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Effectiveness of the Malleus to Oval Window Technique for
Revision Stapedotomy
1
MD ,
1
BS ,
Ling Zhou,
Robert Peng,
Darius Kohan, MD
1Department of Otolaryngology, NYU School of Medicine
Abstract
Objective: To determine the long-term effectiveness of the malleus
to oval window technique for revision stapedotomy.
Methods: The charts of 17 patients who underwent 19 revision
stapedotomies performed between 2000 and 2012 were
retrospectively reviewed. The surgeries were performed under local
anesthesia using a standard transcanal approach using a laser
technique and the malleus to oval window prosthesis.
Results: Among 19 stapedotomies performed, 11 were primary
revisions, 7 were second revisions, and 1 was a third revision. The
average preoperative air-bone gap was 29.0dB. The average
postoperative air-bone gap was 9.3dB. Of the 11 primary revisions
performed, 9/11 (81.8%) achieved ABG < 10dB. Of the secondary
and tertiary revisions, 4/8 (50%) achieved ABG < 10dB. These results
were comparable with previously reported revision stapes surgery
techniques. The average length of follow up after revision
stapedotomy was 31 months. There was no significant difference in
air-bone gaps between the initial postoperative visit and the most
recent visit (p=0.5).
Methods and Materials
Results
The charts of 19 revision stapedotomies performed between 2000
and 2012 were reviewed. Demographic information, number of
previous revision surgeries, and intraoperative findings were
reviewed. Only patients who received a malleus to oval window
prosthesis were included.
Among 19 stapedotomies performed, 11 were primary revisions, 7
were second revisions, and 1 was a third revision.
The surgeries were performed under local anesthesia using a
standard transcanal approach. An Argon or potassium titanyl
phosphate (KTP) laser was used in all cases.
Of the 11 primary revisions performed, 9/11 (81.8%) achieved ABG <
10dB. Of the secondary and tertiary revisions, 4/8 (50%) achieved
ABG < 10dB. Despite a strong trend, there was no statistical
difference between these groups (p=0.09)
Auditory results conform to the guidelines provided by the American
Academy of Otolaryngology and Head and Neck Surgery’s
Committee on Hearing and Equilibrium. Air-bone Gaps (ABG) were
reported as the difference between air and bone pure-tone averages
(PTA) at frequencies of 500, 1,000, 2,000, and 3,000 Hz (and 4,000
Hz if the 3,000Hz was unavailable).
Successful surgery was defined as closure of the ABG to within 10dB.
Worsening of sensorineural hearing loss greater than 10 dB was
considered a complication. When available, follow-up audiograms
were examined to assess the durability of the revision.
Conclusion: In experienced hands, revision stapedotomy using the
malleus to oval window technique is both feasible and durable.
Optimal revision stapes surgery results are difficult to achieve when
there is erosion of the incus. This precludes the simple replacement
or resizing of the incus to oval window piston. Options to address
this problem include the use of a Lippy modified Robinson
prosthesis, the Kurtz titanium prosthesis, reconstruction of the long
process of the incus with bone cement, placement of a total
ossicular replacement prosthesis (TORP), or the use of a malleus
handle to oval window prosthesis. This study aims to examine a
single surgeon’s 10 year experience with using the malleus to oval
window technique for revision stapes surgery.
The average length of follow up after revision stapedectomy was 31
months. There was no significant difference in air-bone gaps
between the initial postoperative visit and the most recent visit
(p=0.5).
15 patients had erosion of the incus, 6 categorized as mild and 9
categorized as severe. Prosthesis dislocation was observed in 11
patients. Significant fibrous adhesions were found in 8 patients and
4 obstructed the oval window. 2 patients had bony regrowth at the
footplate.
1 patient had worsening of postop sensorineural hearing >10dB.
