Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes

Abstract

Objective Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. Study Design Retrospective review. Setting Single tertiary neurotology center. Methods Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. Results During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB ( P < .0005). The most common intraoperative findings for these patients were prosthesis displacement with incus necrosis (38%) or without it (43%), normal anatomy with seemingly good prosthesis placement (6%), and abundant scar tissue (6%). Patients with recurrent hearing loss achieved lower mean ABGs than patients with persistent hearing loss (8.8 vs 13.2 dB, P = .02). There were no associations between onset pattern of CHL or intraoperative findings and hearing outcomes ( P > .05). Four patients (2.7%) developed sensorineural hearing loss after revision, defined as an increase in bone conduction pure tone average ≥15 dB, all of whom had previous replacement of a malpositioned prosthesis. Conclusions Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

Brazilian Society of Otology task force – Otosclerosis: evaluation and treatment

“… 247 , 248 , 249 , 250 Symptom onset may occur early, such as persistent hypoacusis, vertigo, or SNHL typically associated with intense tinnitus, or they may appear later in a sudden, fluctuating, or progressive manner, such as recurrent ABG. Except in cases of suspected perilymphatic fistula or granulation tissue, which according to some authors should be treated early, 251 an observational period of 6 weeks 252 to 3 months 253 is recommended. Because the outcomes of revision surgery in the literature are inferior to those of primary surgery, its indication should be carefully evaluated.…”

“…Persistent ABG ≥ 20 dB may indicate incorrect technique in the primary surgery, lateral fixation of the malleus or incus to the attic, or the presence of a previously undetected third window, usually leading to worse results in revision surgery. 112 , 252 , 253 Recurrent or increasing ABG may indicate erosion of the long process of the incus, prosthesis displacement, inadequately sized prosthesis, scar adhesions, ossification of the fenestra, or granuloma. 247 , 251 , 253 In up to 82% of cases, there is necrosis of the long process of the incus and/or prosthesis displacement.…”

“… 112 , 252 , 253 Recurrent or increasing ABG may indicate erosion of the long process of the incus, prosthesis displacement, inadequately sized prosthesis, scar adhesions, ossification of the fenestra, or granuloma. 247 , 251 , 253 In up to 82% of cases, there is necrosis of the long process of the incus and/or prosthesis displacement. 253 Massimilla et al 257 investigated 21 patients with incus erosion who either received a new prosthesis placed proximally to the long process or underwent incus reconstruction with bone cement.…”

“… 247 , 251 , 253 In up to 82% of cases, there is necrosis of the long process of the incus and/or prosthesis displacement. 253 Massimilla et al 257 investigated 21 patients with incus erosion who either received a new prosthesis placed proximally to the long process or underwent incus reconstruction with bone cement. ABG was reduced to ≤10 dB in 59% of cases and to ≤20 dB in 86.4% cases, with no cases of SNHL.…”

“…Adhesions and granulation tissue should be removed, and an appropriately sized prosthesis should be used. 252 , 253 Fat, vein, and blood grafts are used around the prosthesis to prevent the occurrence of fistula. 257 …”