Otosclerosis and Stapes Surgery - part 9 pptx

Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 300–307 Protecting the Cochlea during Stapes Surgery: Is There a Role for Corticosteroids? Jan Kiefer a , Qing Ye b , Jochen Tillein c , O. Adunka b , Wolfgang Arnold a , Wolfgang Gstöttner b a Klinik für Hals-Nasen-Ohrenheilkunde, Klinikum rechts der Isar, Technische Universität München, Munich, b Klinik für Hals-Nasen-Ohrenheilkunde und c Zentrum der Physiologie, Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany Abstract The aim of the present study was to evaluate possible protective effects of corticos- teroids on the inner ear after surgical trauma and to exclude any ototoxicity. A corticosteroid (triamcinolone, Volon A ® ) was topically applied to the inner ear of guinea pigs, either by extracochlear application with permeation and diffusion through the round window mem- brane or by intracochlear application with direct infusion into the inner ear via a cochleostomy. Threshold and input/output functions of compound action potentials (CAPs) were determined before and after application of the corticosteroid. We found that extra- cochlear application of the corticosteroid induced insignificant mild shifts of mean CAP thresholds, but significantly increased mean maximal amplitudes of input/output function after the 14th day following application of the steroid. No detrimental effects on cochlear function were noted in the extracochlear group, indicating absence of ototoxicity with the concentrations used. In the intracochlear group, CAP thresholds and amplitudes of input/ output function recovered from partial hearing loss due to cochleostomy between 7 and 14 days after application of the steroid, whereas in controls without steroid application, no such recovery of hearing was detected. These results suggest that topical application of triamci- nolone has no ototoxic effect and that it leads to increased recovery of cochlear functions after trauma in the guinea pig inner ear. Copyright © 2007 S. Karger AG, Basel Stapes surgery in experienced hands is a safe procedure and inner ear dam- age with hearing loss or severe vertigo only seldom occurs. However, in these rare instances, it represents a severe complication and should be avoided in any Protecting the Cochlea during Stapes Surgery 301 case. The most important issue in prevention of hearing loss after stapes surgery is a meticulous surgical technique; nevertheless, hearing loss may occur even in technically correct and uneventful surgical procedures. Mechanisms other than direct mechanical trauma, e.g. inflammation or infection, acoustic and meta- bolic stress and disturbance of fluid balance, may be at the origin of postopera- tive hearing loss. Additional pharmacological treatment for the protection of the inner ear, e.g. with corticosteroids, has found interest and is applied in clinical practice in an attempt to prevent or alleviate auditory dysfunction. Corticosteroids have been shown to reduce noise-induced cochlear damage and hearing loss [1–3], increase recovery after noise trauma [4, 5] and are the mainstay in the treatment of sudden sensorineural hearing loss [6, 7]. However, efficacy in stapedoplasty is still under debate. Riechelmann et al. [8] found no positive effect but increased patient discomfort after intravenous administration of corticosteroids in stapedoplasty; Hendershot [9] stated that short-acting cor- ticosteroids were able to alleviate postoperative serous labyrinthitis, whereas long-acting corticosteroids increased the incidence of postoperative vertigo and reduced the success rate. Spandow et al. [10] reported possible ototoxicity after local administration of hydrocortisone. Possible ways of application are systemic and local application, either via diffusion through the round window or by direct instillation after opening of inner ear spaces. Niedermeyer et al. [11] have measured concentrations of prednisolone in the human perilymph after systemic application and found that high doses of 250 mg were necessary to obtain a significant increase of concentration. They