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Ear Surgery Outcomes in Patients Operated on for Otosclerosis
I ORIGINAL ARTICLES
Ear Surgery Outcomes in Patients Operated on for Otosclerosis Antonio Paz Cordovés, Elisa Leyva Montero, Alina M. García de Hombre, and Glenda M. Prieto Zelaya Servicio de Otorrinolaringología, Hospital Clínico Quirúrgico Hermanos Ameijeiras, La Habana, Cuba
Background: Stapedectomy is currently the treatment with which the best results are obtained among patients with otosclerosis, which is why it is the treatment of choice. Objective: The objective of our paper is to evaluate the auditory results of patients diagnosed with this illness who were subjected to surgery. Material and method: The study population comprised all patients attending the otosurgery clinic with a diagnosis of otosclerosis and who were selected to undergo stapedectomy treatment with the Schuknecht technique between June 2003 and June 2005. Results: Our sample contained 44 patients, 3 of whom received bilateral treatment, for a total of 47 operated ears. 70.2% were women and men the remaining 29.8%, between the 3rd and 5th decades of life. Partial platinectomy was done in 53.2% of the patients, total platinectomy in 40.4%, and platinotomy in 6.4%. Conclusion: The conclusion of our study is that all the patients who received surgical treatment had an auditory improvement of 36.7 dB on average and there was no significant difference in the type of platinectomy performed. Complications were rare and with no auditory repercussions.
Resultados audioquirúrgicos en pacientes operados de otosclerosis
Key words: Otosclerosis. Stapedectomy. Stapedotomy. Results.
Palabras clave: Otosclerosis. Estapedectomía. Estapedotomía. Resultados.
INTRODUCTION
tendency to withdraw from society, depression and social discrimination1. There are many causes of hypoacusis, including otosclerosis. This illness usually appears when the individual is fully prepared to play a role in society. For years, the treatment for this illness has been looking for ways to delay or repair hypoacusis, which has become one of the greatest challenges of otology2. It is now known that surgery is the most effective option for getting the best results in otosclerosis3-6. Otosclerosis is a primary disease of the bony labyrinth capsule, limited to the temporal bone, that exclusively affects humans. It is transmitted by an autosomal dominant gene with incomplete penetrance, consisting of one or more
Since ancient times, the sense of hearing has played a fundamental role as an essential element in the process of communication. For different reasons, it can be affected, resulting in hypoacusis, which can lead to frustration, the Correspondence: Dra. A.M. García de Hombre. Hospital General de Fuerteventura. Ctra. al Aeropuerto, km 1. 35600 Puerto del Rosario. Las Palmas. España. E-mail: [email protected] Received August 9, 2006. Accepted for publication December 19, 2006.
Introducción: La estapedectomía es actualmente el tratamiento con el que se obtienen mejores resultados en los pacientes con otosclerosis, por lo cual es el tratamiento de elección. Objetivo: El objetivo de nuestro trabajo es evaluar los resultados auditivos en los pacientes diagnosticados de esta enfermedad que fueron sometidos a cirugía. Material y método: El universo de estudio estuvo integrado por todos los pacientes atendidos en la consulta de otocirugía con diagnóstico de otosclerosis, que fueron seleccionados para realizarles estapedectomía con la técnica de Schuknecht, en el período comprendido entre junio de 2003 y junio de 2005. Resultados: Nuestra muestra fue de 44 pacientes, de los que 3 recibieron el tratamiento bilateral, con un total de 47 oídos operados. El 70,2% eran mujeres y el 29,8%, varones entre la tercera y la quinta década de la vida. Se realizó platinectomía parcial en el 53,2% de los pacientes, total en el 40,4% y platinotomía en el 6,4%. Conclusión: La conclusión de nuestro estudio muestra que todos los pacientes que recibieron tratamiento quirúrgico tuvieron ganancia auditiva, con un promedio de 36,7 dB, y que no hubo una diferencia significativa entre los tipos de platinectomía realizada. Las complicaciones fueron escasas y sin repercusión auditiva.
