The learning curve in stapes surgery and its implication to training

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.

Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial

OBJECTIVE

After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents.

STUDY DESIGN

Multicenter randomized prospective international study.

SETTING

Four academic institutions.

METHODS

Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales.

RESULTS

A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores ( p < 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture.

CONCLUSION

Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator.

Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition

OBJECTIVES

to compare hearing outcomes between endoscopic transcanal rebridging with bone cement and endoscopic transcanal incus interposition in patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type).

METHODS

This retrospective study was performed on 83 ears of 83 consecutive patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). According to the extent of incus long process erosion and subsequent ossiculoplasty technique, patients were divided into 2 groups. Patients in group 1 had erosion involving up to two thirds of the length of the incus long process and underwent endoscopic transcanal rebridging with bone cement. Patients in group 2 had erosion involving more than two thirds of the length of the incus long process and underwent endoscopic transcanal incus interposition.

RESULTS

Hearing gain (mean ± standard deviation) was 21.39 ± 2.15 dB in group 1 and 19.71 ± 6.12 dB in group 2. A significantly greater hearing gain was achieved in bone cement group than in incus interposition group (P value < 0.001). Successful hearing outcome (post-operative air bone gap closure within 20 dB) was achieved in 81.6% and 71.1% of patients of group 1 and group 2 respectively.

CONCLUSION

Endoscopic transcanal rebridging with bone cement offers greater hearing gain than endoscopic transcanal incus interposition. The two techniques remain reliable and cost-effective techniques in management of patients with incus long process defects. The main limitation of this study was the short follow-up period. Further studies with relatively long-term follow-up are strongly recommended.

Endoscopic vs. microscopic stapes surgery: An anatomical feasibility study

Objectives

To investigate the feasibility of the endoscopic approach vs. microscopic approach during stapes surgery, focusing on the visualization of the important anatomical structures of the middle ear, the volume of the resected scutum and chorda tympani (CT) injury.

Methods

Fresh frozen human cadaveric heads underwent two stapes surgeries using an operating microscope on one ear and an endoscope on the other ear. The surgeon documented the visualization of critical landmarks, as well as exposure and injury of the CT. The volume of resected scutum was evaluated using cone beam computed tomography scanning and three-dimensional imaging.

Results

We performed endoscopic stapes surgery in 10 ears and microscopic stapes surgery in 11 ears. A stapes prosthesis was placed in all ears. The volume of bony scutum resection was significantly lower in the endoscopic group (median = 2.20 mm³, IQR = 4.17) than in the microscopic group (median 13.25 mm³, IQR = 8.71). No scutum was removed in two endoscopic ears, while scutum was removed in all microscopic ears. The endoscopic and microscopic group had similar CT injury.

Conclusions

This study showed that the endoscopic stapes surgery procedure is feasible and might be less invasive than microscopic stapes surgery. Future clinical prospective and functional studies will be needed to support our findings.

Are there differences in revision stapes surgery outcomes between university and county clinics? A study from the quality register for otosclerosis surgery in Sweden

Purpose

The aim of the study was to investigate hearing outcomes in stapes revision surgery with regard to the type of clinic (university clinic or county clinic). Furthermore, the aim was to investigate the risk of complications with a focus on tinnitus, hearing deterioration, and taste disturbance 1 year after surgery.

Methods

The study is based on data from the Swedish Quality Register for Otosclerosis Surgery (SQOS). Two study protocols were completed by the surgeon, and a questionnaire was distributed to the patients 1 year after surgery. A total of 156 revisions were available for analysis with both preoperative and postoperative audiometry data.

Results

Seventy-five percent of the patients reported better to much better hearing 1 year after revision surgery. An air bone gap ≤ 20 dB postoperatively was seen in 77% of the patients. Four percent had hearing deterioration ≥ 20 dB PTA4 AC. Eleven percent had worsened or newly developed tinnitus, 5% had taste disturbance, and 3% had dizziness 1 year after surgery. Preoperative and postoperative hearing did not differ between patients operated on in university vs. county clinics.

Conclusions

Revision surgery in otosclerosis is a challenge for otologists, but no differences in hearing outcomes between university and county clinics were found in this nationwide study. The risk of hearing deterioration and deafness is higher than in primary stapes surgery, and revision surgery should be recommended primarily in cases with a large air–bone gap and moderate to severe preoperative hearing loss.

