Eur Arch Otorhinolaryngol DOI 10.1007/s00405-015-3560-6
OTOLOGY
Stapes surgery: a National Survey of British Otologists Hannah Lancer • Jaiganesh Manickavasagam Azreena Zaman • Jack Lancer
•
Received: 28 October 2014 / Accepted: 14 February 2015 Springer-Verlag Berlin Heidelberg 2015
Abstract To investigate individual stapes surgery practice in the UK, a retrospective study was conducted by postal questionnaire to all ‘assumed’ stapes-performing otologists. 225 questionnaires were sent out to practicing otologists in the UK. 184 replies (81.8 %) indicated that 134 (72.9 %) otologists perform stapes surgery [stapedectomy (8.2 %), stapedotomy (91.0 %) or other (0.8 %)]. The ‘6–10 stapes operation per year’ category is the most common, with most using general anaesthetic (GA) (78.3 %). Unilateral surgery is advised in 89.6 %, and 96.3 % perform second-side surgery, with all advising the option of a hearing aid prior to surgery. The majority (88.1 %) would fit the prosthesis after removing the stapes, with the top three prostheses being Causse, Smart and Teflon (as described by respondents). 42.5 % always use a vein graft or fat to cover the fenestration, 9.3 % use a laser and 48.5 % carry out the surgery as a day case. For an overhanging facial nerve (less than 50 % of the footplate obscured), the majority stated that it would depend whether they would abandon surgery. 25.4 % have The paper was presented at the 14th British Academic Conference in Otolaryngology (BACO), held in Glasgow (UK) from 4th to 6th July 2012, and the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) held in Washington DC, October 2012. H. Lancer CT2 Vascular Surgery, Royal Free Hospital, London, UK J. Manickavasagam (&) Ninewells Hospital and University of Dundee, 84 West Road, Newport on Tay, Dundee, Scotland, UK e-mail: [email protected]
encountered a ‘gusher’ and 83.6 % would recommend revision surgery. 82.8 % have a registrar present when carrying out stapes operations, but 69.4 % only offer training to trainees with an otological interest. In the UK, stapedotomy is the preferred technique. Most prefer the Causse prosthesis, general anaesthesia and an inpatient stay. Hearing aids are advised prior to surgery. Day-case and inpatient practice is about equal. ‘Gushers’ are encountered rarely. Revision surgery is advised if a conductive loss returns. Flying is recommended from 6 weeks. Most otologists are willing to teach trainees with an otological interest. Keywords United Kingdom Stapedectomy Stapedotomy National survey
Introduction Successful management of otosclerosis requires a detailed knowledge of the disease process and a flexibility of surgical technique. Stapedotomy (making a small fenestra in the footplate and removing the stapes suprastructure), when performed by skilled surgeons, is the surgical treatment of choice for otosclerosis, with good success rates. It is one of the most technically challenging procedures, demanding excellence in surgical preparation, precision and performance. No standardized treatment protocols or guidelines are available with regard to stapes surgery in the UK. We have, therefore, investigated individual stapes surgery practice.
A. Zaman ST3 Paediatric Surgery, Alder Hey Hospital, Liverpool, UK
Methods
J. Lancer Park Hill Hospital, Doncaster, UK
In the UK there is no accurate or reliable subspecialty database and, therefore, to ascertain working practices for a
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particular (otological) procedure, one has to make allowance for this fact and be prepared to be flexible, offering a degree of latitude, as otherwise such information would seldom, if ever be obtained. This fact should be borne in mind when interpreting the findings in this paper. For without this information, we would be less informed about current UK stapes surgical practice. This study was conducted by postal questionnaire to all assumed stapes-performing otologists. Two authors individually collected contact details of all NHS hospitals in the UK by obtaining details from the BAO (British Association of Otolaryngologists) and also by detailed personal enquiries contacting individual ENT departments. Otologists not performing stapes surgery were excluded from our list. Postal questionnaires (‘‘Appendix’’) were sent to all assumed stapes surgeons with a covering letter and a reply envelope. Further postal reminders were subsequently sent to non-responders. ‘‘Appendix’’ lists the 23 questions asked. A decision was made to limit the number of questions to those listed. A more expansive list could have been prepared including details of types of audiometry performed, other pre-operative investigations including radiology, percentage risks explained to the patient, indications for surgery, precise individual technique including local anaesthesia methods where applicable, and even more precise operative findings including size of platinotomy, length of prosthesis, type of laser used where appropriate, post-operative care including drugs, dressings, instructions and complications. The senior author, who has carried out over 500 stapes operations, does offer some of his personal experiences with regard to surgical and anaesthetic techniques which may at least partly assist in advising on the above matters. Our previous experiences have informed us that if too many questions are asked, and taking the above points into account may have raised around 50 questions, there is a tendency for the respondent not to respond to the survey as it would be too onerous and time-consuming to complete. Therefore, there must be a balance and we hope that the information below offers a reasonable and balanced insight into how UK stapes surgeons practice. It may be possible in the future to expand the survey to Europe and beyond.
Results Out of 225 questionnaires that were sent out, we received 184 replies (81.8 %). Of these, 134 (72.8 %) stated that they do perform stapes surgery [stapedectomy (8.2 %), stapedotomy (91.0 %) or other (0.8 %)]. (Note this is the description offered by the respondent. The authors feel that to be called a stapedectomy the footplate should be
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removed virtually in its entirety as opposed to making a small fenestra, 0.4–0.6 mm usually, when the procedure will be called a stapedotomy). 46 (25 %) do not perform stapes surgery and 4 (2.2 %) left the question blank (3 retired, 1 maternity leave). Only those who perform stapes surgery (134) were included in the study. The number of stapes operations performed per year is represented below, with the ‘6–10 per year’ category as the most common range. Of those, 62.6 % said that this figure was accurate. The number of stapes operations performed each year were as follows: 19 perform less than 5, 47 perform 6–10, 30 perform 11–15, 16 perform 16–20, 9 perform 21–25, 6 perform 26–30 and 7 perform more than 30 operations per year (Fig. 1a). Most (105) perform stapes surgery under general anaesthesia (GA), some using GA (27) and local anaesthesia (LA) and two under LA only (Fig. 1b). Procedures carried out under LA constitute less than 10 % of overall stapes workload. On whether an anaesthetist is present during stapes surgery under LA, 102 surgeons either left the answer blank or stated non applicable and 32 answered: 59.3 % always have an anaesthetist present, 15.6 % never and 21.9 % have one present some of the time. Stapes surgery in unilateral disease is advised 89.6 % of the time (Fig. 2a). All patients are advised about trying a hearing aid prior to surgery either all of the time or some of the time (Fig. 2b). Assuming the first operation is successful, 96.3 % would perform second side stapes surgery and this is most likely to be at either 6–12 months (22.4 %), or more than 1 year post-operatively (68.7 %) (Fig. 3a, b). For the insertion of the prosthesis, the majority (88.1 %) would choose to insert the prosthesis after removing the stapes (total or partial), and the types of prosthesis used varied greatly, with a selection of 28 varieties. The top three used are Causse, Smart and Teflon (Fig. 4a). (Note these are the prosthesis descriptions offered by the respondent). 42.5 % always use a vein graft or fat to cover the fenestration, 21.6 % sometimes and 34.3 % never do (Fig. 4b). 49.3 % use a laser, 46.3 % do not and of those who do, 35.1 % always use one. 48.5 % carry out stapes as a day case. For an overhanging facial nerve ([50 % of the footplate obscured), the majority stated that it would depend on the individual circumstance as to whether they would abandon surgery (Fig. 5a). During surgery, 25.4 % have encountered a ‘gusher’ whose treatment methods include plugging, waiting, and abandoning the procedure. If after a period of success a conductive loss returns, 83.6 % would recommend revision surgery (Fig. 5b). When advising patients at what stage they were able to fly post-operatively, several categories were advised (Fig. 6a). By 6 weeks post-operatively, virtually all
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Fig. 1 a How many stapes procedures do you perform per year on average? b What type of anaesthesia do you use for stapes surgery?
