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Primary and revision stapedectomy in elderly patients
Ted A. Meyer and Paul R. Lambert
Purpose of review
This review discusses the recent literature on short- and
long-term hearing results for primary and revision stapes
surgery on young and elderly patients.
Recent findings
The epidemiology of clinical otosclerosis appears be changing.
The average age for patients undergoing primary stapes
surgery is increasing, and the percentage of revision
stapedectomies is increasing. As the population ages, the
otologist should expect to perform more surgeries on elderly
patients. Short- and long-term hearing results after primary
stapes surgery are good, regardless of age. Approximately
90% of patients obtain closure of their ABG to within 10 dB.
Long-term results demonstrate that hearing decreases over
time after stapedectomy at a rate of approximately 1 dB/y for
both young and elderly populations. Sensorineural hearing loss
accounts for most of this decrease and a relatively small ABG
is maintained in many patients. However, at least 10 to 20% of
patients will redevelop conductive hearing loss after
undergoing stapes surgery and will desire revision surgery to
correct this hearing loss. With modern otologic equipment,
including the laser, most patients undergoing revision
stapedectomy should obtain significant improvement in
hearing, regardless of age.
Summary
Primary and revision stapedectomy are beneficial procedures
in the elderly population. The success rate is similar to that in
the younger population with otosclerosis.
Keywords
otosclerosis, stapedectomy, stapedotomy, revision, elderly
Curr Opin Otolaryngol Head Neck Surg 12:387–392. © 2004 Lippincott Williams
& Wilkins.
Medical University of South Carolina, Department of Otolaryngology–HNS,
Charleston, South Carolina, USA
Correspondence to Ted A. Meyer, Medical University of South Carolina,
Department of Otolaryngology–HNS, 135 Rutledge Avenue, P.O. Box 250550,
Charleston, SC 29425, USA
Tel: 843 792 9572; fax: 843 792 5910; e-mail: meyerta@musc.edu
Current Opinion in Otolaryngology & Head and Neck Surgery 2004,
12:387–392
© 2004 Lippincott Williams & Wilkins
1068-9508
Introduction
Since 1704, when Valsalva [1] described stapes fixation,
clinicians and scientists have produced a vast body of
literature on the etiology, pathogenesis, and treatment of
otosclerosis. Surgery to improve conductive hearing loss
from otosclerosis has evolved tremendously. Elegant
procedures such as Lempert’s single-stage horizontal
semicircular canal fenestration [2], Rosen’s stapes mobilization [3], Shea’s stapedectomy [4], and Perkins’s use
of the otologic laser [5] represent major advancements in
techniques, equipment, and materials. With these and
other advancements, otologists obtained progressively
higher rates of hearing improvement and decreased rates
of complications, especially profound sensorineural hearing loss. Surgeons at prominent centers performed hundreds of procedures for otosclerosis yearly. The “backlog” of patients with otosclerosis desiring surgical
correction of their conductive hearing loss diminished as
more surgeons became proficient with these procedures.
Although stapedectomies remain relatively common otologic procedures, few individual surgeons today perform
hundreds of stapes surgeries yearly.
The otosclerotic lesion is described histopathologically
as pleomorphic with varying amounts of bone deposition
and resorption. Osteoclasts remove mature bone and osteoblasts replace this bone with new bone of differing
vascularity and cellularity. The active vascular areas
(spongiotic) have large spaces that are replaced by fibrous tissue with few capillaries (fibrotic). Dense mineralization occurs filling the vacuolated spaces with interwoven osseous tissue (sclerotic). As the otosclerotic
lesion matures, the stapes becomes fixed causing a progressive conductive hearing loss. A substantial percentage of patients with otosclerosis also have sensorineural
hearing loss from cochlear involvement.
Clinical otosclerosis affects women approximately twice
as often as men [6••], it may be exacerbated by pregnancy [7], and it occurs in a relatively young population.