Hearing outcomes and patient satisfaction after stapes surgery: local versus general anaesthesia

Objective

Otosclerosis is a frequent ear disorder causing a stapedo-ovalar ankylosis and conductive hearing loss. Stapedoplasty, performed under both general (GA) and local anaesthesia (LA), is the most advisable surgical solution. Auditory recovery relies on the patient's conditions and on the intervention itself. The aim of our work was to compare hearing outcomes with stapedoplasty performed under GA or LA and to investigate patients' compliance to both methods.

Methods

Fifty-five otosclerotic patients underwent stapedoplasty both under GA (32/55) and LA (23/55). Pre- and post-operative air and bone tone audiometry threshold values as well as the air-bone gap and its closure score, were analysed. All patients filled in a satisfaction questionnaire regarding their concern and level of appreciation of the type of anaesthesia.

Results and conclusions

Our data show that the auditory results with stapedoplasty are good and do not differ between LA and GA. Even considering the advantages and limits of the two methods, one cannot favour one or the other type of anaesthesia. Finally, the patient's satisfaction cannot be considered a criterion of choice, since this was found to be high in both cases.

Chorda tympani nerve course and feasibility of its preservation during atresiaplasty for congenital aural atresia

Objectives

The association between the chorda tympani nerve (CTN) and atresiaplasty has not been investigated. This study aimed to describe the course of the CTN observed during atresiaplasty for congenital aural atresia (CAA) and explore the feasibility of CTN preservation.

Methods

In this retrospective study, six consecutive patients who underwent atresiaplasty in a tertiary academic center were included. The course of the tympanic segment of the CTN and its preservation feasibility were evaluated. Atresiaplasty was performed using an anterior approach. The average Jahrsdoerfer score was 8.7 points (range, 8-9 points).

Results

The CTN was located in the atretic plate in all patients. It emerged from an average of 5.6 mm (range, 5.2-6.1) inferior to the incus buttress and crossed the middle ear in an anterior-superior direction. The distance between the neck of the malleus and the CTN varied in the absence of the malleus handle. However, when the malleus handle developed, the CTN passed between the incus and the malleus handle. The CTN was preserved in two of the six patients. They had a Jahrsdoerfer score of 9 and grade I microtia.

Conclusion

The CTN was located in the atretic plate, emerging from an average distance of 5.6 mm inferior to the incus buttress. The incus buttress might serve as a good anatomical landmark to identify and preserve the CTN. CTN preservation is feasible in atresiaplasty candidates with a Jahrsdoerfer score of 9 and auricular deformity of grade I.

Level of Evidence

4.

Endoscopic and Robotic Stapes Surgery: Review with Emphasis on Recent Surgical Refinements

Purpose of Review

Stapes surgery has been established as the gold standard for surgical treatment of conductive hearing loss in otosclerosis. Excellent outcomes with very low complication rate are reported for this surgery. Recent advances to improve surgical outcome have modified the surgical technique with endoscopes, and recent studies report development of robotical assistance. This article reviews the use of endoscopes and robotical assistance for stapes surgery.

Recent Findings

While different robotic models have been developed, 2 models for stapes surgery have been used in the clinical setting. These can be used concomitant to an endoscope or microscope. Endoscopes are used on a regular base regarding stapes surgery with similar outcomes as microscopes. Endoscopic stapes surgery shows similar audiological results to microscopic technique with an advantage of less postoperative dysgeusia and pain. Its utility in cases of revision surgery or malformation is emphasized.

Summary

Endoscopic stapes surgery is used on a regular basis with excellent outcomes similar to the microscopic approach, while reducing surgical morbidity. Robotic technology is increasingly being developed in the experimental setting, and first applications are reported in its clinical use.

Three dimensional printing of a low-cost middle-ear training model for surgical management of otosclerosis

BACKGROUND

Surgical management of otosclerosis is technically challenging with studies demonstrating that outcomes are commensurate with surgical experience. Moreover, experts apply less force on the ossicular chain during prosthesis placement than their novice counterparts. Given the predicted decreasing patient pool and the rising cost of human temporal bone specimens it has become more challenging for trainees to receive adequate intraoperative or laboratory-based experience in this procedure. As such, there is a need for a low-cost training model for the procedure. Here we describe such a model.

