Κατεύθυνση Ακοολογία–ΝευροωτολογίαLibrary of the School of Health Sciences
Θωμάς Νικολόπουλος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ, Επιβλέπων
Παύλος Μαραγκουδάκης, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αλέξανδρος Δελίδης, Επίκουρος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Χειρουργική θεραπεία της ωτοσκλήρυνσης
The surgical management of otosclerosis
Otosclerosis is a localized primary disease which is characterized by one or more foci of irregular – spongiotic bone deposition in the labyrinthine capsule thus replacing the normal dense osseous tissue. A detailed description of the disease was done by Politzer in 1894 where he described the osseous transformation of the stapes’s footplate. Patients suffering from otosclerosis will manifest gradual hearing loss usually in their 20’s or 30’s. The otosclerotic alterations are bilateral in 70-80% of cases but the size of the otosclerotic foci, varies. The otosclerotic foci become visible with the aid of the microscope during stapes surgery where the normal labyrinthine bone can be distinguished from the dense, vascularized mucuperiostium which covers the otosclerotic lesion.
The disease manifests itself with a characteristic gradual conductive hearing loss when the patient is young usually in their 20’s. The tympanic membrane is intact and translucent and the eustachian tube is functioning properly. Sometimes a red spot can be visualized (Schwatze’s sighn) on the membrane which is indicative of the vascular otosclerotic changes occurring on the promontory. Tinnitus is often a symptom and rarely it may coexist with vertigo. Patients also describe having improved hearing in a noisy environment. (Paracusis of Willis)
The audiological evaluation will present a variety of audiograms depending on the level of ankylosis of the stapes as well as the participation of the cochlea. A characteristic air – bone gap exists ranging from the lower decibels when the disease is first manifested in the low frequencies, to the higher decibels where the otosclerotic lesion expands to the annular ligament and fixates the stapes. The bone conduction curve could still remain at 0 or show some deterioration depending on the participation of the cochlea in the disease.
Stapes surgery is the method of choice for treating otosclerosis and it should be performed in every patient who has bone conduction or mixed hearing loss due to stapes fixation. Even in advanced hearing loss the operation could offer the patient the choice of wearing a hearing aid where before the operation, it was impossible.
The first efforts of treating surgically otosclerosis begun at the end of the 19th century by removing the stapes and leaving the oval window open (Jack FL 1893). Many years passed (over half a century) for the oto – surgeons to re-operate on the oval window since this technique was deemed dangerous and it was abandoned. Lempert and others tried circumventing the footplate and fenestrated the horizontal semicircular canal. Up until 1952 this was the surgical treatment of otosclerosis and it was considered successful. Rosen in 1952 who was a student of Lempert tried to mobilize the stapes. Later on in 1956, John Shea removed the stapes and sealed the oval window using an autologous graft. He also used an aritificial prothesis to reestablish the acoustic continuity. This technique gained universal acceptance and it is used up until today with some modifications. In the 1970’s Myers was the first to use piston type prothesis and in the beginning of the 1980’s Perkins begins using argon laser for stapes surgery. He succeded in making a small opening on the footplate. Some years later the KTP laser is used, and later on the CO2 laser is introduced with good results. Important contributions to the improvement of the modern stapedotomy where made by Antonio De La Cruz from the House Ear Institute of Los Angeles in the USA, and professor Henri André Martin from the hospital” Edouard Herriot “ in Lyon of France, where the added the calibrated platinotomy and trans-footplate piston surgery. In this modern era the otologic society has been handed a dilemma. The choice of the microscope usage or the ear endoscope. Each method has advantages and disadvantages. Simultaneously there are reports that robotic systems are being built and evolving which could increase the accuracy of the surgeon’s movements thus decreasing the possible complications.
Main subject category:
Otosclerosis, Stapes, Stapedotomy, Lempert, Shea, Politzer
Ikonomidis Iakovos MSc.pdf
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