Acta Otolaryngol83: 328-335, 1977
OTOSCLEROSIS SURGERY T. Palva, J. Karja and A. Palva
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
From the Departments of Otolaryngology, University of Helsinki, the Medical School of Kuopio, and the University of Oulu, Finland
(Received March 13, 1976)
Abstract. Results of otosclerosis surgery using the
stapes footplate removal with various types of reconstruction are reported in 456 ears (360 patients). Primary success was obtained in around 95 % while 83 % retained their improvement over the years. The posterior crus on fascia has become the preferred method because of its stability and relative lack of inner ear complications. Inner ear damage is mostly due to perilymph fistulae, which should be promptly recognized and repaired, since revision after the ear has become deaf does not restore hearing. Some late inner ear losses may be due to reactions to foreign material introduced with the graft. Bilateral operations should not be done if the first operation was dificult or caused vertigo for several days.
hearing tests made. During this period, several techniques have been used for sound conduction reconstruction. This makes it possible to compare the effectiveness of these techniques and the risk of the complications involved.
MATERIAL AND METHODS
During the period 1964 to 1973 primary surgery for otosclerosis was performed in 482 ears (385 patients). The following survey consists of 456 ears (360 patients); in the case of 26 Since Shea (1956) made the first successful ears the postoperative follow-up was less than stapes footplate removals and sound-conduct- 2 years which had been fixed as the shortest ing system reconstruction for otosclerosis, the observation period. Fifty patients (13.8 %) had basic operative principle has remained the unilateral and 3 10 bilateral hearing impairsame. These operations have been associated ment. Of the latter group, 203 cases (65.5%) with occasional mishaps, which in the course had operations on one ear, and of the remainof time have been more fully understood and ing 107 cases, 96 had bilateral operations, some of them discussed in detail in recent generally with a one-year interval. Of the rearticles (Dawes et al., 1973; Burtner & Good- maining 11 bilateral cases, 8 had undergone man, 1974; Smyth et al., 1975). It seems that, stapes surgery in one ear elsewhere and 3 had while the benefits are fully recognized, a a radical operation on one ear because of a cautious approach is gaining ground as the chronic middle ear infection. The operative method consisted in removal sometimes very grave but admittedly few, late of all or part of the footplate. The reconstrucsequelae of surgery are coming to light. We have now analysed our combined ma- tion was effected with either a polythene tube, terial operated on in the Department of Oto- House stainless steel wire, or the posterior or laryngology, University of Oulu from 1964. anterior crus. The window was sealed with The patients were followed up postopera- temporal muscle fascia, in all cases using a tively at least once a year, their subjective polythene tube. Fascia was also used in the symptoms were recorded, ears inspected and great majority in the other reconstruction Acto Otolaryngol83
Otosclerosis surgery
329
Table I. Stapes reconstruction and bilaterality in 456 ears
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
Bilateral hearing impairment Type of reconstruction
Unilateral hearing impairment
Polythene tube Steel wire Posterior crus Anterior crus Mobilization Total ears
17 9 22 I 1 50
'
Unilateral operation
Bilateral operation
80 49 55 6 13 203
173 I23 I3 I 12 17 456
76 65 54 5 3
203
groups but, in altogether 16 of these ears, the wire or crus was placed on top of a piece of gelfoam. In a small number of ears mobilization of the footplate only was carried out. Table I shows the distribution of patients into various subgroups according to surgical method. The hearing was evaluated by pure tone and speech audiometry (pure tone audiometer calibrated to ISO-standards). Masking was employed according to the principles described earlier using insert receivers (Palva & Palva, 1962) and keeping the masking level unchanged at pre- and postoperative bone conduction measurements. RESULTS The overall results of the primary surgery are shown in Table 11. The highest figures for permanently good results are found in the groups in which the patient's own crura were
Total operated ears
used for reconstruction, and the poorest in cases subjected to mobilization only. After primary surgery 3 ears became poorer in hearing, all in the group of stainless steel wire. Taking together the groups involving footplate removal (439 ears), overall primary success was obtained in 95.4% and 83.2% retained this gain over the total observation period. Permanently Improved Ears The average improvement for 500, 1000 and 2000 Hz during the observation period is shown in Fig. 1. The one-year results obtained with polythene tubing were the best, significantly better than with posterior crus (plo&) Total
3
3
173 123 13 1 12 17 456 ACIUOtoluryngol83
330 I
T . Palva et al.
