Issues In Stapedectomy

Douglas D. Backous, MD
February 6, 1992

The history of stapedectomy is one of near discovery, condemnation, reintroduction and refinement.  Prior to the twentieth century poor lighting and magnification, nonstandardized audiometry, and a lack of understanding of the middle ear conduction mechanism plagued early researchers. Procedures concentrated on either partial or total removal of the tympanic membrane and ossicles. Mobilization of the stapes, described by Miot and later by Blake, would eventually be condemned by the otologic world.  Siebenmann, in 1900, capped the early era of stapes surgery by stating, “Clinical experience teaches that all endeavors at mobilization of the stapes in otosclerosis are not only useless but often harmful.”

Between 1900 and 1952 attempts at fenestration of the horizontal semicircular canal came to the spotlight. Results were reported as excellent but temporary. Microscopy and rotating drills were introduced. In 1929 the American Otologic Society commissioned a committee to compile a resume of  all literature concerning otosclerosis up to 1928. The result included a 700 page, two volume document covering histology of the otic capsule, heredity, audiology, and treatment of otosclerosis.

Successful surgery for hearing restoration truly began with Lempert’s fenestration operation. Rosen, a student of Lempert, serendipitously discovered that footplate mobilization improved hearing immediately in a patient with otosclerosis. He continued to refine his mobilization procedure until Shea, his student,  reopened the era of stapedectomy in 1956. Shea developed the modern technique of footplate mobilization, soft tissue grafting of the oval window, and ossicular replacement.

Shea is also credited with the first stapedotomy, performed on a young girl in 1960. A 6 millimeter stapedotomy with piston insertion and soft tissue packing provides equally improved hearing with less risk for damage to inner ear structures. Higher frequency hearing is preserved better with stapedotomy.
Robinson summed up the stapedectomy/stapedotomy debate best by declaring the “best” procedure is the operation which provides the individual surgeon with a predictable and safe outcome along with improved hearing to levels consistent with current otologic standards.

Depletion of the pool of patients with otosclerosis occurred during the “golden age” of stapes surgery throughout the sixty’s and early seventies. Increased numbers of trained otolaryngologists and improved hearing amplification further contribute to an overall limited exposure in modern practice and residency. Stapedectomy is the second least performed procedure in American residency, as shown by Harris and Osborne in 1990.

The issue of training residents to do successful stapedectomy first appeared in the literature in 1983.  Chandler and Rodriguez-Torro revealed a 62% closure of the air-bone gap to within 10 dB in resident cases, well below the 90-95% standard expected of practicing otologists. Five studies of results from training programs have since revealed results ranging from 64%-82% closure to within 10 Db in training programs. Of interest are the results of Shapira, et al. Their residents, in Israel, did stapedectomy in all four years of training. Results during the first two years of residency compared with American programs. During the second two years, however,results approached and often equaled those of staff. These findings further emphasized the critical importance of adequate numbers of procedures to insure acquisition of competence.

Solutions to the problem of numbers of cases include increased observation of otologic procedures with correlation in the temporal bone laboratory. Residents should display competence in surgery for chronic middle ear disease prior to attempting stapedectomy. Finally, all procedures should be supervised by senior otologic staff and one consistent technique used. For physicians in practice, batching stapedectomies into groups with review of needed skills in the temporal bone lab followed by consecutive case completion and review of results could provide valuable feedback in regard to outcome and maintenance of required skills.

In summary, stapedectomy has a fascinating history. Had Rosen not been open-minded to his first accidental mobilization, more delay in technique development was inevitable. The best procedure is surgeon dependent varying with individual skills and experience. Otosclerosis is now at a steady incidence making increased work in the temporal bone laboratory mandatory for both the acquisition and maintenance of required skills in footplate manipulation.

