Audiologic and Surgical Outcomes in Endoscopic Revision Stapes Surgery

by Ashley M. Nassiri, MD, MBA, Robert J. Yawn, MD, Matthew M. Dedmon, MD, PhD, Anthony M. Tolisano, MD, Jacob B. Hunter, MD, Brandon Isaacson, MD, and Alejandro Rivas, MD •

Discussion

The purpose of this study is to present the authors’ technique and results in applying an endoscopic approach to revision stapes surgery. Five out of six patients had an improved ABG, and two-thirds of patients had closure of the ABG to ≤20 dB. Although a small case series, these results are comparable to a large review of microscopic revision stapedotomy, which noted an ABG closure of ≤20 dB in 74.6% of cases (Otol Neurotol. 2010;31:875–882). Of the six cases included in this series, there was one case of postoperative labyrinthitis that resolved with a steroid course, and one case of postoperative dysgeusia that self-resolved within three weeks. Patient 5 was noted to have malleus fixation that was addressed intraoperatively; it is possible that recurrence of malleus fixation may account for a lack of improvement in postoperative ABG; however, this has not been confirmed.

Proponents of the endoscopic approach for primary stapes surgery cite enhanced visualization of the oval window and ossicles, with resultant improvement in diagnostic accuracy, as a primary advantage of the approach (Eur Arch Otorhinolaryngol. 2016;273:1723–1729. Int J Pediatr Otorhinolaryngol. 2017;96:21–24. Otol Neurotol. 2016;37:1071–1076). These same advantages apply to revision stapes surgery for surgeons already routinely performing totally endoscopic stapes surgery. In this series, all patients presented for revision surgery after having primary surgery performed elsewhere. For patients who have had prior surgery and variably altered anatomy, an endoscopic view can provide enhanced visualization of the oval window, prosthesis, and the lateral chain.

Importantly, success in revision stapes surgery is correlated with an accurate diagnosis of the cause of failure (Laryngoscope. 2018;128:2390–2396). For example, the extent of incus necrosis dictates repair options and ultimately clinical outcomes (J Int Adv Otol. 2017;13:28–31). A close analysis of the incus and accurate evaluation of the extent of necrosis requires excellent visualization of the ossicular chain. Similarly, malleostapedotomy requires detailed visualization and inspection of the oval window and lateral ossicular chain; the endoscopic approach has been applied in this setting and shown to be effective in a small case series (Laryngoscope. 2018;128:2611–2614). Notably, the cause of surgical failure was accurately diagnosed with imaging in one of three patients who had preoperative CT scans; however, conclusions regarding the utility of preoperative CT scans cannot be drawn from this small sample size.

Conclusion

Because TEES is more widely adopted, this approach will be explored in new applications. For the surgeon who is using TEES in other cases, an endoscopic approach in revision stapes surgery may provide advantageous visualization and diagnostic accuracy. The results of this small case series suggest that endoscopic revision stapes surgery is feasible and may provide a platform for a larger study to validate the efficacy of this approach with long-term outcomes.