METHODS

A surgical model of the middle ear was designed using computer aided design (CAD) software. The model consists of four components, the superior three dimensional (3D)-printed component representing the external auditory canal, a 90° torsion spring representing the incus, a 3D-printed base with a stapedotomy underlying the torsion spring, and a 3D-printed phone holder to facilitate video-recording of trials and subsequent calculation of the force applied on the modeled incus. Force applied on the incus is calculated based on Hooke's Law from post-trial computer-vision analysis of recorded video following experimental determination of the spring constant of the modeled incus.

RESULTS

The described model was manufactured with a total cost of $56.50. The spring constant was experimentally determined to be 97.0 mN mm/deg, resulting in an ability to detect force applied to the modeled incus across a range of 1.2 to 5200 mN.

CONCLUSIONS

We have created a low-cost middle-ear training model with measurable objective performance outcomes. The range of detectable force exceeds expected values for the task.Level of Evidence: IV.

Effect of Surgical Start Time on Stapedotomy Outcomes

OBJECTIVE

To examine if performing stapedotomy as the first case of the day provides improved outcomes compared with those performed later in the day.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients undergoing stapedotomy for otosclerosis.

MAIN OUTCOME MEASURES

Patients were separated into either a first case group or a later case group based on surgical start time. Audiologic outcomes and complications were compared between the two groups.

RESULTS

The first case group had a smaller postoperative air-bone gap (ABG) compared with the later case group of 9.81 dB HL compared with 11.73dB HL and 3.79 dB HL compared with 6.29 dB HL at 1000 and 2000 Hz, respectively (p = 0.03, p < 0.01). The mean postoperative ABG was 10.63 dB HL for the first start group compared with 12.12 dB HL for the later start group, which was statistically significant (p = 0.05).

CONCLUSIONS

First start stapedotomy is associated with slightly improved audiologic outcomes compared with those starting later in the day, although both groups had significantly improved postoperative outcomes overall. There was no significant difference in complications when comparing stapedotomy by case start time.

Comparison of hearing outcomes in stapedotomy with fat and Hyaluronic acid gel as a sealing material: a prospective double-blind randomized clinical trial

PURPOSE

In the literature on stapes surgery, various materials have been used to seal the vestibulotomy. To date, there are only a few published randomized clinical trials with focus on hearing outcomes, using different sealing materials. Hence, the aim of this study was to compare hearing outcomes when using fat or Hyaluronic acid gel (HAG) to seal the stapedotomy.

METHODS

The present double-blind, prospective, randomized clinical trial was conducted on ears undergoing stapedotomy in Dasthgheib Hospital, a referral otology center in Southern Iran, and Dena private hospital, Shiraz Iran. A total of 150 primary stapedotomies were evaluated, and sealing material was fat in 77 ears and HAG in 73.

RESULTS

60 (77.9%) of the fat group ears and 63 (86.3%) of the HAG group ears obtained postoperative air-bone gap (ABG) within 20 dB, but the difference was not significant (p = 0.182).

CONCLUSION

As a sealing material in stapedotomy, HAG is comparable with fat in terms of hearing outcomes. Therefore, HAG is recommended as a safe sealing material in stapedotomy.

Surgical treatment of otosclerosis using a unique stapes prosthesis without a hook

BACKGROUND

During stapes surgery, the Teflon wire piston prosthesis is prone to postoperative 'slips' and subsequent necrosis and fracture of the long process of the incus.

AIMS/OBJECTIVE

We invented and used a novel cup-shaped apatite prosthesis to reduce the incidence of necrosis of the long process of the incus and analysed the postoperative results.

MATERIAL AND METHODS

Thirty-one ears in 25 patients with otosclerosis who underwent stapes surgery with our apatite prosthesis were evaluated.

RESULTS

The air conduction improved by 24.0 dB (the average) from pre- to post-operation. Additionally, 84.8% of patients achieved an air-bone gap of ≤10 dB for the 4-frequency measurements (p < .01).

CONCLUSIONS

Our findings indicate that our new prosthesis was associated with a good postoperative prognosis in patients with otosclerosis.

SIGNIFICANCE

Our unique prosthesis yielded good outcomes for the treatment of otosclerosis even in the short term.

