A meta-analysis of surgical success rates in congenital stapes fixation and juvenile otosclerosis

Juvenile otosclerosis and congenital stapes footplate fixation. A systematic review and meta-analysis of surgical outcomes and management

OBJECTIVE

Juvenile Otosclerosis (JO) and Congenital Stapes Footplate Fixation (CSFF) are rare ossicular chain disorders seen in the paediatric population and present with conductive hearing loss. Ongoing controversy exists regarding the role of surgical intervention in JO and CSFF given the poorer hearing outcomes and complications when compared with surgical intervention for adult otosclerosis. The objective of this study is to assess the published data on the surgical outcomes of JO and CSFF in order to guide clinicians and counsel patients on the various medical options for these disease entities.

METHODS

A systematic review of MEDLINE, EMBASE and Cochrane was performed with inclusion criteria of children with JO or CSFF and hearing outcomes following stapes surgery. Studies identified by the search were reviewed and assessed by two independent reviewers in line with the PRISMA guidelines.

RESULTS

464 articles were initially reviewed and 28 articles met inclusion in the systematic review and meta-analysis. A total of 810 ears (473 and 337 cases of JO and CSFF respectively) underwent stapes surgery. Average age at time of surgery for JO and CSFF was 14.3 and 10.2 years old respectively. The mean pre-operative Air-Bone-Gap (ABG) for JO and CSFF was 31.8 ± 5.2 dB and 39.4 ± 10 dB respectively. Following stapes surgery, the mean post-operative ABG for JO and CSFF was 9.6 ± 6 dB and 19.2 ± 12.5 dB respectively. Surgical success rate (defined as ABG <10 dB) was 81% for JO and 41% for CSFF. Mean ABG gain for JO and CSFF was 24.8 dB (95% CI: 18.6-33.1) and 22.6 dB (95% CI: 18.4-27.8) respectively. The reported number of dead ears was 4/473 (0.8%) for JO and 2/337 (0.6%) for CSFF. 23 cases (2.8%) reported sensorineural hearing loss (SNHL) >10 dB.

CONCLUSION

CSFF was associated with poorer hearing outcomes compared to JO, however both entities showed similar improvement in ABG post operatively. Counselling patients and their families on the surgical success rates and complications of JO or CSFF is an important part of the decision making process when deciding between a surgical option or conservative measures such as hearing aids.

Management of Juvenile Otosclerosis: A Systematic Review

Background. Otosclerosis can occur during childhood, resulting in the early onset of conductive hearing loss. The approach to a child with otosclerosis can present some difficulties in terms of diagnosis and treatment, and the literature on juvenile otosclerosis (JO) is still relatively limited. Aim. To explore the current approaches to JO, in order to clear the management of this condition and evaluate the outcomes and the possible complications of surgical treatment. Methods. A systematic review was performed according to PRISMA guidelines, searching Medline and Embase from January 2002 through to 30 September 2022. A total of 759 papers were identified but based on specified criteria, nine were included in this study. Results. There were 94 children affected by JO and treated by stapes surgery. According to the available data, Male: Female ratio was 1:3−4, whilst the mean ages ranged from 10 to 16.3 years at the time of stapes surgery. After stapes surgery, the target of ABG < 10 dB was achieved in most of the patients. Overall, the 4 complications were reported (4/94= 4%): stenosis of the external ear canal, deterioration of hearing, anacusis with vertigo, tinnitus. Conclusions. The heterogeneity of the available studies does not allow us to draw straight conclusions on this topic, currently. More data about the natural history of the disease in children could help in approaching the treatment correctly, and possibly in drawing guidelines. Studies with a prolonged follow-up could be helpful for assisting clinicians and families in taking the most favorable decision about treatment.

Preoperative Evaluation of Otosclerosis: A National Survey of Otologists

OBJECTIVE

Describe practice patterns in preoperative assessment for stapedectomy.

STUDY DESIGN

Survey.

SETTING

Tertiary referral center.

SUBJECTS

Active members of the American Neurotologic Society and American Otologic Society.

INTERVENTION

Survey.

MAIN OUTCOME MEASURES

Percent of respondents performing preoperative testing with acoustic reflexes (ARs), electrocochleography, vestibular evoked myogenic potentials, and computed tomography (CT). Further analysis of those not ordering routine CT to determine whether imaging would be ordered for previous ear surgery, vestibular complaints, childhood hearing loss, AR inconsistent with otosclerosis, possible advanced otosclerosis, or atypical complaints, including autophony. Further subgroup analysis based on years in practice and practice setting (private versus academic).

