International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The surgical results of stapes fixation in children Yun Suk An, Kwang-Sun Lee * Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 June 2013 Received in revised form 23 October 2013 Accepted 29 October 2013 Available online 7 November 2013
Objectives: The aims of this study were to review the causes of stapes fixation in children undergoing stapes surgery and to analyze the results of stapes surgery in children in the short term, at 1 year, and over the long term. Methods: The medical records of 18 children (28 ears) who had undergone stapes surgery between January 1999 and December 2012 were retrospectively reviewed. The medical history, computed tomography results, intraoperative findings, video clips, and hearing outcomes of all patients were reported. Results: The mean age of patients was 11.1 years (range, 5.9–15.3 years). Congenital stapes fixation (22/ 28 ears, 79%) and juvenile otosclerosis (6/28 ears, 21%) were responsible for all cases of stapes fixation. Intraoperatively, abnormal facial nerves that were downwardly displaced over the stapes footplate were noted in four ears. Incudostapedotomy was performed in 24 ears, malleostapedotomy in three, and partial stapedectomy in one. The early postoperative audiometric outcome was favorable in 21 ears (87.5%). There was no significant difference between early postoperative (87.5%), 1 year postoperative (91%), and long term (92.3%) favorable audiometric results. There was no significant difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis. Conclusion: Congenital stapes fixation was diagnosed in 22 (79%) ears and juvenile otosclerosis in six (21%) ears from a series of 28 ears that were operated on for stapes fixation. Facial nerve anomalies were found in four of 22 ears (18%) that had congenital stapes fixation. There was no difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis. Regardless of the cause of stapes fixation, stapedotomy is a safe and effective procedure for managing the condition. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Stapedotomy Children Congenital stapes fixation Juvenile otosclerosis Ossicular anomaly
1. Introduction Stapes surgery for correction of conductive hearing loss is a well-established procedure in adults. However, stapes surgery in children is less commonly reported, primarily because of the risk of postoperative sensorineural hearing loss (SNHL). Due to this risk, most otologists operate on children who are old enough to participate in the decision-making process. Also, hearing aids are a viable alternative to stapes surgery and offer good prospects for rehabilitation following conductive or mixed hearing loss due to stapes fixation. Thus, stapes surgery in the pediatric population remains controversial despite improvements in surgical technique. Since the first case series was published by House et al. [1] in 1980, there have been few reports on stapes surgery in children under the age of 18. In these reports, the major causes of stapes
* Corresponding author at: Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, South Korea. Tel.: +82 2 3010 3711; fax: +82 2 489 2773. E-mail address: [email protected] (K.-S. Lee). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.10.043
fixation were congenital stapes fixation and otosclerosis, which had a similar prevalence. However, in our experience with Korean patients, juvenile otosclerosis was rare compared with congenital stapes fixation. The aims of this study were to determine the incidence of congenital stapes fixation and otosclerosis in children who had undergone surgery for stapes fixation and to analyze the postoperative audiologic results in the short term, at 1 year, and over the long term. 2. Materials and methods The medical records of 18 pediatric patients (28 ears) who underwent stapes surgery for conductive hearing loss between January 1999 and December 2012 were retrospectively reviewed. All patients were younger than 15 years and underwent stapes surgery by one surgeon at the Asan Medical Center (Seoul, South Korea). This retrospective study was approved by the Institutional Review Board of Asan Medical Center and for data collection and analysis, and informed consent was waived. There were nine males (13 ears) and nine females (15 ears). The mean age at the time of
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Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
Fig. 1. Axial CT scan demonstrating osteolytic foci (arrow) of juvenile otosclerosis.
