CO2 Laser Stapedotomy with the “One-Shot” Technique— Clinical Results

Endoscopic stapedotomy: A comparison between the conventional approach versus CO2 laser-assisted surgery

Background

Although the utility of laser fiber in microscopic stapes surgery has been documented in the past, their role can be highly emphasized in endoscopic stapes surgery, especially in difficult anatomical situations.

Methods

This is a retrospective analysis of cases where a total of 46 patients (22 in conventional stapedotomy and 24 in CO2 laser-assisted stapedotomy) were included in the study. The clinical parameters were assessed both in the preoperative and postoperative periods in the respective groups and later compared 12 weeks after stapedotomy.

Results

A total of 90.90% (20/22) of the patients in the conventional stapedotomy and 95.83% (23/24) of patients in laser-assisted stapedotomy had <20 dB of AB gap in the postoperative period (P = 0.71). Canaloplasty was required in six patients in the conventional stapedotomy and none of the patients in the laser group needed the same (P = 0.01). Chorda tympani nerve was manipulated in 59.09% (13/22) and 25.00% (6/24) of cases in the conventional group and in the CO2 laser group, respectively (P = 0.01).

Conclusion

Although the audiological outcomes with fiber-enabled CO2 laser in endoscopic stapedotomy are comparable to conventional surgery, it is a better tool in a narrow auditory canal, requiring minimal manipulation of the chorda tympani nerve.

Rates of Sensorineural Hearing Loss and Revision Surgery After Stapedotomy: A Single-institution Experience Using the Nitinol Prosthesis

Background

Historically, stapedectomy complication rates are quoted as 1% profound postoperative sensorineural hearing loss (SNHL), 5%-10% nonprofound SNHL, and 5%-10% revision surgery.

Objective

We sought to reassess rates of post-stapedotomy complications based on our experience using contemporary surgical technique.

Methods

A retrospective case series was carried out at an academic tertiary referral center. Adult patients undergoing stapedotomy from 2013 to 2020 were included. Primary outcomes were rates of hearing loss and revision surgery. Rates of dizziness, tinnitus, dysgeusia, and proportions of patients who achieved air-bone gap (ABG) closure at 8-12 weeks postoperatively were also assessed.

Results

Four hundred sixty-eight stapedotomies in 399 patients with a median follow-up duration of 99 days (range, 11-5134) were reviewed. One patient (0.21%) suffered profound SHNL and 15 (3.20%) patients suffered nonprofound SNHL. The revision rate for stapedotomies from our institution was 4.49% (21 total revision surgeries). In 277 operations (59.19%), the patient had closure of the ABG within 10 dB. A further 132 (28.21%) had closure of the ABG between 10 and 20 dB. Air pure-tone audiometry scores improved by an average of 25.03 dB. Eighty-three (17.74%) patients complained of postoperative dizziness, which resolved by the time of the first follow-up appointment in all but 26 (5.56%). Seventeen patients (3.63%) complained of tinnitus, and 22 (4.70%) complained of dysgeusia.

Conclusions

SNHL, complications, and revision rates for stapedotomy in the modern era may be substantially lower than those currently presented to patients based on classic techniques and historical data.

“Hot” vs “Cold” endoscopic stapes surgery: a matched case–control study

Purpose

To compare hearing results and complication rates between two groups of patients operated on by endoscopic stapes surgery (ESS) for otosclerosis, either with CO2 fiber laser or microdrill.

Methods

A case–control study was performed. All consecutive cases of CO2 fiber laser ESS operated at a single center during the period 2017–2020 (case group) were matched to a control group of patients operated by traditional technique, according to year of surgery, preoperative mean air–bone gap, sex and age. Audiological data from preoperative and postoperative examinations and complication rates were compared.

Results

46 cases were included. Mean operative time was significantly longer in the laser cohort (65 min) than in the drill one (45 min) (p = 0.003). Similar results were found in the two groups regarding the mean postoperative BC-PTA. The high-frequency bone conduction resulted significantly higher in the laser group (p = 0.002), suggesting an overclosure effect in the laser group. Consistently, a significant improvement of the BC-PTA threshold at 2000 Hz postoperatively was found in the laser group (p = 0.034). The postoperative AC-PTA significantly improved in both groups at all frequencies (p < 0.05), except for the AC threshold at 8 kHz. Similar rates of complications were found in the two groups.

