Otosclerosis and Stapes Surgery - part 8 ppsx

Technical and Clinical Aspects of ‘One-Shot’ CO 2 Laser Stapedotomy 261 Complications Five of the 240 patients (2%) required revision surgery, 7 days postoper- atively at the earliest and after 9 months at the latest. Intraoperative Complications. No intraoperative complications [acciden- tal mobilization of the footplate (floating footplate), accidental fracturing of a thin footplate] occurred. Neither of the 2 patients who underwent surgery under local anesthesia complained of vertigo during and/or directly following vapor- ization of the stapes footplate with the CO 2 laser. Postoperative Complications. Two (1%) of the 240 patients postoperatively developed a progressive significant sensorineural hearing loss. In 1 case, a thresh- old shift of up to 20 dB in all frequencies occurred together with a persistent tin- nitus. One patient (0.5%) developed a severe sensorineural hearing loss of up to 40 dB in all frequencies 1 week postoperatively. These 2 patients who underwent revision surgery after 1 week were found to have a too short a prosthesis with a perilymph fistula. Revision surgery improved the sensorineural hearing loss and the tinnitus. Early and/or late cases of deafness were not observed in our group of patients. No patient suffered from permanent tinnitus, which did not exist pre- operatively, and only 2 patients reported a slight increase in preexistent tinnitus. One patient had to undergo revision within the first postoperative week because of persistent vestibular symptoms caused by too long a prosthesis. The complaints disappeared after insertion of a shorter one. In the first postoperative week, 7 patients reported mild vertigo with queasiness when standing up or during rapid head movements. Four weeks postoperatively, none of the patients had any resid- ual symptoms of vestibular irritation. Four patients (2%) had transient taste dis- turbance. There were no tympanic membrane perforations. Preoperative 1 year after operation 0 20 40 60 80 100 nϭ 110 Patients (%) 0–10 dB 11–20 dB 21–30 dB >30 dB Fig. 4. Distribution of the patients with a postoperative air-bone gap (average of 0.5, 1, 2 and 3 kHz for air conduction minus the average for bone conduction) of 0–10 dB, 11–20 dB, 21–30 dB or Ͼ30 dB with a follow-up of at least 1 year postoperatively. Jovanovic 262 Delayed Complications. Two additional patients underwent revision surgery for conductive hearing loss 5–9 months postoperatively. One patient had a dis- placed prosthesis, combined with total incus erosion due to a too short a prosthe- sis. The new prosthesis could be fixed at the residual incus. One patient developed a loose wire with prosthesis and incus fixation resulting from adhesions. Lasering these adhesions and refixing the prosthesis at the incus improved the conductive hearing loss. Discussion The aim of laser stapedotomy is to enable management of the stapes in such a way as to ensure the greatest possible protection of the inner ear and to avoid damage to residual middle ear structures. Advocates of the laser technique agree that noncontact laser vaporization of the bone covering the vestibule is less trau- matic for the inner ear than manual instrumental extraction or perforation of the stapes footplate. It is also true, however, that the laser-related absorption of irra- diation energy and generation of heat potentially endanger membranous inner ear structures during perforation of the stapes footplate. The energy setting should be such that a 0.5- to 0.7-mm perforation dia- meter is achieved with a one-shot application. The laser perforation should be circular with a clean-cut edge. This study demonstrated that an adequate footplate perforation diameter of 0.5–0.7 mm could be achieved with a single laser