Acta Otorrinolaringol Esp. 2007;58(3):79-82
79
Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Men
Women
29.8% 70.2%
Figure 1. Sex distribution.
localised foci where repeated resorption and bone deposition has occurred7,8. This illness starts out as a spongy lesion in the endochondral layer of the labyrinthine capsule. It can appear on different parts of the temporal bone, starting in a region of bone near the oval window with areas of demineralization and sclerosis. As the bony process invades the oval window, it is completely asymptomatic. However, on gradually invading the annular ligament of the stapes, it causes fixation of its base or footplate and deteriorates air conduction of sound7,9. It is known that the illness fundamentally appears between the third and fifth decades of life, being more frequent in white women with a close family history of the disease8-10. At our department, otosclerosis has been surgically treated using the Schuknecht technique since 1990 and therefore we have considered evaluating the technique’s ear surgery outcomes over the last 2 years in order to verify its effectiveness and compare the technique with outcomes obtained worldwide.
OBJECTIVES General: to evaluate ear surgery outcomes in patients undergoing stapedectomy for otosclerosis. Specific: to describe the demographic behaviour of the study population; identify whether there is a family history of otosclerosis in patients undergoing surgery; describe the most frequent symptoms, reason for attending the clinic and time over which symptoms have developed; describe otoscopic characteristics of patients undergoing surgery; determine footplate characteristics and the type of platinectomy performed; evaluate auditory improvement in patients undergoing surgery and compare this to the type of platinectomy performed, and list any complications found.
MATERIAL AND METHOD A prospective, longitudinal, descriptive study was conducted using all patients attending the otosurgery clinic with a diagnosis of otosclerosis who underwent 80
Acta Otorrinolaringol Esp. 2007;58(3):79-82
stapedectomy surgery with the Schuknecht technique or stapedotomy between June 2003 and June 2005 as our study population. Audiological follow-up was performed using pre-operative and post-operative audiometry 15 days and 3 months after the stapedectomy. Results obtained were gathered for analysis and discussion. A database was prepared in Excel and results were summarized according to averages and percentages, which are shown in tables and graphs to make them easier to interpret. In order to compare auditory improvement according to the type of platinectomy performed, Student’s t test for independent samples was applied using a significance level of P=.05.
RESULTS AND DISCUSSION Our cases included a total of 44 patients, 3 of whom received surgery on both ears, for a total of 47 operated ears. Of these patients, 70.2% were women and 29.8% men (Figure 1), which generally agrees with the bibliography reviewed2,6,7,11,12. In our study, 38 (80.9%) patients were white, agreeing with authors such as Escajadillo7 and Rivas and Ariza8, who mention that otosclerosis is up to 10 times more frequent in white people than in black. Taking into account the fact that this study has been conducted on a population that is half white and half black, results are interpreted as being in agreement with other authors. On distributing the results according to age group, it was shown that the largest number of cases (30 [63.8%] patients) were between the third and fifth decades of life. This has already been shown in other studies indicating that this is due to the illness developing with the progressive formation of otosclerotic foci that cause fixation of the footplate3,9,11. A family history of otosclerosis was present in 51.1% of the study population, proving the genetic component of the illness (agreeing with studies conducted by different authors, which indicate that up to 66% of patients have a family history of the illness2,9,13), transmitted by an autosomal dominant gene with incomplete penetrance. The most frequent symptoms needing medical attention were hypoacusis, in 100% of patients, and tinnitus, in 89.4%, which agrees with the literature reviewed (Figure 2). Rivas and Ariza8 and Antolí-Candela et al.3 indicate that the bone process is completely asymptomatic while it is invading the oval window but, on gradually invading the annular ligament of the stapes, it causes fixation of the base or footplate and deteriorates air conduction of sound7,9. Symptoms were progressive and most patients receiving surgery had an illness evolution time of less than 5 years (Table I), which favours a positive response to treatment3. Otoscopy in our study population showed a wax-free, wide external auditory meatus (ear canal) and a shiny tympanic membrane in 59.6%, as commonly described in patients with this illness6,9,12,13. In 8.5% of the ears examined, we found Schwartze’s sign, which, according to descriptions,
Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Diplacusis
6.4
Vertigo
10.6
Paracusia
14.9
Tinnitus
89.4 100
Hypoacusis 0
20
40
60
80
100
Percentage Figure 2. Distribution according to most frequent symptoms and signs. Table I. Distribution of the Most Frequent Symptoms According to Evolution Time
Evolution, Years
Hypoacusis, n (%)
Tinnitus, n (%)
<5
19 (40.4)
20 (47.6)
5-9
9 (19.1)
10 (23.8)
10-14
12 (25.5)
7 (16.7)
15-19
3 (6.4)
2 (4.8)
20 Total
4 (8.5)
3 (7.1)
47 (100)
42 (100)
Pre-Operative Post-Operative 3 Months
50 40 Threshold, dB
can be found in some patients8-10 and indicates highly vascularized otosclerotic foci. We must point out that, in our opinion, the thorough examination of the external auditory canal and the characteristics of the tympanic membrane, together with past medical history, make us suspect a diagnosis of otosclerosis. In otosclerosis, as a focal illness of the otic capsule, we generally see localised foci, with greater predilection for certain areas, according to Delarcki’s classification, plus the following, in order of frequency: the anterior portion of the footplate, the annular ligament, the posterior portion of the footplate and obliterated footplates, whether thin or thick8,9,14. We found that the otosclerotic focus on the anterior portion of the footplate was the most frequent, with 32%, followed by fixation of the footplate by the annular ligament, with 25%. Thin and thick obliterated footplates were found in 6 and 4 ears, respectively, which are extremely important aspects for the surgeon to be able to take the correct action in each case to obtain good results. Depending on the type of footplate found, a platinectomy is usually performed, although a partial platinectomy is much more frequent in our case: anterior in 21.3% and posterior in 31.9% of the ears operated on, since, as is already known, the saccule lies just 2.5 mm from the anterior edge of the oval window and presents a greater risk of complication15. A platinotomy was only practised on 3 ears, in patients with a thick obliterated footplate. An industrial Teflon-wire piston was inserted. There is currently controversy as to whether to perform a platinectomy or platinotomy. Those favouring platinotomy base their arguments on good results achieved from the auditory point of view, with very few complications and a reduced surgery time, and with few complaints of bone conduction at higher frequencies14,16,17. In our case, we consider that the results achieved are similar to those using commercial pistons as, if the surgeon has experience and skill, bone conduction is not affected and complications are similar. Therefore, we propose that the traditional Schuknecht technique is still valid. Figure 3 shows bone conduction behaviour prior to surgery and 3 months after surgery at the main frequencies of speech. It can be seen that there were no significant variations, except at the frequency of 4000 Hz, where the average difference was very slightly higher, corresponding to the technique used in most patients, the Schuknecht technique, where it is indicated that this frequency may reduce labyrinthine fluid movement2,3,8,13. At frequencies of 500, 1000 and 2000 Hz, bone conduction improved slightly, as indicated by most authors2,3,8. This corresponds to the improved hypertension of labyrinthine fluid due to the compression of the otosclerotic foci, which justifies the disappearance of the Carhart notch following surgery3,13. Figure 4 shows the average auditory improvement in bone conduction 15 days and 3 months after surgery, in comparison to the pre-operative level, and the average improvement of 36.8 dB in air conduction at main frequencies 3 months after surgery, which is better than after 15 days,
30 20 12.7
10
8.4
8.7 7.5
7.2
10.0 8.0
9.5
0 500
1.000
2.000
4.000
Frequencies, Hz Figure 3. Pre-operative and post-operative auditory threshold in bone conduction at the main frequencies.
which proves a socially useful recovery of hearing. These results are similar to those achieved by other authors3,8,13,18,19. In was interesting to evaluate the auditory outcome according to the type of platinectomy performed and the average auditory improvement, where it was found that the average auditory improvement in a total platinectomy was Acta Otorrinolaringol Esp. 2007;58(3):79-82
81
Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Pre-Operative Post-Operative 15 Days Post-Operative 3 Months
60 50.9
50
48.0
47.4 45.7
Threshold, dB
40 30.0
30
REFERENCES 20
15.0 15.0
15.0 10.0 10.0
10
10.0 5.0
0 500
1000
2000
4000
Frequencies, Hz Figure 4. Pre-operative and post-ooperative average auditory threshold in air conduction at the main frequencies.