two groups the difference, owing to the small number of cases, was not statistically significant. Table IV compares the hearing improvement in terms of air-bone gap. If the preoperative bone conduction was taken as reference level, then the gap nearly closed in the two best groups (tube and posterior crus). The gap was largest in cases treated by mobilization, as much as 23.1 dB. Comparison of air-bone gap and postoperative bone conduction levels reveals distinctly larger values, between 11.5 to 15.2 dB in the four best groups, which also indicates a distinct improvement in postoperative bone conduction averages.
401 blythen tube
f! 3o .
Posterior crus
Stainless steel
8
Anterior crus
zz m
2
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
1
3
4
5
8
POSTOPERATIVE OBSERVATION (years
10
)
Fig. I . Air conduction hearing gain related to years of observation, the reconstruction method as a parameter.
Ears with Severe Hearing Loss In aLl groups of reconstruction there were ears which are not included in Tables 111 and IV because bone conduction was so low as to make recording impossible at 2 000 Hz, and in some cases even at 1000 Hz. The outcome as regards air conduction is summarized in Table V. The final air conduction, though not reaching the useful level, showed distinct improvement in speech threshold, which made the use of a hearing aid easier.
mary operations are shown in Table 111. The ears with non-measurable bone conduction values at some frequency (Table V) and the ears showing no improvement after surgery (Table 11) are excluded. On the average, the hearing levels for the three middle frequencies in cases with footplate removal were preoperatively between 53-57 dB whereas the average level in ears treated by mobilization was significantly lower, 44.3 dB (pCO.05). According to follow-up averages, the best air conduction values, for polythene tube and posterior CI-US, were around 27 dB. All groups with footplate removal were highly significantly (p
OTOSCLEROSIS SURGERY T. Palva, J. Karja and A. Palva
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
From the Departments of Otolaryngology, University of Helsinki, the Medical School of Kuopio, and the University of Oulu, Finland
(Received March 13, 1976)
Abstract. Results of otosclerosis surgery using the
stapes footplate removal with various types of reconstruction are reported in 456 ears (360 patients). Primary success was obtained in around 95 % while 83 % retained their improvement over the years. The posterior crus on fascia has become the preferred method because of its stability and relative lack of inner ear complications. Inner ear damage is mostly due to perilymph fistulae, which should be promptly recognized and repaired, since revision after the ear has become deaf does not restore hearing. Some late inner ear losses may be due to reactions to foreign material introduced with the graft. Bilateral operations should not be done if the first operation was dificult or caused vertigo for several days.
hearing tests made. During this period, several techniques have been used for sound conduction reconstruction. This makes it possible to compare the effectiveness of these techniques and the risk of the complications involved.