application by using a suitable scanner system. Integrating the control of the scanner in the laser system (SurgiTouch scanner) enabled synchronization of the spiral laser beam course with the trig- gering of a laser impulse, so that the laser beam starts the spiral figure at the same point and runs through the same figure each time. This results in higher reproducibility of the laser-induced tissue effect. In addition, the laser beam is moved at an increased speed, so that the spiral completes its course in only 0.04 or 0.05 s. With a maximal single-pulse energy of 1 J, the laser power of a sin- gle scanner application can thus be increased to 20–22 W (power density of 80,000–88,000 W/cm 2 ). In this way, the success rate of the one-shot technique, i.e. creating an adequately large perforation with a single laser application, could be increased to 68% of the cases. In 14%, the requisite perforation size was achieved by a second application with the scanner at the same site, and in 18% the perforation was enlarged at the edge by slightly overlapping applica- tions without using a scanner. The results of previous studies support the use of both visible (argon and KTP) and invisible, far-infrared (CO 2 and Er:YAG) laser systems for primary otosclerosis surgery [1–7, 16–28]. Technical and Clinical Aspects of ‘One-Shot’ CO 2 Laser Stapedotomy 263 All studies use the multiple-application technique for footplate perfora- tion. Since the beam of the argon or KTP laser has a diameter of about 0.15 mm, most authors use the so-called rosette technique with a multiple circular appli- cation pattern. Argon and KTP lasers appear to be valuable tools in primary and revision cases [1, 2, 5, 17, 29]. Here, the insertion of a fiber-optic microhandpiece (Endo-Otoprobe) [2] is superior to laser application with micromanipulators attached to the microscope, since the strong laser beam divergence at the exit of the optical fiber rapidly decreases the power density in relation to the increase in distance [21, 20]. This reduces the risk of inner ear damage associated with the penetration depth and temperature problem in the perilymph. Moreover, the use of the fiber-optic microhandpiece facilitates the vaporization, especially also of the anterior crus, while reducing the amount of technical equipment required [25]. The CO 2 laser is also widely applied in the clinical routine [6, 7, 16, 22, 30, 31, 34]. With a beam diameter of 0.18–0.2 mm, all authors use the multiple- application technique for footplate perforation. In the group of pulsed laser systems, the Er:YAG laser at first seemed to possess the most suitable wavelength for middle ear surgery. The Er:YAG and CO 2 lasers do not coincide in their tissue impact and effectiveness, since they differ in their wavelength and irradiation time ratio. The continuous-wave CO 2 laser is suitable for use on soft tissue and, if well focussed, for vaporization of thin bone structures [12], while the Er:YAG laser offers advantages mainly in the treatment of bone structures [17, 23, 32]. However, as soon as bleeding occurs, the oligothermic Er:YAG laser radiation is completely absorbed by blood and no longer reaches the target area. It is then ineffective. The introduction of new techniques in stapes surgery is always associated with the question of possible risks to inner ear structures. The clinical applica- tion must be preceded by experimental in vitro studies for risk assessment [10–14]. In the final analysis, however, only the postoperative audiometric results can provide information about the effects on inner ear structures. A com- parison between post- and preoperative bone conduction auditory thresholds showed that, on average, patients in the authors’ population had no postopera- tive deterioration of inner ear