35.2 dB compared in 38.3 dB in a partial platinectomy, showing no statistical importance, in agreement with many authors7,8,13. The following complications were recorded: transoperative, 1 (2.1%) severed cord of tympanum; postoperative, 2 (4.3%) haemotympanum and 3 (6.4%) patients with immediate vertigo. These did not have a repercussion on the patients’ hearing and disappeared within a few days of surgery, very different from the large number of complications reported in medical literature3,8,19-21, where severe complications include facial paralysis and deafness, confirming that the outcome of stapes surgery is closely related to the surgeon’s competence resulting from his knowledge, training and experience3.
CONCLUSIONS In our study, most patients undergoing surgery were white women between the third and fifth decades of life. The most frequent symptoms needing medical attention were hypoacusis and tinnitus with an evolution time of less than 5 years in most cases. The existence of a family history of otosclerosis was seen in more than half our patients.
82
The otosclerotic focus found most frequently was located on the anterior portion of the footplate. All patients undergoing surgery experienced an auditory improvement, with an average of 36 dB. There was no significant difference in auditory improvement between patients undergoing a total or partial platinectomy. There were no great variations in bone conduction in patients undergoing surgery. Our patients’ complications were minimum, without auditory repercussions.
Acta Otorrinolaringol Esp. 2007;58(3):79-82
1. Gómez J. Genio y drama: La sordera de Beethoven. Bogotá: Academia Nacional de Medicina de Colombia; 2002 [cited August 4th, 2006]. Available from: http://anm.encolombia.com/academ24259-geniodrama.htm 2. Caballero J, Paz A. Hallazgos quirúrgicos en la cirugía de la otosclerosis [doctoral thesis]. LA Habana: Educación y Ciencia; 1997. 3. Antolí-Candela F, Gil-Carcedo E, Vallejo LA. Estapedotomía, estapedectomía y cirugía de revisión realizados con técnica láser. Análisis de la evolución de los sistemas. Acta Otorrinolaringol Esp. 2003;54:286-94. 4. Stott C, Nazar R, Manieu D. Manejo quirúrgico en otosclerosis unilateral. Rev Otorrinolaringol Cir Cabeza Cuello. 2005;65:111-6. 5. Thiel G, Mills R. Rosen mobilization of the stapes: does it have a place in modern otology? J Laryngol Otol. 2006;2:1-5. 6. Hernández E, Fraile J, Marín C, Carmen L, Llorente E, Naya MJ, et al. Resultados a largo plazo de las estapedectomías. Acta Otorrinolaringol Esp. 2002;53:237-42. 7. Escajadillo JR. Oídos, nariz, garganta y cirugía de cabeza y cuello. Vol. 1. 2nd ed. Mexico: El Manual Moderno; 2003. p. 82-6. 8. Rivas JA, Ariza HF. Otoesclerosis. In: Otología. Santa Fé de Bogotá: Imprenta y Publicaciones Fuerzas Militares; 1992. p. 369-93. 9. Vargas JL, Alañón MA, Rodríguez RM, Ruiz-Coello J, Ruiz JM, Sainz M. Otosclerosis y su tratamiento. In: Baragaño L, Frágola C, Gil-Carcedo LM, Muñoz C, Ortega P, Sánchez J, editors. Manual del residente de O.R.L y patología cérvico-facial. Madrid: IM&C; 2002. p. 723-39. 10. Paparrella M, Gluckman S. Otología. In: Paparrella M, Gluckman S, editors. Otorrinolaringología. 3rd ed. Buenos Aires: Panamericana; 1994. pp. 1625-35. 