LASER ASSISTED SMALL FENESTRA STAPEDOTOMYTECHNIQUE & ANALYSIS

Dr V.V.Raut, Dr J.Halik

Dept. of Otolaryngology

Toronto

N= 135 (Primary cases)

• Markham Stouffville Hospital

• M:F = 54: 81(1: 1.5)

• Age Range: 20-78 yrs

• Second Ear surgery: 35

• Follow-up: 4 months –24 months(avg 10 months)

Technique

• Local anaesthesia with IV sedation• Argon Laser 2.5 watt (coherent)• Otoprobe –20 deg. Angled, 0.2 mm tip diameter• Halik footplate perforators:0.3,0.4,0.5, 0.6mm

diameter (Richards)• Cawthorne piston: 0.3 x 5mm Teflon prosthesis

with notch at 3 o’clock(Modified Halik)

Laser Settings

• Stapedial Tendon and Crurae

• 0.2 sec at 2.0 watts

• Footplate• 0.1 sec at 1.0 watts

COST

• Laser - $ 45,000(cdn)

• Otoprobe-$190(cdn)-Single use- offset against cost of prosthesis which is cheap

ResultsN=135

Avg A-B gap closure(Post op air minus pre-op bone)

A-B gap 0.5,1,2 KHz 0.5,1,2,4 KHz

< 10dB 118/135(87.4%) 107/135(79.3%)

<20dB 13/135(9.6%) 24/135(17.7%)

>20dB 4/135(3%) 4/135(3%)

Over Closure of Air-Bone GapN=135

• 40/135(29.6%)

• Range 5-40dB

• Average over closure = 13dB

Improvement in High Frequency Hearing

(post-op air minus pre-op air)

4 KHz 8 KHz

Improved 110/135(81.4%)

(17dB)

82/135(60.7%)

(15dB)

Same 14/135(10.3%) 26/135(19.3%)

Worse 11/135(8.1%)

(9dB)

27/135(20%)

(13dB)

• Post-op SRT< 30dB=111

• Pre-op possible SRT<30db=107

• %Improvement=111/107 (103%)

A-B gap Bauch et al

0.5,1,2kHz

N=39

Hodgson et al 0.5,1,2kHz

N=62

Raut/Halik

0.5,1,2kHz

N=135

Raut/Halik

0.5,1,2kHz

N=135

<10 dB 31 (79.5%) 54(87%) 118(87.4%) 107(79.7%)

< 20dB 4(10.3%) 5(8%) 13(9.6%) 24(17.7%)

> 20dB 4(10.3%) 3(5%) 4(3%) 4(3%)

ComplicationsN=135Minor

• Taste:29 cases(21%)-resolved in 3 months

• Tinnitus:9cases(6%)- 2 persisted beyond 3 months

• Vertigo: 6 cases(4%)-1 persisted beyomd 3 months

Major • Immediate SNHL-nil

• Delayed SNHL-nil

• Perilymph fistula- 1 case(young female perilymph gusher-reexplored, prosthesis removed,OW sealed with fat,ME sealed with

tisseal, no SNHL, persistent cond loss)

• Persistent conductive loss-4 cases

Advantages of Small Fenestra Stapedotomy

• Lower incidence of perilymph fistula

• Lower incidence of immediate SNHL

• Long term hearing loss progresses more slowly*

• 4kHz & Speech Discrimination scores show less significant deterioration*

• * Smyth,Hassard & El Kordy, 1980

Advantages of Laser

• Precision• Least traumatic• Better control of bleeding• Technically easier• Floating footplate• Results-Over closure• Decreased post-operative morbidity- Day surgery

Step-reordering

(1998)

Laser

(2001)

Day Surgery 87 118

Inpatient 76 5

Conclusion

• Safe

• Minimal Vestibular upset

• Acceptable A-B gap closure with significant improvement in hearing at 4kHz & 8kHz

• Significant over closure rate (29.6%)

• Functionally excellent results(10%SRT<30dB)

• An easier ear to aid than conventional techniques

• Neurolept anaesthesia- out patient procedure

• Surgery on second ear can be offered