surgery was 11.1 years (SD, 3.2; age range, 5.9–15.3 years). There were 16 right-sided ears and 12 left-sided; 10 from 18 children underwent bilateral surgery. All patients had undergone a preoperative workup comprising of a clinical examination, audiometric data collection, and highresolution temporal bone computed tomography (HR TBCT). Age at surgery, age at onset, bilaterality, sex, and intraoperative finding were analyzed using operation records and video clips. Postoperative complications and hearing results were compared for various clinical parameters. Revision surgeries were excluded from this study. The diagnosis of juvenile otosclerosis was made based on the presence of progressive deafness associated with a typical otosclerosis focus in the HR TBCT (Fig. 1). A positive family history, and/or exclusion of other causes of progressive conductive hearing loss were considered. The presence of malformed ossicles was determined on the basis of surgical findings and HR TBCT. Surgical methods. All patients underwent general anesthesia. An endo-meatal approach with ear canal speculum was used in all cases. After elevation of the tympanomeatal flap, the chorda tympani nerve was slightly detached from the bony annulus anteriorly, and bone over the incudostapedial joint (ISJ) was removed with a small osteotome with mallet. After exposure of the ISJ, the shape and mobility of the ossicular chain was observed. When stapes fixation was identified, the stapes tendon was cut followed by separation of the ISJ. The posterior crura were cut with cururotome scissors, the anterior crus with capitulum of stapes was down fractured with a fine pick, and then the stapes superstructure was removed. An approximately 0.6 mm fenestrum was made in the stapes footplate using a 0.5 mm Skeeter drill. Routinely, a Fish type polytetrafluoroethylene (Teflon1) piston-wire prosthesis was attached in the long process of the incus. When an anomalous incus long process or incus fixation was found, the prosthesis was attached to the handle of malleus (malleostapedotomy). Audiometric evaluation. Preoperative audiometric data were compared to early postoperative (less than 4 months), approximate 1 year postoperative, and last follow-up (more than 18 months) data. Preoperative and postoperative air conduction (AC) and bone conduction (BC) tests at 0.5, 1, 2, and 3 kHz were included in the analysis. When a frequency of 3 kHz was not used, the mean value of the 2 and 4 kHz results was substituted.
The air-bone gap (ABG) was calculated only for those patients who had BC and AC values collected at the same time. The patient’s hearing level in the postoperative period was classified into four groups: (1) very good, ABG less than 10 dB; (2) good, ABG between 10 and 20 dB; (3) acceptable, ABG between 20 and 30 dB; and (4) bad, ABG over 30 dB. The mean preoperative AC was 51.8 dB (SD, 9.4; range, 30– 65 dB), and the mean preoperative ABG was 35.3 dB (SD, 10.3; range 9.5–55 dB; Table 1). Statistical data analysis. Categorical data were expressed as percentages and continuous variables were expressed as means with standard deviations (SDs). The Fisher exact test was used to compare categorical data. Paired t-tests were used for changes in hearing within a group, and independent t-tests for the comparison of hearing between groups. A p value of less than 0.05 was the criterion for statistical significance. Statistical analyses were performed using SPSS software (version 21). 3. Results 3.1. Surgical findings Congenital stapes fixation was found in 15 patients (22 ears) and juvenile osclerosis in 3 patients (6 ears). Two girls (four ears) and one boy (two ears) had juvenile bilateral otosclerosis. Interestingly, two girls with juvenile otosclerosis were identical twins. Congenital stapes fixation with an anomaly of the ossicular chain was found in 10 of 22 ears. Among them, stapes suprastructure anomalies were found in five ears, a fibrous band of ISJ (Fig. 2) in three ears, ISJ fusion in one ear, and a stapes suprastructure anomaly with incus fixation in one ear. Four patients had an anomalous facial nerve course with the tympanic segment located inferior to the oval window niche (Fig. 3). Incudostapedotomy was performed in 24 ears, malleostapedotomy in three, and partial stapedectomy in one due to incidental footplate fracture. 3.2. Postoperative audiometric results: early, 1 year, and last follow-up Early postoperative (2.1 1.2 months) audiometric data were available for 24 ears. The mean early postoperative AC was 23.5 dB (SD, 7.7; range 13.7–38.8 dB) and the mean residual ABG was 11.6 dB (SD, 7.4; range 0–27.5 dB). The early postoperative audiometric outcome was classified as very good in 13 ears (54.2%), good in eight (33.3%), and acceptable in three (12.5%). There were no cases of bad outcomes. At 1 year after surgery (22 ears), the mean AC was 23.1 dB (SD, 5.3; range 12.5–32.5 dB) and the mean residual ABG was 11.3 dB (SD, 6.5; range 0.50–29.3 dB). The mean AC was 24.6 dB (SD, 11.9; range 10.0–76.3 dB) and the mean residual ABG was 11.5 dB (SD, 8.5; range 0.5–45.0 dB). The audiometric outcome at 1 year was classified as very good or good in 20 ears (91%), which was not
Table 1 Preoperative and postoperative audiometric outcomes for 18 children (28 ears) who underwent stapes surgery. Period
No. of ears
Mean (SD) [range] AC (dB)
BC (dB)
Preoperative Early postop 1 year Last
28 24 22 13
51.8 23.5 23.1 24.9
16.5 11.9 11.8 13.4
(9.4) [30–65] (7.7) [13.7–38.8] (5.3) [12.5–32.5] (16.4) [10.0–76.3]
(7.8) (4.0) (4.3) (6.3)
ABG (dB) [3–31] [5.0–21.3] [3–22] [7.5–31.3]
35.3 11.6 11.3 11.5
(10.3) [9.5–55.0] (7.4) [0–27.5] (6.5) [0.5–29.3] (11.1) [2–45.0]
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last, postoperative results more than 18 months.
Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
Fig. 2. Intraoperative finding of a fibrous band (black arrow) in the incudostapedial joint; asterisk, chorda tympani nerve.
57
Fig. 3. Intraoperative findings of an anomalous facial nerve (arrows). The tympanic segment of facial nerve was downwardly displaced over the atretic oval window (A). Coronal CT scan demonstrating anterior inferior location of facial nerve (arrow) (B).
significantly different from the early postoperative results (87.7% classified as very good or good). The mean duration to last follow-up in 13 ears was 46.8 23.5 months. The mean last follow-up ABG was 11.5 dB (range, 2.0– 45.0 dB). From 13 ears, nine (69.2%) had a very good and three (2%) had a good result. One case of postoperative SNHL, a loss of 21.25 dB compared with the preoperative mean BC value, was found at longterm follow-up audiometry (Table 1, Fig. 4). There was no significant difference in either preoperative or postoperative ABG between incudostapedeotomy and malleostapedotomy. 3.3. Comparison hearing results between congenital stapes fixation and juvenile otosclerosis There was no significant difference in either the preoperative and 1 year postoperative BC and ABG values or the last postoperative follow-up AC, BC, and ABG values between congenital stapes fixation and juvenile otosclerosis. However, there was a significant difference in both preoperative and early postoperative BC values between congenital stapes fixation and juvenile otosclerosis (p = 0.035 and 0.041, respectively; Table 2). In early postoperative audiometric outcomes, six of 18 ears (44.4%) with congenital stapes fixation had a very good result and 15 ears (83.3%) had either a very good or good result, whereas four of six ears (66.7%) with juvenile otosclerosis had a very good result and six ears (100%) had either a very good or good result. ABG closure after stapedotomy was more likely in juvenile otosclerosis than in congenital stapes fixation, but the finding was not significant (p = 0.546; Fig. 5).
Fig. 4. The audiometric outcomes in the preoperative and postoperative periods. ‘‘Very good’’ was defined as an air-bone gap (ABG) 10 dB; ‘‘Good’’ was defined as an ABG of 11–20 dB; ‘‘Acceptable’’ was defined as an ABG of 21–30 dB; and ‘‘Bad’’ was defined as ABG higher than 30 dB.
3.4. Comparison of hearing results between congenital isolated stapes fixation and congenital stapes fixation with ossicular anomaly There was no significant difference in either the preoperative ABG or BC values between stapes fixation with ossicular anomaly and isolated stapes fixation. However, there was a significant difference in preoperative AC values between stapes fixation with ossicular anomaly and isolated stapes fixation (p = 0.001). There was no statistical difference in the early postoperative, 1 year postoperative, and last postoperative follow-up AC, BC, and ABG values between stapes fixation with ossicular anomaly and isolated stapes fixation (Table 3).