Functional Results and Learning Curve of Endoscopic Stapes Surgery: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy.

STUDY DESIGN

Retrospective study.

METHODS

This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment.

RESULTS

One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air-bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P > .05). No association between stapedotomy success and the increasing number of procedures was found.

CONCLUSIONS

Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:885-891, 2021.

Primary endoscopic stapedotomy using 3 mm nasal endoscope: Audiologic and clinical outcomes

Objective

To report the use of a 3 mm rigid nasal endoscope in primary endoscopic stapedotomy and clinical and audiological outcomes.

Materials and methods

Thirty patients diagnosed with primary otosclerosis underwent endoscopic stapedotomy that was performed using a 3 mm nasal endoscope (Karl Storz). At 6 months follow-up, the patients were evaluated for intraoperative findings, postoperative hearing outcomes and complications.

Results

Canaloplasty was performed in 2 (6.66%) patients, and no curettage of the canal wall was required in 12 (40%) patients. Transposition of the chorda tympani nerve was conducted in 11 (36.66%) patients. The average duration of surgery was 36 min (range 31–65 min). The air-bone gap (ABG) was 35 dB (range 24–50 dB) preoperatively and 14.63 dB (range 9–20 dB) postoperatively (p = 0.00). At 6 months follow-up, <20 dB ABG was achieved in 93.33% of the patients. No major intraoperative/postoperative complications were detected.

Conclusion

A 3 mm rigid nasal endoscope can be effectively used in stapedotomy to obtain adequate audiological outcomes. It can be considered as a better alternative to the standard microscope or 4 mm endoscope in preserving the posterior canal wall and chorda tympani nerve while minimizing operative time without causing significant complications.

Training model for salvage procedures in endoscopic stapes surgery

PURPOSE

The learning curve in endoscopic stapes surgery, is flat and long. There is limited space during training for advanced and salvage procedures, which could be necessary in unexpected intraoperative scenarios. The aim of the present study is to develop an ex-vivo animal model for training in salvage and advanced procedures in endoscopic stapes surgery METHODS: After defining the difficult intraoperative scenarios requiring a salvage procedure during stapes surgery, we used the ovine model to create those intraoperative situations. After assessing the suitability of the model for that purpose, it was validated by subjective feedback rating (scale from 1 to 10) and by comparing the relevant anatomical structures for stapes surgery with the human. Finally, an optimal sequence of surgical steps was defined.

RESULTS

8 Fresh frozen lamb heads (16 ears) were studied. The selected intraoperative scenarios were: floating footplate, footplate fracture, luxation of the incus or necrosis of the long process, overhanging facial nerve, obliterative otosclerosis. The simulation resulted feasible and close to real. The mean overall rating for surgical scenarios ranged from 7.5 to 8.8 for residents and was consistent with the rating of senior surgeons, ranging from 7.67 and 9.0. Anatomical measures of the oval window area resulted similar between the ovine and the human.

CONCLUSION

The ex-vivo ovine model is a suitable model for training in salvage and advanced procedures in exclusively endoscopic stapes surgery. The model can be used both for the training and maintenance of the acquired advanced skills in endoscopic stapes surgery.

Total endoscopic stapes surgery: Systematic review and pooled analysis of audiological outcomes

OBJECTIVE

This study evaluates the current evidence base for total endoscopic stapes surgery, specifically to establish current efficacy and safety of the technique within clinical practice.

DATA SOURCES

A systematic review of the literature on endoscopic stapes surgery was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist. A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials database for relevant publications for all available dates with appropriate Medical Subject Headings search criteria in January 2018.

STUDY SELECTION

Out of the 160 articles identified in the search, 14 met the inclusion criteria for further analysis. Four of these were level III and 10 level IV evidence.

DATA EXTRACTION

A pooled patient population of 314 individuals was analyzed.

DATA SYNTHESIS

Documented postoperative air bone gap closure to within 20 dB was found in 95.3% of individuals (285 patients). Facial nerve palsy (temporary) occurred in three patients (0.6%), with all recovering. No total sensorineural hearing losses were recorded, but two moderate sensorineural hearing losses occurred (0.6%). Perilymph fistula was noted on four occasions (1.3%). Chorda tympani trauma was documented in 3.5% of cases, with taste disturbance documented in 13 patients (5%).