Fig. 2 a Is stapes surgery advised in unilateral disease? b Are hearing aids recommended prior to surgery?
Fig. 3 a If the first operation is successful, how long would you wait to perform surgery on the second side? b Would you perform second side stapes surgery in bilateral disease assuming the first operation was successful?
surgeons allow their patients to fly. Lastly, in terms of teaching, 82.8 % have a registrar present when carrying out stapes operations, but only 25 (19 %) offer training for
stapes surgery to all trainees and 93 (69.4 %) do offer training to trainees with an otological interest only (Fig. 6b).
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Fig. 4 a What prosthesis do you use? b Do you use a vein graft or fat to cover the fenestration?
Fig. 5 a Would you abandon surgery for an overhanging facial nerve? b If conductive loss returns following a period of success, would you recommend revision surgery?
Fig. 6 a When would you advise patients that they can fly? b Do you offer training for stapes surgery to trainees?
Discussion Smyth and Hassard discovered that a smaller 0.4 mm footplate fenestra provided hearing gains similar to the standard total footplate removal techniques. The small fenestra technique was associated with a significantly
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lower incidence, both of fistula formation and immediate or delayed sensorineural hearing loss [1]. Shea has reported his experience with the small versus large fenestra technique. His stapedectomy technique included a piston over a vein graft that covered the oval window. The stapedotomy required placing a piston
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directly into the vestibule with blood as the tissue seal. He found that a smaller fenestra offered better high-frequency hearing and was easier, less traumatic and was associated with fewer complications [2]. Bailey et al. had similar results, and with small fenestra stapedotomy, there were equivalent pure-tone averages but better high frequency hearing, better speech discrimination, fewer vestibular problems and no sensorineural hearing loss compared with stapedectomy. This was postulated to be because stapedotomy was a more precise technique and the vestibule was subjected to less trauma [3]. In our study stapedotomy is preferred by 122 surgeons and stapedectomy by 11. Small-fenestra stapedotomy is the safer procedure to be performed as day-case surgery than total stapedectomy (48.5 % carry out stapes surgery as a day case) [4]. Sedwick et al. compared large and small fenestra techniques, as well as the instrument used to make the fenestra (drill or laser) with regard to effectiveness and rate of side effects. The charts of 875 patients, who underwent primary stapedectomy performed by members of the House Ear Clinic, were reviewed; a statistically significant difference between the large and small fenestra techniques in postoperative sensorineural hearing loss at higher frequency was found. However, the difference is small and is probably not clinically significant. Therefore, they found that similarly good results can be obtained by the experienced surgeon using either the large or small fenestra technique. Also, they found the laser and microdrill to be equally safe and effective in the creation of the fenestra [5]. Argon, KTP or CO2 laser has been used successfully for stapedotomy by many authors [6, 7], and in our survey, 49.3 % use a laser. A number of authors have reported that stapes surgery, in addition to improving hearing, also improves tinnitus in a majority of cases [8, 9]. Our own results show an improvement in tinnitus in around 60–70 %, but it must not be forgotten that there is a 1–2 % risk of severe and debilitating tinnitus. If after a period of success a conductive loss returns, 83.6 % would recommend revision surgery. Revision stapedectomy should be approached with caution. The risk of severe sensorineural hearing loss is from two to ten times higher than with primary stapedectomy, and these surgical procedures should only be performed by experienced surgeons [10]. If the post-operative hearing loss was immediate and conductive, it is probably because of unsuccessful ossicular chain reconstruction. If the post-operative hearing deterioration has been progressive and conductive, it may be caused by bony regrowth with refixation or displacement of the prosthesis. The type of ossicular chain reconstruction used and the type of oval window repair may be predictive of incus necrosis, oval window fistula or scarring [11].