Conclusion

This study is the first to compare hearing results and complications between CO2 fiber laser and microdrill in ESS. Our results demonstrated similar functional outcomes between the two groups, confirming ESS as safe and effective, regardless of the technique used.

Comparative ex vivo Investigations on the Cutting Quality of the CO2 Laser and the Diode Pumped Er:YAG Laser

Objectives: A sufficient histological evaluation is a key pillar in oncological treatment, especially in situations of cancer of unknown primary. CO2 laser technology is used in clinical routine of soft tissue surgery because of its cutting quality and availability. Diode pumped solid state Er(bium):YAG laser systems promise a higher cutting efficiency and minor thermal damages. The aim of this study was to compare both laser systems with respect to their suitability for cutting soft tissue. Methods: A setup was realized which enables comparable experiments with the clinical CO2 laser (AcuPulse 40ST DUO, Lumenis) and the Er:YAG laser system (DPM 40, Pantec Biosolutions AG). Fresh mucosal samples of porcine tongues were used to determine the influence of laser power and sample velocity on cutting depth and thermal damage width for both lasers. In addition, for the Er:YAG laser, the influence of the pulse repetition rate was examined additionally. For analysis, images of histological sections were taken. Results: In all experiments, the Er:YAG laser shows a significantly higher cutting depth (P < 0.0001) and less thermal damage width (P < 0.0001) than the CO2 laser. For example, at an average power of 7.7 W and a sample velocity of 5 mm/s the Er:YAG laser shows a mean cutting depth of 1.1 mm compared to the CO2 laser with 500 μm. While the Er:YAG laser shows a mean thermal damage width of 70 μm compared to 120 μm. Furthermore, the Er:YAG enables the adjustment of the cutting depth and thermal damage width by varying the irradiation parameters. A decrease of the repetition rate leads to a reduction of thermal damage. For example, a repetition rate of 100 Hz results in a thermal damage width of 46 μm compared to 87 μm at 800 Hz at an average power of 7.7 W and a cutting velocity = 5 mm/s while a homogenous cutting quality can be achieved. Conclusions: In conclusion, the results of these ex vivo experiments demonstrate significant advantages of the diode pumped Er:YAG laser system for soft tissue ablation compared to the CO2 laser, in particular regarding cutting efficiency and thermal damage width.

Evaluation of Audiological Results and Cochleo-Vestibular Subclinical Injury After CO2 Laser Stapedotomy

BACKGROUND AND OBJECTIVES

Evaluation of the effectiveness and safety of CO₂ laser stapedotomy, focusing on the audiological results, and on the surgical cochleo-vestibular trauma.

STUDY DESIGN/MATERIALS AND METHODS

Retrospective clinical trial on 38 patients with the diagnosis of otosclerosis, who underwent CO₂ laser stapedotomy between January 2015 and October 2019. Postoperative air-bone gap (ABG), mean air conduction gain, and postoperative changes of high frequency threshold were evaluated 1, 3, 6, and 12 months after surgery. Videoculography (VOG) was performed to assess the vestibular impairment preoperatively and 1 day, 1 week, and 1 month after surgery.

RESULTS

Postoperative ABG closure within 10 dB was obtained in 35 cases (92.1%), with a mean postoperative ABG of 4.4 dB and a mean air conduction improvement of 32.3 dB. No significant worsening of high frequency threshold was observed. Spontaneous nystagmus was found preoperatively in 5/38 patients (13.2%), 1 day after surgery in 13/38 patients (34.2%), 1 week after surgery in 12/38 patients (31.6%), and 1 month after surgery in 4/38 patients (10.5%). Positional nystagmus was found preoperatively in 12/38 patients (31.6%), 1 day after surgery in 25/38 patients (65.8%), 1 week after surgery in 22/38 patients (57.9%), and 1 month after surgery in 10/38 patients (26.3%). The occurrence of nystagmus did not always correlate with vestibular symptoms: after surgery, 10 patients (26.3%) experienced vertigo associated with dizziness, 8 patients (21.1%) suffered from dizziness without vertigo, and 14 patients (36.8%) showed nystagmus without any symptomatology. At 1 month after surgery none of the patients complained about vestibular symptoms.