11. Emmett JR. Physical examination and clinical evaluation of the patient with otosclerosis. Otolaryngol Clin North Am. 1993;26:353-7. 12. Cummimgs CW, Frederickson JM, Harker CA, Sculler DE. Otorrinolaringology head and neck surgery. 2nd ed. St. Louis: Mosby-Year Book; 1993. p. 2298-3016. 13. Silverstein H. The future of stapes surgery. Ear Nose Throat J. 2005;84:394-5. 14. Pérez-Carro A, Espiña G, Ibarra JI, Araujo J, Fariña JL, Sánchez D. Estapedectomía: nuestros resultados. Acta Otorrinolaringol Esp. 2005;56:400-2. 15. Lewi E, Saunders W, Paparrella M, Miglets A. Atlas cirugía del oído. 4th ed. Buenos Aires: Médica Panamericana; 1988. p. 42-50; 298-362. 16. Quaranta N, Besozzi G, Fallacara RA, Quaranta A. Air and bone conduction change after stapedotomy and partial stapedectomy for otosclerosis. Otolaryngol Head Neck Surg. 2005;133:116-20. 17. Levy R, Severo J, Hardart T. Stapedotomy technique and results: ten years’ experience and comparative study with stapedectomy. Laryngoscope. 1990;100:1097-9. 18. Lanas A, Stott C, Olavaria C. Otosclerosis: Resultados auditivos en estapedectomía y estapedostomía. Rev Otorrinolaringol Cir Cabeza Cuello. 2002; 62:251-4. 19. Henríquez M, Altuna X, Luque I, Gorostiaga F, Algaba J. Estapedectomía como cirugía ambulatoria. Acta Otorrinolaringol Esp. 2004;55:218-24. 20. Lacosta JL, Sánchez A, García J. Posible beneficio de la calcitonina en el tratamiento de la otosclerosis. Acta Otorrinolaringol Esp. 2003;54:169-72. 21. Lee KJ. Enfermedades no infecciosas del oído. In: Lee KJ. Otorrinolaringología cirugía de cabeza y cuello. 7th ed. Mexico: McGraw-Hill Interamericana; 2002. p. 779-89.
Ear Surgery Outcomes in Patients Operated on for Otosclerosis Antonio Paz Cordovés, Elisa Leyva Montero, Alina M. García de Hombre, and Glenda M. Prieto Zelaya Servicio de Otorrinolaringología, Hospital Clínico Quirúrgico Hermanos Ameijeiras, La Habana, Cuba
Background: Stapedectomy is currently the treatment with which the best results are obtained among patients with otosclerosis, which is why it is the treatment of choice. Objective: The objective of our paper is to evaluate the auditory results of patients diagnosed with this illness who were subjected to surgery. Material and method: The study population comprised all patients attending the otosurgery clinic with a diagnosis of otosclerosis and who were selected to undergo stapedectomy treatment with the Schuknecht technique between June 2003 and June 2005. Results: Our sample contained 44 patients, 3 of whom received bilateral treatment, for a total of 47 operated ears. 70.2% were women and men the remaining 29.8%, between the 3rd and 5th decades of life. Partial platinectomy was done in 53.2% of the patients, total platinectomy in 40.4%, and platinotomy in 6.4%. Conclusion: The conclusion of our study is that all the patients who received surgical treatment had an auditory improvement of 36.7 dB on average and there was no significant difference in the type of platinectomy performed. Complications were rare and with no auditory repercussions.
Resultados audioquirúrgicos en pacientes operados de otosclerosis
Key words: Otosclerosis. Stapedectomy. Stapedotomy. Results.
Palabras clave: Otosclerosis. Estapedectomía. Estapedotomía. Resultados.