CONCLUSIONS

Our pooled analysis uses the current published evidence to establish the complication rate and audiological outcome for the endoscopic approach to stapes surgery. These outcomes are comparable to those documented in traditional use of the microscope for stapedectomy. Laryngoscope, 130:1282-1286, 2020.

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.

Endoscopic approach in second stage ossicular chain reconstruction

PURPOSE

Today limited studies regarding surgical and hearing outcomes in patients undergoing the totally endoscopic ossicular chain reconstruction has been published. The aim of this study is to show the different materials and endoscopic technique used in our experience to perform a second stage endoscopic ossiculoplasty.

MATERIALS AND METHODS

Patients underwent to second stage endoscopic ossiculoplasty has been enrolled in the study. According to the ossicular defect the endoscopic surgical procedures of ossicular chain reconstruction used in our clinical practice were: ossicular chain reconstruction using PORP (13 cases); ossicular chain reconstruction using TORP (11 cases); incus interposition ossiculoplasty (6 cases); cartilage ossiculoplasty (10 cases). Intraoperative and postoperative complications were analyzed. Final hearing recovery at 6 months follow-up was used to evaluate audiological outcomes.

RESULTS

None of the patients developed intraoperative complications. Postoperative TM complications emerged in 5% of cases: one patient (2.5%) presented TM perforation and prosthesis extrusion (TORP) after 3 months follow up. A significative difference between preoperative and postoperative values of AC-PTA, ABG and WRS (p < 0.05 in each case) emerged.

CONCLUSIONS

Different materials and methods can be used for performing an endoscopic ossicular chain reconstruction in order to obtain optimal clinical-audiological outcomes. Endoscopic surgery can be considered a valid alternative technique to traditional microscopic surgery for ossiculoplasty surgery.

Getting started in endoscopic ear surgery

Endoscopic ear surgery (EES) is an exciting, rapidly developing and innovative field of otologic surgery. Technically and conceptually, EES is a significant departure from traditional microscopic transcanal approaches to the middle ear and canal that has shown very positive results with respect to patient outcomes. This review serves as a primer for the otologist and otology resident embarking on EES and discusses the theory surrounding the learning process, the optical chain for endoscopic surgery as well as other important underlying principles.

Stapes surgery preserving the superstructure of stapes (Takagi's stapedotomy) in otosclerosis: A retrospective study of 24 consecutive cases

OBJECTIVE

The aim of this study was to evaluate the hearing outcomes and complications of stapedotomy in which the stapes superstructure was preserved (Takagi's stapedotomy). In this surgical approach, the lenticular process of the incus rather is removed, than the superstructure of the stapes.

METHODS

A single-center retrospective observational study was performed. We included all patients having Takagi's stapedotomy for otosclerosis between January 2005 and April 2016. Both primary and revision stapes surgery were included. We evaluated audiometric outcomes and surgical complications.

RESULTS

Twenty-four patients who underwent stapedotomy preserving superstructure were included in this study. The postoperative air-bone gap at 1year postoperatively was ≤10dB in 66.7% of patients and ≤20dB in all cases. In longer follow-up period, elevation of the air-bone gap was not observed over the 5 postoperative years in available cases. The postoperative air-bone gap was ≤10dB in 72.2% at 3years and 81.8% at 5years postoperatively.

CONCLUSION

Takagi's stapedotomy restore ossicular conduction without the removal of superstructure of stapes. The air-bone gap did not get worse in long-term follow-up, although audiometric results would be unsatisfactory. Further larger studies are needed to evaluate the efficacy and safety of Takagi's stapedotomy.

Can the learning curve in stapes surgery predict future functional outcome?

Over the last 20 years, the number of stapes operations performed has decreased steadily. This inadequate exposure to stapes surgery poses problems for both trainees and trainers. We retrospectively reviewed the outcomes of stapedotomy performed by a young physician at the ENT Clinic of the "A. Gemelli" Hospital of Rome. We used the technique of "one-shot" CO₂ Laser stapedotomy using a titanium-Teflon piston. For data analysis, we considered the audiograms obtained 24 hours preoperatively and at the last follow-up examination (mean 45 months). Air conduction (AC) and bone conduction (BC) PTA were calculated for 0.25, 0.5, 1, 2 and 4 kHz thresholds. Air bone gap (ABG) were obtained from ACPTA and BCPTA. Postoperative hearing gain was calculated from the ABG before the operation minus the ABG at late follow-up examination. Analysis of outcomes did not show a clear endpoint for the learning curve; complete closure of the ABG was obtained in a large number of patients at the beginning followed by patients who showed a higher ABG. Fortunately, we did not observed any "dead ear". The study supports a learning curve in stapes surgery, but the results can vary widely among surgeries with excellent results followed by others that are not fully satisfactory. Stapes surgery should not be one of the first ear surgeries performed by a young otologist due to the functional outcome expected by patients and the lack of necessary surgical skills.