CONCLUSION

CO₂ laser stapedotomy is a safe and effective technique, which allows to obtain good functional results with minimal perioperative cochleo-vestibular trauma.© 2021 Wiley Periodicals LLC.

Flexible Fiber Optic Carbon-Dioxide Laser Assisted Stapedotomy in Otosclerosis

Objective. The aim of this study is to analyze the hearing and vestibular outcome of patients with otosclerosis who have been operated on by fiber optic flexible CO₂ laser. Study Design. A preliminary and retrospective study was conducted in 30 patients with otosclerosis. Results. Comparative analysis of average air conduction thresholds (53.41 ± 11.81 dB versus 26.37 ± 11.04 dB) and air-bone gaps (34 ± 9.92 dB versus 12.03 ± 6.02 dB) before and after the surgery were statistically significant (<0.001). Air-bone gap closed within 10 dB or less in 50% of the cases and within 20 dB or less in 90% of the cases. Average bone conduction threshold after the surgery (16.68 ± 12.00 dB) was better than that before the surgery (20.13 ± 8.59). However, no statistically significant difference was found (p = 0.213). One patient had tinnitus after surgery. None of the patients had severe sickness or vomiting due to surgery. Eleven patients (36.6%) had very mild nystagmus beating toward the counter-lateral side. All patients were stable at 10 days after surgery. Conclusion. The results indicate that fiber optic flexible CO₂ laser provides the surgeon with a very safe and precise surgical instrumentation even in cases with extensive and obliterative otosclerosis.

Long-term follow-up after "one-shot" CO2 laser stapedotomy: is the functional outcome stable during the years?

The use of "one-shot" CO₂ laser technique for a primary small-fenestra stapedotomy is well established, but few papers report the long-term functional results. We retrospectively reviewed medical records of 198 patients, treated for otosclerosis from January 2008 to December 2011, at the Department of Head and Neck Surgery, Catholic University of Rome. Statistical comparison between audiological thresholds obtained 24 h preoperatively, at early (4 weeks) and late postoperative examinations (mean time 45 months), was performed. Comparison of preoperative vs both early and late postoperative ACPTA showed a statistically significant difference (respectively 55 vs 33 and 31 dB; p < 0.001). No statistical difference was observed between preoperative, early and late postoperative BCPTA (respectively 23 vs 23 and 22 dB; p > 0.05). Both early and late postoperative ABG improved significantly compared to the preoperative one (respectively 10 and 9 vs 32 dB; p < 0.001). No statistical difference was found in comparison of early vs late postoperative ACPTA (respectively 33 vs 31 dB; p > 0.05), early vs late postoperative ABG (respectively 10 vs 9 dB; p > 0.05) and early vs late ABG gain (respectively 22 vs 23 dB; p > 0.05). No subjects developed postoperative complications requiring revision surgery or late deterioration of hearing threshold. The analysis of our data suggests that "one-shot" CO₂ laser stapedotomy is an effective and safe procedure: it allows a rapid stapedotomy without damages for the inner ear and optimal functional results that remain stable during the years.

The "One Shot" Diode Laser Stapedotomy

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and the safety of diode laser stapedotomy, through the functional results analysis.

MATERIALS AND METHODS

A total of 179 primary cases of otosclerosis that had been operated on with a diode laser technique from 2004 to 2012 were retrospectively reviewed. Preoperative, 1 month postoperative, and late annual follow-up audiograms (up to 8 years) were obtained in all the cases. Mean preoperative and 1 month postoperative pure-tone average (500-1000-2000-4000 Hz) bone conduction thresholds (PTA-BCs), air conduction (AC) hearing outcomes for 8 kHz and mean postoperative air-bone gap (PTA-ABG) closure were analyzed.

RESULTS

The mean preoperative (pre) PTA-BC was 24.22 dB (±8.7 SD) whereas the mean postoperative (post) PTA-BC was 21.11 dB (±9.1 SD). The mean preoperative 8 kHz AC was 56.41 dB (±22.86 SD) and the postoperative 8 kHz AC was 52.56 dB (±24.35 SD). A statistically significant improvement of the PTA-BC post and of the postoperative 8 kHz AC was observed. The 1 month ABG closure within 10 dB in 89.02% of the patients and within 20 dB in 97.69% of the patients was obtained with statistically significant stability over long-term follow-up. No major complications occurred in the series.

