser. Therefore, two different laser energies for the Er:YAG laser (30 and 60 mJ) were used for footplate perforation of three human cadaver stapes each. Main outcome measure Comparisons were made using histology and environmental scanning electron microscopy (ESEM) analysis. Results The perforations performed by the PIRL (total energy: 640-1070 mJ) revealed a precise cutting edge with an intact trabecular bone structure and no considerable signs of coagulation. Using the Er:YAG-Laser with a pulse energy of 30 mJ (total energy: 450-600 mJ), a perforation only in the center of the ablation zone was possible, whereas with a pulse energy of 60 mJ (total energy: of 195-260 mJ) the whole ablation zone was perforated. For both energies, the cutting edge appeared irregular with trabecular structure of the bone only be conjecturable and signs of superficial carbonization. Conclusion The microscopic results following stapes footplate perforation suggest a superiority of the PIRL in comparison to the Er:YAG laser regarding the precision and tissue preserving ablation.

Purpose: Analysis of the differences in inner ear admittance achieved by a large fenestra in comparison with a small fenestra and its effect on bone conduction in stapes surgery. Materials and methods: Description of an interesting case of bilateral otosclerosis with an atypical and symmetrical behaviour of bone conduction, treated with a stapedotomy on the right ear some years before, and recently submitted to stapedectomy on the left year. Results: Concerning the left side, the first complete audiometry was made 15 days after stapedectomy and confirmed a bone conduction improvement, that subsequently increased until almost to the normality 42 days after surgery. The mean postoperative bone conduction difference was 13 dB considering all frequencies; when considering the frequencies between 500 and 2000 Hz the mean difference raised to 20 dB. Conclusions: The reported case, in which the stapedectomy was not scheduled as the first option, but derived from a particular intraoperative situation thus resulting in an almost obligatory choice, permits some interesting conceptual considerations.

INTRODUCTION: Otosclerosis is one of the commonest non infective causes of acquired deafness in adults’. ‘Otosclerosis’ literally means hardening of the ear. It is a primary and exclusive disease of otic capsule of human temporal bone. Otosclerosis is characterised by alternate phases of bone resorption and formation. If the location of bony changes produces evident clinical manifestations term “C linical Otosclerosis” is used. If bony changes are not translated into clinical manifestations, the term used is “histologica l Otosclerosis”. Antonio Valsalva in 1735 gave first description of ankylosis of stapes to margins of oval window. Von Troltsch in 1881 coined the term ‘Otosclerosis’. Politzer in 1893 first described Otosclerosis as a primary disease of otic capsule. Alth ough the clinical course of the disease is well documented, its aetiology remains unclear; thus, multiple theories are available. But none of them has established a definite cause. Otosclerosis usually manifests as a progressive conductive or mixed hearing loss occurring clinically to varying degrees in 0.5% - 1% of the general population. The clinical diagnosis of Otosclerosis, as clarified by Bezold in 1908, requires a careful history, physical examination, tuning fork evaluation and audiometric testing. Radiographic examinations can be done as adjuncts when needed. Therapeutic options for Otosclerosis include medical, surgical and use of hearing aids, alone or in combination. Stapes surgery is an effective treatment for hearing loss and tinnitus of Otoscl erosis and stapedectomy is the current treatment of choice for conductive component of Otosclerosis. The first stapes mobilization was employed by Kessel in 1878. The procedure of extracting the stapes for Otosclerosis was first performed by Jack of Boston in 1892 but was beset with obvious difficulties because he lacked proper magnification and antibiotic coverage. In 1956 Dr. John Shea revived the stapedectomy operation for Otosclerosis and replaced the stapes bone with a polyethylene tube prosthesis and vein graft. Small fenestra stapedectomy is a more precise method of creating a hole in footplate rather than total footplate removal. It gives less post - operative vertigo and better high frequency hearing compared to total footplate removal. The present st udy is a longitudinal clinical study on Otosclerosis with emphasis on clinical and audiological features, per operative findings, outcome and complications of stapedectomy. The objective is to study the demographic and clinical features of Otosclerosis in this part of Kerala; to analyze the results of audiometry and operative notes of Otosclerosis; to describe the outcome and incidence of complications of small fenestra stapedectomy in Otosclerosis

