Keywords
otosclerosis - stapedotomy - stapedectomy
Introduction
Otosclerosis is a condition caused by abnormal bone remodeling in the optic capsule
that leads to stapes fixation and consequent conductive hearing loss. Diagnosis is
presumed by the presence of conductive hearing impairment in patients with normal
external auditory canal and tympanic membrane, and computed tomography (CT) scan findings
of abnormal bone densities within the optic capsule.[1] Stapes surgery is the gold standard treatment for otosclerosis and aims to restore
the sound transmission mechanism by replacing the stapes with a prosthetic device
that allows the sound waves to travel to the inner ear.
Since the first stapedectomy performed by John Shea in 1956, stapes surgery has evolved,
and many variations of the technique have been published.[2] The major innovation was the replacement of stapedectomy (total removal of the footplate)
for stapedotomy (small fenestra in the footplate just large enough to accommodate
the piston) as the preferred technique by most otologists, due to the belief that
stapedotomy provides: i) better hearing improvement, ii) more stable long-term hearing
results, iii) lower incidence of complications (sensorineural hearing loss, postoperative
vertigo, perilymphatic fistula).[1] Because of this perception, most ear surgeons opt for stapedotomy whenever possible.[3] However, these differences remain debatable, with many studies reporting similar
results between the two techniques.[4]
[5]
[6]
[7]
The authors have two main purposes with this study: i) to assess the hearing outcomes
and complications of stapes surgery performed in a series of patients with otosclerosis;
and ii) to compare the results of stapedotomy with stapedectomy performed in our otorhinolaryngology
department.
Methods
We conducted a retrospective study of 142 ears in 125 patients with otosclerosis that
underwent stapes surgery in the otorhinolaryngology department of a tertiary level
hospital in the last 10 years (2014–2023). Revision surgeries (n = 8) were excluded
from the study. Medical records were investigated for data collection regarding demographic
information, surgical report, audiometric results, and postoperative complications.
The last preoperative audiogram before surgery and the 6 months postoperative audiogram
were used. The air-bone gap (ABG) was calculated from the difference between the mean
air- and bone-conduction thresholds obtained at 0.5, 1, 2, and 4 kHz. The speech recognition
threshold (SRT) was defined as the minimum hearing level for speech at which an individual
can recognize 50% of the information, and was measured in the pre- and postoperative
hearing evaluations.
Every surgery was performed under general anesthesia. After confirmation of a stapedial
fixation, a hole was made in the footplate with a perforator to perform stapedotomy.
On the other hand, stapedectomy was performed only when the footplate accidentally
cracked or was removed along with the stapes superstructure. In stapedectomy cases,
the decision to use a tissue seal of the fenestra (tragus perichondrium or temporalis
fascia graft) or not was made by the surgeon. A Teflon prosthesis with 0.6 mm in width
was used in all cases.
The ears were divided into the stapedotomy and stapedectomy groups according to the
chosen surgery technique. Hearing outcomes and surgical complications were analyzed
and compared between the groups. Patients who underwent stapedotomy in one ear and
stapedectomy in the other were placed in a subgroup in order to compare surgical outcomes
between them.
Statistical analysis was performed using the IBM SPSS Statistics for Windows (IBM
Corp., Armonk, NY, USA) software, version 27.0. The nonparametric Mann-Whitney U test
was used to compare hearing outcomes and complication between the stapedotomy and
the stapedectomy groups. Values of p < 0.05 were considered statistically significant.
Results
During the study period, 134 ears from 125 patients were deemed eligible based on
the inclusion and exclusion criteria (revision surgeries from 6 stapedectomies and
2 stapedotomies were excluded). Among the 134 cases analyzed, 109 (81%) underwent
stapedotomy, while 25 (19%) underwent stapedectomy. The mean age of the surgical patients
was of 47.3 ± 10.8 years, with 34% male and 66% female subjects. [Table 1] presents demographic data for patients in the stapedotomy and stapedectomy groups,
excluding revision cases. There were no statistically significant differences (p > 0.05) between the groups regarding age, gender, laterality, type of hearing loss
or length of hospital stay.