MATERIAL AND METHODS
During the period 1964 to 1973 primary surgery for otosclerosis was performed in 482 ears (385 patients). The following survey consists of 456 ears (360 patients); in the case of 26 Since Shea (1956) made the first successful ears the postoperative follow-up was less than stapes footplate removals and sound-conduct- 2 years which had been fixed as the shortest ing system reconstruction for otosclerosis, the observation period. Fifty patients (13.8 %) had basic operative principle has remained the unilateral and 3 10 bilateral hearing impairsame. These operations have been associated ment. Of the latter group, 203 cases (65.5%) with occasional mishaps, which in the course had operations on one ear, and of the remainof time have been more fully understood and ing 107 cases, 96 had bilateral operations, some of them discussed in detail in recent generally with a one-year interval. Of the rearticles (Dawes et al., 1973; Burtner & Good- maining 11 bilateral cases, 8 had undergone man, 1974; Smyth et al., 1975). It seems that, stapes surgery in one ear elsewhere and 3 had while the benefits are fully recognized, a a radical operation on one ear because of a cautious approach is gaining ground as the chronic middle ear infection. The operative method consisted in removal sometimes very grave but admittedly few, late of all or part of the footplate. The reconstrucsequelae of surgery are coming to light. We have now analysed our combined ma- tion was effected with either a polythene tube, terial operated on in the Department of Oto- House stainless steel wire, or the posterior or laryngology, University of Oulu from 1964. anterior crus. The window was sealed with The patients were followed up postopera- temporal muscle fascia, in all cases using a tively at least once a year, their subjective polythene tube. Fascia was also used in the symptoms were recorded, ears inspected and great majority in the other reconstruction Acto Otolaryngol83
Otosclerosis surgery
329
Table I. Stapes reconstruction and bilaterality in 456 ears
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
Bilateral hearing impairment Type of reconstruction
Unilateral hearing impairment
Polythene tube Steel wire Posterior crus Anterior crus Mobilization Total ears
17 9 22 I 1 50
'
Unilateral operation
Bilateral operation
80 49 55 6 13 203
173 I23 I3 I 12 17 456
76 65 54 5 3
203
groups but, in altogether 16 of these ears, the wire or crus was placed on top of a piece of gelfoam. In a small number of ears mobilization of the footplate only was carried out. Table I shows the distribution of patients into various subgroups according to surgical method. The hearing was evaluated by pure tone and speech audiometry (pure tone audiometer calibrated to ISO-standards). Masking was employed according to the principles described earlier using insert receivers (Palva & Palva, 1962) and keeping the masking level unchanged at pre- and postoperative bone conduction measurements. RESULTS The overall results of the primary surgery are shown in Table 11. The highest figures for permanently good results are found in the groups in which the patient's own crura were
Total operated ears
used for reconstruction, and the poorest in cases subjected to mobilization only. After primary surgery 3 ears became poorer in hearing, all in the group of stainless steel wire. Taking together the groups involving footplate removal (439 ears), overall primary success was obtained in 95.4% and 83.2% retained this gain over the total observation period. Permanently Improved Ears The average improvement for 500, 1000 and 2000 Hz during the observation period is shown in Fig. 1. The one-year results obtained with polythene tubing were the best, significantly better than with posterior crus (plo&) Total
3
3
173 123 13 1 12 17 456 ACIUOtoluryngol83
330 I
T . Palva et al.
two groups the difference, owing to the small number of cases, was not statistically significant. Table IV compares the hearing improvement in terms of air-bone gap. If the preoperative bone conduction was taken as reference level, then the gap nearly closed in the two best groups (tube and posterior crus). The gap was largest in cases treated by mobilization, as much as 23.1 dB. Comparison of air-bone gap and postoperative bone conduction levels reveals distinctly larger values, between 11.5 to 15.2 dB in the four best groups, which also indicates a distinct improvement in postoperative bone conduction averages.
401 blythen tube
f! 3o .
Posterior crus
Stainless steel
8
Anterior crus
zz m
2
Acta Otolaryngol Downloaded from informahealthcare.com by Northwestern University on 01/13/15 For personal use only.
1
3
4
5
8
POSTOPERATIVE OBSERVATION (years
10
)
Fig. I . Air conduction hearing gain related to years of observation, the reconstruction method as a parameter.
Ears with Severe Hearing Loss In aLl groups of reconstruction there were ears which are not included in Tables 111 and IV because bone conduction was so low as to make recording impossible at 2 000 Hz, and in some cases even at 1000 Hz. The outcome as regards air conduction is summarized in Table V. The final air conduction, though not reaching the useful level, showed distinct improvement in speech threshold, which made the use of a hearing aid easier.
mary operations are shown in Table 111. The ears with non-measurable bone conduction values at some frequency (Table V) and the ears showing no improvement after surgery (Table 11) are excluded. On the average, the hearing levels for the three middle frequencies in cases with footplate removal were preoperatively between 53-57 dB whereas the average level in ears treated by mobilization was significantly lower, 44.3 dB (pCO.05). According to follow-up averages, the best air conduction values, for polythene tube and posterior CI-US, were around 27 dB. All groups with footplate removal were highly significantly (p