HOW MANY REPETITIONS OF CHILD CARE SKILLS ARE REQUIRED FOR HEALTH WORKER STUDENTS TO ACHIEVE PROFICIENCY? LEARNING CURVE PATTERNS IN CHILD CARE SKILLS ACQUISITION

Introduction:

The vulnerability of children under 5 years old requires paying more attention to the health of this group. In the Iranian health care system, health workers are the first line of human resources for health care in rural areas. Because most health workers begin working in conditions with minimal facilities, their clinical qualifications are crucial. The aim of this study was to determine the number of repetitions of child care skills, required for health worker students to achieve proficiency based on the learning curve.

Methods:

A time series research design was used. Participants in this study were first year health worker students enrolled in three health schools in 2011. Data were collected using a questionnaire consisting of demographic information and a checklist evaluating the health worker students’ clinical skills proficiency for child care. Data were analyzed using SPSS version 16.0 software (SPSS Inc., Chicago, IL) using descriptive and inferential statistics including Kruskal-Wallis and Pearson correlation coefficient tests.

Results:

Learning curve patterns in child care skills acquisition showed that for less than 20 and between 20 to 29 times, the level of skill acquisition had an upward slope. Between 30- 39 the learning curve was descending, however the slope became ascending once more and then it leveled off (with change of less than 5%).

Conclusion:

It seems that 40 repetitions of child care skills are sufficient for health worker students to achieve proficiency. This suggests that time, resources and additional costs for training health worker students’ trainees can be saved by this level of repetition.

Stapedectomy in sheep: an animal model for surgical training

HYPOTHESIS AND BACKGROUND

Stapedectomy is a surgical technique that requires progressive training. The external and middle ear of sheep have a close resemblance to the human and have been previously used as surgical training models. In our project we describe the anatomy of the middle and external ear in sheep focusing on surgical landmarks and technique in order to determine whether the sheep's ear is an adequate model for stapedectomy training.

MATERIALS AND METHODS

We reviewed the literature on sheep anatomy and use of sheep as an otologic surgical model. Macroscopic sections as well as temporal bone computed tomography were obtained. Stapedectomy was performed on 40 sheep, using 4 mm platinum piston prosthesis, by first year residents.

RESULTS

Most of the structures in the sheep's middle ear are similar to those in humans although their size is about two thirds smaller. Incus long process is shorter, thicker, and closer to the malleus body, making the piston insertion and adjustment more difficult. The median surgical time of stapedectomy was reduced from 70 (52.5-100.3) minutes to 39.5 (35.5-48) minutes after completing training. There was also a reduction in rate of complications (flap disruption, incus dislocation, and footplate mobilization).

CONCLUSION

Sheep ears constitute a cheap, easy to obtain and anatomically adequate model for stapedectomy training.

Time of cochlear implant surgery in academic settings

OBJECTIVE

Establish the time required to perform cochlear implantation (CI) in academic settings.

STUDY DESIGN

Historical cohort study.

SETTING

German and American academic centers.

PATIENTS

A total of 2639 patients underwent CI (1997-2007). We excluded patients receiving an experimental device or technique and those with abnormal cochlear anatomy or incomplete charts, leaving 2253 for analysis.

INTERVENTION

Unilateral, bilateral, and revision CI with devices approved in the U.S. and Europe.

MAIN OUTCOME MEASURES

Mean surgical time (ST) and total operating room time (TORT).