also noted a great interindividual variability of results. Tobita et al. [12] were able to measure uptake of prednisolone, with a peak 1 h after application and a prolonged stay in cochlear tissue only at high doses of 100mg/kg (corresponding to a human dosage of 7,000 mg for a 70-kg patient); at 30mg/kg, corresponding to 1,000 mg human dosage, they could not detect an increase in steroid concentration in the tissue with their measurement system. Relatively high doses of corticosteroid seem to be necessary to exert measurable effects in the inner ear, but they carry the risk of systemic side effects. Therefore, direct instillation of drugs into the cochlea offers several advantages, allowing delivery of high drug concentrations to the target organ while minimizing side effects. Some attempts at steroid delivery directly into the cochlea, such as intratympanic therapy [13] and osmotic micropump infu- sion [14, 15], have been reported. To further evaluate the efficacy and exclude any ototoxic effects, we decided to design an experimental study on the safety of topically applied steroid and protective effects on acoustic hearing in guinea pigs after specific trauma. Kiefer/Ye/Tillein/Adunka/Arnold/Gstöttner 302 Methods Study Design The design of the study included two arms. In the first study arm, steroids were applied extracochlearly at the round window, avoiding any direct mechanical impingement on the cochlea, to test whether steroids have any ototoxic effect. In the second arm of the study, steroids were applied intracochlearly to evaluate possible protective effects of a locally applied steroid on the inner ear after a specific surgical trauma to the cochlea, namely cochleostomy. Animal Preparation and Application of Corticosteroids This study complied with the guidelines of the Institutional Review Board. All efforts were made to minimize both the number of animals used and their suffering. Eleven pigmented guinea pigs (21 ears), weighing from 400 to 630 g, were used in the study. Guinea pigs were anesthetized by intraperitoneal injection of Ketavet (ketamine, Pharmacia & Upjohn GmbH, Erlangen, Germany; dose: 85 mg/kg), xylazine (Rompun, Bayer, Leverkusen, Germany; dose: 8.5mg/kg), and atropine (Braun, Melsungen, Germany; dose: 0.3 mg/kg). Body temperature was maintained at 37ЊC during the experiments. The otic bulla was exposed via a postauricular incision and opened with a hole of 2 ϫ 2 mm to allow visualization of the round window. In the extracochlear study arm, a size of 1 ϫ 1 mm Gelfoam with 5␮l Volon A ® (crys- talline triamcinolone acetonide solution, 5 ears, verum group) or saline (Ringer’s solution, 5 ears, control group) was implanted in contact with the round window membrane. In the intracochlear study arm, a cochleostomy of about 1 ϫ 1 mm in the basal turn of the cochlea was drilled and 3 ␮l Volon A (7 ears, verum group), or Ringer’s solution (4 ears, control group) were infused into the scala tympani, using a microsyringe. Measurements of Compound Action Potentials A gold hook electrode was anchored to the bony edge of the round window and con- nected to a percutaneous plug at the vertex to serve as recording electrodes for the acousti- cally evoked compound action potentials (CAPs) of the auditory nerve. Acoustic thresholds were determined in a soundproof chamber using frequency- specific gauss pips. The acoustic stimuli were delivered to the ear via a tightly sealed tubed earphone. The intensity of the gauss pip was changed in 5-dB steps between 20 and 119 dB SPL. Thresholds of CAPs were determined at 25 frequencies, distributed logarithmi- cally between 250 Hz and 64 kHz. In addition, input/output (I/O) functions of CAPs in response to click stimuli of increasing intensity were recorded to assess the cochlear function at threshold and suprathreshold levels. CAP amplitudes were measured from the first nega- tive peak to the subsequent positive peak of the waveform through a programmed algorithm. Frequency-specific thresholds and I/O functions were determined after opening of the bulla, prior to the placement of Gelfoam at the round window or