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: email@example.com Current Opinion in Otolaryngology & Head and Neck Surgery 2004, 12:387–392 © 2004 Lippincott Williams & Wilkins 1068-9508 Introduction Since 1704, when Valsalva  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 , Rosen’s stapes mobilization , Shea’s stapedectomy , and Perkins’s use of the otologic laser  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 , and it occurs in a relatively young population. It is often bilateral, and many patients with otosclerosis have tinnitus  and balance difficulties. A recent study  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% . 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  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 ; 7q ). McKenna  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 . Lippy et al.  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 , 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 . New prostheses and materials are also being developed to assist the otologist with problems encountered in revision stapes surgeries. Chen and Arriaga  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  or tympanic membrane . The hearing results with these devices are not as good as the results with a revision stapedectomy or stapedotomy . 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.  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  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  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 , 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 Shea JJ Jr: A personal history of stapedectomy. Am J Otol 1998, 19:S2–12. 17 Niedermeyer HP, Arnold W, Schwub D, et al.: Shift of the distribution of age in patients with otosclerosis. Acta Otolaryngol 2001, 121:197–199. 18 Tomek MS, Brown MR, Mani SR, et al.: Localization of a gene for otosclerosis to chromosome 15q25-q26. Hum Mol Genet 1998, 7:285–290. 19 Van Den BK, Govaerts PJ, Schatteman I, et al.: A second gene for otosclerosis, OTSC2, maps to chromosome 7q34-36. Am J Hum Genet 2001, 68:495–500. 20 McKenna MJ, Kristiansen AG, Bartley ML, et al.: Association of COL1A1 and otosclerosis: evidence for a shared genetic etiology with mild osteogenesis imperfecta. Am J Otol 1998, 19:604–610. 21 Salvinelli F, Casale M, Peco VD, et al.: Stapedoplasty in patients with small air-bone gap: why not? Med Hypotheses 2003, 60:535–537. 22 Lippy WH, Burkey JM, Schuring AG, et al.: Stapedectomy in patients with small air-bone gaps. Laryngoscope 1997, 107:919–922. 23 Silverstein H: Laser stapedotomy minus prosthesis (laser STAMP): a minimally invasive procedure. 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Otol Neurotol 2003, 24:567–571. •• A thorough examination of a relatively large patient population with otosclerosis observed for 20 years after stapedectomy. 36 House HP, Hansen MR, Al Dakhail AA, et al.: Stapedectomy versus stapedotomy: comparison of results with long-term follow-up. Laryngoscope 2002, 112:2046–2050. 37 Ayache D, Corre A, Van Prooyen S, et al.: Surgical treatment of otosclerosis in elderly patients. Otolaryngol Head Neck Surg 2003, 129:674–677. • Short-term hearing results for a small number of elderly patients undergoing stapes surgery. 38 Lippy WH, Burkey JM, Fucci MJ, et al.: Stapedectomy in the elderly. Am J Otol 1996, 17:831–834. 392 Otology and neuro-otology 39 Sheehy JL, Nelson RA, House HP: Revision stapedectomy: a review of 258 cases. Laryngoscope 1981, 91:43–51. 48 Pearman K, Dawes JD: Post-stapedectomy conductive deafness and results of revision surgery. 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Laryngoscope 1998, 108:1794–1800. 53 Lippy WH, Wingate J, Burkey JM, et al.: Stapedectomy revision in elderly patients. Laryngoscope 2002, 112:1100–1103. 46 Han WW, Incesulu A, McKenna MJ, et al.: Revision stapedectomy: intraoperative findings, results, and review of the literature. Laryngoscope 1997, 107:1185–1192. 54 Bailes BK: Perioperative care of the elderly surgical patient. AORN J 2000, 72:186–207. 55 Liu LL, Wiener-Kronish JP: Perioperative anesthesia issues in the elderly. Crit Care Clin 2003, 19:641–656. 47 Lesinski SG, Stein JA: Stapedectomy revision with the CO2 laser. Laryngoscope 1989, 99:13–19. 52 Lippy WH, Battista RA, Berenholz L, et al.: Twenty-year review of revision stapedectomy. Otol Neurotol 2003, 24:560–566. •• An excellent examination of short-term results after revision stapes surgery for a very large patient cohort.