Long Process Incus necrosis in Revision Stapedotomy: Retrospective Clinical Study

Objectives: We describe our experience with long process incus (LPI) necrosis in revision stapedotomy and discuss the different management methods proposed in the literature to identify surgical techniques that can lead to satisfactory results over time. Methods: Twenty-two stapedotomy revisions, in 21 patients with the necrosis of the long process of the incus, are performed from 1997 to 2017. In cases of erosion or minimal necrosis of LPI, a new prosthesis of the same type or an angled prosthesis was applied higher on the residual incus stump. In cases of partial necrosis of LPI, a Donaldson type ventilation tube reshaped and placed on the residual incus stump to stabilize prosthesis, or glass ionomer bone cement was used. In cases of subtotal necrosis of LPI, a cup piston prosthesis in polycel was applied on incus residual stump. Pre- and postoperative (≥1 year) pure tone audiometry was performed for all cases. Air conduction threshold, bone conduction (BC) threshold, and air-bone gap (ABG) were documented according to the American Academy of Otolaryngology Head and Neck Surgery Committee of Hearing and Equilibrium guidelines. Results: At 1-year follow-up, postoperative ABG was reduced to ≤10 dB in 13 (59%) cases and ≤20 dB in 19 (86.4%) cases. The mean postoperative ABG significantly decreased in each group. There was no significant change in postoperative BC thresholds, and there were no cases with postoperative SNHL. Conclusion: Excellent functional results can also be achieved in cases of long incus process necrosis. The choice of technique should be considered according to the degree of necrosis. Piston replacement with the same type or angled type prosthesis, in cases of erosion or minimal LPI necrosis, and modified Donaldson type ventilation tube, in cases of partial LPI necrosis, provided excellent hearing results.

Endoscopic exploratory tympanotomy in cases of conductive hearing loss with intact tympanic membrane: our experience

<p class="abstract"><strong>Background:</strong> Determining the cause of conductive hearing loss with an intact tympanic membrane has been a challenge for the otologists for over decades<strong>. </strong>The aim of this study is to ascertain the usefulness of endoscopes to study the various middle ear pathologies on performing endoscopic exploratory tympanotomy.</p><p class="abstract"><strong>Methods:</strong> A retrospective analysis of various pathologies encountered in the middle ear in 88 patients who underwent endoscopic exploratory tympanotomy done over a study period of 3.5 years (January 2015 to June 2018). </p><p class="abstract"><strong>Results:</strong> In our study, age of the patients ranged from 14 to 50 years with a mean age of 32 years. Most common finding on exploration was otosclerosis in 59 patients followed by revision stapedotomy in 12 patients. 5 patients had normal middle ear findings with all ossicles intact and mobile while other pathologies encountered were tympanosclerosis (4.6%), biscuit foot plate (2.3%), mucosal bands (3.4%) and middle ear developmental anomalies (3.4%).</p><p class="abstract"><strong>Conclusions:</strong> On exploring the middle ear<strong> </strong>knowing the various aetiologies helps in better preoperative counseling of the patients for the outcome of surgery. Endoscopic approach for exploratory tympanotomy has the benefit of excellent resolution with higher magnification and wider panoramic view of middle ear anatomy.</p><p> </p>

A Critical Look Into Stapedotomy Learning Curve: Influence of Patient Characteristics and Different Criteria Defining Success

Purpose: To evaluate stapedotomy learning curve with cumulative summation methodology using different success criteria (ie, air-bone gap [ABG] ≤10 dB, ABG ≤15 dB, restoration of interaural symmetry, or hearing threshold gain >20 dB), and to assess patient characteristics influencing or modifying the learning curve. Methods: Retrospective chart review of primary and revision stapedotomy cases performed by surgeon 1 (S1, n = 78) and surgeon 2 (S2, n = 85). Results: Using the classic criterion for a successful stapedotomy (ABG ≤10 dB), patients with preoperative ABG >34 dB were associated with unsuccessful procedures (S1 P = .02; S2 P = .07). Revision surgery was associated with unsuccessful outcomes (S1 P = .005; S2 P = .0012). Cumulative summation plots using different criteria did not show a linear trend of association between stapedotomy success and number of operations, but preoperative characteristics of the patients who underwent stapedotomy significantly influenced the plots. Cumulative summation plots showed an initial increasing tendency with improving results, but when ear surgeons got more skilled, they operated on more complex cases (ie, patients with higher preoperative ABG or revision stapedotomy) and they could not meet the success criteria. Conclusions: Cumulative summation plots do not seem useful to evaluate the stapedotomy learning curve, as they do not correctly deal with heterogeneous case series. The increasing complexity of the stapedotomy patients during the surgeons’ career impacts on the outcome of stapedotomy and confounds the evaluation of the growing skills of the surgeon. Stapedotomy audiological success rates are strongly influenced by the success criteria used.