Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes

Objective Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. Study Design Retrospective review. Setting Single tertiary neurotology center. Methods Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. Results During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB ( P < .0005). The most common intraoperative findings for these patients were prosthesis displacement with incus necrosis (38%) or without it (43%), normal anatomy with seemingly good prosthesis placement (6%), and abundant scar tissue (6%). Patients with recurrent hearing loss achieved lower mean ABGs than patients with persistent hearing loss (8.8 vs 13.2 dB, P = .02). There were no associations between onset pattern of CHL or intraoperative findings and hearing outcomes ( P > .05). Four patients (2.7%) developed sensorineural hearing loss after revision, defined as an increase in bone conduction pure tone average ≥15 dB, all of whom had previous replacement of a malpositioned prosthesis. Conclusions Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

Outcomes in Revision Stapes Surgery

Objectives To compare audiometric outcomes and complication rates between primary and revision stapes surgical cases. Study Design Retrospective cohort study. Setting Large single-institution database. Methods Data on 809 patients (including 170 revisions) undergoing primary and revision stapes surgery were reviewed, with Pearson chi-square and multivariable logistic regression analysis performed. Results Rates of postoperative air-bone gap (ABG) closure to ≤10 dB were significantly worse in the revision group (40.2% vs 61.8%, P < .001), as were those to ≤20 dB (78.1% vs 90.9%, P < .001). The bone conduction pure tone average worsened by >10 dB in 7.1% of primary cases and 13.1% of revisions ( P = .016). The mean postoperative ABG for revision cases was significantly higher at 15.5 dB as compared with 11.0 dB for primaries ( P < .001), despite a slightly higher preoperative ABG for primary cases (30.6 vs 28.24 dB, P = .010). In multivariate analysis, revision surgery had an odds ratio 0.41 ( P < .001) in closing the ABG to ≤10 dB. Postoperative reparative granuloma (2.4% vs 0.2%, P = .001) and hydrops (1.8% vs 0.2%, P = .008) were higher in revision cases. Conclusions Revision stapes surgery was found to have less predictable and inferior results as compared with primary cases. Level of Evidence: 4 (retrospective observational research).

Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery

Objectives: To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses. Methods: A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed. Results: Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively ( P < .0001), while the ABG improved on average from 27 dB to 9 dB ( P < .0001). There was no significant difference in postoperative ABG between primary and revision stapes surgery (6 dB vs 10 dB, P = .07). These results persisted through long-term follow-up in a subgroup of patients with significantly longer follow-up time (mean 44 months). There was no significant change in BC PTA or word recognition scores. Three patients underwent subsequent revisions, one patient developed sensorineural hearing loss. Conclusion: Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

Revision Stapes Surgery in a Tertiary Referral Center: Surgical and Audiometric Outcomes

Objectives: To evaluate pure-tone audiometric results in otosclerosis patients undergoing revision stapes surgery following previous middle ear interventions. Methods: A retrospective cohort study was performed in a tertiary referral center. Consecutive otosclerosis patients who underwent revision stapes surgeries, following previous middle ear interventions, for persistent conductive hearing loss, recurrent conductive hearing loss, or vertigo and had available postoperative pure-tone audiometry were included. Mean pre- and postoperative air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2, and 3 kHz were obtained. Audiometric outcomes were obtained at 7 weeks postoperatively. Results: In total, 63 consecutive otosclerosis patients who underwent 66 revision stapes surgeries were included. Air-bone gap improved significantly with a mean gain of 19 dB (95% CI, 15-22). Air conduction improved significantly with a mean gain of 18 dB (95% CI, 14-23). Bone conduction did not change significantly, with a mean deterioration of 0 dB (95% CI, –2 to 1). Air-bone gap closure to 10 dB or less was achieved in 38% of cases and to 20 dB or less in 80% of cases. Indication for surgery, previous type of procedure, primary cause of failure, and current surgical technique were not significantly associated with air-bone gap closure to 10 dB or less. Indication for surgery and primary cause of failure were associated with one another. Conclusions: Compared to the available literature, a slightly larger gain in air conduction and air-bone gap was achieved in our study. Air-bone gap closure to 10 dB or less was achieved less often in our study.

Pediatric Stapes Surgery: Hearing and Surgical Outcomes in Endoscopic vs Microscopic Approaches

Objective To compare endoscopic and microscopic pediatric stapes surgery. Study Design Case series with chart review. Setting Two academic otology practices. Subjects and Methods Surgical and hearing outcomes were compared for consecutive children (<18 years) undergoing microscopic and endoscopic stapes surgery. The main outcome measure was closure of the air-bone gap (ABG) to ≤20 dB. Results Twenty-two endoscopic surgeries (17 stapedectomies, 4 stapedotomies, and 1 stapes mobilization) and 52 microscopic surgeries (30 stapedectomies, 19 stapedotomies, and 3 stapes mobilizations) were performed. Patient demographics, history of ipsilateral middle ear surgery, and revision stapes surgery status were similar. The most common diagnosis for the endoscopic group and microscopic group were congenital stapes footplate fixation (45.5%) and juvenile otosclerosis (46.2%), respectively. Preoperative ABGs in the endoscopic (37.7 dB) and microscopic (32.8 dB) groups ( P = .170) were similar. There were no major complications, including facial nerve injury or anacusis, in the endoscopic group. Postoperative sensorineural hearing loss (>15 dB) did not occur in any patients in the endoscopic group but was present in 2 patients in the microscopic group ( P = .546). Improvement in pure-tone average (25.9 dB vs 18.5 dB, P = .382) and ABG (21.7 dB vs 14.7 dB, P = .181) was similar, and postoperatively, the median ABG was 11.3 dB and 15.0 dB for endoscopic and microscopic cases ( P = .703), respectively. ABG closure to ≤20 dB (72.7% vs 65.2%, P = .591) was also similar. Conclusion Pediatric endoscopic stapes surgery is safe and hearing outcomes are similar to the microscopic approach when performed by experienced endoscopic ear surgeons.