ObjectiveTo describe persistent post-stapedotomy vertigo (PSV) and its treatment using migraine prophylaxis.PatientsA retrospective review of all patients with persistent PSV spanning 10 years at a tertiary academic hospital was performed. Patients who experienced persistent vertigo for a minimum of 3 months after surgery were included. Those with possible perilymph fistula, long prosthesis, and benign paroxysmal positional vertigo were excluded.InterventionsAll patients received instructions on migraine dietary and lifestyle changes and Vitamin B2 and magnesium. In addition, prophylactic treatment with nortriptyline, verapamil, or a combination thereof was started.Main outcome measureChanges in vertigo frequency was the main outcome variable. The secondary outcome variables included the time period and medications necessary to achieve symptomatic resolution.ResultsFour women and one man with an average age of 53 years were identified that met criteria for persistent PSV indicating an incidence of 0.9% at our institution. The onset of vertigo symptoms was on average 20 days postoperatively. All five patients had daily vertigo episodes and experienced complete resolution with no vertigo episodes after treatment. Symptomatic resolution was achieved over an average of 9 weeks after initiating treatments.ConclusionsPersistent PSV beyond 3 months is a rare occurrence and its treatment can be challenging when there is no evidence of an underlying pathology. This subset of patients may be suffering from migraine, which was triggered postoperatively. Treatment with migraine prophylaxis in this cohort of patients may result in resolution of vertigo.

Otoskleroza je metabolička koštana bolest labirintne kapsule i pločice stremena te je jedan od najčešćih uzroka stečenog gubitaka sluha. Najčešće se javlja među bijelom populacijom s incidencijom od 1%, a žene su pogođene dva puta češće od muškaraca. Smatra se da je otoskleroza multifaktorska bolest, uzrokovana genetičkim i okolišnim čimbenicima. Nasljeđuje se autosomno dominantnim načinom s varijabilnom penetracijom. Uloga autoimunosti, virusa, hormona i mnogih drugih faktora u etiopatogenezi bolesti je predmet brojnih istraživanja, ali je točan uzrok otoskleroze još uvijek nepoznat. Vodeći simptom otoskleroze je progresivna provodna nagluhost, ali se može javiti i šum te jako rijetko vrtoglavica. Bolest se obično prezentira između drugog i petog desetljeća života. Dijagnoza se temelji na anamnezi, kliničkom pregledu i ispitivanju sluha. Audiometrija tipično pokazuje provodnu nagluhost sa širim razmakom zračno-koštane krivulje u nižim frekvencijama. Kada postoji fiksacija stremena, odsutan je stapedijski refleks. Konzervativna terapija natrijevim flouridom može samo usporiti napredovanje bolesti pa se preferira kirurška terapija. Kirurške tehnike koje se koriste u terapiji otoskleroze su totalna i parcijalna stapedektomija i stapedotomija., Otosclerosis is a disease affecting the bony metabolism of the otic capsule and stapes footpalate, and is among the most common causes of acquired hearing loss. It occurs most commonly among Caucasians with an incidence of 1%, and women are affected twice as often as men. Otosclerosis is considered a multifactor disease, caused by both genetic and environmental factors. It is inherited in an autosomal dominant pattern with incomplete penetrance. The role od autoimmunity, viruses, hormones and many other factors in the etiopathophysiology of disease has been subject of recent studies, but the exact cause of otosclerosis is unknown. Progressive conductive hearing loss is the predominant symptom but patients also present with tinnitus and, rarely, dizziness. The clinical presentation usually occurs between the second and fifth decades of life. The diagnosis is based on medical history, clinical features, and hearing tests. The audiometric exam typically shows conductive hearing loss with a wider air-bone gap at lower frequencies. The stapedial reflex is absent when stapedial fixation is present. As medical treatment with sodium fluoride can only slow down the progression of disease, surgical management is preferred. Approaches to surgical management include total stapedectomy, partial stapedectomy, and stapedotomy.

