Diagnostic performance of high resolution computed tomography in otosclerosis

AIM To determine the sensitivity and specificity of high resolution computed tomography(HRCT) in the diagnosis of otosclerosis.METHODS A systematic literature review was undertaken to include Level I-III studies(Oxford Centre for Evidenced based Medicine) that utilised HRCT to detect histology confirmed otosclerosis.Quantitative synthesis was then performed.RESULTS Based on available level III literature,HRCT has a relatively low sensitivity of 58%(95%CI: 49.4-66.9),a high specificity,95%(95%CI: 89.9-98.0) and a positive predictive value of 92%(95%CI: 84.1-95.8).HRCT is better at diagnosing the more prevalent fenestral form of otosclerosis but remains vulnerable to inframillimetre,retrofenestral and dense sclerotic lesions,despite the advent of more advanced CT scanners with improved collimation.CONCLUSION Whilst the diagnosis of otosclerosis remains largely clinical,HRCT remains the gold standard imaging of choice for the middle ear and serves as a useful adjunct to the clinician,helping to delineate extent of disease and exclude other causes.

Malleostapedotomy for otosclerosis,our experience of nitinol piston on twelve patients

Objective:Malleostapedotomy allows to completely by-pass the incus in otosclerosis surgery.Recently its use has been rivaled by hydroxyapatite cement for cases of mild and moderate necrosis of the incus.However,it remains gold standard for cases of extensive necrosis,incus dislocation,or epitympanic fixation.Modern heat-crimping pistons make surgery easier and safer.This study focuses on our experience with this technique.Methods:Retrospective analysis of patient’s files and pre-and post-operative audiograms,for cases of surgically treated otosclerosis with malleostapedotomy.Results:Twelve patients underwent malleostapedotomy for otosclerosis between 2011 and 2019.Amongst them there were 10 revision surgeries and 2 primary cases.75%had incus long-process necrosis,17%had epitympanic fixation and one had a history of incus transposition.Nine patients(75%)had closure of air-bone gap(ABG)of<10 dB(p<0.001)and 11(92%)had a threshold of 20 dB(p<0.001).Mean pre-operative ABG was 31 dB(15 dBe55 dB),and mean post-operative ABG was 7 dB(0 dBe21 dB;p<0.001).There was no sensorineural hearing loss nor any other post-operative complication.Conclusions:Malleostapedotomy is a safe and reliable technique,allowing an ABG closure comparable to conventional incus to vestibule prosthesis.It remains the preferred technique whenever the incus cannot be used.

Stability of computed tomography densitometry in patients with otosclerosis:a two-year follow-up

Objectives:To quantify the progression of otosclerosis in the unoperated ear between two stapedotomy procedures for patients with bilateral otosclerosis which can help to determine whether a HRCT scan should be re-performed before the second surgery for patients who already received HRCT imaging before the initial surgery.Methods:35 patients who underwent bilateral stapedotomy were included.Two rounds of HRCT examination and audiometry were performed at the time of the first surgery and second surgery on the ear that was not operated on during the initial surgery.The relationship between the changes in HRCT densitometry and audiometry over time was analyzed.Results:The second round of HRCT did not add significant information about the changes to the otosclerosis lesions in either the imaging diagnosis or the HRCT density values except for small changes in the HRCT densitometry readings at the area anterior to the inner auditory(P=0.01).While the changes in HRCT manifestation are small,changes near the fissula ante fenestram(FAF)were still positively correlated with the air bone gap(ABG)of patients(p=0.031,r=0.388).Conclusions:The progression of lesions in otosclerosis is slow resulting in small and insignificant changes to the HRCT features.Therefore,a repeat HRCT evaluations prior to surgery is not necessary for patients who have had a previous HRCT evaluation within 2 years of the operation.The small changes in HRCT manifestation near the FAF were still correlated with negative effects on the ABG which could cause worsened hearing thresholds over this timeframe。

Does bilateral otosclerosis make pre-operative bone conduction more inaccurate?