RESULTS

Mixed model analysis was used; estimated marginal means were calculated in minutes after adjusting for random effect of individual surgeon. There were no differences between unilateral (ST = 171, TORT = 245) and revision CI (ST = 160, TORT = 232), but bilateral procedures were longer (ST = 295, TORT = 377, P < 0.001). In unilateral surgeries, Cochlear Limited (CL) devices were implanted faster (ST = 165, TORT = 225) than Advanced Bionics (ABC) (ST = 183, P = 0.001; TORT = 240, P = 0.023) or MedEl (ST = 193, P < 0.001; TORT = 253, P = 0.002) devices. There were no differences for unilateral CI between ABC and MedEl devices. For revision CI, ABC devices (ST = 141, TORT = 219) were implanted faster than CL devices (ST = 181, P = 0.001; TORT = 266, P < 0.001). There were no differences by age group or between Germany and the U.S. ST and TORT were shorter for 575 CIs performed in the final two years of the study (unilateral CI: ST = 145, TORT = 209; bilateral CI: ST = 259, TORT = 330; revision CI: ST = 138, TORT = 205). For unilateral CI, ST and TORT decreased yearly (linear regression, P < 0.001) and inversely correlated with surgeon experience (linear regression, P < 0.01).

CONCLUSIONS

We report the time required to perform CI in academic settings-data that are vital for cost-benefit analyses and assessing new CI techniques.

Hearing results of 1145 stapedotomies evaluated with Amsterdam hearing evaluation plots

Aims:

To evaluate the hearing results of a large series of primary stapedotomies, according to American Academy of Otolaryngology, Head and Neck Surgery guidelines and Amsterdam hearing evaluation plots.

Study design:

Retrospective chart review.

Methods:

The charts for 1369 consecutive stapedotomy cases were reviewed; 1145 cases of primary stapedotomy were included. Raw data from the audiometric database were evaluated using Amsterdam hearing evaluation plots. The effect on outcomes of using different audiological parameters was analysed.

Results:

A significant improvement was demonstrated in mean post-operative air conduction and speech reception thresholds, with no change in bone conduction. Air–bone gap closure of 10 dB or more was achieved in 82 per cent of cases. A ‘dead ear’ occurred in one patient (0.1 per cent).

Conclusion:

This study reports the largest series of primary stapedotomies evaluated with Amsterdam hearing evaluation plots. This method enables visual identification of successful and unfavourable results, providing more accurate and detailed presentation of surgical outcomes.

Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve

Object

The endoscopic endonasal approach for resection of pituitary lesions is an effective surgical option for tumors of the sella turcica. In this study the authors compared outcomes after either purely endoscopic resection or traditional microscope-aided resection. They also attempted to determine the learning curve associated with a surgical team converting to endoscopic techniques.

Methods

Retrospective data were collected on patients who were surgically treated for a pituitary lesion at the Hospital of the University of Pennsylvania between July 2003 and May 2008. Age, sex, race, presenting symptoms, length of hospital stay, surgical approach, duration of surgery, tumor pathological features, gross-total resection (GTR) of tumor, recurrence of the lesion, and intraoperative and postoperative complications were noted. All procedures were performed by the same senior neurosurgeon, who was initially unfamiliar with the endoscopic endonasal approach.

Results

A total of 25 patients underwent microscopic resection and 25 patients underwent endoscopic resection performed by a single skull base team consisting of the same senior neurosurgeon and otorhinolaryngologist (M.S.G. and B.W.O.). In the microscopically treated cohort, there were 8 intra- or postoperative complications, 6 intraoperative CSF leaks, 17 (77%) of 22 patients had GTR on postoperative imaging, 5 patients underwent ≥ 2 operations, and 10 (59%) of 17 patients reported total symptom resolution at follow-up. The endoscopically treated group had 7 intraor postoperative complications and 7 intraoperative CSF leaks. Of the patients who had pre- and postoperative imaging studies, 14 (66%) of 21 endoscopically treated patients had GTR; 4 patients had ≥ 2 operations, and 10 (66%) of 15 patients reported complete symptom resolution at follow-up. The first 9 patients who were treated endoscopically had a mean surgical time of 3.42 hours and a mean hospital stay of 4.67 days. The next 8 patients treated had a mean surgical time of 3.11 hours and a mean hospital stay of 3.13 days. The final 8 patients treated endoscopically had a mean surgical time of 2.22 hours and a mean hospital stay of 3.88 days. The difference in length of operation between the first 9 and the last 8 patients treated endoscopically was significantly different. There was a trend toward decreased CSF leaks and other complications from the first 2 groups compared with the third group.