before cochleostomy, and repeated soon after the placement of Gelfoam or cochleostomy and regularly on days 1, 3, 7, 14, 21 and 28 after the operation. Statistical Analyses Paired t tests were used to analyze pre- and postoperative results within animals. Unpaired t tests were used for comparison of group results. Differences were considered sta- tistically significant when p Ͻ 0.05. Mean values are given  SD. Protecting the Cochlea during Stapes Surgery 303 Results Extracochlear Study Arm No significant shifts of mean CAP thresholds at different frequencies have been observed after the application of the corticosteroid or in the control group. Whereas thresholds remained unchanged, mean maximal amplitudes of I/O function in response to click stimuli at suprathreshold levels increased signifi- cantly (p Ͻ 0.05) at days 14, 21, and 28 after application of the steroid in com- parison with amplitudes prior to the application. There were no significant changes of amplitudes from pre- to postapplication of saline in the control group (fig. 1). These results indicate that there are no ototoxic effects, but on the contrary, steroids increased amplitudes of CAPs. Intracochlear Study Arm Soon after cochleostomy, thresholds increased up to about 10–20 dB in both the corticosteroid group as well as in the control group. Cochleostomy itself induced a significant hearing loss (p Ͻ 0.05) in comparison with the 0 50 100 150 200 250 Amplitude (mV) pre 1st day 28th day 21st day 14th day 7th day Steroid groups Control groups pre 1st day 7th day 14th day 21st day 28th day * * * Fig. 1. Mean maximum amplitudes of CAPs at different intervals after extracochlear application of either corticosteroid or saline. Note the significant increase of amplitudes in the steroid group at days 14, 21 and 28. Significant changes (p Ͻ 0.05) are marked with an asterisk. Kiefer/Ye/Tillein/Adunka/Arnold/Gstöttner 304 values prior to cochleostomy. The shift of thresholds was most prominent in the high-frequency range from 8 to 64kHz. In the control group without corticosteroids, thresholds continued to increase up to day 7 and only little recovery has been seen afterwards. In the steroid group, thresholds also increased up to day 3, but then, recov- ery of CAP thresholds was found on day 7, and gradually continued until day 28, when it returned close to the presurgical level. In the control group, no notable recovery occurred until the end of the experiment. Statistic comparison of mean CAP thresholds in the steroid group showed significant differences between pre- and postcochleostomy at the time of surgery and on days 1, 3, 7 and 14, but no longer on days 21, and 28, whereas in the control group, statisti- cally significant differences of mean CAP thresholds persisted at all intervals (fig. 2). Mean maximal amplitudes of I/O function, both from the steroid and the control group, decreased immediately after cochleostomy, and were down to the lowest level at the 3rd day. In the steroid group, recovery could be found on day 14, which continued until day 28. Amplitudes from the control group stayed at a low level until day 14 and recovered only after the 21st day following opera- tion, about 1 week later than in the steroid group. Ϫ35 Ϫ30 Ϫ25 Ϫ20 Ϫ15 Ϫ10 Ϫ5 0 1 01 3 7 14 21 28 234567 Time after cochleostomy (days) Hearing loss (dB) * * * * * Steroid groups Control groups Fig. 2. Mean changes of thresholds after cochleostomy in the steroid and the control group at different time intervals after operation. Significant changes (p Ͻ 0.05) are marked with an asterisk. Protecting the Cochlea during Stapes Surgery 305 Discussion The safety and efficacy of topic application of steroids to the inner ear is still controversial and few reports on possible ototoxicity are available. Doubts about the effects of steroids on inner ear function still exist [16–18]. In this study, we investigated the safety of topically applied steroid and possible protective effects on acoustic hearing in guinea pigs after surgical trauma to the inner ear. Our findings from this study were consistent with those studies which did