Objectives:To assess whether bilateral otosclerosis renders pre-operative bone conduction more inaccurate by increasing the Carhart effect.Methods:Retrospective review of a database of pre and post-operative audiograms of 745 ears with otosclerosis treated with stapedectomy from 2013 to 2020 in a tertiary centre.Main outcome measures:Change in bone conduction after stapedectomy for otosclerosis in:unilateral otosclerosis(U1);bilateral otosclerosis undergoing first side surgery(B1);bilateral otosclerosis undergoing second side surgery(B2).The magnitude of change in bone conduction post-operatively within and between each group.Results:The average difference in pre and post-operative bone conduction was significant within in all groups(T-stat>2 and P-value<0.05)with the greatest change observed in the U1 group.Analysis of average change in bone conduction between groups did not reach statistical significance(Pvalue=0.37).Analysis of change per frequency demonstrated the greatest change in bone conduction post-operatively at 2000 Hz in all groups.The magnitude of change at 2000 Hz was the greatest in the bilateral groups;however,it did not reach statistical significance when compared to the unilateral group(P-value=0.36).Conclusions:This is the first study in the literature to assess the accuracy of pre-operative bone conduction in bilateral versus unilateral otosclerosis.There is no evidence that pre-operative bone conduction in bilateral otosclerosis is more inaccurate than in unilateral disease.In order to assess accuracy of pre-operative bone conduction in otosclerosis a reliable method of assessing post-operative bone conduction is required,without assumption of its equivalence to cochlear reserve.

Measuring the density of the fissula antefenestram and the section of the basal turn of the cochlea:Are they useful in the radiological diagnosis of otosclerosis?

Introduction:The role of objective parameters in terms of improvement of the accuracy of highresolution computed tomography(HRCT)of the temporal bone in the diagnosis of otosclerosis remains unclear.Objectives:To investigate the relationship between the density of the fissula antefenestram(FAF)and of the width of the transversal section of the basal turn of the cochlea(BTC),and the diagnosis of otosclerosis.Methods:This is a retrospective study in which preoperative HRCT data from ears of patients submitted to stapedotomy due to otosclerosis(case group)were evaluated.For the control group,normal hearing ears having undergone HRCT for other purposes were included.Case and control HRCT images were objectively assessed by an experienced blinded radiologist.During this evaluation,measurements of the relative radiological density of the FAF and of the transversal section of the BTC were obtained.The results were compared between the groups.Also,a receiver operating characteristic curve was created and the area under the curve(AUC)was calculated for each variable.Significance level was set at.05.Results:40 ears were included in each group.Case ears presented reduced values for the relative radiological density on the FAF(p-value<0.0001).Moreover,ears with otosclerosis(p-value:0.022)presented lower transversal section of the BTC.The AUC for these variables reached 0.929 and 0.646,respectively.Conclusions:Otosclerotic ears present reduced radiological density on the FAF and narrower BTC.The relative density of the FAF also shows a great diagnostic power in the context of this disease.

The distance between stapedial footplate and incus in otosclerosis surgery

Background: The measurement of the piston length during stapedotomy is important and it may have significant effects on the surgical outcome.Objective: To determine the piston length in a group of otosclerosis patients who underwent primary stapedotomy.Material and methods: Between Sep 2013 and Sep 2014, 85 patients with diagnosed otosclerosis underwent primary stapedotomy. Teflon prosthesis of 0.6 mm of diameter was used in all patients. The distance between medial surface of the long process of incus and center point of the stapedial footplate measured. The piston length calculated by adding 0.25 mm for the thickness of footplate and 0.50 mm for placement of the prosthesis into the vestibule.Results: The distance between stapedial foot plate and incus ranged from 3.50 to 4.50 mm. The mean distance was 3.95 ± 0.16 mm. In majority of cases(74.1%) piston length was 4.75 mm followed by 4.50 mm in 15.3% and 5.00 mm in 5.9%. Piston length was 4.25 mm in 3.5% and5.25 mm in only 1.2% of patients. There was no significant post-operative complication and air bone gap closure obtained in all patients.Conclusion: The most common distance between foot plate and incus is 4.00 mm. No case needed a piston longer than 5.25 mm or shorter than4.25 mm.