The general consensus from reviews of revision stapedectomy is that it is less successful than primary stapedectomy, with success rates varying from 50 to 60 % [12]. Higher success rates in revision stapes surgery are obtained when the incus can be incorporated into the repair. A number of problems can occur in relation to the prosthesis and oval window. These include displaced prosthesis, short prosthesis and oval window fibrosis. A displaced prosthesis is the most common cause of failure, requiring revision surgery. This has been reported in 30–46 % cases [13, 14]. Twenty-six have encountered a ‘gusher’ during surgery. In most cases, this is associated with a congenital footplate fixation. The aetiology of the CSF gusher has been postulated to be either a widened cochlear aqueduct or a defect in the fundus of the internal auditory canal. Stapes surgery on the second ear is a controversial topic, with variable results being reported [15, 16]. Hearing loss may occur in either the first or the second operated ear. Serious sensorineural hearing loss may occur several years after the operation and, therefore, a surgeon should be cautious about recommending second-side surgery. In our survey, assuming the first operation is successful, 96.3 % would perform second side stapes surgery and this is most likely to be at either 6–12 months (22.4 %), or from 1 year post-operatively (68.7 %). De Bruijn et al. assessed the benefit obtained after second-ear stapedotomy with the Glasgow benefit plot. From the results it appears that a second operation on the contralateral side increases the chances of achieving at least one ‘normal’ hearing ear and that it makes symmetrical ‘normal’ hearing possible in the majority of the cases [17]. He concluded that bilateral stapedotomy is a safe procedure with good results [18]. A dehiscent and prolapsed facial nerve obscuring the footplate is a rare finding that can lead to the procedure being abandoned. A dehiscence of the facial nerve, where the epineurium is exposed, has been demonstrated in as many as 11.4 % of stapedectomy cases [19]. The incidence of a prolapsed or protruding facial nerve is lower, approximately 2–7 % [14, 20]. In only 0.2–0.3 % of affected patients does a prolapsed facial nerve completely obstruct the visualization of the stapes footplate [14, 15]. Of those patients in whom a facial nerve dehiscence is discovered, 25–29 % have a dehiscence in the contralateral ear [14, 21]. It has been thought that factors that contribute to facial nerve canal dehiscence include hereditary predisposition, inhibition of proper canal wall formation and a persistent stapedial artery [22]. In our survey, 37 would abandon surgery for a 50 % or more overhanging facial nerve, (18 would not) (75 undecided). Anomalies of the course of the facial nerve require specific management. Knowledge of any possible abnormalities and relevant procedures to deal
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with these is crucial for safe and successful stapedectomy [23]. Neff et al. found that, when the facial nerve covered at least 50 % of the oval window, the post-stapedectomy hearing results at 6 months and 1 year were similar to those of a matched control group of stapedectomy patients with a normal facial nerve course. They concluded that stapedectomy in patients with significant facial nerve prolapse can be performed safely with good hearing results [20]. Promontory drilling in stapedectomy may be required in cases with a narrow oval window niche, facial nerve overhang and an obliterated footplate. Drilling of the promontory in stapedectomy is required in only a small percentage of cases. Although audiometric results indicated the possibility of a slight amount of acoustic trauma from the drilling, the effect on hearing was minimal and not considered a contraindication to this procedure [24]. Lippy et al. [25] compared titanium and Robinson stainless steel stapes piston prostheses and found there was no significant difference between groups in hearing improvement or postoperative air-bone gap. Rondini-Gilli et al. analysed outcomes after otosclerosis surgery with stapedeotomy using a blood clot seal. In their study, functional failures were related to significant intralabyrinthine bleeding and revision procedures, and the following factors had no effect on outcome: (1) stapedotomy versus partial or total stapedectomy, (2) footplate opening sealed by clot or vein, (3) diameter of the stapedotomy and/or the prosthesis and (4) surgical procedure performed by a junior surgeon. They concluded that sealing the stapedotomy opening with blood clot appeared to provide reliable and reproducible functional outcome that remained stable over time. In this study, changing from partial to total stapedectomy with vein interposition did not modify the functional outcome [26]. In our survey 57 always, 29 sometimes and 46 never use a vein graft or fat to cover the fenestration. De La Cruz et al. performed a retrospective review of 356 revision stapedectomy operations performed at the House Ear Clinic and found that poorer outcome was related to incus necrosis, multiple revisions and indications for surgery other than conductive hearing loss. Revision stapedectomy can provide good air-bone gap closure in 60 % of cases, with only a small risk of sensorineural hearing loss. Although not as satisfactory as primary stapedectomy, revision stapedectomy can be offered to patients with a reasonable expectation for good air-bone gap closure [27]. Raut et al. evaluated the current practice among British Otolaryngology consultants using a questionnaire in 2002. They found that overall trend is towards centralisation,
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with a reduction in the number of surgeons undertaking stapes surgery (49.9 %). The majority of consultants (81.3 %) who undertook stapes surgery would operate for a unilateral conductive loss and 75.1 % would undertake bilateral stapes surgery. Stapedotomy was the operation of choice (82 %), with a few consultants performing partial or rarely total stapedectomies. Post-operative restrictions and follow-up times varied widely amongst surgeons, with the senior surgeons tending to be more conservative than the younger consultants [28]. In contrast to their survey, our survey covered more controversial areas around stapes surgery. Shabana et al. [29] concluded that the 0.4 mm and the 0.6 mm Teflon prostheses produced the same hearing improvement in stapes surgery for otosclerosis. Farrior et al. [30] found that there was no statistically significant difference in either hearing gain or air-bone gap overclosure between the Teflon-wire piston and the stainless-steel bucket stapes prosthesis. De Bruijn et al. determined parameters for successful stapedectomy and whether this procedure can be performed safely by surgical residents in a teaching hospital. Charts were reviewed for technique, audiological test results, complications, operative time and type of anaesthetic used. Overall, closure of the air-bone gap at 10 dB was achieved in 87 % of patients. Use of general anaesthesia and a laser-assisted, small-fenestra technique allowed residents to complete more operations, and no severe sensorineural hearing loss was noted. They concluded that residents can safely and successfully perform stapes surgery using a laser-assisted, small-fenestra technique [31]. In our study in terms of teaching, 82.8 % have a registrar present when carrying out stapes operations, but 69.4 % offer training to trainees with an otological interest only. Hughes said that fewer stapes operations are available to train residents and to maintain individual competence. Most residents in the United States perform 0–10 cases during training and produce results which are not as good as expert results, even with close supervision. After graduation, fewer cases are available to achieve expert results in private or academic practice [32]. JAA Manual of Civil Aviation Medicine states that if surgery is performed in a pilot suffering from otosclerosis, a so-called ‘closed-window-technique’ must be employed. During surgery, a perilymphatic fistula is created in the stapes footplate; then, a small piston prosthesis replacing the supra-structure of the stapes is attached to the long process of the incus and inserted into the fistula. The closed-window technique involves a sealing of this fistula by means of a vein or fascia graft. If the fistula is not sealed, the lateral displacement of the piston during a decompression could result in an opening of the fistula which