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc. Objective: To evaluate the outcome and per-and postoperative complications of the surgical management of patients with a persistent stapedial artery (PSA). Methods: A systemic literature search for reports on patients treated for pulsatile tinnitus and/or conductive hearing loss caused by a PSA was conducted of the PubMed and Embase databases using the terms "stapedial" and "artery." Inclusion criteria were adequate description of the intervention and pre-and postoperative signs and symptoms. In addition, one case of a PSA, treated at VU University Medical Center Amsterdam, The Netherlands, was included in this series. Intervention: Middle ear surgery consisting of stapedotomy or stapedectomy, and/or transection of the PSA. Main Outcome Measures: Pre-and postoperative hearing levels, pre-and postoperative pulsatile tinnitus, and per-and postoperative complications. Results: Seventeen patients and 18 operated ears were evaluated (16 patients described in 14 articles and our case). Twelve out of 14 ears in which a stapedotomy or stapedectomy was initiated experienced improvement in hearing. In four cases pulsatile tinnitus was described pre-and postoperatively. In all four, pulsatile tinnitus subsided after transection of the PSA. Peroperative bleeding from the PSA was described in four patients, which could be controlled during the procedure. No significant postoperative sequelae were reported. Conclusions: In case of a PSA, improvement of conductive hearing loss is best achieved by stapes surgery, while pulsatile tinnitus is effectively treated with transection of the PSA. To date no long-term postoperative complications have been reported.

Background and Objectives A free-beam-type CO2 laser, which use a micromanipulator mounted on a microscope as the delivery system, has the merit of not being affected by hand tremor at the time of shooting. However, this delivery system has several disadvantages, including a restricted operation range and a risk of incorrect focusing. A fiber-type CO2 laser uses a hand-held delivery system and has the opposite merits and demerits. We compared the results of stapes surgery with free-beam and fiber type delivery systems. Subjects and Methods The study enrolled 36 patients who underwent stapedotomy with free-beam- (n=26) or fiber- (n=10) type CO2 lasers. The air-bone (AB) gap closure, bone conduction (BC) change, and operating time were evaluated. The AB gap closure was calculated by subtracting the preoperative BC thresholds from the postoperative air conduction thresholds. The BC change was calculated by subtracting the postoperative BC thresholds from the preoperative BC thresholds. Results The mean operating time was significantly (p=0.035) shorter in the fiber-type group (72.5±8.2 min) than in the free-beam-type group (80.5±11.4 min). The mean AB gap closure did not differ significantly (p=0.297) between the free-beamand fiber-type groups (5.8±10.1 and 1.4±6.8 dB, respectively). The mean BC change did not differ significantly (p=0.873) between the free-beam- and fiber-type groups (2.4±6.9 and 2.8±5.3 dB, respectively). The hearing outcomes did not differ significantly between the two groups. Conclusions Operating times were significantly shorter using the fiber-type CO2 laser, while hearing outcomes did not differ significantly between the two groups.

Objectives: To assess the long-term effectiveness of stapedotomies performed on patients with otosclerosis and preoperative small air-bone gaps (ABGs). Methods: Retrospective study comparing the 10-year postoperative hearing outcomes after primary stapedotomies in patients with small (≤20 dB) and large ABGs (> 20 dB). Ninety out of 175 stapedotomies (22 and 68 in the small and large ABG groups, respectively) were monitored with long-term follow-ups. Results: Ten years after the operation, hearing measurements were similar for both groups, although a significant decline of bone conduction thresholds was evident (p = 0.007 and p < 0.001, respectively). An improvement of ≥10 dB in the postoperative ABG (clinical improvement) was achieved only in the large ABG group. Conclusions: Even though long-term hearing levels will evolve similarly in patients with ≤20 and > 20 dB preoperative ABGs, the lack of clinical improvement found in the small ABG group is not in favor of an early surgery.