Table 2 Comparison of hearing results between congenital stapes fixation and juvenile otosclerosis. Congenital stapes fixation
Preoperative BC Preoperative AC Preoperative ABG Early postop BC Early postop AC Early postop ABG 1 year postop BC 1 year postop AC 1 year postop ABG Last follow-up postop BC Last follow-up postop AC Last follow-up postop ABG
Juvenile otosclerosis
p value
No. of ears
Hearing (dB)
No. of ears
Hearing (dB)
22 22 22 18 18 18 16 16 16 9 9 9
14.9 7.9 50.9 9.8 36.0 10.9 11.0 3.8 23.5 7.6 12.5 7.7 11.5 4.4 24.0 5.5 12.5 7.1 13.7 7.1 28.3 18.8 14.6 4.6
6 6 6 6 6 6 6 6 6 4 4 4
22.4 3.9 55.2 7.5 32.8 8.4 14.9 3.6 23.5 9.0 8.7 6.0 12.7 4.2 20.8 4.6 8.2 3.6 12.6 4.9 17.2 4.8 4.6 3.3
0.035* 0.330 0.515 0.041* 0.999 0.277 0.570 0.226 0.169 0.786 0.277 0.136
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last follow-up, postoperative results more than 18 months. * p < 0.05.
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Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
Fig. 5. Postoperative audiometric outcomes (air-bone gap) for pediatric stapedotomy for congenital stapes fixation and juvenile otosclerosis.
In early postoperative audiometric outcomes, five of eight ears (62.5%) with congenital isolated stapes fixation had a very good result and six ears (75.0%) had a very good or good result whereas four of 10 ears (40.0%) with congenital stapes fixation with ossicular anomaly had a very good result and nine ears (90.0%) had a very good or good result. ABG closure to within 10 dB after stapedotomy was more likely in congenital isolated stapes fixation than in congenital stapes fixation with ossicular anomaly but the finding was not significant (p = 0.319; Fig. 6). 4. Discussion Although there are many reports of the surgical outcomes of stapes surgery in adults, reports of the results of this surgery in children are rare. Preadolescents are usually strongly motivated to undergo surgery between the ages of 10 and 12 years and stapes surgery is uncommon under this age. However, recent studies [1–6] demonstrate that there is good potential to achieve satisfactory hearing improvements in children undergoing stapes surgery. Otosclerosis is one of the most common causes of adult-onset hearing loss in the Caucasian population, with a prevalence of 0.3– 0.4% [7]. The incidence of otosclerosis is different between ethnic groups. Otosclerosis incidence is high in Caucasians, but low in East Asians, people of African descent, and Native Americans. Recently the incidence of otosclerosis seems to be increasing amongst Japanese people. Ohtani reported that the incidence of histologic otosclerosis among Japanese people seemed to be similar to that among Caucasians [8]. In 2012, at the Asan Medical Center, otological surgeries were performed on 1157 ears. Among these ears, tympanomastoid
Fig. 6. Postoperative audiometric outcomes (air-bone gap) for pediatric stapedotomy for isolated stapes fixation and stapes fixation with ossicular anomaly.
surgeries were performed on 643 ears compared to stapes surgeries on 36 ears. Compared to the incidence of chronic otitis media, stapes fixation had a relative incidence of 5.6%. In our study, 121 patients (175 ears) underwent stapes surgery for conductive hearing loss with normal tympanic membrane from 1999 to 2012. Among 175 ears, only 28 ears (19.4%) were associated with patients less than 15 years old. In the 1980 pediatric stapedectomy series of House et al. [1], congenital stapes fixation was noted in 20 of 34 ears (58.8%) and juvenile otosclerosis in 14 (41.2%). In 2010, Denoyelle et al. [2] reported that congenital stapes fixation was diagnosed in 25 of 35 ears (71%) and juvenile otosclerosis in six of 35. In 2013, Carlson et al. [6] reported that congenital stapes fixation was diagnosed in 27 of 44 ears (61.4%) and juvenile otosclerosis in 17. We found that congenital stapes fixation occurred in 22 of 28 ears (79%) and juvenile osclerosis in six (21%). Denoyelle et al. [2] reported that 94% of the results of 35 stapedectomies in children were considered good or very good. They noted no significant differences between early postoperative, 1 year postoperative, and last follow-up audiometric results. We found that 87.5% of ears at the early postoperative period, 91% at 1 year after surgery, and 92.3% at last follow-up showed an improvement in hearing of less than 20 dB in ABG. The ABG did not widen significantly over time; however, one ear had a poor result in long-term follow-up necessitating revision surgery and incus fixation due to new bone formation, which was confirmed in revision explorative tympanotomy. Stapedotomy in children has been performed for correction of conductive hearing loss caused by congenital stapedial fixation or juvenile otosclerosis. Most studies report that juvenile otosclerosis is associated with more favorable audiometric outcomes than
Table 3 Comparison of hearing results due to existence of concomitant ossicular anomalies.