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would cause a severe attack of vestibular vertigo and a sudden loss of hearing. In order to ensure healing, pilots who have undergone stapes surgery should not fly for the next 3 months. Emphasis must be placed on the risk of opening a potential perilymphatic fistula when the ear is subjected to sudden pressure variations. If the pilot is going to fly pressurisedcabin aeroplanes, events resulting from a sudden decompression must be anticipated [33]. Between 1977 and 1995, Katzav et al. performed nine stapedectomies using the Robinson-vein graft technique on six high-performance airplane pilots diagnosed with otosclerosis. All of them returned to full active duty after stapedectomy without any vestibular symptoms. These cases illustrate that it can be safe for fighter or test pilots to return to full flight status after stapedectomy. These cases also suggest that full flight status can be reinstated as soon as 3 months after stapedectomy without endangering flight safety [34]. In the UK, most (105) perform stapes surgery under GA, some (27) using GA and LA and two under LA only. The technique of performing stapes surgery under LA, the senior author’s preferred technique in over 80 % of his cases, is well-described [35], and Lancer and Fisch found excellent outcomes with regard to both surgeon and patient satisfaction ratings when performing stapes surgery under LA [35]. While clearly all surgeons will have their own technique of performing stapes surgery, the senior author has utilised the same technique over a 25-year period, learnt from Prof Ugo Fisch. It was felt that including individual techniques in detail from the respondents would be too lengthy, although the senior author offers his technique, utilised in most cases, but variation is obviously expected. The method of regional ear anaesthesia is well documented (35) and is performed by the surgeon. The anaesthetist then administers intravenous midazolam up to 10 mg and deals with appropriate cardiovascular and airway monitoring. Steroids are not given. A nasal catheter is applied supplying oxygen. No premedication is given as the surgery would usually be performed as a day case. A moderate degree of patient arousal is necessary as the surgeon will speak to the patient at the end of the procedure to ensure improved hearing and appropriate prosthesis placement. An endaural incision is made and a tympanomeatal flap is raised. The overhang is curetted and the chorda would usually be preserved. The diagnosis is confirmed and the incus-footplate distance is measured. At this point intravenous prochlorperazine 12.5 mg is given to help counteract the effects of nausea sometimes associated with the next step. A fenestra is fashioned in the footplate using graduated hand trephines (0.3–0.6 mm). In all cases a
Fisch Teflon-platinum prosthesis 0.4 9 6 mm (cut to size) is used and the prosthesis is inserted and crimped. Then the stapedius tendon is divided, the posterior crus is cut with crurotomy scissors, the anterior crus is fractured and the stapes suprastructure is removed. Pieces of fat taken from around the incision are used to seal the footplate to help reduce any leak of perilymph and the flap is then closed. A Pope oto-wick is inserted into the ear canal and enlarged with saline, and antibiotic-soaked ribbon gauze packs the remainder of the ear canal. A hyoscine patch is placed over the contralateral mastoid process. An ear pad is applied. The patient goes home with oral prochlorperazine 5 mg twice daily, and dressings are removed in 1 week. The patient then receives a 1-week course of topical antibiotic/ steroid drops. There are few limitations in our study. Sampling bias could be possible with the study group as this study was conducted by postal questionnaire to all assumed stapesperforming otologists. However, and to minimise selection bias, multiple checks were carried out to make sure only stapes-performing otologists were included in this survey. The questionnaire has not been validated; however, it deals with all key controversial aspects in stapes surgery. Although the revealed retrospective data are not all new, this paper depicts both the overall general approach to stapes surgery and the current practice in UK. As most surgeons performed less than ten cases per year, their opinion on difficult situations such as managing an overhanging facial nerve or a ‘gusher’ should be received with caution. Unfortunately, this is one of the challenges for future stapes surgeons in UK. Decreasing number of cases leave the surgeons less skillful, with need for centralization. Most UK patients receive treatment via the National Health Service (NHS). Such treatment is free at the point of delivery and is funded from general taxation, and as a result there are major cost pressures. With regard to preoperative CT scanning, of course there are benefits, but the positive pick-up rate which could determine a possible ‘gusher’, or indeed any other abnormality, is extremely low. Such an investigation is, therefore, carried out seldom, but of course a high suspicion of a possible abnormality would indeed warrant such an investigation.
Conclusion In the UK, stapedotomy is the preferred technique. The Causse prosthesis is the most widely used, and general anaesthesia is preferred, along with an inpatient stay. Hearing aids are advised prior to surgery. The frequency of operations as day-case and inpatient is reasonably similar. ‘Gushers’, although rare, can be treated in numerous ways.
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Revision surgery is advised if a conductive loss returns. Flying is generally recommended from 6 weeks post-operatively. Most otology surgeons are willing to teach trainees, especially those with an otological interest. No standardised treatment protocols or guidelines are available with regard to stapes surgery in the UK, where there are wide variations in stapes surgery practice. Conflict of interest
None.
Appendix: Questionnaire The questionnaire was composed of 23 questions, as listed below: • • • • • •
• • • •
• • • • • • • • • • • • • •
Do you perform stapes surgery? How many operations do you perform per year on average? Is this figure an estimate? Or is this figure accurate? Do you ever perform stapes surgery under general anaesthetic/local anaesthetic/both? If you do use local anaesthesia, what percentage of stapes operations of your overall workload would that be? If under local anaesthesia, do you have an anaesthetist present? Would you advise stapes surgery in unilateral disease? In clinic, would you advise patients about trying a hearing aid prior to surgery? Would you perform second side stapes surgery in bilateral disease, assuming the first operation was successful? If the first operation was successful, how long do you wait until you carry out surgery on the second side? Which is your preferred technique? At what point in the procedure would you insert the prosthesis? What prosthesis do you use? Do you use vein graft or fat to cover the fenestration? Do you use a laser? If yes, then how often? Do you carry out stapes surgery as a day case? Would you abandon surgery for an overhanging facial nerve? Have you ever encountered a ‘gusher’ during surgery? If yes then how did you treat it? Would you recommend revision surgery if a conductive hearing loss returns? When would you advise patients that they can fly? Do you have a registrar present when carrying out stapes surgery?
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•
Do you offer training for stapes surgery to all trainees or those with otological interest only?
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Eur Arch Otorhinolaryngol 22. Kaplan J (1960) Congenital dehiscence of the fallopian canal in middle ear surgery. Arch Otolaryngol 72:197–200 23. Szymanski M, Golabek W, Morshed K (2003) Stapedectomy and variations of the facial nerve. Ann Univ Mariae Curie Sklodowska Med 58(2):101–105 24. Lippy WH, Berenholz LP, Schuring AG, Rizer FM, Burkey JM (2002) Promontory drilling in stapedectomy. Otol Neurotol 23(4):439–441 25. Lippy WH, Burkey JM, Schuring AG, Berenholz LP (2005) Comparison of titanium and Robinson stainless steel stapes piston prostheses. Otol Neurotol 26(5):874–877 26. Rondini-Gilli E, Bozorg Grayeli A, Boutin P, Tormin Borges Crosara PF, Mosnier I, Bouccara D et al (2002) Otosclerosis surgical techniques and results in 150 patients [French]. Ann Otolaryngol Chir Cervico-Faciale 119(4):227–233 27. De La Cruz A, Fayad JN (2000) Revision stapedectomy. Otolaryngol Head Neck Surg 123(6):728–732 28. Raut VV, Toner JG, Kerr AG, Stevenson M (2002) Management of otosclerosis in the UK. Clin Otolaryngol Allied Sci 27(2):113–119
29. Shabana YK, Ghonim MR, Pedersen CBS (1999) tapedotomy: does prosthesis diameter affect outcome? Clin Otolaryngol Allied Sci 24(2):91–94 30. Farrior JB, Temple AE (1999) Teflon-wire piston or stainlesssteel bucket stapes prosthesis: does it make a difference? Ear Nose Throat J 78(4):252–253 (257–60) 31. Mathews SB, Rasgon BM, Byl FM (1999) Stapes surgery in a residency training program. Laryngoscope 109(1):52–53 32. Hughes GB (1991) The learning curve in stapes surgery. Laryngoscope 101(12):1280–1284 33. Joint Aviation Authorities (2009) JAA Manual of Civil Aviation Medicine. http://www.norskflymedisin.no/filer/kompendier/JAA% 20Manual%20of%20Civil%20Aviation%20Medicine%20Amdt% 206%202009%20web.pdf. Accessed 13 Dec 2012 34. Katzav J, Lippy WH, Shamiss A, Davidson BZ (1996) Stapedectomy in combat pilots. Am J Otol 17(6):847–849 35. Lancer JM, Fisch U (1988) Local Anaesthesia for middle ear surgery. Clin Otolaryngol Allied Sci Oct 13(5):367–374
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OTOLOGY