Table 1
Demographic data of the study population
|
Demographic data
|
Stapedotomy
n = 109
|
Stapedectomy
n = 25
|
|
Mean age
,
years
|
47.4 ± 8.8
|
48.3 ± 8.6
|
|
Gender
|
|
Male
|
39 (35.8%)
|
6 (24.0%)
|
|
Female
|
70 (64.2%)
|
19 (76.0%)
|
|
Both ears affected
|
63 (57.8%)
|
17 (68.0%)
|
|
Type of hearing loss
|
|
Conductive
|
38 (34.9%)
|
12 (48.0%)
|
|
Mixed
|
71 (65.1%)
|
13 (52.0%)
|
|
Side of surgery
|
|
Right
|
58 (53.2%)
|
15 (60.0%)
|
|
Left
|
51 (46.8%)
|
10 (40.0%)
|
|
Days of hospitalization
|
2.36 ± 0.86
|
2.40 ± 0.85
|
The length and diameter of prostheses used in both patient groups were recorded and
compared ([Table 2]). Teflon pistons with a width of 0.6 mm and lengths ranging from 4 to 5 mm were
selected based on the distance between the incus process and stapes footplate measured
during surgery. In stapedectomy surgeries, most surgeons used tragal perichondrium
to seal the oval window (n = 16; 64.0%), while only 1 (4.0%) used temporal fascia,
and 8 (32.0%) did not use any additional tissue besides the prostheses.
Table 2
Prostheses used in each surgical procedure
|
Prostheses
(widthxlenght in mm)
|
Stapedotomy
n = 109
|
Stapedectomy
n = 25
|
|
0.6 × 4
|
6 (5.5%)
|
2 (8.0%)
|
|
0.6 × 4.25
|
26 (23.9%)
|
7 (28.0%)
|
|
0.6 × 4.5
|
65 (59.6%)
|
14 (56.0%)
|
|
0.6 × 4.75
|
12 (11.0%)
|
1 (4.0%)
|
|
0.6 × 5
|
0 (0%)
|
1 (4.0%)
|
The presurgical ABG in patients who underwent stapedotomy was of 37.42 ± 8.63, and
the postsurgical ABG was of 7.27 ± 13.64, with a p-value < 0.001. For patients who underwent stapedectomy, the pre-surgical ABG was
of 34.88 ± 7.84, and the postsurgical ABG was of 5.54 ± 9.88, also with a p-value < 0.001 ([Fig. 1]). Pre- and postsurgical ABG between these 2 groups were not statistically significant
(p: 0.533 and 0.196 respectively).
Fig. 1 Differences in pre- and postoperative air-bone gap in both groups.
The postoperative ABG was evaluated to determine surgery success. In the stapedotomy
group, 78 (71.6%) patients achieved an ABG below 10 dB, and 94 (86.2%) achieved an
ABG below 20 dB. In the stapedectomy group, 17 (68.0%) patients achieved an ABG below
10 dB, and 21 (84.0%) achieved an ABG below 20 dB. There were no statistically significant
differences between the 2 groups (p = 0.745). These postoperative results are depicted in [Figure 2].
Fig. 2 Postoperative air-bone gap < 10 and < 20 dB in both groups.
The SRT before (68.67 ± 13.48) and after (44.88 ± 16.49) stapedotomy showed statistical
significance (p < 0.001). Similarly, for stapedectomy, the SRT before (65.20 ± 15.17) and after (37.61 ± 11.37)
surgery was statistically significant (p < 0.001), as shown in [Fig. 3]. There was no statistically significant difference in terms of SRT between the two
groups (p: 0.509 and 0.077 respectively).
Fig. 3 Speech reception threshold pre- and postsurgery in both groups.
There was no significant difference in the percentage of patients with ABG closure
within 10 (p = 0.726) or 20 dB (p = 0.556), indicating no discernible differences in postoperative hearing outcomes
between the two surgical techniques.
Additionally, five patients underwent stapedotomy in one ear and stapedectomy in the
other, with all ten ears achieving a postoperative ABG below 10 dB.
Concerning postoperative complications, 1 patient experienced labyrinthitis after
stapedotomy, while 3 patients in the stapedotomy group (2.7%) and 1 in the stapedectomy
group (4%) suffered from profound sensorineural hearing loss (2 patients in the first
week, 1 patient 4 weeks after surgery, 1 patient 6 months after surgery). Additionally,
symptoms of vertigo were present at 6 months postoperatively in 11 poststapedotomy
(10.1%) and 4 poststapedectomy (16%) cases. Statistical analysis revealed no significant
differences in postoperative complications between the surgical techniques (p = 0.911), as summarized in [Table 3].