Preop BC Preop AC Preop ABG Early postop BC Early postop AC Early postop ABG (dB) 1 yr postop BC 1 yr postop AC 1 yr postop ABG Last follow-up postop BC Last follow-up postop AC Last follow-up postop ABG (dB)
Congenital isolated stapes fixation
Congenital stapes fixation with ossicular anomaly
No. of ears
Hearing (dB)
No. of ears
Hearing (dB)
12 12 12 8 8 8 10 10 10 6 6 6
12.2 8.8 45.3 9.4 33.1 12.0 9.7 3.8 20.8 8.3 11.1 10.1 11.2 5.3 22.6 5.2 11.4 8.1 14.0 8.6 30.2 23.0 16.2 14.7
10 10 10 10 10 10 6 6 6 3 3 3
18.2 5.5 57.6 4.9 39.5 8.7 12.1 3.6 26.8 6.5 12.4 3.7 11.9 2.6 26.3 5.7 14.3 4.7 13.1 3.9 24.6 7.5 11.5 4.1
p value
0.075 0.001* 0.182 0.177 0.173 0.736 0.762 0.211 0.443 0.450 0.756 0.938
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last, postoperative results more than 18 months. * p < 0.05.
Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
congenital stapedial fixation. House et al. [1] found that 77% (10/ 14) of ears had successful ABG closure (
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The surgical results of stapes fixation in children Yun Suk An, Kwang-Sun Lee * Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 June 2013 Received in revised form 23 October 2013 Accepted 29 October 2013 Available online 7 November 2013
Objectives: The aims of this study were to review the causes of stapes fixation in children undergoing stapes surgery and to analyze the results of stapes surgery in children in the short term, at 1 year, and over the long term. Methods: The medical records of 18 children (28 ears) who had undergone stapes surgery between January 1999 and December 2012 were retrospectively reviewed. The medical history, computed tomography results, intraoperative findings, video clips, and hearing outcomes of all patients were reported. Results: The mean age of patients was 11.1 years (range, 5.9–15.3 years). Congenital stapes fixation (22/ 28 ears, 79%) and juvenile otosclerosis (6/28 ears, 21%) were responsible for all cases of stapes fixation. Intraoperatively, abnormal facial nerves that were downwardly displaced over the stapes footplate were noted in four ears. Incudostapedotomy was performed in 24 ears, malleostapedotomy in three, and partial stapedectomy in one. The early postoperative audiometric outcome was favorable in 21 ears (87.5%). There was no significant difference between early postoperative (87.5%), 1 year postoperative (91%), and long term (92.3%) favorable audiometric results. There was no significant difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis. Conclusion: Congenital stapes fixation was diagnosed in 22 (79%) ears and juvenile otosclerosis in six (21%) ears from a series of 28 ears that were operated on for stapes fixation. Facial nerve anomalies were found in four of 22 ears (18%) that had congenital stapes fixation. There was no difference in the postoperative hearing results between patients with congenital stapes fixation and juvenile otosclerosis. Regardless of the cause of stapes fixation, stapedotomy is a safe and effective procedure for managing the condition. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Stapedotomy Children Congenital stapes fixation Juvenile otosclerosis Ossicular anomaly
1. Introduction Stapes surgery for correction of conductive hearing loss is a well-established procedure in adults. However, stapes surgery in children is less commonly reported, primarily because of the risk of postoperative sensorineural hearing loss (SNHL). Due to this risk, most otologists operate on children who are old enough to participate in the decision-making process. Also, hearing aids are a viable alternative to stapes surgery and offer good prospects for rehabilitation following conductive or mixed hearing loss due to stapes fixation. Thus, stapes surgery in the pediatric population remains controversial despite improvements in surgical technique. Since the first case series was published by House et al. [1] in 1980, there have been few reports on stapes surgery in children under the age of 18. In these reports, the major causes of stapes