Otosclerosis: Contribution of Computed Tomography and Radio-Anatomical Correlations

Otosclerosis is an osteodystrophia of the otic capsule, responsible for hearing loss by blocking of the stapes footplate. The purpose of this study was to evaluate the reliability of computed tomography (CT) in the positive diagnosis of otosclerosis, to compare the radiological findings to those intraoperatively, and to seek a correlation between imaging data and postoperative audiometric results. This is a retrospective study of 60 patients having otosclerosis, treated in our department between 2009 and 2011. All patients underwent an otoscopic examination, pure tone and vocal audiometry, impedancemetry and petrous CT scan. At petrous CT scan, a footplate thickening was found in 9 cases. Labyrinthine bone hypodensity was noted in 51 cases. Sensitivity of CT in the diagnosis of otosclerosis was 100%. Regarding the operative findings and their correlation with imaging, we found that among the 7 facial canal procidences reported intraoperatively, CT had identified 6, with a sensitivity of 86%. Of the 53 facial nerve in normal position intraoperatively, CT had only identified 34, with a specificity of 64%. Regarding the ossicles, there were 6 cases of abnormalities of the incus, among them 3 were identified on CT, with a sensitivity of 50%. The 54 patients with normal ossicular chain intraoperatively were all identified as such on CT, with a specificity of 100% (p = 0.001). For correlation between imaging and postoperative results, it was found that patients with extended otosclerosis had lower postoperative audiometric improvement than those having localized disease (p < 0.05). Computed tomography is necessary for the diagnosis of otosclerosis. It also helps, with good sensitivity and specificity, seeking for anatomical variants that the surgeon could possibly encounter during surgical procedure. Finally, there is a statistically significant correlation between imaging data and postoperative audiometric results, allowing establishing a functional prognosis even before surgery.

Revision surgery for otosclerosis:An overview

Stapes surgery for otosclerosis has been proved to be a very satisfying procedure. However, the condition is difficult for the patients with no or little hearing gain after surgery and for those who had sudden or gradual hearing loss after a successful air-bone gap closure in the follow-up period. The issue of re-exploring the middle ear is challenging. A general review of this subject from several points of view remains lacking. In this study, articles related with the revision surgery for otosclerosis have been reviewed after a Pub Med research and common and/or contradictory points were documented. The aim of this study is to give an insight to diagnostic and therapeutic approaches forthe clinicians in patients who need a revision surgery. In conclusion, prosthesis problems, loose prosthesis in stapedotomy and migrated prosthesis in stapedectomy are the most common causes for revision surgery. Most important indicators which effect better hearing outcome following revision surgery are those ears with the presence of incus, with no obliteration of oval window, with small fenestra stapedotomy and the experience of surgeon. The risk of neurosensorial hearing loss in revision cases is not high but the hearing gain is limited as compared to primary cases. The rate of 10 d B air-bone gap closure is around 60%-70% at most and even less promising results have been reported. Patient's demands and expectations have to be clarified in a realistic way.

A REVOLUTIONARY PATH IN TREATMENT OF OTOSCLEROSIS AND ITS RELEVANCE IN CHINA

Otosclerosis was first discovered by Valsalva in 1704[1], and the term was first used by Anton von Troltsch in 1872 to differentiate from tympanosclerosis[2].Normallythe otic cyst in human remains stationary after full development and contains no visible activated osteoblasts or