INTRODUCTION
tendency to withdraw from society, depression and social discrimination1. There are many causes of hypoacusis, including otosclerosis. This illness usually appears when the individual is fully prepared to play a role in society. For years, the treatment for this illness has been looking for ways to delay or repair hypoacusis, which has become one of the greatest challenges of otology2. It is now known that surgery is the most effective option for getting the best results in otosclerosis3-6. Otosclerosis is a primary disease of the bony labyrinth capsule, limited to the temporal bone, that exclusively affects humans. It is transmitted by an autosomal dominant gene with incomplete penetrance, consisting of one or more
Since ancient times, the sense of hearing has played a fundamental role as an essential element in the process of communication. For different reasons, it can be affected, resulting in hypoacusis, which can lead to frustration, the Correspondence: Dra. A.M. García de Hombre. Hospital General de Fuerteventura. Ctra. al Aeropuerto, km 1. 35600 Puerto del Rosario. Las Palmas. España. E-mail: [email protected] Received August 9, 2006. Accepted for publication December 19, 2006.
Introducción: La estapedectomía es actualmente el tratamiento con el que se obtienen mejores resultados en los pacientes con otosclerosis, por lo cual es el tratamiento de elección. Objetivo: El objetivo de nuestro trabajo es evaluar los resultados auditivos en los pacientes diagnosticados de esta enfermedad que fueron sometidos a cirugía. Material y método: El universo de estudio estuvo integrado por todos los pacientes atendidos en la consulta de otocirugía con diagnóstico de otosclerosis, que fueron seleccionados para realizarles estapedectomía con la técnica de Schuknecht, en el período comprendido entre junio de 2003 y junio de 2005. Resultados: Nuestra muestra fue de 44 pacientes, de los que 3 recibieron el tratamiento bilateral, con un total de 47 oídos operados. El 70,2% eran mujeres y el 29,8%, varones entre la tercera y la quinta década de la vida. Se realizó platinectomía parcial en el 53,2% de los pacientes, total en el 40,4% y platinotomía en el 6,4%. Conclusión: La conclusión de nuestro estudio muestra que todos los pacientes que recibieron tratamiento quirúrgico tuvieron ganancia auditiva, con un promedio de 36,7 dB, y que no hubo una diferencia significativa entre los tipos de platinectomía realizada. Las complicaciones fueron escasas y sin repercusión auditiva.
Acta Otorrinolaringol Esp. 2007;58(3):79-82
79
Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Men
Women
29.8% 70.2%
Figure 1. Sex distribution.
localised foci where repeated resorption and bone deposition has occurred7,8. This illness starts out as a spongy lesion in the endochondral layer of the labyrinthine capsule. It can appear on different parts of the temporal bone, starting in a region of bone near the oval window with areas of demineralization and sclerosis. As the bony process invades the oval window, it is completely asymptomatic. However, on gradually invading the annular ligament of the stapes, it causes fixation of its base or footplate and deteriorates air conduction of sound7,9. It is known that the illness fundamentally appears between the third and fifth decades of life, being more frequent in white women with a close family history of the disease8-10. At our department, otosclerosis has been surgically treated using the Schuknecht technique since 1990 and therefore we have considered evaluating the technique’s ear surgery outcomes over the last 2 years in order to verify its effectiveness and compare the technique with outcomes obtained worldwide.
OBJECTIVES General: to evaluate ear surgery outcomes in patients undergoing stapedectomy for otosclerosis. Specific: to describe the demographic behaviour of the study population; identify whether there is a family history of otosclerosis in patients undergoing surgery; describe the most frequent symptoms, reason for attending the clinic and time over which symptoms have developed; describe otoscopic characteristics of patients undergoing surgery; determine footplate characteristics and the type of platinectomy performed; evaluate auditory improvement in patients undergoing surgery and compare this to the type of platinectomy performed, and list any complications found.
MATERIAL AND METHOD A prospective, longitudinal, descriptive study was conducted using all patients attending the otosurgery clinic with a diagnosis of otosclerosis who underwent 80
Acta Otorrinolaringol Esp. 2007;58(3):79-82
stapedectomy surgery with the Schuknecht technique or stapedotomy between June 2003 and June 2005 as our study population. Audiological follow-up was performed using pre-operative and post-operative audiometry 15 days and 3 months after the stapedectomy. Results obtained were gathered for analysis and discussion. A database was prepared in Excel and results were summarized according to averages and percentages, which are shown in tables and graphs to make them easier to interpret. In order to compare auditory improvement according to the type of platinectomy performed, Student’s t test for independent samples was applied using a significance level of P=.05.