It is often bilateral, and many patients with otosclerosis
have tinnitus [8] and balance difficulties. A recent study
[9] found higher rates of tinnitus and vestibular problems
in patients with sclerotic foci on the stapes footplate
compared with those with spongiotic or fibrotic foci. Of
interest, approximately 90% of patients with otosclerosis
and tinnitus have complete absence or improvement of
tinnitus after surgery [8,10]. Otosclerosis is more common in Caucasians than other races. It is present histo387
388 Otology and neuro-otology
logically at autopsy in approximately 10% of Caucasians
while clinically demonstrable in only 1% of Caucasians
[6••]. A recent paper estimated the prevalence of histologic otosclerosis at autopsy in a Japanese population to
be 2.6% [11].
It has been postulated that the incidence of clinical otosclerosis has diminished in recent years from the addition
of fluoride in the drinking water [7,12–14]. Others
[15,16] have hypothesized that progression of otosclerosis might be related to the measles virus, and they suggest that the administration of the measles vaccination to
children has altered the clinical presentation of otosclerosis. In a recent paper from Germany, Niedermeyer [17]
reported that the increase in the average age of patients
having primary stapes surgery from 1978 to 1999 strongly
supported the effect of measles vaccination in decreasing
the incidence of otosclerosis. A viral influence, however,
is not supported by significant racial differences in the
disease.
Although much is known about the histopathology of
and the clinical presentation of patients with otosclerosis,
the cause of this disease remains unknown. At present,
otosclerosis is thought to be inherited through an autosomal dominant pattern with approximately 40% penetrance. However, the “otosclerosis gene” has been
linked to at least two regions on two different chromosomes (15q [18]; 7q [19]). McKenna [20] has also described abnormalities in markers on the COL1A1 gene
for type I collagen that might account for a small percentage of cases of otosclerosis.
Whether the otosclerosis gene(s) are identified and
whether fluoride or the measles vaccination has impacted the development or progression of otosclerosis
should be of interest to the otologist. Are the incidence
and prevalence of clinical otosclerosis being reduced or is
the clinical presentation of otosclerosis being prolonged
by these or other interventions? Is otosclerosis present
histologically at autopsy in the same percentage of patients who lived prior to or after the addition of fluoride
to the drinking water and the measles vaccination? New
medical advances might further delay the onset of or
diminish the progression of otosclerosis. If the clinical
presentation of otosclerosis changes, the number of new
cases of otosclerosis will decline, and the percentage of
stapes surgeries that are revisions will increase. Patients
will present with conductive hearing losses at older ages,
and the average age of the patient undergoing stapes
surgery will increase.
Surgical issues
Is the clinical threshold for performing a stapedectomy
changing? A group in Italy suggested that patients with
milder conductive hearing losses from otosclerosis
should have surgery to prevent progression of the disease
[21]. Lippy et al. [22] evaluated hearing outcomes for 136
patients with mild conductive hearing losses (average
preop ABG was 8.3 dB) who underwent a stapedectomy.
Ninety percent of their patients had complete closure or
overclosure of their preoperative ABG (ⱕ 0 dB). One
patient lost hearing completely (0.7%).
Silverstein examined results with the Laser STAMP procedure [23–25] for patients with otosclerosis limited to
the anterior footplate and milder conductive hearing
losses (average 22 dB ABG). In this procedure, the anterior crus is transected with the laser, and a stapedotomy
is created to separate the posterior footplate from the
small anterior otosclerotic plaque. The malleus, incus,
and posterior stapes remain connected, no prosthesis is
used, and fat is placed to seal the stapedotomy. Silverstein [26•] reports excellent hearing results (2 year average) for 55 patients who had the STAMP procedure (average postop ABG of 6 dB). The authors report that this
procedure protects high-frequency hearing more than a
standard stapedotomy; however, 2 of their 55 patients
(4%) lost hearing completely with the Laser STAMP
procedure. Five patients (9%) who had the STAMP procedure had persistent or recurrent CHL and had revision
stapedotomy. We suspect that over a longer observational period, more patients who had the STAMP procedure will require a revision stapedectomy or stapedotomy for continued or progressive CHL.
Although today’s otologist has numerous options for the
surgical treatment of otosclerosis, revision stapedectomies remain challenging cases. In the October 2003 issue
of this Journal, Dr. Lesinski [27••] provided a thorough
review of revision stapedectomy with detailed illustrations of some of the pathology encountered with the
remaining ossicles and the prosthesis in the oval window.