Einleitung: Die Stapedotomie und im Besonderen die Laserstapedotomie ist in den letzten Jahren zur Standardtherapie der Otosklerose in Primär- und Revisionsfällen geworden. Ziel der vorliegenden Arbeit war die Untersuchung der Sicherheit und Effektivität der berührungslosen Ein-Schuss-Technik mit dem CO2-Laser, kombiniert mit einem Scannersystem, bei Stapesrevisionsoperationen. Methodik: Es erfolgte eine prospektive Untersuchung, Dokumentation in einem Datenbanksystem und statistische Auswertung von präoperativen Symptomen, intraoperativen Befunden sowie Hörergebnissen bei 106 Patienten, die sich im Zeitraum von 1991 bis 2006 einer Revisionsstapedotomie mit dem CO2-Laser an der Klinik für Hals-Nasen-Ohrenheilkunde der Charité Berlin, Campus Benjamin Franklin, unterzogen. Ergebnisse: Die Analyse von 106 Patienten ergab, dass die berührungslose Operationstechnik mit dem CO2-Laser bei der Revisionsstapedotomie zuverlässig und komplikationsarm (0,9%) war sowie regelmäßig zu einer Verbesserung der Luftleitungshörschwelle führte. Ein Einfluss der applizierten kumulativen Laserenergie auf die Innenohrhörschwelle wurde nicht beobachtet. Die am häufigsten beobachteten Ursachen für eine Revision waren dislozierte Prothesen, Incusarrosionen, bindegewebige Verwachsungen, knöcherne Reobliterationen oder eine zu lange bzw. zu kurze Prothese. Unter Verwendung des CO2-Lasers, kombiniert mit einem Scannersystem und einem Mikromanipulator, konnten nachfolgend sowohl massiv obliterierte Fußplatten und dünne Neomembranen als auch mobile Fußplatten ohne mechanisches Trauma erfolgreich perforiert werden. Schlussfolgerung: Es konnte gezeigt werden, dass mit dem neu vorgestellten Operationsverfahren Veränderungen im Bereich der ovalen Nische und der Stapesfußplatte mit einem minimalen Risiko für ein mechanisches Trauma und somit auch für eine Innenohrschädigung vom Bindegewebe befreit werden konnten. Dadurch gelang es, die vorliegende Pathologie eindeutig zu definieren. Im Rahmen zukünftiger Studien wird sich zeigen, ob sich die ermutigenden postoperativen Hörergebnisse und die geringe Rate an Komplikationen bestätigen lassen. Mit zunehmender Zahl an operierten Patienten wird sich auch herausstellen, ob sich der theoretische Vorteil des neu vorgestellten berührungslosen Operationsverfahrens auch in den klinischen Ergebnissen wiederfindet., Introduction: Stapedotomy and in particular laser stapedotomy has recently become the standard treatment for otosclerosis in primary and revision cases. Purpose of this study was to evaluate the safety and efficacy of the one-shot non-contact technique for revision stapes surgery using a CO2-Laser combined with a scanning system. Methods: A prospective study and documentation in a database of pre-operative symptoms, intra-operative findings and analysis of hearing results in 106 patients who underwent revision-stapedotomy with a CO2-Laser from 1991 to 2006 at the ENT-Department of Charité Berlin, Campus Benjamin Franklin was performed. Results: The intraoperative and postoperative analysis of 106 patients showed that the non-touch technique with the CO2-Laser is a reliable surgical technique for cases of revison stapedotomy with a low rate of complications (0.9%) that resulted regularly in an improvement of the air-conduction threshold. An influence of the applied cumulative laser energy on the inner ear hearing threshold was not observed. The most frequently observed causes for revisions were displacement of the prosthesis, incus arrosions, fibrous adhesions and bony reobliteration or a too long or too short prosthesis. Subsequently, by using the CO2-Laser combined with a scanning system and a micromanipulator, massively obliterated footplates, thin neomembranes and mobile footplates could successfully be perforated without mechanical trauma. Conclusion: It could therefore be demonstrated that alterations of the oval niche and the stapes footplate could be freed from connective tissue with a minimal risk for mechanical trauma and inner ear damage by using the newly introduced surgical technique. Thereby, the existing pathology could be defined. Further studies need to demonstrate if these encouraging postoperative hearing results as well as the low rate of complications can be confirmed. With an increasing number of surgically treated patients it will become obvious if the advantage of the new non-touch surgical technique is only a theoretical one or can be clinically confirmed as well.

Objective: Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design: Case series with chart review. Setting: Tertiary referral center. Subjects and Methods: We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results: Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion: The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