RESULTS

Most respondents (56.5%) had practiced more than 15 years and worked in academic settings (69.4%). Rates of routine use of preoperative AR, vestibular evoked myogenic potential, and electrocochleography were 80, 4.7, and 0%, respectively. There were no significant differences based on time in practice or practice settings. For CT, 35.3% reported routine use with a statistically significant difference between academic and private practice respondents (42.4% versus 19.2%, p = 0.040). For CT contingent on specific clinical factors, only AR inconsistent with otosclerosis showed a statistically significant difference between academic and private practice providers (85.3% versus 57.1%, p = 0.020).

CONCLUSION

Most otologists routinely obtain AR before stapedectomy. Academic providers more commonly order CT routinely and for AR inconsistent with otosclerosis. Most respondents not ordering routine CT ordered imaging in specific clinical scenarios. Overall, there is a high level of consistency in preoperative testing regardless of practice setting or time in practice.

Outcomes in primary and revision surgery for pediatric onset stapedial pathology

OBJECTIVES

To analyze audiometric outcomes of surgery for pediatric onset stapedial pathology (POSP).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single-institution database.

METHODS

Retrospective analysis of 809 stapes procedures performed at a single high-volume tertiary referral otology practice, 75 of which were POSP cases.

RESULTS

Oval window drillout for thick footplate and aborting the procedure were more common in POSP cases compared to the rest of the cohort (28.0% versus 9.8% [p < .001] and 5.3% versus 1.2% [p = .007], respectively). Postoperative complications were rare. Postoperative Air-Bone Gap (pABG) closure to ≤20 dB was significantly lower in the POSP group (80.0% versus 89.0%, p = .021). Rates of sensorineural hearing loss (SNHL) were not different between the two groups. Poor audiometric outcomes in the POSP group were largely driven by revision cases; pABG≤10 dB was 60.3% in primary cases but only 11.8% in revisions (p < .001), and postoperative SNHL was significantly higher in revisions (29.4% versus 0.0%, p < .001). In multivariate analysis, POSP was not a predictor of successful closure of the pABG at either level, nor did it predict significant postoperative SNHL.

CONCLUSIONS

Surgery for pediatric onset stapedial pathology had significantly worse audiometric outcomes, particularly in revision cases, as compared to the rest of the cohort.

Multicenter Study of Congenital Middle Ear Anomalies. Report on 246 Ears

OBJECTIVES/HYPOTHESIS

Congenital middle ear anomalies represent a relatively rare condition. This study aimed to describe the characteristics and the surgical outcomes for patients with middle ear anomalies.

METHODS

A multicenter study was conducted of consecutive patients with congenital middle ear anomalies who underwent primary surgical treatment between January 2008 and December 2017. Demographics, surgical procedures, and audiometric data were registered into the institutional database. Hearing changes and postoperative air-bone gap (ABG) were evaluated 1 year after surgery.

RESULTS

A total of 246 patients (246 ears) (median age: 14 years, range: 4-75 years old) were included in this study. Anomalies were subdivided using the Teunissen and Cremers classification: 53 ears (22%) were categorized as class I, comprising only stapes ankylosis; 35 ears (14%) as class II, having ossicular chain anomalies with stapes ankylosis; 139 ears (57%) as class III, having ossicular chain anomalies with a mobile stapes-footplate; and 19 ears (8%) as class IV, with aplasia of the oval window. Evaluation of hearing outcomes for 198 ears with more than 1 year of follow-up revealed that good postoperative ABG (≤20 dB) was achieved in 82% of class I, 68% of class II, 74% of class III, and 23% of class IV anomalies. The postoperative ABG in class IV was significantly worse than in class I (P < .001) or class III (P < .01).

CONCLUSIONS

This study demonstrated that class III anomalies comprised the majority of middle ear anomalies and surgical outcomes for class IV anomalies are unfavorable.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2323-E2328, 2021.

Delayed-Onset NOG Gene-Related Syndromic Conductive Deafness: A Case Report

We report a 6-year-old girl with progressive bilateral conductive hearing loss for 2 years. She passed the newborn hearing screening conducted with otoacoustic emissions testing and had a normal development of speech and language, which indicated that her deafness was delayed-onset. She also had congenital proximal interphalangeal joints. Proximal symphalangism was confirmed by genetic testing (NOG gene: c.406C > T, p.R136C). Bilateral stapes ankyloses were proved by surgery and her hearing was improved after stapedotomy by over 30 dB. Besides, this case should remind clinicians to carefully distinguish NOG gene-related deafness from congenital ossicular malformation and pediatric otosclerosis.