Stapes surgery: a National Survey of British Otologists Hannah Lancer • Jaiganesh Manickavasagam Azreena Zaman • Jack Lancer
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Received: 28 October 2014 / Accepted: 14 February 2015 Springer-Verlag Berlin Heidelberg 2015
Abstract To investigate individual stapes surgery practice in the UK, a retrospective study was conducted by postal questionnaire to all ‘assumed’ stapes-performing otologists. 225 questionnaires were sent out to practicing otologists in the UK. 184 replies (81.8 %) indicated that 134 (72.9 %) otologists perform stapes surgery [stapedectomy (8.2 %), stapedotomy (91.0 %) or other (0.8 %)]. The ‘6–10 stapes operation per year’ category is the most common, with most using general anaesthetic (GA) (78.3 %). Unilateral surgery is advised in 89.6 %, and 96.3 % perform second-side surgery, with all advising the option of a hearing aid prior to surgery. The majority (88.1 %) would fit the prosthesis after removing the stapes, with the top three prostheses being Causse, Smart and Teflon (as described by respondents). 42.5 % always use a vein graft or fat to cover the fenestration, 9.3 % use a laser and 48.5 % carry out the surgery as a day case. For an overhanging facial nerve (less than 50 % of the footplate obscured), the majority stated that it would depend whether they would abandon surgery. 25.4 % have The paper was presented at the 14th British Academic Conference in Otolaryngology (BACO), held in Glasgow (UK) from 4th to 6th July 2012, and the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) held in Washington DC, October 2012. H. Lancer CT2 Vascular Surgery, Royal Free Hospital, London, UK J. Manickavasagam (&) Ninewells Hospital and University of Dundee, 84 West Road, Newport on Tay, Dundee, Scotland, UK e-mail: [email protected]
encountered a ‘gusher’ and 83.6 % would recommend revision surgery. 82.8 % have a registrar present when carrying out stapes operations, but 69.4 % only offer training to trainees with an otological interest. In the UK, stapedotomy is the preferred technique. Most prefer the Causse prosthesis, general anaesthesia and an inpatient stay. Hearing aids are advised prior to surgery. Day-case and inpatient practice is about equal. ‘Gushers’ are encountered rarely. Revision surgery is advised if a conductive loss returns. Flying is recommended from 6 weeks. Most otologists are willing to teach trainees with an otological interest. Keywords United Kingdom Stapedectomy Stapedotomy National survey
Introduction Successful management of otosclerosis requires a detailed knowledge of the disease process and a flexibility of surgical technique. Stapedotomy (making a small fenestra in the footplate and removing the stapes suprastructure), when performed by skilled surgeons, is the surgical treatment of choice for otosclerosis, with good success rates. It is one of the most technically challenging procedures, demanding excellence in surgical preparation, precision and performance. No standardized treatment protocols or guidelines are available with regard to stapes surgery in the UK. We have, therefore, investigated individual stapes surgery practice.
A. Zaman ST3 Paediatric Surgery, Alder Hey Hospital, Liverpool, UK
Methods
J. Lancer Park Hill Hospital, Doncaster, UK
In the UK there is no accurate or reliable subspecialty database and, therefore, to ascertain working practices for a
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particular (otological) procedure, one has to make allowance for this fact and be prepared to be flexible, offering a degree of latitude, as otherwise such information would seldom, if ever be obtained. This fact should be borne in mind when interpreting the findings in this paper. For without this information, we would be less informed about current UK stapes surgical practice. This study was conducted by postal questionnaire to all assumed stapes-performing otologists. Two authors individually collected contact details of all NHS hospitals in the UK by obtaining details from the BAO (British Association of Otolaryngologists) and also by detailed personal enquiries contacting individual ENT departments. Otologists not performing stapes surgery were excluded from our list. Postal questionnaires (‘‘Appendix’’) were sent to all assumed stapes surgeons with a covering letter and a reply envelope. Further postal reminders were subsequently sent to non-responders. ‘‘Appendix’’ lists the 23 questions asked. A decision was made to limit the number of questions to those listed. A more expansive list could have been prepared including details of types of audiometry performed, other pre-operative investigations including radiology, percentage risks explained to the patient, indications for surgery, precise individual technique including local anaesthesia methods where applicable, and even more precise operative findings including size of platinotomy, length of prosthesis, type of laser used where appropriate, post-operative care including drugs, dressings, instructions and complications. The senior author, who has carried out over 500 stapes operations, does offer some of his personal experiences with regard to surgical and anaesthetic techniques which may at least partly assist in advising on the above matters. Our previous experiences have informed us that if too many questions are asked, and taking the above points into account may have raised around 50 questions, there is a tendency for the respondent not to respond to the survey as it would be too onerous and time-consuming to complete. Therefore, there must be a balance and we hope that the information below offers a reasonable and balanced insight into how UK stapes surgeons practice. It may be possible in the future to expand the survey to Europe and beyond.
Results Out of 225 questionnaires that were sent out, we received 184 replies (81.8 %). Of these, 134 (72.8 %) stated that they do perform stapes surgery [stapedectomy (8.2 %), stapedotomy (91.0 %) or other (0.8 %)]. (Note this is the description offered by the respondent. The authors feel that to be called a stapedectomy the footplate should be
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removed virtually in its entirety as opposed to making a small fenestra, 0.4–0.6 mm usually, when the procedure will be called a stapedotomy). 46 (25 %) do not perform stapes surgery and 4 (2.2 %) left the question blank (3 retired, 1 maternity leave). Only those who perform stapes surgery (134) were included in the study. The number of stapes operations performed per year is represented below, with the ‘6–10 per year’ category as the most common range. Of those, 62.6 % said that this figure was accurate. The number of stapes operations performed each year were as follows: 19 perform less than 5, 47 perform 6–10, 30 perform 11–15, 16 perform 16–20, 9 perform 21–25, 6 perform 26–30 and 7 perform more than 30 operations per year (Fig. 1a). Most (105) perform stapes surgery under general anaesthesia (GA), some using GA (27) and local anaesthesia (LA) and two under LA only (Fig. 1b). Procedures carried out under LA constitute less than 10 % of overall stapes workload. On whether an anaesthetist is present during stapes surgery under LA, 102 surgeons either left the answer blank or stated non applicable and 32 answered: 59.3 % always have an anaesthetist present, 15.6 % never and 21.9 % have one present some of the time. Stapes surgery in unilateral disease is advised 89.6 % of the time (Fig. 2a). All patients are advised about trying a hearing aid prior to surgery either all of the time or some of the time (Fig. 2b). Assuming the first operation is successful, 96.3 % would perform second side stapes surgery and this is most likely to be at either 6–12 months (22.4 %), or more than 1 year post-operatively (68.7 %) (Fig. 3a, b). For the insertion of the prosthesis, the majority (88.1 %) would choose to insert the prosthesis after removing the stapes (total or partial), and the types of prosthesis used varied greatly, with a selection of 28 varieties. The top three used are Causse, Smart and Teflon (Fig. 4a). (Note these are the prosthesis descriptions offered by the respondent). 42.5 % always use a vein graft or fat to cover the fenestration, 21.6 % sometimes and 34.3 % never do (Fig. 4b). 49.3 % use a laser, 46.3 % do not and of those who do, 35.1 % always use one. 48.5 % carry out stapes as a day case. For an overhanging facial nerve ([50 % of the footplate obscured), the majority stated that it would depend on the individual circumstance as to whether they would abandon surgery (Fig. 5a). During surgery, 25.4 % have encountered a ‘gusher’ whose treatment methods include plugging, waiting, and abandoning the procedure. If after a period of success a conductive loss returns, 83.6 % would recommend revision surgery (Fig. 5b). When advising patients at what stage they were able to fly post-operatively, several categories were advised (Fig. 6a). By 6 weeks post-operatively, virtually all
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Fig. 1 a How many stapes procedures do you perform per year on average? b What type of anaesthesia do you use for stapes surgery?