function in the examined frequency range of 0.5–4 kHz. Thus, applying higher powers using the one-shot technique with the scanner does not have a higher potential for damage than the multiple-application technique [15]. Comparing published audiometric results after laser stapedotomy in relation to mean differences in the bone conduction auditory thresholds in the main speech region shows that postoperative improvements of 0.53–5.6dB in those thresholds are achieved regardless of the laser system applied [6, 7, 22, 24, 28, 30, 31]. Jovanovic 264 The mean value for the frequency range of 0.5–4 kHz is 4.3 dB in our patient population. The higher sound level measured in Er:YAG laser therapy is associated with the risk of inner ear trauma and tinnitus [13, 24, 32]. Moreover, it is sus- pected that the pressure waves resulting from Er:YAG laser therapy may cause transitory or even permanent inner ear damage such as high-frequency hearing loss or tinnitus [24; our own experience]. Thus, the Er:YAG laser has a lower application safety than the CO 2 laser and cannot be recommended for stapes surgery at the present time. The literature comparing hearing results after conventional and laser stape- dotomy is not suitable for all series, since most authors dealt with more or less selected groups. Older studies often averaged the air-bone gap for 0.5, 1 and 2 kHz, whereas the more recent ones include the frequencies of 3 or 4 kHz as well. In this study, 99% of the patients showed successful closure of the post- operative air-bone gap to 20dB (average of 0.5, 1, 2 and 3 kHz). In the litera- ture, closure of the air-bone gap to 10 dB was achieved by 67–99% and closure to 20 dB by 85–99% of the patients who underwent laser stapedotomy [1, 2, 4–7]. Assessing the results of conventional stapes surgery in the literature showed that a mean residual air-bone gap of 10 dB was achieved by 40–96% of the patients and a gap of 20 dB by 68–99% [25, 33–37]. These data are comparable to those of laser stapes surgery. Conclusion Our findings as well as data in the literature suggest that CO 2 laser stapedo- tomy is a safe procedure with a lower incidence and severity of intra- and post- operative complications (e.g. floating footplate, accidental fracturing of a thin footplate, vertigo) than conventional interventions [6, 7, 16]. Our results sup- port these published data. No laser-induced sensorineural hearing loss could be observed in our patients. The closure of the air-bone gap in our study is compa- rable to conventional stapes surgery. One-shot stapedotomy achieves an adequately large (0.5–0.7mm in diameter) circular footplate perforation without appreciable thermal damage to the surrounding area. It represents a considerable advance in CO 2 laser stapedotomy. The CO 2 laser combined with modern scanner systems is well suited for application in stapes surgery, and, with strict adherence to the parameters, will help to optimize this high-precision intervention and should reduce the inci- dence of inner ear damage. Technical and Clinical Aspects of ‘One-Shot’ CO 2 Laser Stapedotomy 265 References 1 McGee TM: The argon laser in surgery for chronic ear disease and otosclerosis. Laryngoscope 1983;93:1177–1182. 2 Horn KL, Gherini S, Griffin GM: Argon laser stapedectomy using an endo-otoprobe system. Otolaryngol Head Neck Surg 1990;102:193–198. 3 Lesinski SG: Lasers for otosclerosis. Laryngoscope 1989;99(suppl 46):1–24. 4 Lesinski SG: Lasers for otosclerosis – Which one if any and why. Lasers Surg Med 1990;10: 448–457. 5 Vernick DM: A comparison of the results of KTP and CO 2 laser stapedotomy. Am J Otol 1996;17:221–224. 6 Shabana YK, Allam H, Pedersen CB: Laser stapedotomy. J Laryngol Otol 1999;113:413–416. 