CONCLUSIONS

The use of diode laser with high power and short time exposure as setup can be considered a safe, precise, and useful tool in stapes surgery.

First experience with the fiber-enabled CO2 laser in stapes surgery and a comparison with the "one-shot" technique

OBJECTIVE

To compare bone conduction after fiber-enabled CO2 laser perforation of the stapes footplate with conduction after the "one-shot" technique during stapedotomy in patients with otosclerosis.

STUDY DESIGN

Retrospective clinical study.

SETTING

Tertiary reference center.

MATERIALS AND METHODS

We evaluated data from 178 patients who had undergone primary stapedotomy for suspected stapedial ankylosis. The stapes footplate was perforated using a fiber-enabled CO2 laser in 89 patients and the "one-shot" technique in the other 89. Only consecutive surgery was considered. Bone conduction thresholds were determined at 0.5, 1, 2, and 4 kHz on the first and third postoperative days in all patients; 172 patients were followed up after 1 month. Audiograms were compared with preoperative bone conduction.

RESULTS

The postoperative bone conduction threshold on Day 1 was significantly worse at almost all frequencies. At 0.5 and 2 kHz, it improved within a month and was significantly different from the preoperative value. Bone conduction threshold at 4 kHz showed the greatest deterioration immediately after surgery, improving considerably in 1 month but remaining worse than at baseline. Only at 1 kHz was there no significant immediate hearing loss. Direct comparison of the fiber-enabled CO2 laser and the "one-shot" technique showed no statistically significant differences.

CONCLUSION

Compared with the "one-shot" technique, the fiber-enabled CO2 laser can be used safely in stapes surgery, without great risk to the patient. In our opinion, it has practical advantages, especially in difficult anatomic conditions.

[Stapedotomie with the use of CO2 laser--"one shot" technique]

INTRODUCTION

CO2 laser is used in stapes surgery due to good water absorption and quite optimal ablation of a bony structure without the influence of inner ear parameters.

AIM OF THE STUDY

the assessment of the influence of CO2 - "one shot" laser on hearing results in the patients group with otosclerosis.

MATERIAL AND METHOD

The study was carried out on a patients group after surgical treatment. The follow up time was at least 6 months. The hearing results were described according to the guidelines of the American Committee on Hearing and Equilibrium. The obtained results were statistically analysed with the use of the Wilcoxon sequence pair test.

RESULTS

The CO2 - "one shot" laser has been used in Department of Otolaryngology in Poznań since July 2009. Using this system 101 operations were carried out to the end of December 2011. 54 patients were in the analysed group, there were 40 women and 14 men, the age range from 22 to 59. In the Wilcoxon sequence pair test there was a statistically significant correlation between the value of the hearing threshold in pre- and post-operative examinations at 0.5, 1, 2 and 3kHz for bone and air conduction. We found also a statistically significant correlation between the mean value of the air-bone gap before and after treatment. In the group after the surgery the cochlear reserved became closed or decreased (p<0.001).

CONCLUSION

based of the hearing results we found great usefulness of CO2 - "one shot" laser in stapes surgery.

Effect of the stapedotomy technique on early post-operative hearing results--Preliminary results

OBJECTIVE

To compare three stapedotomy modalities used to fenestrate the stapes footplate in patients with primary otosclerosis.

MATERIALS

The non-randomized and unblinded one-center study included 48 patients with primary otosclerosis who underwent stapes surgery between May 2008 and April 2009. The patients were divided into three groups (single shot and two-shot CO(2) laser stapedotomy, perforator) depending on the modality used for stapedotomy. Bone conduction (BC) and air conduction (AC) thresholds, air-bone gap (ABG), and the difference between mean pre-operative and 2- to 3-week post-operative BC thresholds were analyzed.

RESULTS

The temporary BC deterioration was most pronounced at 6 and 8kHz after 2-shot laser stapedotomy. A significant drop in AC or BC was not found in any of our 48 patients. Age, high-dose cortisone therapy, and 'preoperative hearing' did not influence the post-operative hearing results.