Conclusions

In this subset of patients, the use of endoscopic endonasal resection results in a similar complication and symptom resolution rate compared with traditional techniques. The authors postulate that the learning curve for endoscopic resection can be ≤ 17 procedures.

Outcome and lack of prognostic factors in stapes surgery

OBJECTIVE

To analyze predictive factors of outcome after primary stapes surgery for otosclerosis.

STUDY DESIGN

Retrospective review of 139 patients with otosclerosis and 147 operations performed by the same senior surgeon with the same surgical technique.

SETTING

Academic hospital and tertiary referral center.

PATIENTS

All patients had documented preoperative and peroperative audiologic assessments and preoperative records. The mean age of patients was 44.31 years.

INTERVENTION

Stapedotomy with diode laser using Teflon prosthesis.

MAIN OUTCOME MEASURES

The bone conduction threshold changes, the improvement of pure-tone average air-bone gaps (PTA-ABGs), and ABGs for each frequency were analyzed using 0.5, 1, 2, and 4 kHz. Success rate was defined by postoperative ABG. Log-rank test was used to define significant factors.

RESULTS

At 24 hours postoperative, there was a significant deterioration in bone conduction threshold at 1, 2, and 4 kHz. However, at 4 kHz, the threshold remained significantly worse at longer term. There was a significant improvement of the PTA-ABG. Eighty-six percent of patients obtained a PTA-ABG of 20 dB or less. We also obtained a significant ABG closure on every frequency except on 4 kHz. Multivariate statistical analysis had not identified a predictive factor of hearing outcomes such as the anatomy of the facial nerve, the incus, the stapes footplate and the external auditory canal, the prosthesis crimping, bleeding, and surgical damage of the tympanic membrane.

CONCLUSION

In experienced hands, we observed a significantly transient depression of bone conduction hearing levels that was definitively present at 4 kHz. Peroperative difficult or abnormal situations did not seem to have an influence on the hearing outcome. Those statements will enable accurate preoperative counseling. It will also permit precise matching of future series to allow accurate comparisons.

An alternative model for stapedectomy training in residency program: sheep cadaver ear

To determine the usefulness of sheep cadaver ear as a complementary model for training of stapedectomy at residency programs, 2 of our 4 year residents were included in the study and each operated 20 sheep ears. All routine steps of stapedectomy operation were performed, and their success and complication scores were recorded. Performance of residents for stapedectomy and teflon piston placement in sheep ears were evaluated by the authors. Success of both residents improved progressively. Success and complications were impressively better in the second 10 ears than the initial 10 for each resident. Both residents had better outcomes in last 10 ears. Sheep cadaver ear is an excellent model for stapedectomy training in residency and helps to improve surgical skills. We offer sheep cadaver ear training model especially in the countries where obtaining human cadaver temporal bone is difficult.

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW

The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis?

RECENT FINDINGS

A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients.

SUMMARY

Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Stapedectomy

OBJECTIVE

To evaluate whether the performance of stapes surgery by residents during residency has decreased during the last 40 years, and if so, whether such a decrease has impacted the number of general otolaryngologists performing stapedectomy in the private practice setting.

STUDY DESIGN

Survey questionnaire of members of the American Academy of Otolaryngology-Head and Neck Surgery.

METHODS

A short questionnaire was mailed to 1,700 members of the American Academy of Otolaryngology-Head and Neck Surgery. Data collected included age, year of residency graduation, fellowship (if any), practice setting, geographic location, number of stapedectomies performed in residency, and number of stapedectomies performed currently.

RESULTS

Seven hundred fifty-six (44%) of 1,700 surveys were returned; 558 (74%) of 756 respondents did not complete a fellowship and were included in the general otolaryngologist group. Overall, 41% of general otolaryngologists are performing stapes surgery. There was a significant decline in the number of resident stapedectomies performed between 1960 and 1986; since 1986, this number has plateaued to an average of 8 to 9 (self-reported) cases per resident. More recent graduation from residency trended toward decreased inclination to do stapedectomy, although the result was not statistically significant. Increasing number of stapedectomy cases performed in residency correlated with an increased likelihood of performing the operation in practice.

CONCLUSION

Despite a decreasing case volume of stapes surgery in residency, stapedectomy remains an operation performed by general otolaryngologists.