Fig. 2 a Is stapes surgery advised in unilateral disease? b Are hearing aids recommended prior to surgery?
Fig. 3 a If the first operation is successful, how long would you wait to perform surgery on the second side? b Would you perform second side stapes surgery in bilateral disease assuming the first operation was successful?
surgeons allow their patients to fly. Lastly, in terms of teaching, 82.8 % have a registrar present when carrying out stapes operations, but only 25 (19 %) offer training for
stapes surgery to all trainees and 93 (69.4 %) do offer training to trainees with an otological interest only (Fig. 6b).
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Fig. 4 a What prosthesis do you use? b Do you use a vein graft or fat to cover the fenestration?
Fig. 5 a Would you abandon surgery for an overhanging facial nerve? b If conductive loss returns following a period of success, would you recommend revision surgery?
Fig. 6 a When would you advise patients that they can fly? b Do you offer training for stapes surgery to trainees?
Discussion Smyth and Hassard discovered that a smaller 0.4 mm footplate fenestra provided hearing gains similar to the standard total footplate removal techniques. The small fenestra technique was associated with a significantly
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lower incidence, both of fistula formation and immediate or delayed sensorineural hearing loss [1]. Shea has reported his experience with the small versus large fenestra technique. His stapedectomy technique included a piston over a vein graft that covered the oval window. The stapedotomy required placing a piston
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directly into the vestibule with blood as the tissue seal. He found that a smaller fenestra offered better high-frequency hearing and was easier, less traumatic and was associated with fewer complications [2]. Bailey et al. had similar results, and with small fenestra stapedotomy, there were equivalent pure-tone averages but better high frequency hearing, better speech discrimination, fewer vestibular problems and no sensorineural hearing loss compared with stapedectomy. This was postulated to be because stapedotomy was a more precise technique and the vestibule was subjected to less trauma [3]. In our study stapedotomy is preferred by 122 surgeons and stapedectomy by 11. Small-fenestra stapedotomy is the safer procedure to be performed as day-case surgery than total stapedectomy (48.5 % carry out stapes surgery as a day case) [4]. Sedwick et al. compared large and small fenestra techniques, as well as the instrument used to make the fenestra (drill or laser) with regard to effectiveness and rate of side effects. The charts of 875 patients, who underwent primary stapedectomy performed by members of the House Ear Clinic, were reviewed; a statistically significant difference between the large and small fenestra techniques in postoperative sensorineural hearing loss at higher frequency was found. However, the difference is small and is probably not clinically significant. Therefore, they found that similarly good results can be obtained by the experienced surgeon using either the large or small fenestra technique. Also, they found the laser and microdrill to be equally safe and effective in the creation of the fenestra [5]. Argon, KTP or CO2 laser has been used successfully for stapedotomy by many authors [6, 7], and in our survey, 49.3 % use a laser. A number of authors have reported that stapes surgery, in addition to improving hearing, also improves tinnitus in a majority of cases [8, 9]. Our own results show an improvement in tinnitus in around 60–70 %, but it must not be forgotten that there is a 1–2 % risk of severe and debilitating tinnitus. If after a period of success a conductive loss returns, 83.6 % would recommend revision surgery. Revision stapedectomy should be approached with caution. The risk of severe sensorineural hearing loss is from two to ten times higher than with primary stapedectomy, and these surgical procedures should only be performed by experienced surgeons [10]. If the post-operative hearing loss was immediate and conductive, it is probably because of unsuccessful ossicular chain reconstruction. If the post-operative hearing deterioration has been progressive and conductive, it may be caused by bony regrowth with refixation or displacement of the prosthesis. The type of ossicular chain reconstruction used and the type of oval window repair may be predictive of incus necrosis, oval window fistula or scarring [11].
The general consensus from reviews of revision stapedectomy is that it is less successful than primary stapedectomy, with success rates varying from 50 to 60 % [12]. Higher success rates in revision stapes surgery are obtained when the incus can be incorporated into the repair. A number of problems can occur in relation to the prosthesis and oval window. These include displaced prosthesis, short prosthesis and oval window fibrosis. A displaced prosthesis is the most common cause of failure, requiring revision surgery. This has been reported in 30–46 % cases [13, 14]. Twenty-six have encountered a ‘gusher’ during surgery. In most cases, this is associated with a congenital footplate fixation. The aetiology of the CSF gusher has been postulated to be either a widened cochlear aqueduct or a defect in the fundus of the internal auditory canal. Stapes surgery on the second ear is a controversial topic, with variable results being reported [15, 16]. Hearing loss may occur in either the first or the second operated ear. Serious sensorineural hearing loss may occur several years after the operation and, therefore, a surgeon should be cautious about recommending second-side surgery. In our survey, assuming the first operation is successful, 96.3 % would perform second side stapes surgery and this is most likely to be at either 6–12 months (22.4 %), or from 1 year post-operatively (68.7 %). De Bruijn et al. assessed the benefit obtained after second-ear stapedotomy with the Glasgow benefit plot. From the results it appears that a second operation on the contralateral side increases the chances of achieving at least one ‘normal’ hearing ear and that it makes symmetrical ‘normal’ hearing possible in the majority of the cases [17]. He concluded that bilateral stapedotomy is a safe procedure with good results [18]. A dehiscent and prolapsed facial nerve obscuring the footplate is a rare finding that can lead to the procedure being abandoned. A dehiscence of the facial nerve, where the epineurium is exposed, has been demonstrated in as many as 11.4 % of stapedectomy cases [19]. The incidence of a prolapsed or protruding facial nerve is lower, approximately 2–7 % [14, 20]. In only 0.2–0.3 % of affected patients does a prolapsed facial nerve completely obstruct the visualization of the stapes footplate [14, 15]. Of those patients in whom a facial nerve dehiscence is discovered, 25–29 % have a dehiscence in the contralateral ear [14, 21]. It has been thought that factors that contribute to facial nerve canal dehiscence include hereditary predisposition, inhibition of proper canal wall formation and a persistent stapedial artery [22]. In our survey, 37 would abandon surgery for a 50 % or more overhanging facial nerve, (18 would not) (75 undecided). Anomalies of the course of the facial nerve require specific management. Knowledge of any possible abnormalities and relevant procedures to deal