CONCLUSION

Even though the number of patients presented here was small and statistical analysis was limited, the study showed a trend toward worse BC thresholds at 6 and 8kHz after a second shot CO(2) application. Whenever possible, treatment should avoid a second laser shot on the already opened inner ear with the laser parameters used for the initial shot.

Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative study

OBJECTIVE

To compare 3 different devices used to perforate the stapes footplate in otosclerotic patients.

STUDY DESIGN

The study design was a prospective unblinded study. It was conducted at the ENT Department of a general hospital.

MATERIALS AND METHODS

Ninety subjects undergoing primary stapedotomy for otosclerosis by a senior surgeon participated. A stapedotomy operation was performed under local anesthesia with reversed sequence of surgical steps. Three different devices were used to perforate the posterior half of the footplate: a microdrill (MD), a CO2 laser (CO2), and a Piezosurgery bone device (PZS). The hole diameter was 0.7 mm. Three consecutive samples of unselected patients were recruited. All patients of each sample were operated with the same device. Main outcome measures were preoperative and postoperative air- (AC) and bone-conduction (BC) audiometry, intraoperative findings, and postoperative complications. Postoperative pure-tone audiometry was done 1 month after surgery.

RESULTS

The CO2 laser was used in 30 stapedotomies, the PZS in 30, and the MD was used in 30. Bone-conduction pure-tone averages did not worsen in the MD and CO2 groups. CO2 laser shows a trend toward less residual air-bone gap and more functional gain at low frequencies. Piezosurgery bone device patients lost approximately 10 dB in BC at 4,000 Hz. Significant differences in AC thresholds gain and in the residual air-bone gap were found between groups. Piezosurgery bone device patients had less gain and more residual gap at high frequencies as a result of a slight deterioration of BC threshold. A higher rate of postoperative vertigo was also found in PZS patients.

CONCLUSION

The use of the CO2 laser seems associated with the best functional results, although on a statistical basis, they do not differ significantly from that obtained with the standard MD platinotomy. The PZS stapedotomy is effective from a surgical point of view for most patients. However, it is associated with a slight but significant deterioration of BC at high frequency and at higher vertigo rate. More basic validation of the stimulation parameters is necessary for safe use of this new technology.

Early hearing assessment after "one shot" CO2 laser stapedotomy: is it helpful to predict inner ear damage and the functional outcome?

OBJECTIVE

Auditory testing is not routinely performed within 4 to 6 weeks after stapedotomy because hearing acuity is thought to be transiently depressed. The early postoperative effects of the 1-shot carbon dioxide (CO2) laser have never been reported. The purpose of this study is to present data for auditory thresholds measured within 2 days of laser stapedotomy and at the last follow-up.

STUDY DESIGN

The study was prospective and unblinded.

SETTING

The study was conducted at the "A. Gemelli" University Hospital.

METHODS

From January to December 2008, 58 subjects underwent "1-shot" CO2 laser stapedotomies for otosclerosis. Pure-tonal audiometric test was performed preoperatively 2 days after surgery and at least 1 month after surgery during the follow-up.

RESULTS

The closure of air-bone gap began in the early postoperative period and continued to improve through the late postoperative period. Bone-conduction hearing thresholds were stable even in the early postoperative follow-up and remained stable trough all the course of the study.

CONCLUSION

Our data, supported by the literature, suggest that 1-shot CO2 laser stapedotomy is an effective and safe procedure for the treatment of otosclerosis.

Penetration of CO2 laser into the otic capsule using a hand-held, flexible-fiber delivery system

BACKGROUND AND OBJECTIVE

Recently, a new, flexible-fiber, CO2 laser delivery system has been FDA-cleared for clinical use. However, for otologic surgery, no data have been reported correlating power settings to depth of penetration into the otic capsule-the bone that covers the inner ear. This was the goal of our study.

STUDY DESIGN/MATERIALS AND METHODS

Eight cadaveric temporal bones were procured as per our institution's protocols. For each specimen, nine different laser holes were burned into the otic capsule using the flexible-fiber CO2 laser delivery system. Power settings were varied from 10 to 20 W in 2 W increments, and duration of exposure was 100, 200, 300, 400, or 600 milliseconds. Each setting (power and duration) was tested on two specimens. Following laser exposure, each specimen was scanned in a microCT scanner, and the depth of penetration measured from these images.