not find ototoxic effects. In the extracochlear group, hearing of animals in both the steroid as well as the control group did not change significantly from the time of application of the drug up to 28 days after surgery; on the contrary, even enhanced amplitudes of CAPs were found in the steroid group. The latter phenomena could be par- tially interpreted by the study of Shirwany et al. [19], in which they observed that blood flow in the cochlea increased after application of the steroid. Another possible interpretation could be that the surgical procedure of preparation and opening of the bulla and placing the recording electrode already introduced a minor trauma to the inner ear. Application of the steroid might, as in the intra- cochlear group, have some rescuing effect on inner ear structures. Results from this first set of experiments clearly demonstrated absence of ototoxicity of the steroid for the substance, concentration and route of application that were used. Applying drugs onto the round window membrane has previously been shown to be a reliable route for the delivery of drugs to the inner ear. Nomura [20], Bachmann et al. [21] and Parnes et al. [13] using triamcinolone, dexametha- sone, prednisolone-21-hydrogen succinate and hydrocortisone, respectively, demonstrated that corticosteroids permeate through the round window mem- brane into the perilymph and they reported success in the treatment of patients with sudden hearing loss [22, 23]. In the case of intracochlear application of steroid to the inner ear after a surgical trauma, hearing of animals decreased soon after cochleostomy in both groups. While hearing loss was initially similar in both groups, thresholds in the steroid group started to recover from the 7th day and returned close to the preapplication level on day 28, whereas recovery of thresholds in the control group did not reach the preapplication level on day 28. Possible reasons of hear- ing loss after cochleostomy may be loss of perilymph, acoustic trauma due to drilling noise, and inflammation due to surgical disturbance. In principle, peri- lymph loss should be stopped by sealing the opening of the cochleostomy and should be compensated spontaneously by cerebrospinal fluid, which reaches the cochlea via the open cochlear aqueduct. Influence of drilling noise on hearing can either be a temporal threshold shift, disappearing within a few hours to a week, or a permanent damage. Corticosteroids may contribute to related intracochlear Kiefer/Ye/Tillein/Adunka/Arnold/Gstöttner 306 recovery processes associated with restoration of the auditory function by influ- ence on carbohydrate metabolism, transcription of specific genes, as indicated by an increase in specific mRNAs, and influence on potassium turnover in the stria vascularis. Inflammation can severely impair the inner ear structure, if without effective control. It is well known that corticosteroids have a strong anti-inflammatory action, inhibiting the reactive processes of inflammation and scar tissue formation. In this study, recovery of hearing in the intracochlear steroid group may be partly attributable to the inflammation-inhibiting effect of steroid. In recent years, more studies on apoptosis in the auditory system have been reported. It is agreed that any trauma associated with cochlear implant electrode insertion has the potential to form reactive oxygen species and to result in loss of auditory sensory cells through oxidative stress-induced apoptosis [24]. It is hypothesized that steroids may have the ability to block the initiating pathways of sensory cell apoptosis and inhibit the subsequent degeneration of the periph- eral processes of the auditory neurons, thereby enhancing neural preservation for patients receiving cochlear implants. In conclusion, results from this study indicated that topical application of steroid had no ototoxic effect and was able to rescue some cochlear functions in the guinea pig after trauma to the inner ear. Moreover, it was shown that corti- costeroids can have a protective effect against damage of inner ear structures and hearing loss in stapes surgery. They were not able to prevent hearing loss but to increase recovery. There are indications that local application by direct instillation is more effective than diffusion via the round window and can avoid the side effect of systemic application. However, possible local effects, e.g. delayed healing, will have to be investigated. References 1 Henry KR: Noise-induced auditory loss: influence of genotype, naloxone and methyl- prednisolone. Acta Otolaryngol 1992;112:599–603. 