Malleus fixation [28], incus erosion, cholesteatoma, lateralization or medialization of the stapes prosthesis, scar
tissue formation, a retained stapes footplate, regrowth of
the otosclerotic focus, an exposed facial nerve, and perilymph fistula have all been encountered in revision stapes surgery [27••–29]. Given the multitude of potential
pathologies, many surgeons advocate the use of the otologic laser for revision procedures to decrease vascularity,
free the prosthesis, obliterate scar tissue around the oval
window, and create the fenestration. Better visualization
of the oval window improves the surgeon’s ability to
understand the pathologic processes involved and determine the correct position and depth of penetration
needed for safe refenestration [30].
New prostheses and materials are also being developed
to assist the otologist with problems encountered in revision stapes surgeries. Chen and Arriaga [31] reported
preliminary results on the use of ionomeric cement to
reconstruct the incus in six patients undergoing revision
stapedectomy. They obtained hearing improvement in
Stapedectomy in elderly patients Meyer and Lambert 389
four of the six patients. The remaining two patients received little if any improvement in hearing. Offset pistons have also been developed to attach a partially
eroded incus to the fenestrated footplate. If the incus is
significantly eroded or missing, prostheses are available
to connect the oval window to the malleus [32] or tympanic membrane [33]. The hearing results with these
devices are not as good as the results with a revision
stapedectomy or stapedotomy [34].
From data published in the current literature, we estimate at least a 10 to 20% revision rate for stapes surgery
over a 6- to 20-year observation period [35••,36]. Over
the past 50 years, thousands of revision stapedectomies
have been performed, and there are thousands of other
patients who have had a stapedectomy who will have
increased difficulty hearing as they age.
Surgical results—recent publications
Few authors have evaluated long-term hearing results for
their patients with otosclerosis undergoing stapedectomy. Published data for elderly patients are even more
scarce. Clinicians must gather more data on the aging
population to better understand the long-term results
from primary and revision stapes surgery.
Two prominent groups have recently reported long-term
results following stapes surgery. Aarnisalo et al. [35••]
reported 20-year follow-up results on 142 patients; 80
had a stapedectomy and 62 had a stapedotomy. The average preoperative ABG was 28 dB for both groups. The
patients had excellent average ABG closure after surgery
(ABG stapedectomy 9.6 dB; ABG stapedotomy 7.6 dB).
Long-term hearing results did not differ between the
two techniques. Over the 20-year period, both air and
bone thresholds decreased at an approximate rate of 0.9
dB/y. This drop placed the long-term air-conduction
thresholds at levels similar to the preoperative levels, but
because the bone-conduction thresholds dropped over
time as well, the average long-term ABG was approximately 12 dB. One patient lost hearing completely and
14 (10%) had revision surgery over the 20-year observation period.
House et al. [36] reported long-term results for 145 patients who had a stapedectomy or stapedotomy for an
average of 11 and 6 years, respectively. There were no
significant differences in hearing results between the
two procedures in the short-term or the long-term.
House found an average 20-dB improvement in the airconduction PTA with surgery and a worsening of the
PTA over the observational period by approximately 8
dB. The inferred bone-conduction thresholds also decreased during this time period. The rate of decline in
hearing is similar to that discussed in the previous study
by Aarnisalo [35••] (0.9 dB/y). The authors estimate that
approximately 20% of their patients had revision surgery
during this time period. If we can extrapolate these results to even longer periods of time, a significant proportion of patients with otosclerosis will redevelop a significant conductive hearing loss and desire revision
stapedectomy as they age.
Stapes surgery has been felt to be less successful for
elderly patients than it has for young patients. New data
refute this assumption. Ayache et al. [37•] recently reviewed their stapes surgery results for 16 patients older
than 65 years. Ten patients had stapedectomies and six
had stapedotomies. Ayache reports excellent audiological results with 82% of patients obtaining closure of the
3-frequency ABG to < 10 dB, and 100% of patients
within 20 dB (at an average follow-up of 1.5 years). Of
interest, all procedures were performed with the patient
under general anesthesia. The authors do not follow any
special guidelines for either the surgical or postoperative
period for their elderly patients.