7 Buchman CA, Fucci MJ, Roberson JB Jr, De La Cruz A: Comparison of argon and CO 2 laser stapedotomy in primary otosclerosis surgery. Am J Otolaryngol 2000;21:227–230. 8 Jovanovic S, Schönfeld U, Fischer R, Scherer H: CO 2 laser in stapes surgery. Proc SPIE 1993;1876:17–27. 9 Jovanovic S, Schönfeld U: Application of the CO 2 laser in stapedotomy. Adv Otorhinolaryngol 1995;49:95–100. 10 Jovanovic S, Schönfeld U, Prapavat V: Die Bearbeitung der Steigbügelfussplatte mit verschiede- nen Lasersystemen. 1. Kontinuierlich strahlende Laser. HNO 1995;43:149–158. 11 Jovanovic S, Schönfeld U, Fischer R: Thermische Belastung des Innenohres bei der Laser- Stapedotomie. 1. Kontinuierlich strahlende Laser. HNO 1995;43:702–709. 12 Jovanovic S, Schönfeld U, Prapavat V: Effects of continuous wave laser systems on stapes foot- plate. Lasers Surg Med 1996;19:424–432. 13 Jovanovic S: Der Einsatz neuer Lasersysteme in der Stapeschirurgie; in Müller GJ, Berlien HP (eds): Fortschritte der Lasermedizin 14. Landsberg, Ecomed, 1996. 14 Jovanovic S, Anft D, Schönfeld U: Influence of CO 2 laser application of the guinea-pig cochlea on compound action potentials. Am J Otol 1999;20:166–173. 15 Jovanovic S: CO 2 laser in stapes surgery; in Oswal V, Remacle M, Jovanovic S, Krespi J (eds): Principles and Practice of Lasers in Otolaryngology, Head and Neck Surgery. Den Haag, Kugler, 2002, pp 335–357. 16 Lesinski SG, Newrock R: Carbon dioxide lasers for otosclerosis. Otolaryngol Clin North Am 1993;26:417–441. 17 Perkins RC: Laser stapedotomy for otosclerosis. Laryngoscope 1980;90:228–241. 18 DiBartolomeo JR, Ellis M: The argon laser in otology. Laryngoscope 1980;90:1786–1796. 19 Palva T: Argon laser in otosclerosis surgery. Acta Otolaryngol (Stockh) 1987;104:153–157. 20 Causse JB, Gherini S, Horn KL: Surgical treatment of stapes fixation by fiberoptic argon laser stapedotomy with reconstruction of the annular ligament. Otolaryngol Clin North Am 1993;26: 395–416. 21 Gherini S, Horn KL, Causse JB, McArthur GR: Fiberoptic argon laser stapedotomy: is it safe? Am J Otol 1993;14:283–289. 22 Antonelli PJ, Gianoli GJ, Lundy LB: Early post-laser stapedotomy hearing thresholds. Am J Otol 1998;19:443–446. 23 Nagel D: The Er:YAG laser in ear surgery: first clinical results. Lasers Surg Med 1997;21:79–87. 24 Häusler R, Schar PJ, Pratisto H: Advantages and dangers of erbium laser application in stape- dotomy. Acta Otolaryngol 1999;119:207–213. 25 Häusler R: Fortschritte in der Stapeschirurgie. Laryngorhinootologie 2000;79(suppl 2):95–139. 26 Huber A, Linder T, Fisch U: Is the Er:YAG laser damaging to inner ear function? Otol Neurotol 2001;22:311–315. 27 Lippert BM, Gottschlich S, Kulkens C: Experimental and clinical results of Er:YAG laser stape- dotomy. Lasers Surg Med 2001;28:11–17. 28 Keck T, Wiebe M, Rettinger G, Riechelmann H: Safety of the erbium:yttrium-aluminium-garnet laser in stapes surgery in otosclerosis. Otol Neurotol 2002;23:21–24. 29 Nissen RL: Argon laser in difficult stapedotomy cases. Laryngoscope 1989;108:1669–1673. Jovanovic 266 30 Garin P, Van PK, Jamart J: Hearing outcome following laser-assisted stapes surgery. J Otolaryngol 2002;31:31–34. 31 Motta G, Moscillo L: Functional results in stapedotomy with and without CO 2 laser. ORL J Otorhinolaryngol Relat Spec 2002;64:307–310. 32 Pratisto H, Frenz M, Ith M: Temperature and pressure effects during erbium laser stapedotomy. Lasers Surg Med 1996;18:100–108. 33 Levy R, Shvero J, Hadar T: Stapedotomy technique and results: ten years’ experience and compar- ative study with stapedectomy. Laryngoscope 1990;100:1097–1099. 34 Fisch U: Tympanoplasty, Mastoidectomy, and Stapes Surgery. Stuttgart, Thieme, 1994. 35 Somers T, Govaerts P, Marquet T, Offeciers E: Statistical analysis of otosclerosis surgery per- formed by Jean Marquet. Ann Otol Laryngol 1994;103:945–951. 