2 Michel O, Steinmann R, Walger M, Stennert E: Die medikamentöse Beeinflussung der Innenohrfunktion in einem neuen Lärmschädigungsmodell. Otorhinolaryngol Nova 1993;3: 292–297. 3 Wang Y, Libermann MC: Restraint stress and protection from acoustic injury in mice. Hear Res 2002;165:96–102. 4 Lamm K, Arnold W: The effect of prednisolone and non-steroidal anti-inflammatory agents on the normal and noise-damaged guinea pig inner ear. Hear Res 1998;115:149–161. 5 Lamm K, Arnold W: Successful treatment of noise induced cochlear ischemia, hypoxia and hear- ing loss. Ann NY Acad Sci 1999;28:233–248. 6 Wilson WR, Byl FM, Laird N: The efficacy of steroids in the treatment of idiopathic sudden hear- ing loss: a double-blind clinical study. Arch Otolaryngol 1980;106:772–776. 7 Lamm K, Arnold W: How useful is corticosteroid treatment in cochlear disorders? Otorhinolaryngol Nova 1999;9:203–216. Protecting the Cochlea during Stapes Surgery 307 8 Riechelmann H, Tholen M, Keck T, Rettinger G: Perioperative glucocorticoid treatment does not influence early post-laser stapedotomy hearing thresholds. Am J Otol 2000;21:809–812. 9 Hendershot EL: Corticosteroid therapy in stapedectomy: a clinical study. Laryngoscope 1974;84:1346–1351. 10 Spandow O, Anniko M, Hellström S: Hydrocortisone applied into the round window niche causes electrophysiological dysfunction of the inner ear. ORL J Otorhinolaryngol Relat Spec 1989;51: 94–102. 11 Niedermeyer HP, Zahneisen G, Luppa P, Busch R, Arnold W: Cortisol levels in the human peri- lymph after intravenous administration of prednisolone. Audiol Neurotol 2003;8:316–321. 12 Tobita T, Senarita M, Hara A, Kusakari J: Determination of prednisolone in the cochlear tissue. Hear Res 2002;165:30–34. 13 Parnes LS, Sun AH, Freeman DJ: Corticosteroid pharmacokinetics in the inner ear fluids: an ani- mal study followed by clinical application. Laryngoscope 1999;109:1–17. 14 Lefebvre P, Staecker H: Steroid perfusion of the inner ear for sudden sensorineural hearing loss after failure of conventional therapy: a pilot study. Acta Otolaryngol 2002;122:698–702. 15 Kopke RD, Hoffer ME, Weter D, O’Leary MJ, Jackson RL: Targeted topical steroid therapy in sud- den sensorineural hearing loss. Otol Neurotol 2001;22:475–479. 16 Nordang L, Linder B, Anniko M: Morphologic changes in round window membrane after topical hydrocortisone and dexamethasone treatment. Otol Neurotol 2003;24:339–343. 17 Arriaga MA, Goldman S: Hearing results of intratympanic steroid treatment of endolymphatic hydrops. Laryngoscope 1998;108:1682–1685. 18 Karlidag T, Yalcin S, Ozturk A, Ustundag B, et al: The role of free oxygen radicals in noise induced hearing loss: effects of melatonin and methylprednisolone. Auris Nasus Larynx 2002;29:147–152. 19 Shirwany NA, Seidman MD, Tang W: Effect of transtympanic injection of steroids on cochlear blood flow, auditory sensitivity, and histology in the guinea pig. Am J Otol 1998;19:230–235. 20 Nomura Y: Otological significance of the round window, in Pfaltz CR (ed): Advances in Oto- Rhino-Laryngology. Basel, Karger, 1984, pp 63–71. 21 Bachmann G, Su J, Zumegen C, Wittekindt C, Michel O: Permeability of the round window mem- brane for prednisolone-21-hydrogen succinate. Prednisolone content of the perilymph after local administration vs systemic injection. HNO 2001;49:538–542. 22 Chandrasekhar SS: Intratympanic dexamethasone for sudden sensorineural hearing loss: clinical and laboratory evaluation. Otol Neurotol 2001;22:18–23. 23 Hillman TM, Arriaga MA, Chen DA: Intratympanic steroids: do they acutely improve hearing in cases of cochlear hydrops? Laryngoscope 2003;113:1903–1907. 