Bone Cement and Revision Stapedectomy

For revision stapedectomy, can the use of bone cement produce acceptable outcomes in the presence of incus necrosis?

Synopsis: Revision stapedectomy surgery can be challenging. A variety of problems might lead to a recurrence of a conductive loss, even after a very successful primary surgery. Some problems are fairly straightforward, such as a displaced prosthesis or adhesions, but the presence of incus erosion can make the surgery a mountain of a challenge. The long arm of the incus and the lenticular process are the cornerstones of the reconstruction during primary or revision stapedectomy; without them, alternatives such as malleus-to-oval window or total ossicular prosthesis (TOP/TORP) have been used with variable success. Reconstruction of the distal incus holds the promise of using the stable lateral ossicular chain to support the stapes prosthesis.

Two recent retrospective studies, both from tertiary referral centers, have assessed the use of hydroxyapatite bone cement in revision stapedectomy surgery with incus necrosis. House and colleagues reported on 37 patients, and Hudson and colleagues reported on 27 patients. In both studies, it appeared that a hydroxyapatite bone cement was used to augment the connection or stability of a conventional stapes prosthesis attached to an eroded, but existing, long arm of the incus. In the House study, three different types of stapes prostheses were used, and in the Hudson study, a single type of prosthesis was used. Neither study appeared to use the hydroxyapatite bone cement to completely reconstruct the distal long arm of the incus and then attach the stapes prosthesis to the solidified bone cement. Neither study had a comparison group or long-term outcomes. Post-operative complications were minimal: transient vertigo in three of 37 patients, transient taste disturbance in one of 37 patients in the House study, and no total sensorineural loss in either study.

Each study was able to document good results:

House:

• 81.1% with air-bone gap less than or equal to 10 dB;
• 89.2% with air-bone gap less than or equal to 20 dB; and mean follow-up of 12 months.

Hudson:

• 77.8% with air-bone gap less than or equal to 10 dB;
• 96.3% with air-bone gap less than or equal to 20 dB; and mean follow-up of seven months.

Bottom line: Hydroxyapatite bone cement appears to be a safe adjunctive tool for the management of partial incus erosion found at the time of revision stapes surgery. The stapes prosthesis seems to be held securely, with good hearing outcomes in the hands of these experienced otologic surgeons.