36 Persson P, Harder H, Magnuson B: Hearing results in otosclerosis surgery after partial stapedec- tomy, total stapedectomy and stapedotomy. Acta Otolaryngol (Stock) 1997;117:94–99. 37 Ramsay H, Karkkainen J, Palva T: Success in surgery for otosclerosis: hearing improvement and other indicators. Am J Otolaryngol 1997;18:23. Prof. Dr. Sergije Jovanovic Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin Hals-Nasen-Ohrenklinik mit Hochschulambulanz, Hindenburgdamm 30 DE–12200 Berlin (Germany) Tel. 49 30 8445 2440, Fax 49 30 8445 4460, E-Mail sergije.jovanovic@charite.de Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 267–272 Transient Depression of Inner Ear Function after Stapedotomy: Skeeter versus CO 2 Laser Technique T. Somers, J.P. Vercruysse, A. Zarowski, M. Verstreken, I. Schatteman, F.E. Offeciers Univ ersity ENT Department, Sint-Augustinus Hospital, W ilrijk, Belgium Abstract Performing stapes surgery for otosclerosis is known to be potentially irreversibly harm- ful to the inner ear function in about 1% of the cases. An early postoperative transient depres- sion of the bone conduction thresholds is frequently detected after stapes surgery. The purpose of this study was to compare the evolution of bone conduction thresholds after primary stapedotomy with two different techniques: skeeter versus CO 2 laser stapedotomy. Audiological data of 336 otosclerosis operations performed by 2 surgeons between 1997 and 2003 were subjected to analysis. The calibrated hole in the footplate was performed ran- domly either with the skeeter drill or with the CO 2 laser. Preoperative bone conduction thresholds were compared with the postoperative levels (day 2–3, week 2, week 6 and month 6) in all patients. Evolution of the bone conduction was compared for the two studied subgroups (laser versus skeeter). Copyright © 2007 S. Karger AG, Basel Performing stapes surgery for otosclerosis is known to be potentially irre- versibly harmful to the inner ear function in about 1% of the cases. An early postoperative transient depression of the bone conduction (BC) thresholds is frequently detected after stapes surgery. The purpose of this study was to com- pare the evolution of BC thresholds after primary stapedotomy with two differ- ent techniques: skeeter versus CO 2 laser stapedotomy. Audiological data of 336 otosclerosis operations performed by 2 surgeons between 1997 and 2003 were subjected to analysis. The calibrated hole in the footplate was performed randomly either with the skeeter drill or with the CO 2 laser. Preoperative BC thresholds were compared with the postoperative levels (day 2–3, week 2, week 6 Somers/Vercruysse/Zarowski/Verstreken/Schatteman/Offeciers 268 and month 6) in all patients. Evolution of the BC was compared for the two studied subgroups (laser versus skeeter). Three hundred and thirty-six patients were evaluated between 1997 and 2003. A CO 2 laser stapedotomy was performed in 205 patients (61%) and the skeeter technique was used in 131 cases (39%). Figure 1 shows the mean preoperative and postoperative air (0.125–8kHz) and BC thresholds (0.25–4 kHz). The average preoperative air conduction thresholds revealed a Fletcher index (average threshold for 0.5, 1, and 2 kHz) of 55 dB and an air-bone gap of 29 dB in the Fletcher frequencies. The BC over- closure for the Fletcher index was 4.2 dB. The average air conduction gain for the Fletcher frequencies was 27.2 dB. The evolution of the BC thresholds for the different frequencies is summa- rized and magnified to a larger scale in figure 2 and shows a minimal but sig- nificant downward shift (first arrow on the left) on days 2–3 in all frequencies (p Ͻ 0.001). On days 2–3, an overall average loss of 1.8dB was measured in the Fletcher frequencies. The temporary drop was minimal for frequencies 0.5, 1 and 2 