Objective To prospectively evaluate hearing outcomes in patients with osteogenesis imperfecta undergoing primary stapes surgery and to isolate prognostic factors for success. Study design A nonrandomized, open, prospective case series. Setting A tertiary referral center. Patients Twenty-five consecutive patients who underwent 32 primary stapedotomies for osteogenesis imperfecta with evidence of stapes fixation and available postoperative pure-tone audiometry. Intervention Primary stapedotomy with vein graft interposition and reconstruction with a regular Teflon piston or bucket handle-type piston. Main outcome measures Preoperative and postoperative audiometric evaluation using conventional 4-frequency (0.5, 1, 2, and 4 kHz) audiometry. Air-conduction thresholds, bone-conduction thresholds, and air-bone gap were measured. The overall audiometric results as well as the results of audiometric evaluation at 3 months and at least 1 year after surgery were used. Results Overall, postoperative air-bone gap closure to within 10 dB was achieved in 88% of cases. Mean (standard deviation) gain in air-conduction threshold was 22 (9.4) dB for the entire case series, and mean (standard deviation) air-bone gap closure was 22 (9.0) dB. Backward multivariate logistic regression showed that a model with preoperative air-bone gap closure and intraoperatively established incus length accurately predicts success after primary stapes surgery. Conclusion Stapes surgery is a feasible and safe treatment option in patients with osteogenesis imperfecta. Success is associated with preoperative air-bone gap and intraoperatively established incus length.

Objectives/Hypothesis To assess hearing results and complications following primary stapedotomy in otosclerosis patients comparing the use of laser and conventional techniques for fenestration. Study Design Systematic literature review. Methods A systematic bibliographic search was conducted in PubMed, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Studies reporting original data on the effect of laser fenestration, compared to conventional techniques, on closure of air-bone gap in patients undergoing primary stapedotomy were included. Directness of evidence and risk of bias of the selected articles were assessed. Studies with low directness of evidence, high risk of bias, or both were not further analyzed. The absolute risks, risk differences, and 95% confidence intervals were extracted only for studies with moderate to high directness of evidence and moderate to low risk of bias. Results In total, 383 unique studies were retrieved. Eight of these (including 999 procedures) provided high or moderate directness of evidence and carried a moderate risk of bias, and were considered eligible for data extraction. The included studies show no consistent difference in postoperative air-bone gap closure or immediate postoperative vertigo. Conclusions Both footplate fractures and sensorineural hearing loss appear to occur more frequently in the conventional group than in the laser group. Therefore, we prefer laser above conventional methods for footplate fenestration in primary stapedotomy. Level of Evidence NALaryngoscope, 124:1687-1693, 2014

Hypothesis: The use of larger-diameter pistons in stapedotomy leads to better hearing outcomes compared with the use of smaller-diameter pistons. There is an interaction between stapes piston diameter and fenestration diameter. Background: Otosclerosis can be treated surgically by removing part of the stapes and bypassing the stapes footplate with a prosthesis. Available piston shaft diameters range between 0.3 and 0.8 mm. There has been a tendency toward the use of smaller-diameter pistons, because of a suspected decreased risk of cochlear trauma and subsequent sensorineural hearing loss (SNHL) with smaller pistons. However, mathematical models, temporal bone studies, and clinical studies suggest that the use of larger-diameter pistons is associated with better hearing outcomes. Methods: Three fresh-frozen, non-pathologic temporal bones were harvested from human cadaveric donors. Acoustic stimuli in the form of pure tones from 250 to 8000 Hz were generated at 110 dB sound pressure level. A total of 16 frequencies in a 1/3-octave series were used. Stapes and round window velocities in response to the acoustic stimuli were measured at multiple equally spaced points covering the stapes footplate and round window using a scanning laser Doppler interferometry system. Eight sets of measurements were performed in each temporal bone: 1) normal condition (mobile stapes), 2) stapes fixation and stapedotomy followed by insertion of 3) a 0.4-mm-diameter piston in a 0.5-mmdiameter fenestration, 4) a 0.4-mm-diameter piston in a 0.7- mm-diameter fenestration, 5) a 0.4-mm-diameter piston in a 0.9-mm-diameter fenestration, 6) a 0.6-mm-diameter piston in a 0.7-mm-diameter fenestration, 7) a 0.6-mm-diameter piston in a 0.9-mm-diameter fenestration, and 8) a 0.8-mmdiameter piston in a 0.9-mm-diameter fenestration. Results: At midrange frequencies, between 500 and 4000 Hz, round window velocities increased by 2 to 3 dB when using a 0.6-mm-diameter piston compared with a 0.4- mm-diameter piston. Using a 0.8-mm-diameter piston led to a further increase in round window velocities by 2 to 4 dB. Conclusion: Our results suggest a modest effect of piston diameter on hearing results following stapedotomy.