RESULTS

Of the 72 laser shots, 8 were excluded due to double hits (4), oblique hits (3), or complete penetration (1). After excluding these 8, bone penetration was found to vary from 160 to 670 microm based on power and time settings. Spearman analysis on ranked data showed that time had a greater impact on depth than power. The correlation coefficients for time and power were 0.84 (P = 0.013) and 0.40 (P<0.001), respectively.

CONCLUSION

The flexible-fiber CO2 laser is effective for otic capsule ablation in this model. High power setting and long pulse duration can lead to complete penetration of the otic capsule potentially causing damage of underlying structures such as the facial nerve, horizontal semicircular canal, and cochlea.

Erbium: yttrium-aluminum-garnet laser stapedotomy—A safe technique

Objective

To standardize the technical parameters of the erbium: yttrium-aluminum-garnet (Er:YAG) laser stapedotomy.

Study Design

Retrospective study of all patients with otosclerosis who underwent stapedotomy from January 2002 to January 2006.

Subjects and Methods

The charts of 152 consecutive patients who underwent stapedotomy were reviewed. The patients were stratified into two groups, according to the instrument used. Stapedotomies were performed in group A, with the OPMI®TwinEr: YAG laser; and in group B with manual microperforators.

Results

No statistically significant differences were found over all measured frequencies, between pre- and postoperative bone conduction thresholds, in each group. At the last postoperative follow-up, vertigo and nystagmus were not detected; two patients in group A and one patient in group B showed persistent tinnitus.

Conclusion

Er:YAG laser stapedotomy is a safe and effective procedure, with no damage of the inner ear when strict adherence to the safety parameters is observed. The Er:YAG laser is definitively suitable for stapes surgery, and represents a useful and safe tool in the armamentarium of otological microsurgery.

Laser stapedotomy – the up-to-date solution of otosclerotic stapes fixation

A vezetéses halláscsökkenést okozó otoscleroticus stapesfixatio műtéti megoldásának folyamatos fejlődése az elmúlt fél évszázad egyik fülsebészeti sikertörténete. A stapedectomia, illetve parciális stapedectomia mellett manapság a stapedotomia is elterjedt műtéti megoldásnak tekinthető. Cél: A minimálisan invazív lézerstapedotomia hazai bevezetése, tapasztalatok szerzése, valamint a műtéti halláseredmények és a posztoperatív komplikációk elemzése. Módszer: A szerzők közleményükben KTP-lézerrel asszisztált, Nitinol-pisztonnal végzett 14 esetük kapcsán ismertetik lézerstapedotomiákkal szerzett első tapasztalataikat. 2006 márciusa és 2007 áprilisa között 11 nőbeteget és 3 férfi beteget operáltak. A betegek átlagéletkora 42,2 év volt, 6 esetben bal, 8 esetben jobb fülön történt a műtét. A betegek átlagos követési ideje 9 hónap volt. Eredmények: A posztoperatív audiogramok értékelésekor az 500–1000–2000–3000 Hz frekvenciákat figyelembe véve a légvezetés átlagos javulása 21,5 dB volt. Ugyanezen frekvenciákon a csontlégközértékek átlagos javulása 18,7 dB volt. Kilenc hónap átlagos követési idő mellett az eddigi esetekben a műtéteket követően a betegek 85%-ában az átlagos csontlégköz < 10 dB, de valamennyi beteg esetében < 20 dB. Az átlagos légvezetés értéke egy beteg kivételével < 30 dB. Belsőfül-károsodásra utaló, a magashang-frekvenciákat érintő csontvezetéses romlást, facialis paresist nem észleltek. Következtetések: A szerzők tapasztalatai és az irodalmi adatok alapján a Nitinol-pisztonnal végzett lézerstapedotomiáknak számos előnyük van: 1) a piszton hurkának hőre aktiválódó memóriaeffektusa kiküszöböli az incus hosszú szárára két ponton történő rászorítás hátrányait; 2) a posztoperatív szédülés mértéke enyhébb, időtartama rövidebb, ezért az ápolási idő csökken; 3) a műtét költséghatékony, és minimálisan invazív; 4) a lézer alkalmazása minimális cochlearis traumát, vérmentes környezetet biztosít; 5) a protézis migrációja kiküszöbölhető, körülötte a granuláció mérsékeltebb; 6) magas frekvenciákon tartósan jó halláseredmény érhető el; 7) a komplikációk súlyossága, gyakorisága csökken, ezért a technika jó megoldás kevésbé gyakorlott operatőrök számára is; 8) problémás esetekben (arteria stapedialis jelenléte, obliterativ otosclerosis, úszó stapestalp, rendellenesen futó n. facialis a dobüregben, revíziós műtétek) is alkalmazható; 9) a halláseredmények interindividuális különbsége kisebb. – Eddigi kedvező tapasztalataik alapján a szerzők lézerstapedotomián átesettek hosszú távú követését tervezik nagyobb beteganyagon.