In a larger series, Lippy [38] reported on 154 patients
aged 70 and older who had a stapedectomy. The mean
4-frequency PTA improved 30 dB. The 4-frequency
ABG closed to within 10 dB in more than 90% of patients. One patient lost hearing (−45 dB) from the procedure. Lippy also evaluated the results for 11 elderly
patients with far-advanced otosclerosis. The average preoperative PTA for the patients was approximately 107
dB and word discrimination was, in general, quite poor.
After stapedectomy, the average PTA improved to approximately 80 dB and 4 patients had significant improvements in their word recognition scores. The 7 patients who did not obtain improvement in word
recognition with surgery might have received more benefit from a cochlear implant than from a stapedectomy.
Results from revision surgeries are somewhat less promising. Numerous well-known otologists have reported
“success rates” (ⱕ 10 dB ABG) for revision stapedectomies between 20 and 80% [29,39–48]. Complication rates
for revision procedures have also been reported at higher
levels than those reported for primary stapes surgeries
[49–51]. More recently, however, surgeons are reporting
higher success rates with fewer complications for revision
stapedectomies.
Lippy et al. [52••] reported results from more than 500
revision stapedectomies with at least a 6-month followup over a 20-year period. (Dr. Lippy performs more revision stapedectomies than most surgeons perform primary procedures.) Surgeries were performed under local
anesthesia. The mean 4-frequency PTA improvement
was 16 dB and the average postoperative ABG was 9 dB.
They report an overall ABG closure to within 10 dB for
71% of their patients and within 20 dB for 86%. Only
seven patients had > 10 dB of hearing loss with the procedure with one patient losing hearing completely. They
390 Otology and neuro-otology
report that their results have improved significantly over
time with the use of the argon laser. Now, more than
80% of their patients undergoing revision stapedectomy
obtain an ABG better than 10 dB.
patient is found to be an appropriate candidate for surgery from both an audiologic and medical standpoint,
and the patient is fully informed about the risks and
benefits of stapes surgery, the surgery may proceed.
Lippy also evaluated results for patients undergoing
multiple revision procedures. As the number of revisions
increase, the overall hearing success rate decreased. For
first revision cases, the success rate was 76%, for second
revisions 66%, third revisions 57%, and fourth or higher
revisions, only 38%. The authors offer advice to surgeons
contemplating a revision stapedectomy. If the surgeon
performing the primary procedure was experienced,
there should be strong reluctance to perform a revision
surgery. Lippy also suggested that if the first surgeon was
inexperienced, the odds of a successful revision were
increased, although they did not test this hypothesis directly.
Perioperative management
Data for elderly patients undergoing a revision stapedectomy are very sparse. Lippy [53] recently evaluated hearing results for 120 elderly patients who had a revision
stapedectomy. They obtained a mean 3-frequency PTA
improvement of 17 dB. The average postoperative ABG
was 6.5 dB. Seventy one percent of their patients had an
ABG < 10 dB, and 90% had an ABG < 20 dB. They were
able to evaluate 69 of these patients for a longer period of
time (mean 6.7 years). The PTA decreased approximately 1 dB/y, which is similar to studies with younger
patients. The results indicate that revision stapedectomies, even on elderly patients, are usually successful.
Clinical evaluation
When an elderly patient presents with a hearing loss
suggestive of otosclerosis, the otologist must take a comprehensive general and otological history and perform a
thorough physical examination. Balance problems should
be investigated fully, especially if there is a history of
Meniere disease. If the patient has had prior otologic
surgery, an attempt should be made to secure the operative record from the initial surgeon. Anatomic abnormalities or technical difficulties with the prior procedure
should be noted. The patient should have audiological
testing including tuning forks. If surgery is considered,
the patient’s primary care physician should be consulted
for any preoperative testing deemed necessary.
The patient must be informed of the available therapeutic options: continued observation, amplification, or surgery. If a significant sensorineural hearing loss exists in
the ear in question, the patient will require amplification
even if a stapedectomy is able to completely close the
air-bone gap. The surgeon should know his/her surgical
results. If the recent literature quotes an 80 to 90% “success” rate with either a primary or revision stapes surgery, but the surgeon’s success rates are only 25 to 50%,
the patient should be informed of this discrepancy. If the
Regardless of the type of anesthesia, the age of the patient, or whether the procedure is a primary or a revision
surgery, stapedectomy is in general beneficial and safe
for the elderly patient. Surgical risks are slightly elevated
with healthy elderly patients, and they have a slightly
greater risk of a significant cardiac or cerebrovascular
event than a young patient. In general, the elderly take
more medications and are at increased risk for significant
drug interactions. They can be sensitive to the medications typically used to provide amnesia and anesthesia
[54,55].