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with these is crucial for safe and successful stapedectomy [23]. Neff et al. found that, when the facial nerve covered at least 50 % of the oval window, the post-stapedectomy hearing results at 6 months and 1 year were similar to those of a matched control group of stapedectomy patients with a normal facial nerve course. They concluded that stapedectomy in patients with significant facial nerve prolapse can be performed safely with good hearing results [20]. Promontory drilling in stapedectomy may be required in cases with a narrow oval window niche, facial nerve overhang and an obliterated footplate. Drilling of the promontory in stapedectomy is required in only a small percentage of cases. Although audiometric results indicated the possibility of a slight amount of acoustic trauma from the drilling, the effect on hearing was minimal and not considered a contraindication to this procedure [24]. Lippy et al. [25] compared titanium and Robinson stainless steel stapes piston prostheses and found there was no significant difference between groups in hearing improvement or postoperative air-bone gap. Rondini-Gilli et al. analysed outcomes after otosclerosis surgery with stapedeotomy using a blood clot seal. In their study, functional failures were related to significant intralabyrinthine bleeding and revision procedures, and the following factors had no effect on outcome: (1) stapedotomy versus partial or total stapedectomy, (2) footplate opening sealed by clot or vein, (3) diameter of the stapedotomy and/or the prosthesis and (4) surgical procedure performed by a junior surgeon. They concluded that sealing the stapedotomy opening with blood clot appeared to provide reliable and reproducible functional outcome that remained stable over time. In this study, changing from partial to total stapedectomy with vein interposition did not modify the functional outcome [26]. In our survey 57 always, 29 sometimes and 46 never use a vein graft or fat to cover the fenestration. De La Cruz et al. performed a retrospective review of 356 revision stapedectomy operations performed at the House Ear Clinic and found that poorer outcome was related to incus necrosis, multiple revisions and indications for surgery other than conductive hearing loss. Revision stapedectomy can provide good air-bone gap closure in 60 % of cases, with only a small risk of sensorineural hearing loss. Although not as satisfactory as primary stapedectomy, revision stapedectomy can be offered to patients with a reasonable expectation for good air-bone gap closure [27]. Raut et al. evaluated the current practice among British Otolaryngology consultants using a questionnaire in 2002. They found that overall trend is towards centralisation,
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with a reduction in the number of surgeons undertaking stapes surgery (49.9 %). The majority of consultants (81.3 %) who undertook stapes surgery would operate for a unilateral conductive loss and 75.1 % would undertake bilateral stapes surgery. Stapedotomy was the operation of choice (82 %), with a few consultants performing partial or rarely total stapedectomies. Post-operative restrictions and follow-up times varied widely amongst surgeons, with the senior surgeons tending to be more conservative than the younger consultants [28]. In contrast to their survey, our survey covered more controversial areas around stapes surgery. Shabana et al. [29] concluded that the 0.4 mm and the 0.6 mm Teflon prostheses produced the same hearing improvement in stapes surgery for otosclerosis. Farrior et al. [30] found that there was no statistically significant difference in either hearing gain or air-bone gap overclosure between the Teflon-wire piston and the stainless-steel bucket stapes prosthesis. De Bruijn et al. determined parameters for successful stapedectomy and whether this procedure can be performed safely by surgical residents in a teaching hospital. Charts were reviewed for technique, audiological test results, complications, operative time and type of anaesthetic used. Overall, closure of the air-bone gap at 10 dB was achieved in 87 % of patients. Use of general anaesthesia and a laser-assisted, small-fenestra technique allowed residents to complete more operations, and no severe sensorineural hearing loss was noted. They concluded that residents can safely and successfully perform stapes surgery using a laser-assisted, small-fenestra technique [31]. In our study in terms of teaching, 82.8 % have a registrar present when carrying out stapes operations, but 69.4 % offer training to trainees with an otological interest only. Hughes said that fewer stapes operations are available to train residents and to maintain individual competence. Most residents in the United States perform 0–10 cases during training and produce results which are not as good as expert results, even with close supervision. After graduation, fewer cases are available to achieve expert results in private or academic practice [32]. JAA Manual of Civil Aviation Medicine states that if surgery is performed in a pilot suffering from otosclerosis, a so-called ‘closed-window-technique’ must be employed. During surgery, a perilymphatic fistula is created in the stapes footplate; then, a small piston prosthesis replacing the supra-structure of the stapes is attached to the long process of the incus and inserted into the fistula. The closed-window technique involves a sealing of this fistula by means of a vein or fascia graft. If the fistula is not sealed, the lateral displacement of the piston during a decompression could result in an opening of the fistula which
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would cause a severe attack of vestibular vertigo and a sudden loss of hearing. In order to ensure healing, pilots who have undergone stapes surgery should not fly for the next 3 months. Emphasis must be placed on the risk of opening a potential perilymphatic fistula when the ear is subjected to sudden pressure variations. If the pilot is going to fly pressurisedcabin aeroplanes, events resulting from a sudden decompression must be anticipated [33]. Between 1977 and 1995, Katzav et al. performed nine stapedectomies using the Robinson-vein graft technique on six high-performance airplane pilots diagnosed with otosclerosis. All of them returned to full active duty after stapedectomy without any vestibular symptoms. These cases illustrate that it can be safe for fighter or test pilots to return to full flight status after stapedectomy. These cases also suggest that full flight status can be reinstated as soon as 3 months after stapedectomy without endangering flight safety [34]. In the UK, most (105) perform stapes surgery under GA, some (27) using GA and LA and two under LA only. The technique of performing stapes surgery under LA, the senior author’s preferred technique in over 80 % of his cases, is well-described [35], and Lancer and Fisch found excellent outcomes with regard to both surgeon and patient satisfaction ratings when performing stapes surgery under LA [35]. While clearly all surgeons will have their own technique of performing stapes surgery, the senior author has utilised the same technique over a 25-year period, learnt from Prof Ugo Fisch. It was felt that including individual techniques in detail from the respondents would be too lengthy, although the senior author offers his technique, utilised in most cases, but variation is obviously expected. The method of regional ear anaesthesia is well documented (35) and is performed by the surgeon. The anaesthetist then administers intravenous midazolam up to 10 mg and deals with appropriate cardiovascular and airway monitoring. Steroids are not given. A nasal catheter is applied supplying oxygen. No premedication is given as the surgery would usually be performed as a day case. A moderate degree of patient arousal is necessary as the surgeon will speak to the patient at the end of the procedure to ensure improved hearing and appropriate prosthesis placement. An endaural incision is made and a tympanomeatal flap is raised. The overhang is curetted and the chorda would usually be preserved. The diagnosis is confirmed and the incus-footplate distance is measured. At this point intravenous prochlorperazine 12.5 mg is given to help counteract the effects of nausea sometimes associated with the next step. A fenestra is fashioned in the footplate using graduated hand trephines (0.3–0.6 mm). In all cases a