Piezoelectric bone surgery in otosclerosis

CONCLUSION

This test of the Piezosurgery medical device for osteoplasty of the external auditory duct posterior wall and stapedotomy highlighted the advantages of this device. The device's accuracy and selectivity render it superior to conventionally rotating instruments in otologic surgery. The precise nature of the instrument allows exact, clean, and smooth cut geometries during surgery, without any visible injury to the adjacent soft tissue.

OBJECTIVE

The aim of this work was to test the Piezosurgery device as a new and alternative method to conventional bone tissue management in otologic surgery and in particular in stapedotomy and the external auditory duct posterior wall.

MATERIALS AND METHODS

The Piezosurgery medical device is a piezoelectric ultrasonic bone-cutting surgical instrument designed to perform sharp cutting actions. The equipment consists of two piezoelectric hand-pieces and two insets that are connected to a main unit, which supplies power and has holders for the hand-piece and irrigation fluids. Piezosurgery uses low frequency ultrasonic waves (24.7-29.5 kHz), the applied power can be modulated between 2.8 and 16 W, and the machine is programmed in accordance with the density of the bone cut. The micro-vibrations that are created in the piezoelectric hand-piece cause the inserts to vibrate linearly between 60 and 210 microm and allow a selective cut of mineralized tissues without trauma to soft tissues. The interoperative irrigation cools down the bone surface and make the operating site blood-free. Twenty patients affected by otosclerosis underwent treatment utilizing the device.

RESULTS

In all the patients treated, the characteristics of the ultrasonic frequencies allowed rapid and easy intraoperative management, without any visible injury to the adjacent soft tissue. No side effects were detected.

Hearing Results after Stapedotomy: Role of the Prosthesis Diameter

OBJECTIVE

To evaluate the functional results obtained after stapedotomy in patients affected by otosclerosis, according to the prosthesis diameter.

PATIENTS AND METHODS

A retrospective case review was performed. Two hundred and twelve consecutive ears in 132 patients affected by otosclerosis were operated on. All patients underwent primary small-fenestra stapedotomy. In 112 of the 212 stapedotomies (52.83%) the 0.6-mm piston (group A) and in 100 of the 212 stapedotomies (47.16%) the 0.4-mm piston (group B) were employed.

RESULTS

After surgery, the difference between the two groups in the air conduction improvement (21.04 dB group A vs. 11.14 dB group B) reached statistical significance (p < 0.05). In group A, the postoperative air conduction pure-tone average improvement obtained at 0.5, 1, and 2 kHz was statistically greater as compared with group B (p < 0.05). In group A the postoperative bone conduction pure-tone average decreased by 5.19 dB, whereas in group B it increased by 2.95 dB (p > 0.05). The incidence of ears with a postoperative bone conduction worsening >10 dB (sensorineural hearing loss) was lower in group B than in group A: 5 of 100 ears (5%) versus 9 of 112 ears (8.03%) (p > 0.05). The postoperative air-bone gap was smaller in group A than in group B for all frequencies, but the difference can be considered significant at 1 and 2 kHz. The air-bone gap improvement in group A if compared with group B was statistically greater at 0.5, 1, and 2 kHz (p < 0.05).