Table 1
Introduction
Since the Rosen’s description of stapes mobilization for otosclerosis
in 1952, countless patients have undergone stapes surgery that
successfully reversed their hearing loss. A minority of these
patients require revision of their primary surgery, returning with
complaints of increasing tinnitus, hearing loss , or vertigo.
Major improvements to revision stapes surgery over the past three
decades include the numerous prosthetic options developed to
accommodate for the different anatomic variables encountered at
surgery, and the use of lasers in lysing adhesions and bony
overgrowth. By avoiding direct manipulation of delicate inner ear
structures, laser ablation has helped lower the rate of sensorineural
hearing loss and increase the rate of successful revision, defined as a
narrowing of the air-bone gap to within 10dB with preservation of
discrimination.
The average preoperative air-bone gap was 29.0dB. The average
postoperative air-bone gap was 9.3dB.
Pt
Age
Sex
1
2
3
60
59
61
F
F
M
4
5
6
70
49
47
F
F
M
Discussion
Preop
ABG
Postop
ABG
%
Closure
Revision
Type
28.75
43.25
40
7.5*
20
31.75
12.5
25.75
50
20
23.25
36.25
35
30
35
42.5
32.5
32
18.75
15
0
4
3.75
7.5
10
7.5
8.75
26.5
12.5
17
-1.25
16.25
8
0
6.25
13.75
7
6.25
47.8%
100.0%
90.0%
50.0%
62.5%
68.5%
40.0%
66.0%
47.0%
37.5%
26.9%
103.4%
53.6%
73.3%
100.0%
85.3%
57.7%
78.1%
66.7%
Secondary
Primary
Secondary
Secondary
Primary
Primary
Secondary
Secondary
Secondary
Primary
Secondary
Primary
Primary
Primary
Primary
Primary
Tertiary
Primary
Primary
7
40
F
8
64
F
9
31
F
10
56
F
11
68
M
12
41
M
13
59
F
14
81
F
15
44
F
16
59
F
17
67
F
Table 1 – Summary of demographics, preop, and postop audiologic
findings.
*Prosthesis extruding through TM; Pt elected to have revision surgery
Contact
References
Ling Zhou MD
Department of Otolaryngology, NYU School of Medicine
Email: [email protected]
1.
2.
3.
4.
5.
6.
7.
Currently, there are no prospective randomized trials comparing
outcomes amongst various revision stapes surgery techniques.
Based on retrospective reviews, the expected success rate, with
closure of the ABG to within 10dB is approximately 70-80% for
primary revisions and 10% less for each subsequent revision in the
laser era. (1-4) Erosion of the incus is also typically associated with
poorer hearing outcomes. (5)
Our results compare favorably with other reported series, having
closed the ABG to within 10dB in 81.8% of primary revision and 50%
of secondary/tertiary revisions despite the presence of incus erosion
in nearly all of the reviewed cases. Additionally, at the average
followup period of 31 months, there was no statistically significant
deterioration of the ABG.
One patient in our series experienced a postop SNHL worsening of
12dB. This is also in line with previously reported rates of SNHL
ranging from 0.8-7%. (6-7)
Conclusions
With experience, revision stapedotomy using the malleus to oval
window technique is both feasible and durable.
Kohan, D. and A. Sorin (2003). "Revision stapes surgery: the malleus to oval window wire-piston technique." The Laryngoscope 113(9): 1520-1524.
Han, W. W., A. Incesulu, et al. (1997). "Revision stapedectomy: intraoperative findings, results, and review of the literature." The Laryngoscope 107(9): 1185-1192.
Jahnke, K., D. Solzbacher, et al. (2007). "Revision stapes surgery." Advances in oto-rhino-laryngology 65: 314-319.
Lippy, W. H., R. A. Battista, et al. (2003). "Twenty-year review of revision stapedectomy." Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and]
European Academy of Otology and Neurotology 24(4): 560-566.
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Hammerschlag, P. E., A. Fishman, et al. (1998). "A review of 308 cases of revision stapedectomy." The Laryngoscope 108(12): 1794-1800.
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