24 Scarpidis U, Madnani D, Shoemaker C, et al: Arrest of apoptosis in auditory neurons: implications for sensorineural preservation in cochlear implantation. Otol Neurotol 2003;24:409–417. PD Dr. J. Kiefer Klinik und Poliklinik für HNO-Heilkunde, Klinikum r.d. Isar der Technischen Universität München Ismaninger Strasse 22 DE–81675 Munich (Germany) Tel. ϩ49 89 4140 2389, E-Mail J.Kiefer@lrz.tum.de Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 308–313 Imaging of Postoperative Sensorineural Complications of Stapes Surgery A Pictorial Essay Denis Ayache a , Delphine Lejeune a , Marc T. Williams b a ENT Department, and b Department of Imaging, Fondation Rothschild, Paris, France Abstract Sensorineural hearing loss and/or vertigo are rare but severe complications of stapes surgery for otosclerosis, ranging from 0.2 to 3%. Management of such complications depends on the underlying cause: intravestibular protrusion of the prosthesis, perilymph fis- tula, labyrinthitis, and reparative granuloma extending into the vestibule. Surgery is manda- tory in cases of intravestibular prosthesis or of persistent perilymph fistula. In cases of suppurative labyrinthitis or reparative granuloma extending into the vestibule, prognosis is usually poor, despite aggressive medical therapy or revision surgery. CT scan or magnetic resonance imaging can frequently help to determine the cause of the inner ear complication of stapedectomy. Demonstrative cases are presented to illustrate the prominent place of imaging in managing sensorineural complications of stapes surgery. Copyright © 2007 S. Karger AG, Basel Sensorineural hearing loss (SNHL) is a rare but severe complication of stapes surgery, frequently associated with vertigo, ranging from 0.2 to 3% in primary stapedectomy for otosclerosis [1, 2]. Management and prognosis of postoperative SNHL are closely related to its etiology. According to previous reports [1, 3, 4], surgical revision is mandatory in cases of intravestibular pros- thesis or perilymph fistula (PLF). On the other hand, suppurative labyrinthitis and granuloma extending into the vestibule are of poor prognosis despite surgical revision [1, 3, 4]. To improve diagnosis of post-stapedectomy SNHL, imaging plays a more and more important role [5–8]. Imaging of Postoperative Sensorineural Complications of Stapes Surgery 309 CT Findings In case of postoperative SNHL or disabling vertigo, CT is performed in emergency because it can show causes which need to be surgically managed promptly. The imaging technique consists in helical CT with multiplanar recon- structions (MPR), with particular attention to reconstructing images along the main axis of the prosthesis. Too Long Prosthesis As there is no standard definition, we consider the diagnosis of too long piston syndrome when postoperative vertigo or SNHL are associated with a penetration of the prosthesis of more than 1 mm into the vestibule. This can easily be depicted with CT (fig. 1), leading to revision surgery. Pneumolabyrinth A pneumolabyrinth is defined as the presence of an air bubble in the labyrinth, and has been considered to be the only pathognomonic imaging sign of PLF [7, 8]. Nevertheless, a pneumolabyrinth can be observed on CT within the first post- operative days following stapes surgery, without any pejorative meaning (fig. 2). A pneumolabyrinth can readily suggest PLF if it is not observed in the immediate postoperative period (fig. 3), leading the otologist to prompt revision Fig. 1. Intravestibular protrusion of the tip of the prosthesis on axial CT with MPR. [...]