17例耳硬化症患者的临床与影像学分析

目的分析17例耳硬化症患者的临床特征、影像学表现及手术治疗效果。方法收集2020年5月~2023年5月在湖州市中心医院接受手术治疗的17例(17耳)耳硬化症患者临床、影像学资料,分析其临床表现、颞骨CT影像学表现及手术前后纯音测听结果变化。结果17例(17耳)患者中,11耳(64.71%)为前庭窗型,表现为进行性传导性听力损失,其中9耳有耳鸣,3耳有轻微平衡问题;混合型6耳(35.29%)显示混合性听力损失,5耳有耳鸣,3耳有偶发性平衡障碍。影像学上,前庭窗型显示镫骨底板区域骨质增厚、前庭窗密度增加;混合型则显示镫骨底板增厚及耳蜗周围密度减低,1耳可见“双环征”,两种类型耳硬化症患者骨密度差异无统计学意义(P>0.05)。术后均未见耳鸣加重或其他严重并发症,仅2例(11.76%)出现暂时性头晕,术后随访显示术区恢复良好,无感染或其他迟发性并发症;术后听力测试显示气导阈值、气骨导差较术前显著改善(P均<0.05)。结论前庭窗型和混合型耳硬化症的影像学和临床表现各有特点,镫骨成形术可显著改善听力,降低气导阈值和气骨导差,且手术安全、并发症少。

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 31e65 min).The air-bone gap(ABG)was 35 dB(range 24e50 dB)preoperatively and 14.63 dB(range 9e20 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.

Hyperacusis and stapes surgery:An observation in fifty patients after stapedotomy

Objective:To assess hyperacusis after stapedotomy and its possible influencing factors.Study design:Prospective,interventional,and longitudinal study.Setting:A tertiary referral center.Patients:Fifty consecutive patients(35 females,mean age=46.8 years).Intervention:All patients underwent stapedotomy.The validated Portuguese version of the“Hyperacusis Questionnaire”(HQ)was administered before and two weeks and one month after surgery.Results:No hyperacusis was reported by any patient before surgery.At two weeks after surgery,all patients experienced hyperacusis,with a mean HQ at 16.88±6.54(range 4e25).One month after surgery,hyperacusis had already resolved in most patients.Gender,preoperative presentation or surgeon had no influence on HQ scores(p>0.05).Patients with previous contralateral stapedotomy showed lower HQ scores(p=0.001).Audiological parameters improvement measured at one month after surgery(PTA,SRT and contralateral SRT)were associated with HQ higher scores.Conclusion:This study confirms that hyperacusis is a common complaint after stapedotomy that usually resolves in one month after surgery.The HQ highest scores were registered among patients with the highest audiological gain after surgery.This suggests that hyperacusis may be a positive prognostic factor for audiological success after stapedotomy.

Facial Nerve Stimulation can Improve after Cochlear Reimplantation and Postoperative Advanced Programming Techniques: Case Report

We had a case of 75-year old man with a history of progressive hearing loss on both side who implanted with a Nucleus 24 Contour Advance in the right ear. After 4 years from implantation, the patient started to complaint of right facial twitching when his cochlear implant was active. Despite undergoing numerous alterations in his implant programming, facial nerve stimulation (FNS) persisted. After increasing the pulse width and changing the stimulation mode, there was no facial nerve stimulation. However there was a deterioration in hearing and speech understanding. CT of the temporal bone showed good position of the implant electrodes und cochleomeatal scintigraphy (CMS) showed a highly positive activity with suspicion of otosclerosis, although the medical history was negative for otosclerosis. The FNS was managed with cochlea reimplantation and advanced programming techniques. FNS in cochlear implant patients may be managed through reimplantation and advanced programming techniques.

Hearing Outcome in Stapes Surgery Using Various Biomaterial Prostheses

Aims: To assess the hearing outcome in patients who have undergone stapes surgery using polytetrafluoroethylene (PTFE) and Titanium prosthesis at 1 and 3 months post operatively. Material & Methods: Research design: Prospective study. Setting: ENT department, Pushpagiri Medical College. Study population: All age groups with clinical diagnosis of otosclerosis and air-bone gap more than 15 dB irrespective of sex difference. Patients with Meniere’s disease are excluded. Method: A prospective study was conducted for a period of one and a half years from January 2014 to July 2015 to find out the hearing outcome of stapes surgery in patients with otosclerosis using polytetrafluoroethylene (PTFE) and Titanium prostheses, attending our outpatient department. Results: In this study, 84.21% of ears with polytetrafluoroethylene (PTFE) and 81.81% of ears with titanium were able to achieve good results in terms of Air-Bone gap (ABG) closure (ABG Conclusion: Stapes surgery is the surgical procedure of choice for otosclerosis. In our study, a significant hearing improvement was seen in majority of cases. None of the factors considered relevant for the success of stapes surgery like age, sex, type of prosthesis appeared to affect the post-operative hearing significantly. Hence stapes surgery can be effectively used to improve hearing in otosclerosis.