* Corresponding author at: Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, South Korea. Tel.: +82 2 3010 3711; fax: +82 2 489 2773. E-mail address: [email protected] (K.-S. Lee). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.10.043
fixation were congenital stapes fixation and otosclerosis, which had a similar prevalence. However, in our experience with Korean patients, juvenile otosclerosis was rare compared with congenital stapes fixation. The aims of this study were to determine the incidence of congenital stapes fixation and otosclerosis in children who had undergone surgery for stapes fixation and to analyze the postoperative audiologic results in the short term, at 1 year, and over the long term. 2. Materials and methods The medical records of 18 pediatric patients (28 ears) who underwent stapes surgery for conductive hearing loss between January 1999 and December 2012 were retrospectively reviewed. All patients were younger than 15 years and underwent stapes surgery by one surgeon at the Asan Medical Center (Seoul, South Korea). This retrospective study was approved by the Institutional Review Board of Asan Medical Center and for data collection and analysis, and informed consent was waived. There were nine males (13 ears) and nine females (15 ears). The mean age at the time of
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Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
Fig. 1. Axial CT scan demonstrating osteolytic foci (arrow) of juvenile otosclerosis.
surgery was 11.1 years (SD, 3.2; age range, 5.9–15.3 years). There were 16 right-sided ears and 12 left-sided; 10 from 18 children underwent bilateral surgery. All patients had undergone a preoperative workup comprising of a clinical examination, audiometric data collection, and highresolution temporal bone computed tomography (HR TBCT). Age at surgery, age at onset, bilaterality, sex, and intraoperative finding were analyzed using operation records and video clips. Postoperative complications and hearing results were compared for various clinical parameters. Revision surgeries were excluded from this study. The diagnosis of juvenile otosclerosis was made based on the presence of progressive deafness associated with a typical otosclerosis focus in the HR TBCT (Fig. 1). A positive family history, and/or exclusion of other causes of progressive conductive hearing loss were considered. The presence of malformed ossicles was determined on the basis of surgical findings and HR TBCT. Surgical methods. All patients underwent general anesthesia. An endo-meatal approach with ear canal speculum was used in all cases. After elevation of the tympanomeatal flap, the chorda tympani nerve was slightly detached from the bony annulus anteriorly, and bone over the incudostapedial joint (ISJ) was removed with a small osteotome with mallet. After exposure of the ISJ, the shape and mobility of the ossicular chain was observed. When stapes fixation was identified, the stapes tendon was cut followed by separation of the ISJ. The posterior crura were cut with cururotome scissors, the anterior crus with capitulum of stapes was down fractured with a fine pick, and then the stapes superstructure was removed. An approximately 0.6 mm fenestrum was made in the stapes footplate using a 0.5 mm Skeeter drill. Routinely, a Fish type polytetrafluoroethylene (Teflon1) piston-wire prosthesis was attached in the long process of the incus. When an anomalous incus long process or incus fixation was found, the prosthesis was attached to the handle of malleus (malleostapedotomy). Audiometric evaluation. Preoperative audiometric data were compared to early postoperative (less than 4 months), approximate 1 year postoperative, and last follow-up (more than 18 months) data. Preoperative and postoperative air conduction (AC) and bone conduction (BC) tests at 0.5, 1, 2, and 3 kHz were included in the analysis. When a frequency of 3 kHz was not used, the mean value of the 2 and 4 kHz results was substituted.