CONCLUSIONS

Our study suggests that an increase in piston diameter gives better results, especially at lower frequencies. The functional results obtained after stapedotomy confirm the advantageous effect of a larger piston diameter on hearing of the speech frequencies and support the opinion of a better clinical effect.

The Influence of the Sequence of Surgical Steps on Complications Rate in Stapedotomy

OBJECTIVE

To assess whether the incidence of complications of stapes surgery depended on the sequence of surgical steps and CO2 laser use in stapes surgery.

STUDY DESIGN AND SETTING

Retrospective and prospective analysis of 420 consecutive stapedotomies was set in tertiary referral University Hospital.

PATIENTS

376 patients with otosclerosis in whom 420 primary stapedotomies were performed.

INTERVENTION

Stapedotomy under local anesthesia using manual perforators and CO2 laser.

MAIN OUTCOME MEASURE

The incidence of incus subluxation, floating footplate during stapedotomy.

RESULTS

Comparison of the incidence of incus luxation in groups with the piston inserted after removal of the stapes arch, and groups with the piston inserted on the intact ossicular chain showed statistical significance. In the group where perforation of the footplate was performed after removal of the stapes arch floating footplate occurred more often than in groups with reversed sequence of steps.

CONCLUSION

Perforation of the footplate before removal of stapes arch reduces the risk of floating footplate, and placing the prosthesis on the incus before removal of stapes arch reduces the risk of subluxation of the incus. CO2 laser stapedotomy with reversed sequence of steps was the safest method of stapes surgery.

„Ein-Schuss-CO2-Laser-Stapedotomie“

BACKGROUND

In order to further optimize the surgical technique with CO(2) laser in stapes surgery, a scanner system was used to obtain a footplate perforation of 0.5-0.6 mm with only one laser application ("one-shot" stapedotomy).

PATIENTS AND METHODS

A total of 255 patients with otosclerosis were submitted to primary CO(2) laser stapedotomy with a SurgiTouch scanner. This study discusses the surgical technique and clinical results.

RESULTS

An adequately large perforation diameter could be achieved with a single shot in 68% of the patients treated. In 14% of the patients, a second laser application at the same site was necessary. In 18% the perforation had to be enlarged by several slightly overlapping laser applications without using the scanner. There was no evidence of laser dependent inner ear affections.

CONCLUSION

CO(2) laser, combined with modern scanner systems, is well suited for application in stapes surgery.

Clinical results after stapedotomy: a comparison between the erbium: yttrium-aluminum-garnet laser and the conventional technique

OBJECTIVE

The objective of this study was to assess whether the use of the erbium: yttrium-aluminum-garnet (Er:YAG) laser has negative effects on inner ear function and to compare the short- and long-term hearing outcome of patients undergoing conventional stapedotomy versus laser stapedotomy.

STUDY DESIGN

Retrospective review of prospectively collected audiometric data of patients with otosclerosis operated on by one experienced surgeon.

SETTING

Academic tertiary referral center.

PATIENTS

A total of 266 stapes surgeries were evaluated for intraoperative findings, of which 209 patients were evaluated for preoperative and postoperative hearing thresholds after a 6- to 452-week (mean, 22 wk) audiological follow-up.

INTERVENTION

One hundred fifteen (43%) of the operations were performed conventionally, using manual perforators for stapedotomy (Group A); in 115 (43%) surgeries, the perforators were used in combination with the Er:YAG laser (Group B), and in 36 (14%) operations, the Er:YAG was used exclusively for footplate perforation (Group C).

MAIN OUTCOME MEASURES

Pure-tone audiometry was performed before surgery, 2 days postoperatively (bone conduction only) and at 5, 26, and 57 weeks postoperatively.

RESULTS

A postoperative temporary threshold shift of the bone conduction could be found in all groups. In Group C, where the laser was used exclusively for footplate perforation, this threshold shift was not only the most significant, but also-in contrast to the other groups-not totally reversible. In all techniques, a satisfactory air-bone gap closure could be achieved. The best long-term results (96% of the patients had <or=20 dB air-bone gap after 57 wk) could be found in Group B.

CONCLUSION

If certain rules to minimize inner ear trauma are followed, the Er:YAG laser is a safe tool in middle ear surgery. Combining both the laser and the conventional technique, instead of the separate use of either technique, leads to superior postoperative hearing results.