Table 3
Postoperative complications
|
Postoperative complications
|
Stapedotomy
n = 109
|
Stapedectomy
n = 25
|
|
Revision surgery
|
6 (5.2%)
|
2 (7.4%)
|
|
Severe sensorineural hearing loss
|
3 (2.7%)
|
1 (4%)
|
|
Labyrinthitis
|
1 (0.9%)
|
0 (0%)
|
|
Vertigo at 6 months postoperatively
|
11 (10.1%)
|
4 (16%)
|
Discussion
Conductive hearing loss caused by otosclerosis can be managed by two different approaches:
hearing aids or stapes surgery. Nevertheless, stapes surgery is the only treatment
option for otosclerosis that can restore sound transmission, being recognized as more
effective and with better quality of life improvement for the patient.[8] Currently, stapedotomy is the preferred surgical technique because of the greater
improvements in hearing at higher frequencies shown with this technique, as well as
the perception of lower complication rates.[8] However, it is believed that the surgeons' experience plays the most important part
in the success of stapes surgery.[7]
Most patients in our cohort underwent stapedotomy. The reason for this discrepancy
is that, in our department, that is our standard, and stapedectomy is performed only
when it is not doable, either because the footplate accidentally cracks, or is removed
along with the stapes superstructure. In the present study we focused on comparing
both techniques regarding postoperative hearing results and complications of our department,
in order to enhance the knowledge surrounding stapes surgery.
Regarding hearing outcomes, both stapedotomy and stapedectomy demonstrated good results
and no differences, corroborating previous reports of similar studies.[4]
[5]
[6]
[7] The piston used in all surgeries was Teflon, with 0.6 mm in diameter, while the
length of the prosthesis differed according to intraoperative findings. We did not
calculate the difference of hearing improvement between each frequency because it
is believed that, although stapedotomy offers better results in higher frequencies,
it does not offer clinical significance in terms of hearing function.[4] Disparate reports have been published in the literature. Some advocate greater hearing
outcomes and less complications with stapedotomy,[9]
[10]
[11] and others note no differences in postoperative results between either technique.[4]
[5]
[6]
[7]
[12] Our results support the latter, with both our groups showing similar hearing results
in postoperative ABG and SRT.
Additionally, as House et al.[4] had examined, we compared 5 patients who had undergone stapedotomy in one ear and
stapedectomy in the other, allowing for a paired case comparison, and found complete
closure of the ABG in each of the 10 ears with no complications reported, highlighting
the efficacy of both techniques in ears with the same individual characteristics.
Complication rates have been reported as higher in patients that underwent stapedectomy
over stapedotomy.[13] That was not the case in our cohort, but the small sample of complications in both
techniques prevented us from establishing a causal correlation. Postoperative vertigo
is common following stapes surgery and is the main reason for prolonged hospital stay,
despite usually being resolved with conservative management.[14] In the present study we did not find a difference in days of hospitalization between
the two groups, meaning the extent of the fenestra in the footplate had no association
with the intensity of immediate postoperative vertigo. Furthermore, when comparing
reported vertigo at 6 months postsurgery, we found no difference between groups, which
was in accordance with the findings of Harmat et al..[15]
One of the patients with prolonged vertigo after stapedectomy underwent revision surgery
despite having a postoperative ABG below 10 db, because there was a suspicion that
the prosthesis was too long (0.6 mm in length), as reported by Job et al.[16] The piston was switched for a 0.45-mm one, with complete resolution of vertigo,
maintaining a successful hearing outcome.
The most feared complication of stapes surgery is severe sensorineural hearing loss,
a known rare complication that can occur in 0 to 11% of cases.[1]
[17] In our cohort, we found 4 cases (stapedotomy: 3; stapedectomy: 2), either early
or late in the postoperative period. In one of those, revision surgery was performed
and the prosthesis removed, with no success. This overall rate of 3% is significant,
with two possible explanations: 1) small sample number in comparison with other reports;
2) the different surgeons who operated in our cohort, corroborating that experience
may be the most important determinant of success in stapes surgery.[18]
Conclusion
In the present study, we were able to show that both stapedotomy and stapedectomy
offer good hearing results with a low percentage of complications in patients with
otosclerosis. Although stapedotomy remains the preferred technique for most ear surgeons,
one should note that if the initial plan shifts to a stapedectomy, surgeons should
remain composed and confident in a good hearing outcome.
Bibliographical Record
Francisco Teixeira-Marques, Rita Vaz Osório, Mónica Teixeira, Joana Rebelo, Sandra
Gerós, Diamantino Helena, António Faria de Almeida, Pedro Oliveira. Stapedotomy or
Stapedectomy: Does It Really Matter?. Int Arch Otorhinolaryngol 2025; 29: s00441792086.
DOI: 10.1055/s-0044-1792086