... Stapes Surgery 313 Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol Basel, Karger, 2007, vol 65, pp 314–3 19 Revision Stapes Surgery Klaus Jahnke, Daniela Solzbacher, Philipp Dost Department of Otorhinolaryngology, University Hospital of Essen, Essen, Germany Abstract We present the results of our revision stapes operations from 198 9 to 2004 (n ϭ 217) Long-term follow-up... Essen titanium stapes prosthesis Clin Otolaryngol 2005;30:21–24 Klaus Jahnke, MD Department of Otorhinolaryngology, University Hospital Hufelandstrasse 55 DE–45122 Essen (Germany) Tel ϩ 49 201 723 2481, Fax ϩ 49 201 723 590 3, E-Mail klaus.jahnke@uni-essen.de Revision Stapes Surgery 3 19 Vibrant Soundbridge Middle Ear Implant in Ostosclerosis Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv... Head Neck Surg 199 1;104:826–830 Bredberg G, Lindstrom B: Insertion length of electrode array and its relation to speech communication performance and non-auditory side effects in multi-channel implanted patients Ann Otol Rhinol Laryngol 199 5;104(suppl 98 ) :9 14 Bigelow DC, Kay DJ, Rafter KO, Montes M, Knox W, Yousem DM: Facial nerve stimulation from cochlear implants Am J Otol 199 8; 19: 163–1 69 Cohen NL,... Otol Neurotol 2001;22 :96 2 97 2 Vincent R, Gratacap B, Causse JB: Argon laser and Gherini-Causse Endo-Otoprobe in otologic surgery Ear Nose Throat J 199 6;75:773–780 Dr Thibaud Dumon Clinique J Causse, Traverse de Béziers FR–3444 Colombiers (France) Tel ϩ33 4 67 35 66 22, Fax ϩ33 4 67 35 62 00, E-Mail ThibaudDumon@AOL.com Dumon 322 Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol... 2007, vol 65, pp 323–327 Cochlear Implantation and Far-Advanced Otosclerosis I Mosniera,b, D Bouccaraa, E Ambert-Dahana, E Ferrarya, O Sterkersa,b a Department of Otolaryngology, Hôpital Beaujon, AP-HP, Faculté Xavier-Bichat, Université Paris-7, Clichy, bDepartment of Otolaryngology, Hôpital Louis-Mourier, AP-HP, Faculté Xavier Bichat, Université Paris-7, Colombes, France Abstract Objective: To evaluate... 2003;1 29: 475–480 Weber BP, Lenarz T, Battmer RD, Hartrampf R, Dahm MC, Dietrich B: Otosclerosis and facial nerve stimulation Ann Otol Rhinol Laryngol Suppl 199 5;166:445–447 Khalifa A, el-Guindy A, Erfan F: Stapedectomy for far-advanced otosclerosis J Laryngol Otol 199 8;112:158–160 Mosnier/Bouccara/Ambert-Dahan/Ferrary/Sterkers 326 4 5 6 Ruckenstein MJ, Rafter KO, Montes M, Bigelow DC: Management of far-advanced... 199 7;18:336–341 I Mosnier Service ORL, Hôpital Beaujon, AP-HP, INSERM EMI U0112 100, boulevard du Général Leclerc FR 92 118 Clichy Cedex (France) Tel ϩ33 1 40 87 55 71, Fax ϩ33 1 40 87 01 86, E-Mail isabelle.mosnier@lmr.ap-hop-paris.fr Cochlear Implantation and Far-Advanced Otosclerosis 327 Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol Basel, Karger, 2007, vol 65, pp... References 1 2 3 4 5 6 7 8 9 Mann WJ, Amedee RG, Fuerst G, Tabb HG: Hearing loss as a complication of stapes surgery Otolaryngol Head Neck Surg 199 6;115:324–328 Wiet RJ, Harvey SA, Bauer GP: Complications in stapes surgery Otolaryngol Clin North Am 199 3;26:471– 490 Lippy WH, Schuring AG: Stapedectomy revision following sensorineural hearing loss Otolaryngol Head Neck Surg 198 4 ;92 :580–582 Betsch C, Ayache... time of implantation Device implanted Nucleus (unilateral) Med-El Combi-40 (bilateral) Stapes surgery during implantation Blindness 7 :9 61 (range 44–74) 2.5 (range 0–5) 11 4 7 9 13 3 2 1 Materials and Methods Between 199 1 and 2003, 134 adult patients had undergone cochlear implantation at our institution The cause of the hearing loss was otosclerosis in 16 cases (12%), selected for this study Thirteen... implantation in 53 patients with otosclerosis: demographics, CT scanning, surgery and complications Otol Neurotol 2004;25 :94 3 95 2 Richard Ramsden Department of Otolaryngology Manchester Royal Infirmary Manchester (UK) E-Mail rramsden@fs3.scg.man.ac.uk Ramsden/Rotteveel/Proops/Saeed/van Olphen/Mylanus 334 Outcome Evaluation Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery Adv Otorhinolaryngol . Nova 199 3;3: 292 – 297 . 3 Wang Y, Libermann MC: Restraint stress and protection from acoustic injury in mice. Hear Res 2002;165 :96 –102. 4 Lamm K, Arnold W: The effect of prednisolone and non-steroidal. (arrow). Revision Stapes Surgery 3 19 20 dB in 32 cases and 5–20 dB in 36 cases, i.e. a significant hearing improve- ment of 69. 4% in this series. From 2001 to 2004, stapes revision surgery was performed. the gra- dient fields. After that, a titanium implant was inserted and hearing signifi- cantly improved. References 1 Jahnke K, Dost P, Missfeldt N: Revisionen nach Stapes- Chirurgie. HNO 199 9;47:427. 2