kHz, but BC measured at 4 kHz dropped by 7dB. The upward-directed arrows in figure 2 show the gradual BC recovery. After 2 weeks, there was a partial BC recovery, but this was too slight to be sta- tistically significant (p Ͼ 0.05). The most important recovery, with statistical significance (p Ͻ 0.05), is visible between week 2 and week 6. Some further slight improvement is noticed after 6 months. Figure 3 summarizes the evolution of the BC threshold shifts (postopera- tive BC threshold minus preoperative BC) for the different frequencies. The largest negative BC shifts were observed for the frequencies 250 and 4,000 Hz. The residual BC loss at 6 months for 250 Hz averaged 1.6 dB, and for 4,000 Hz 0 10 20 30 40 50 60 70 80 90 0.125 0.25 0.5 1 2 4 8 Frequency (kHz) Hearing level (dB) Fig. 1. Mean preoperative thresholds for air conduction (᭿) and BC (᭡) and mean postoperative thresholds for air conduction (ٗ) and BC (᭝) in 332 cases. Stapes Surgery and Safety Issues 269 2.7 dB. On the other hand, the largest positive shift or overclosure is seen at fre- quency 2,000Hz (the Carhart notch frequency). Figure 4 shows how often and to which degree a negative BC shift was observed on days 2–3 for the different frequencies. At 250 Hz, a BC drop, even of the slightest degree, was seen in 63% of all cases. At 500 Hz, this was the case in 50%, at 1,000 Hz in 41%, at 2,000Hz in 48% and at 4,000Hz in 64%. If we only take the BC losses of Ն20 dB into consideration, the incidences are: 16% (250 Hz), 9% (500 Hz), 5% (1,000 Hz), 3.5% (2,000 Hz), and 13.5% (4,000 Hz). The evolution of the BC thresholds for the laser stapedotomy is seen in figure 5 and for the skeeter stapedotomy in figure 6. 5 15 25 35 0.25 0.5 1 2 4 Frequency (kHz) Hearing level (dB) Fig. 2. Detailed view of the BC shifts: the first arrow pointing downward is the BC shift from the preoperative BC line (ϫ) to early postoperative BC thresholds (2–3 days) (᭜), the second arrow, which is now pointing upward, is the partial BC recovery at week 2(᭿), and the third and fourth arrows are the further recoveries at 6 weeks (᭡) and 6 months (᭺). Somers/Vercruysse/Zarowski/Verstreken/Schatteman/Offeciers 270 Ϫ8 Ϫ6 Ϫ4 Ϫ2 0 2 4 6 8 0.25 0.5 Hearing level (dB) Frequency (kHz) 124 Days 2–3 Week 2 Week 6 Month 6 Fig. 3. This graph shows the evolution of the BC shift expressed as the difference between the postoperative minus the preoperative BC thresholds and this for different fre- quencies. A negative value is a BC loss (most obvious at 250 and 4,000 Hz) and a positive value is a sign of BC overclosure (the most obvious being for 2,000Hz). Frequency (kHz) <10 dB 10 dB Ͻ x Ͻ 20 dB 20 dB Ͻ x Ͻ 30 dB Ͼ30 dB 0 5 10 15 20 25 30 35 0.25 0.5 Incidence (%) 124 Fig. 4. Incidence of occurrence of BC for the different frequencies with different grades of BC shift (Ͻ10 dB, between 10 and 20 dB, between 20 and 30db, Ͼ30 dB). [...]... revision surgery for otosclerosis Otol Neurotol 2001;22:776– 785 Wiet RJ, Kubek DC, Lemberg P, Byskosh AT: A meta-analysis review of revision stapes surgery with argon laser: effectiveness and safety Am J Otol 1997; 18: 166–171 Magliulo G, Cristofari P, Terranova G: Functional hearing results in revision stapes surgery Am J Otol 1997; 18: 4 08 412 Kos MI, Montandon PB, Guyot JP: Short- and long-term results... Somers/Vercruysse/Zarowski/Verstreken/Schatteman/Offeciers 272 Stapes Revision Surgery and Complications Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol Basel, Karger, 2007, vol 65, pp 273–277 Revision Stapes Surgery – Retrospective Analysis of Surgical Findings in a Series of 21 Otosclerosis Patients Marcin Durkoa, Dariusz Kaczmarczykb, Tomasz Durkoa Departments of aOtosurgery, and bCytophysiology, Histology and Embryology,... stapedotomy and stapedectomy with a teflon-wire