Post-Stapedectomy Granuloma: A Rare Case Report

Reparative granuloma in the oval window region is an uncommon complication of stapes surgery, which usually develops within one to eight weeks after operation and causes a sudden hearing loss and disturbance of balance. It may also cause otalgia. Because of its rarity, no single centre would be able to give conclusive evidence regarding this complication. Hence we would like to report our experience and hope to get a better understanding regarding the stapes surgery induced granulation.

Microdrill,Diode Laser,and Manual Microsurgical Stapedoplasty:A Comparative Study

Background: To evaluate hearing outcome, operation time and post-operative hospital stay after primary stapedoplasty with three different techniques: manual microsurgical, microdrill-assisted, and microdrill- and laser-assisted technique. Methods: A retrospective analysis of 150 consecutive cases of primary otosclerosis was operated by one surgeon. The patients were divided into three groups depending on the utilized surgical techniques: a fully manual microsurgical stapedoplasty (n = 56), microdrill-assisted stapedoplasty (n = 32), and microdrill- and laser-assisted stapedoplasty (n = 62). The mean pre- and post-operative air-bone gap was calculated by using pre- and post-operative mean pure tone air- and bone-conduction thresholds at 500, 1000, 2000 and 4000 Hz. Results: There were no statistically significant differences in the hearing outcome between the groups. The closure of air-bone gap and the improvement of the hearing were demonstrated in all study groups. Introduction of diode laser for stapes surgery resulted in significantly reduced operation time (about one-third) and the increase in the completion of surgery from 81.5% to 96.7%. At the same time, the rate of complications stayed low and hospital stay dropped from three days to one day. There were no major post-operative complications in any study groups. Conclusions: Application of diode laser in stapes surgery significantly reduced operation time and increased completion rate of surgery. No statistically significant difference was found between three surgical techniques regarding hearing outcome.

激光在耳硬化症手术中的应用

随着激光医学的发展，激光应用于耳硬化症手术已有将近30年的历史。本文通过综述激光的生物学效应，以及综合几种具代表性的激光在耳硬化症手术中应用的有效性、安全性，术中、术后可能发生的并发症来阐明激光在耳硬化症手术应用中的各自特点及注意事项。

Preferences in stapes surgery among American otological society otologists

Objective:Stapes surgery is technically challenging,yet its methodology is not standardized.We aim to elucidate preferences in stapes surgery among American Otological Society(AOS)otologists and determine if any common practice patterns exist.Study design:Cross-sectional study via emailed questionnaire.Setting:Surgery centers.Subjects and methods:Members of the AOS were an emailed a survey to quantify variables including surgical volume,anesthetic preference,laser use,type of procedure,footplate sealing technique,antibiotic use,and trainee participation.Results:Most otologists(71%)performed 2 to 5 stapes surgeries per month under general anesthesia(69%)with stapedotomy(71%)as the preferred procedure.Most(56%)used the rosette method of laser stapedotomy with manual pick debris removal for footplate fenestration.Either the handheld potassium titanyl phosphate(KTP)laser(40%)or handheld carbon dioxide(CO2)laser(33%)was used.The heat-activated memory hook(51%)was the preferred prosthesis.Footplate sealing method was variable,as was antibiotic use among respondents.Trainee participation was limited,as 42%of otologists allowed residents to place the prosthesis,and fewer allowed residents to crimp the prosthesis,and laser or drill the footplate.Surgeons with higher surgical volume(≥6 surgeries per month)demonstrated the following statistically significant correlations:footplate fenestration with laser in a rosette pattern and pick for debris removal(rs=-0.365,P=0.014)and trainee participation with fellows only(rs=0.341,P=0.022).Conclusions:Trends in various surgical decisions showed a lack of consensus in all aspects of stapes surgery.