Case Presentation

A 68-year-old white male presented with a fifteen year history of progressive hearing loss. He had the most difficulty hearing in small group conversations. He denied tinnitus, dizziness, otalgia, or chronic middle ear infections. He did admit to a long history of loud noise exposure. Past surgical and medical histories were unremarkable. Weber exam showed localization to the right. Audiometry revealed normal to moderate sensorineural and severe to moderate conductive loss in the right ear with absence of acoustic reflexes. The left ear had mild to moderate sensorineural loss with normal acoustic immittance measures. Speech intelligibility scores were within the normal range bilaterally. The patient underwent right middle ear exploration, stapedectomy, with perichondrial grafting over the oval window and insertion of a standard well Robinson prosthesis.

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Hearing Science & Cochlear Mechanics

Clinical Psycoacoustics Lab
Has links to abstracts for auditory analysis.

Basic Signal Analysis
Advanced site that looks at different formulas for signal analysis. It says basic in the title, but it seems to be pretty advanced and filled full of formulas.

Acoustical Society of America
Nice site that has links to other acoustic related sites, general information about acoustics, and an area where you can listen to sounds.

Speech Reception … Virtual Tour of the Ear
Excellent site! This web site links to a large number of areas in speech perception. Some of the topics are word frequency, speech production, McGurk effect, and auditory perception.

Hearing Loss
This article is about the transduction of sound with an outline of a variety of differential diagnosis for hearing loss.

Technical Essays … UCSC Electronic Music Studios

Sound Propagation
Very nice article about the movement of sound. It has diagrams that help in the understanding of sound propagation and wavelength movement.

Hearing and Perception
Excellent article that has great pictures that help in explaining the anatomy of the ear and the perception of sound. It also has an area that you can click on to get a narrative description of the ear if the computer has a sound card.

Taking the Waveform Apart
Nice article that has information about sine and cosine function, Fourier analysis, and, sonograms and spectral analysis of sound.

Decibels
An intermediate article about the decibel and the different ways to calculate it. It looks at converting voltage or pressure ratios to decibels.

Wave and Vibration Tutorial
Good web site to get lots of valuable information. It is actually from a Physics III class. It would be good to take a look if you are currently in a physics of sound class or anything similar.

Cochlear Mechanics

Cochlear Fluids Research Laboratory
Excellent site!! This web site is a must see. It has a large volume of information about the anatomy of the ear and cochlear fluids. It has excellent pictures and graphics.

Cochlear Mechanics … Boystown
Great website with tons of information on coclear mechanics. It’s like a textbook.

Cochlear Micromechanics … Massachusetts Institute of Technology
Advanced site in cochlear mechanics. Has a few publications that are online, but the video tour has the most information online about cochlear mechanics

Cochlear Mechanic References from the Cochlear Fluids Lab
This is a publication list of articles and abstracts that were written by the Cochlear Fluids Research Lab. There is a total of nine pages.

Cochlear Mechanics Introduction
Good basic web site for seeing all the different formulas and pictures that could be helpful in understanding cochlear mechanics.

General Hearing Loss And Dizziness Information

Ear, Nose, and Throat Center of Salt Lake City
This is an excellent with graphics to help you understand all the different areas of the ear.

Virtual Tour of the Ear…. Augustana College
The best website that I have seen. Covers numerous audiology topics in a very organized format. Don’t miss this site!!!!

ENT Frequently Asked Questions
This site deals with basic questions that people often ask ENT doctors. It is easy to understand and would be beneficial for a patient or student to visit this site.

Center for Disease Control
Has a huge amount of information on a variety of topics and studies. You will have to search the site. Type in hearing loss or hearing aids and you will come up with some good articles.

Hear ITOrg. FAQ about people with Hearing Loss
A good site that is dedicated basically to informing patients and family members about hearing loss. It broaches subjects of prevalence such hearing loss, signs of a hearing loss, and solutions to hearing loss.

Five Minute Hearing Test… Midwest Ear Institute
Nice site that allows people who believe they may have a hearing loss to take a quick test to see if they are in need of a hearing evaluation.