For otologic procedures under local anesthesia, elderly
patients can have difficulty remaining still due to problems such as arthritis of the back or neck, tremor, poor
circulation, or sleep apnea. Loss of muscle tone with
sedation can further impact upper airway collapse necessitating intervention to prevent oxygen desaturations.
Given the delicacy and precision needed to perform a
stapedectomy, any additional movement by the patient
increases the difficulty of the surgery.
Although some surgeons prefer the patient under general
anesthesia [37•], most stapedectomies are performed under local anesthesia with monitored anesthesia care
(MAC) if needed. Many surgeons prefer to have the patient completely awake, especially during revision procedures, to be able to monitor for vertigo. If a patient
becomes severely vertiginous with manipulation around
the oval window, the surgeon should terminate the procedure. If the patient is awake, after the prosthesis is
placed and the tympanic membrane is reflected back
into its normal anatomic position, the surgeon can perform basic audiometric testing either with tuning forks,
an audiometer [53], or speaking to the patient with a
whispered voice. Vertigo and hearing status can not be
assessed when the patient is under general anesthesia.
The elderly patient should be instructed to not perform
any strenuous activity for several days after surgery. The
patient may experience a mild sensorineural drop in
hearing and vague dizziness after surgery. Surgically induced imbalance will only exacerbate a preoperative balance problem, and the elderly patient should be counseled about this prior to surgery. If the patient has
significant vertigo or a significant drop in hearing in the
postoperative period, the patient should return to the
hospital for evaluation, audiological testing, and admission for treatment with intravenous antibiotics and steroids. Serial audiometry should be performed, and if the
Stapedectomy in elderly patients Meyer and Lambert 391
bone curve drops further, the surgeon should consider
reexploring the ear.
ment in patients with otospongiosis. Ann Otol Rhinol Laryngol 1985,
94:103–107.
14
Bretlau P, Salomon G, Johnsen NJ: Otospongiosis and sodium fluoride. A
clinical double-blind, placebo-controlled study on sodium fluoride treatment
in otospongiosis. Am J Otol 1989, 10:20–22.
15
McKenna MJ, Mills BG: Immunohistochemical evidence of measles virus antigens in active otosclerosis. Otolaryngol Head Neck Surg 1989, 101:415–
421.
Conclusion
Primary and revision stapes surgery is in general beneficial and safe in the elderly population. Recent studies
indicate that closure of the ABG to within 10 dB can be
obtained in most patients (young or elderly) undergoing
stapedectomy. Long-term studies indicate that hearing
decreases approximately 1 dB/y and that at least 10 to
20% of patients undergoing stapedectomy will have a
revision to correct further conductive hearing loss. Revision surgeries are usually successful as well with up to 70
to 90% of patients obtaining ABG closure to within 10
dB, regardless of age. Elderly patients with far-advanced
otosclerosis can also obtain some benefit from stapes surgery. If the clinical onset of otosclerosis is delayed or
altered by further global health measures, more patients
will have primary stapes surgeries at older ages. As we
better understand the pathogenesis of otosclerosis, the
incidence of clinically significant otosclerosis might decrease; the prevalence of otosclerosis in the elderly, however, will not decrease for many decades. A substantial
number of elderly patients will also desire revision procedures. Stapes surgery will be a fascinating topic to the
otologic surgeon for years to come.
References and recommended reading
Papers of particular interest, published within the annual period of review,
have been highlighted as:
•
Of special interest
••
Of outstanding interest
16
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26
•
27 Lesinski SG: Revision stapedectomy. Curr Opin Otolaryngol Head Neck
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••
An excellent review of the difficulties encountered by the otologic surgeon during
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••
A thorough examination of a relatively large patient population with otosclerosis
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37 Ayache D, Corre A, Van Prooyen S, et al.: Surgical treatment of otosclerosis
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•
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stapedectomy. Otol Neurotol 2003, 24:560–566.
••
An excellent examination of short-term results after revision stapes surgery for a
very large patient cohort.
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