laser assisted small fenestra stapedotomy technique & analysis dr v.v.raut, dr j.halik dept. of...
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LASER ASSISTED SMALL FENESTRA STAPEDOTOMYTECHNIQUE & ANALYSIS
Dr V.V.Raut, Dr J.Halik
Dept. of Otolaryngology
Toronto
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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)
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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)
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Laser Settings
• Stapedial Tendon and Crurae
• 0.2 sec at 2.0 watts
• Footplate• 0.1 sec at 1.0 watts
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COST
• Laser - $ 45,000(cdn)
• Otoprobe-$190(cdn)-Single use- offset against cost of prosthesis which is cheap
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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%)
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Over Closure of Air-Bone GapN=135
• 40/135(29.6%)
• Range 5-40dB
• Average over closure = 13dB
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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)
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• Post-op SRT< 30dB=111
• Pre-op possible SRT<30db=107
• %Improvement=111/107 (103%)
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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%)
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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
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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
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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
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Advantages of Laser
• Precision• Least traumatic• Better control of bleeding• Technically easier• Floating footplate• Results-Over closure• Decreased post-operative morbidity- Day surgery
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Step-reordering
(1998)
Laser
(2001)
Day Surgery 87 118
Inpatient 76 5
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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