Fisch Teflon-platinum prosthesis 0.4 9 6 mm (cut to size) is used and the prosthesis is inserted and crimped. Then the stapedius tendon is divided, the posterior crus is cut with crurotomy scissors, the anterior crus is fractured and the stapes suprastructure is removed. Pieces of fat taken from around the incision are used to seal the footplate to help reduce any leak of perilymph and the flap is then closed. A Pope oto-wick is inserted into the ear canal and enlarged with saline, and antibiotic-soaked ribbon gauze packs the remainder of the ear canal. A hyoscine patch is placed over the contralateral mastoid process. An ear pad is applied. The patient goes home with oral prochlorperazine 5 mg twice daily, and dressings are removed in 1 week. The patient then receives a 1-week course of topical antibiotic/ steroid drops. There are few limitations in our study. Sampling bias could be possible with the study group as this study was conducted by postal questionnaire to all assumed stapesperforming otologists. However, and to minimise selection bias, multiple checks were carried out to make sure only stapes-performing otologists were included in this survey. The questionnaire has not been validated; however, it deals with all key controversial aspects in stapes surgery. Although the revealed retrospective data are not all new, this paper depicts both the overall general approach to stapes surgery and the current practice in UK. As most surgeons performed less than ten cases per year, their opinion on difficult situations such as managing an overhanging facial nerve or a ‘gusher’ should be received with caution. Unfortunately, this is one of the challenges for future stapes surgeons in UK. Decreasing number of cases leave the surgeons less skillful, with need for centralization. Most UK patients receive treatment via the National Health Service (NHS). Such treatment is free at the point of delivery and is funded from general taxation, and as a result there are major cost pressures. With regard to preoperative CT scanning, of course there are benefits, but the positive pick-up rate which could determine a possible ‘gusher’, or indeed any other abnormality, is extremely low. Such an investigation is, therefore, carried out seldom, but of course a high suspicion of a possible abnormality would indeed warrant such an investigation.
Conclusion In the UK, stapedotomy is the preferred technique. The Causse prosthesis is the most widely used, and general anaesthesia is preferred, along with an inpatient stay. Hearing aids are advised prior to surgery. The frequency of operations as day-case and inpatient is reasonably similar. ‘Gushers’, although rare, can be treated in numerous ways.
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Revision surgery is advised if a conductive loss returns. Flying is generally recommended from 6 weeks post-operatively. Most otology surgeons are willing to teach trainees, especially those with an otological interest. No standardised treatment protocols or guidelines are available with regard to stapes surgery in the UK, where there are wide variations in stapes surgery practice. Conflict of interest
None.
Appendix: Questionnaire The questionnaire was composed of 23 questions, as listed below: • • • • • •
• • • •
• • • • • • • • • • • • • •
Do you perform stapes surgery? How many operations do you perform per year on average? Is this figure an estimate? Or is this figure accurate? Do you ever perform stapes surgery under general anaesthetic/local anaesthetic/both? If you do use local anaesthesia, what percentage of stapes operations of your overall workload would that be? If under local anaesthesia, do you have an anaesthetist present? Would you advise stapes surgery in unilateral disease? In clinic, would you advise patients about trying a hearing aid prior to surgery? Would you perform second side stapes surgery in bilateral disease, assuming the first operation was successful? If the first operation was successful, how long do you wait until you carry out surgery on the second side? Which is your preferred technique? At what point in the procedure would you insert the prosthesis? What prosthesis do you use? Do you use vein graft or fat to cover the fenestration? Do you use a laser? If yes, then how often? Do you carry out stapes surgery as a day case? Would you abandon surgery for an overhanging facial nerve? Have you ever encountered a ‘gusher’ during surgery? If yes then how did you treat it? Would you recommend revision surgery if a conductive hearing loss returns? When would you advise patients that they can fly? Do you have a registrar present when carrying out stapes surgery?
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•
Do you offer training for stapes surgery to all trainees or those with otological interest only?
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Eur Arch Otorhinolaryngol 22. Kaplan J (1960) Congenital dehiscence of the fallopian canal in middle ear surgery. Arch Otolaryngol 72:197–200 23. Szymanski M, Golabek W, Morshed K (2003) Stapedectomy and variations of the facial nerve. Ann Univ Mariae Curie Sklodowska Med 58(2):101–105 24. Lippy WH, Berenholz LP, Schuring AG, Rizer FM, Burkey JM (2002) Promontory drilling in stapedectomy. Otol Neurotol 23(4):439–441 25. Lippy WH, Burkey JM, Schuring AG, Berenholz LP (2005) Comparison of titanium and Robinson stainless steel stapes piston prostheses. Otol Neurotol 26(5):874–877 26. Rondini-Gilli E, Bozorg Grayeli A, Boutin P, Tormin Borges Crosara PF, Mosnier I, Bouccara D et al (2002) Otosclerosis surgical techniques and results in 150 patients [French]. Ann Otolaryngol Chir Cervico-Faciale 119(4):227–233 27. De La Cruz A, Fayad JN (2000) Revision stapedectomy. Otolaryngol Head Neck Surg 123(6):728–732 28. Raut VV, Toner JG, Kerr AG, Stevenson M (2002) Management of otosclerosis in the UK. Clin Otolaryngol Allied Sci 27(2):113–119
29. Shabana YK, Ghonim MR, Pedersen CBS (1999) tapedotomy: does prosthesis diameter affect outcome? Clin Otolaryngol Allied Sci 24(2):91–94 30. Farrior JB, Temple AE (1999) Teflon-wire piston or stainlesssteel bucket stapes prosthesis: does it make a difference? Ear Nose Throat J 78(4):252–253 (257–60) 31. Mathews SB, Rasgon BM, Byl FM (1999) Stapes surgery in a residency training program. Laryngoscope 109(1):52–53 32. Hughes GB (1991) The learning curve in stapes surgery. Laryngoscope 101(12):1280–1284 33. Joint Aviation Authorities (2009) JAA Manual of Civil Aviation Medicine. http://www.norskflymedisin.no/filer/kompendier/JAA% 20Manual%20of%20Civil%20Aviation%20Medicine%20Amdt% 206%202009%20web.pdf. Accessed 13 Dec 2012 34. Katzav J, Lippy WH, Shamiss A, Davidson BZ (1996) Stapedectomy in combat pilots. Am J Otol 17(6):847–849 35. Lancer JM, Fisch U (1988) Local Anaesthesia for middle ear surgery. Clin Otolaryngol Allied Sci Oct 13(5):367–374
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