RESULTS AND DISCUSSION Our cases included a total of 44 patients, 3 of whom received surgery on both ears, for a total of 47 operated ears. Of these patients, 70.2% were women and 29.8% men (Figure 1), which generally agrees with the bibliography reviewed2,6,7,11,12. In our study, 38 (80.9%) patients were white, agreeing with authors such as Escajadillo7 and Rivas and Ariza8, who mention that otosclerosis is up to 10 times more frequent in white people than in black. Taking into account the fact that this study has been conducted on a population that is half white and half black, results are interpreted as being in agreement with other authors. On distributing the results according to age group, it was shown that the largest number of cases (30 [63.8%] patients) were between the third and fifth decades of life. This has already been shown in other studies indicating that this is due to the illness developing with the progressive formation of otosclerotic foci that cause fixation of the footplate3,9,11. A family history of otosclerosis was present in 51.1% of the study population, proving the genetic component of the illness (agreeing with studies conducted by different authors, which indicate that up to 66% of patients have a family history of the illness2,9,13), transmitted by an autosomal dominant gene with incomplete penetrance. The most frequent symptoms needing medical attention were hypoacusis, in 100% of patients, and tinnitus, in 89.4%, which agrees with the literature reviewed (Figure 2). Rivas and Ariza8 and Antolí-Candela et al.3 indicate that the bone process is completely asymptomatic while it is invading the oval window but, on gradually invading the annular ligament of the stapes, it causes fixation of the base or footplate and deteriorates air conduction of sound7,9. Symptoms were progressive and most patients receiving surgery had an illness evolution time of less than 5 years (Table I), which favours a positive response to treatment3. Otoscopy in our study population showed a wax-free, wide external auditory meatus (ear canal) and a shiny tympanic membrane in 59.6%, as commonly described in patients with this illness6,9,12,13. In 8.5% of the ears examined, we found Schwartze’s sign, which, according to descriptions,
Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Diplacusis
6.4
Vertigo
10.6
Paracusia
14.9
Tinnitus
89.4 100
Hypoacusis 0
20
40
60
80
100
Percentage Figure 2. Distribution according to most frequent symptoms and signs. Table I. Distribution of the Most Frequent Symptoms According to Evolution Time
Evolution, Years
Hypoacusis, n (%)
Tinnitus, n (%)
<5
19 (40.4)
20 (47.6)
5-9
9 (19.1)
10 (23.8)
10-14
12 (25.5)
7 (16.7)
15-19
3 (6.4)
2 (4.8)
20 Total
4 (8.5)
3 (7.1)
47 (100)
42 (100)
Pre-Operative Post-Operative 3 Months
50 40 Threshold, dB
can be found in some patients8-10 and indicates highly vascularized otosclerotic foci. We must point out that, in our opinion, the thorough examination of the external auditory canal and the characteristics of the tympanic membrane, together with past medical history, make us suspect a diagnosis of otosclerosis. In otosclerosis, as a focal illness of the otic capsule, we generally see localised foci, with greater predilection for certain areas, according to Delarcki’s classification, plus the following, in order of frequency: the anterior portion of the footplate, the annular ligament, the posterior portion of the footplate and obliterated footplates, whether thin or thick8,9,14. We found that the otosclerotic focus on the anterior portion of the footplate was the most frequent, with 32%, followed by fixation of the footplate by the annular ligament, with 25%. Thin and thick obliterated footplates were found in 6 and 4 ears, respectively, which are extremely important aspects for the surgeon to be able to take the correct action in each case to obtain good results. Depending on the type of footplate found, a platinectomy is usually performed, although a partial platinectomy is much more frequent in our case: anterior in 21.3% and posterior in 31.9% of the ears operated on, since, as is already known, the saccule lies just 2.5 mm from the anterior edge of the oval window and presents a greater risk of complication15. A platinotomy was only practised on 3 ears, in patients with a thick obliterated footplate. An industrial Teflon-wire