Hearing and Older People… NIA
Good web site that has general information on recognizing a hearing loss, information on hearing aids, and the different types of hearing losses.

Midwest Ear Institute Home Page
Midwest Ear Institute web page addresses hearing loss that occurs in children and adults. A large portion deals with patient education and Meniere’s disease.

Mankato University… Hearing and Hearing Disorders
A very thorough site that has numerous topics that are situated in an outline format. Several of the servers were not found, but overall a very good site.

Florida Ear & Sinus Center
Excellent site that has basic description of surgeries with great graphics.

University Regensburg… Audiology
This is a good site that links to numerous servers under different topics. This specific area of the web page is in English.

Doxy’s Doctor’s Assistance Systems
LOOK UNDER DISEASES OF THE EAR, NOSE, AND THROAT. This is a very good site, but a large portion is dedicated to eye and nose problem. You need to scroll down a ways before you find the different Audiology topics.

Medline Plus Health Information
The site is good for both physicians and patients. It is in an easy to understand format.

Entrance to the Everyday World of Hearing and Balance
A nice site that gives information on a variety of audiological areas for consumers, professionals, and students.

Cochlear Implants

Clarion Cochlear Implants
The web site for Clarion has an excellent site that has a large number of areas to visit. It has cochlear implant history, press releases, components of the Clarion Multi-Strategy Cochlear Implant System, candidacy, patient info, and an interactive area.

Cochlear Corporation
Excellent site!! This web site is from the makers of the Nucleus 24Cochlear Implant system. It has information about the product, a kid zone, patient and parent information, and a search site.

MED-EL… MedicalElectronics
Nice site that has an American and international web site area. The American area is currently being updated, but the international portion is in English also. Very basic information in the patient info area. Has a library, product information, and recent news.

Dallas Otolaryngology … Cochlear Implant Program
Very nice web site that has frequently asked questions, cochlear implant devices, and links to other web sites.

Cochlear Implants: Restoring Hearing to the Deaf
This is an article out of The Harvard Mahoney Neuroscience Institute Letter. It is a personal perspective on cochlear implants. It has some basic information about cochlear implants, and how a patient may feel about the experience.

Cochlear Implants… AllHear
A large volume of information that deals more with how a patient is effected by a cochlear implant. The patient’s perspective is heavily covered. It has specific articles for patient and parents to read.

Hearing… A New Choice for Deaf Children and Adults
Nice site that is not technical in nature, but has some good solid information. It is an article that is designed in a question and answer format.  Very basic.

National Institute on Deafness and other Communication Disorders
Good web site that is a basic overview of a cochlear implant. Good resource for other areas.

British Cochlear Implant Group
This site allows patients and other hearing healthcare providers the opportunity to exchange questions and comments with cochlear implant professionals.

The Portland Hospital for Women and Children
Very nice web site for patients and doctors. It has some really good links for cochlear implants. It also has some really cool stuff on other topics. Check out the virtual body.

HealthyHearing.com
Very informative article cochlear implants.

Cochlear Implant Association
Not a really fancy web site, but is dedicated to cochlear implant patients.Has a HUGE number of links!!

FDA Information about Cochlear Implants
Good website!!

Advanced Web Sites

Sound from Silence: The development of Cochlear

Implants
This is the history of the cochlear implant. Great for a paper.

History of the Cochlear Implant
Nice article

SelfHelp for Hard of Hearing People, Inc.
SHHH is an organization dedicated to improving the lifestyles of people who are hard of hearing. It has a variety of links to clubs, international organizations, state commissions on deafness and a large number of other links that may be helpful in other areas.

Centerfor Auditory Prosthesis Research
Excellent site that sends quarterly reports to the National Institute of Health about projects that are being completed. There are several reports that can be viewed online, others are available in print. Very interesting site to visit!

BionicEar.org
Nice web site that has a lot of information for people. I believe it is the web site for the University of Melbourne in Australia