Outcomes Following Revision Stapes Surgery in Children: A Single-Surgeon, Single-Center 15-Year Experience

OBJECTIVE

To review a single surgeon experience with revision pediatric stapes surgery for congenital stapes fixation (CSF) and tympanosclerosis (TS). Secondly, to determine whether hearing outcomes following revision surgery may be predicted by a thorough work-up aimed at assessing whether an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.

SETTING

Tertiary referral center.

STUDY DESIGN

Retrospective chart review.

PATIENTS

Fifteen patients having revision surgery for fixation of the stapes footplate over a 15-year period.

MAIN OUTCOME MEASURES

Hearing results based on pre- and post-revision pure-tone average air-bone gap (PTA-ABG) and speech recognition threshold testing (SRT).

RESULTS

Overall, the mean improvement of PTA-ABG following revision surgery was 11.9 dB (standard deviation [SD] 15.2) while SRTs improved by a mean of 12.3 (SD 19.9). Outcomes were significantly better in patients who reported a history of trauma following their initial surgery, when there was otoscopic evidence of an extruding or extruded prosthesis and/or a pre-revision CT (where performed) suggested an extruded or malpositioned prosthesis. No patients had a significant postoperative sensorineural hearing loss.

CONCLUSION

Revision stapes surgery in children is a safe procedure in experienced hands which nonetheless should only be contemplated in patients in whom preoperative work-up suggests an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Microscopic vs Endoscopic Ear Surgery for Congenital Ossicular Anomaly

Objective

To compare surgical outcomes of transcanal endoscopic ear surgery (TEES) for congenital ossicular anomalies with those of conventional microscopic surgery.

Study Design

Retrospective case review.

Setting

Tertiary referral academic center.

Subjects and Methods

From March 2012 to November 2018, 42 consecutive ears in 40 patients with congenital ossicular anomaly who underwent ossiculoplasty or stapes surgery using either ear endoscopes (TEES group) or an operating microscope (microscopic group) were included. Postoperative audiometric results, operation time, switch of approach, and complications were compared between the 2 groups.

Results

Twenty-four ears (66.1%) were in the microscopic group and 18 ears (33.9%) were in the TEES group. The mean (SD) preoperative air-bone gap was 31.8 (10.0) dB in the microscopic group and 35.2 (11.1) dB in the TEES group. The mean (SD) postoperative air-bone gap was 7.4 (6.5) dB in the microscopic group and 5.6 (5.0) dB in the TEES group. The differences in the preoperative and postoperative air-bone gaps between the 2 groups were not statistically significant ( P = .316 and P = .412, respectively). Average operation time in the TEES group was 24.6 minutes shorter than that in the microscopic group, which was statistically significant ( P = .019). None of patients in the TEES group did require a switch of approach. There was no significant difference in complication incidence between the 2 groups.

Conclusions

TEES for congenital ossicular anomaly has comparable audiometric results and complication rates to conventional microscopic surgery. TEES appears to have the advantages of shorter operation times.

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.

Controversies in the Evaluation and Management of Otosclerosis

Controversies have been associated with the etiology, diagnosis, evaluation, and management of otosclerosis since Valsalva first described stapes fixation as a cause of hearing loss. Although the exact mechanism of the bone remodeling associated with otosclerosis remains uncertain, stapedotomy has been accepted as the surgical treatment of most patients with stapedial otosclerosis. There remains a disparity of opinion, however, regarding the role of preoperative imaging, surgical technique, implant selection, and medical therapy for cochlear otosclerosis. In addition, opinions vary regarding the optimal postoperative care of patients undergoing stapedotomy and a patient's ability to participate in activities that may result in barotrauma.

Revision Stapedectomy in a Female Patient with Inner Ear Malformation

Objectives. We describe an unusual case of surgical management of congenital mixed hearing loss in a female patient with inner ear malformation. This report outlines the role of temporal bone imaging and previous surgical history in evaluating a patient's risk of perilymph gusher during stapes surgery. Methods. A 68-year-old female patient with a history of profound bilateral mixed hearing loss due to ossicular and cochlear malformation presented to our otology clinic. She had undergone multiple unsuccessful previous ear surgeries. Computed tomography revealed bilateral inner ear malformations. She elected to proceed with revision stapedectomy. Results. The patient received modest benefit to hearing, and no operative complications occurred. Conclusions. Although stapedectomy has been shown to improve hearing in patients with stapes fixation, there is risk of perilymph gusher in patients with inner ear abnormalities. Evaluation and counseling of the risk of gusher during stapes surgery should be done on a case-by-case basis.