piston was inserted. There is currently controversy as to whether to perform a platinectomy or platinotomy. Those favouring platinotomy base their arguments on good results achieved from the auditory point of view, with very few complications and a reduced surgery time, and with few complaints of bone conduction at higher frequencies14,16,17. In our case, we consider that the results achieved are similar to those using commercial pistons as, if the surgeon has experience and skill, bone conduction is not affected and complications are similar. Therefore, we propose that the traditional Schuknecht technique is still valid. Figure 3 shows bone conduction behaviour prior to surgery and 3 months after surgery at the main frequencies of speech. It can be seen that there were no significant variations, except at the frequency of 4000 Hz, where the average difference was very slightly higher, corresponding to the technique used in most patients, the Schuknecht technique, where it is indicated that this frequency may reduce labyrinthine fluid movement2,3,8,13. At frequencies of 500, 1000 and 2000 Hz, bone conduction improved slightly, as indicated by most authors2,3,8. This corresponds to the improved hypertension of labyrinthine fluid due to the compression of the otosclerotic foci, which justifies the disappearance of the Carhart notch following surgery3,13. Figure 4 shows the average auditory improvement in bone conduction 15 days and 3 months after surgery, in comparison to the pre-operative level, and the average improvement of 36.8 dB in air conduction at main frequencies 3 months after surgery, which is better than after 15 days,
30 20 12.7
10
8.4
8.7 7.5
7.2
10.0 8.0
9.5
0 500
1.000
2.000
4.000
Frequencies, Hz Figure 3. Pre-operative and post-operative auditory threshold in bone conduction at the main frequencies.
which proves a socially useful recovery of hearing. These results are similar to those achieved by other authors3,8,13,18,19. In was interesting to evaluate the auditory outcome according to the type of platinectomy performed and the average auditory improvement, where it was found that the average auditory improvement in a total platinectomy was Acta Otorrinolaringol Esp. 2007;58(3):79-82
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Paz Cordovés A et al. Ear Surgery Outcomes in Patients Operated on for Otosclerosis
Pre-Operative Post-Operative 15 Days Post-Operative 3 Months
60 50.9
50
48.0
47.4 45.7
Threshold, dB
40 30.0
30
REFERENCES 20
15.0 15.0
15.0 10.0 10.0
10
10.0 5.0
0 500
1000
2000
4000
Frequencies, Hz Figure 4. Pre-operative and post-ooperative average auditory threshold in air conduction at the main frequencies.
35.2 dB compared in 38.3 dB in a partial platinectomy, showing no statistical importance, in agreement with many authors7,8,13. The following complications were recorded: transoperative, 1 (2.1%) severed cord of tympanum; postoperative, 2 (4.3%) haemotympanum and 3 (6.4%) patients with immediate vertigo. These did not have a repercussion on the patients’ hearing and disappeared within a few days of surgery, very different from the large number of complications reported in medical literature3,8,19-21, where severe complications include facial paralysis and deafness, confirming that the outcome of stapes surgery is closely related to the surgeon’s competence resulting from his knowledge, training and experience3.
CONCLUSIONS In our study, most patients undergoing surgery were white women between the third and fifth decades of life. The most frequent symptoms needing medical attention were hypoacusis and tinnitus with an evolution time of less than 5 years in most cases. The existence of a family history of otosclerosis was seen in more than half our patients.
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The otosclerotic focus found most frequently was located on the anterior portion of the footplate. All patients undergoing surgery experienced an auditory improvement, with an average of 36 dB. There was no significant difference in auditory improvement between patients undergoing a total or partial platinectomy. There were no great variations in bone conduction in patients undergoing surgery. Our patients’ complications were minimum, without auditory repercussions.
Acta Otorrinolaringol Esp. 2007;58(3):79-82
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