piston prosthesis Ann Otol Rhinol Laryngol 2001;110:907–911 Persson P, Harder H, Magnuson B: Hearing results in otosclerosis surgery after partial stapedectomy, total stapedectomy and stapedotomy Acta Otolaryngol 1997;117: 94–99 Marcin Durko, MD Otosurgery Department, Medical University of Lodz ul Kopcinskiego 22 PL–9 0-1 53 Lodz (Poland) Tel./Fax ϩ 48 42 6 78 57 85 ,... (Poland) Tel./Fax ϩ 48 42 6 78 57 85 , E-Mail durko@csk.umed.lodz.pl Revision Stapes Surgery 277 Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol Basel, Karger, 2007, vol 65, pp 2 78 284 How to Prevent a Stapes Gusher C.W.R.J Cremers Department of Otolaryngology, University Medical Center St Radboud, Nijmegen, The Netherlands Abstract A stapes gusher is the result of a congenital... University of Lodz, Lodz, Poland Abstract Aim: Retrospective analysis of surgical findings in revision stapes surgery in a group of 21 otosclerosis patients qualified for the secondary procedure at the Otosurgery Department of the Medical University of Lodz, Poland, from 1 980 to 2002 Materials and Methods: 21 cases of revision stapes surgery out of a total of 350 surgically treated otosclerosis cases are... 13.16 13.03 13.10 13. 08 13. 08. 01 13 08. 03 13. 08. 03.02 13. 08. 03.03 13. 08. 03.05 13 08. 05 13 08. 07 13 13 08. 0502 08. 0505 Male, female, normal by history Male, deaf or hard of hearing Female, deaf due to meningitis or to autosomal recessive inheritance Male, female, normal audiogram Female, abnormal audiogram Female, carrier Dead Proband Fig 1 Pedigree of a Dutch family with the X-recessive mixed deafness... (The Netherlands) Tel ϩ31 24 361 44 50, Fax ϩ31 24 354 02 51, E-Mail c.cremers@kno.umcn.nl Cremers 284 Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol Basel, Karger, 2007, vol 65, pp 285 –295 Postoperative Granuloma after Stapedectomy: Is It Destiny or Avoidable? C Batmana, Ö Öztürka, S.S Ramadanb a Department of Otorhinolaryngology Head and Neck Surgery, bDepartment of... retrospective analysis of the surgical findings in revision stapes surgery in a group of 21 otosclerosis patients qualified for the secondary procedure at the Otosurgery Department of the Medical University of Lodz from 1 980 to 2002 Materials and Methods A series of 21 cases of revision stapes surgery out of a total of 350 patients surgically treated for otosclerosis underwent a retrospective analysis (table... history of a stapes gusher during stapes surgery may be present in that family How to Prevent a Stapes Gusher 279 AC Ϫ10 0 0 10 40 20 30 60 40 80 0 20 Threshold (dB) 20 Threshold (dB) BC Ϫ10 0 10 40 50–70 20 30 60 40 80 50 100 60 70 120 0.25 0.5 1 2 4 8 Frequency (kHz) 2 100 120 0.25 0.5 1 2 Frequency (kHz) 4 8 3 Fig 2 Air conduction (AC) hearing levels related to age in a Dutch family with the X-recessive... hearing loss High-Resolution CT Scanning A widening of the vestibule, and especially a widening of the internal acoustic canal, is seen on high-resolution CT scans (figs 5–7) This has been Cremers 280 ABG Ϫ10 0 Threshold (dB) 20 0Ð70 40 60 80 100 120 0.25 4 0.5 1 2 Frequency (kHz) 4 8 Fig 4 Air-bone gap (ABG) related to frequency from a Dutch family and an isolated case with the X-recessive mixed deafness . (Poland) Tel./Fax ϩ 48 42 6 78 57 85 , E-Mail durko@csk.umed.lodz.pl Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 2 78 284 How to Prevent a Stapes. 1997; 18: 166–171. 8 Magliulo G, Cristofari P, Terranova G: Functional hearing results in revision stapes surgery. Am J Otol 1997; 18: 4 08 412. 9 Kos MI, Montandon PB, Guyot JP: Short- and long-term. that family. 13.22 01.02 13 01.04 13 01.01 13 22.01 13.22 13.03 13. 08 13. 08. 03.02 13. 08. 03.03 13. 08. 03.05 13. 08. 01 13 08. 03 13 08. 05 13 08. 0502 13 08. 0505 13 08. 07 13.10 13.24 13.16 Male, deaf or hard of hearing Male,