The air-bone gap (ABG) was calculated only for those patients who had BC and AC values collected at the same time. The patient’s hearing level in the postoperative period was classified into four groups: (1) very good, ABG less than 10 dB; (2) good, ABG between 10 and 20 dB; (3) acceptable, ABG between 20 and 30 dB; and (4) bad, ABG over 30 dB. The mean preoperative AC was 51.8 dB (SD, 9.4; range, 30– 65 dB), and the mean preoperative ABG was 35.3 dB (SD, 10.3; range 9.5–55 dB; Table 1). Statistical data analysis. Categorical data were expressed as percentages and continuous variables were expressed as means with standard deviations (SDs). The Fisher exact test was used to compare categorical data. Paired t-tests were used for changes in hearing within a group, and independent t-tests for the comparison of hearing between groups. A p value of less than 0.05 was the criterion for statistical significance. Statistical analyses were performed using SPSS software (version 21). 3. Results 3.1. Surgical findings Congenital stapes fixation was found in 15 patients (22 ears) and juvenile osclerosis in 3 patients (6 ears). Two girls (four ears) and one boy (two ears) had juvenile bilateral otosclerosis. Interestingly, two girls with juvenile otosclerosis were identical twins. Congenital stapes fixation with an anomaly of the ossicular chain was found in 10 of 22 ears. Among them, stapes suprastructure anomalies were found in five ears, a fibrous band of ISJ (Fig. 2) in three ears, ISJ fusion in one ear, and a stapes suprastructure anomaly with incus fixation in one ear. Four patients had an anomalous facial nerve course with the tympanic segment located inferior to the oval window niche (Fig. 3). Incudostapedotomy was performed in 24 ears, malleostapedotomy in three, and partial stapedectomy in one due to incidental footplate fracture. 3.2. Postoperative audiometric results: early, 1 year, and last follow-up Early postoperative (2.1 1.2 months) audiometric data were available for 24 ears. The mean early postoperative AC was 23.5 dB (SD, 7.7; range 13.7–38.8 dB) and the mean residual ABG was 11.6 dB (SD, 7.4; range 0–27.5 dB). The early postoperative audiometric outcome was classified as very good in 13 ears (54.2%), good in eight (33.3%), and acceptable in three (12.5%). There were no cases of bad outcomes. At 1 year after surgery (22 ears), the mean AC was 23.1 dB (SD, 5.3; range 12.5–32.5 dB) and the mean residual ABG was 11.3 dB (SD, 6.5; range 0.50–29.3 dB). The mean AC was 24.6 dB (SD, 11.9; range 10.0–76.3 dB) and the mean residual ABG was 11.5 dB (SD, 8.5; range 0.5–45.0 dB). The audiometric outcome at 1 year was classified as very good or good in 20 ears (91%), which was not
Table 1 Preoperative and postoperative audiometric outcomes for 18 children (28 ears) who underwent stapes surgery. Period
No. of ears
Mean (SD) [range] AC (dB)
BC (dB)
Preoperative Early postop 1 year Last
28 24 22 13
51.8 23.5 23.1 24.9
16.5 11.9 11.8 13.4
(9.4) [30–65] (7.7) [13.7–38.8] (5.3) [12.5–32.5] (16.4) [10.0–76.3]
(7.8) (4.0) (4.3) (6.3)
ABG (dB) [3–31] [5.0–21.3] [3–22] [7.5–31.3]
35.3 11.6 11.3 11.5
(10.3) [9.5–55.0] (7.4) [0–27.5] (6.5) [0.5–29.3] (11.1) [2–45.0]
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last, postoperative results more than 18 months.
Y.S. An, K.-S. Lee / International Journal of Pediatric Otorhinolaryngology 78 (2014) 55–59
Fig. 2. Intraoperative finding of a fibrous band (black arrow) in the incudostapedial joint; asterisk, chorda tympani nerve.
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Fig. 3. Intraoperative findings of an anomalous facial nerve (arrows). The tympanic segment of facial nerve was downwardly displaced over the atretic oval window (A). Coronal CT scan demonstrating anterior inferior location of facial nerve (arrow) (B).
significantly different from the early postoperative results (87.7% classified as very good or good). The mean duration to last follow-up in 13 ears was 46.8 23.5 months. The mean last follow-up ABG was 11.5 dB (range, 2.0– 45.0 dB). From 13 ears, nine (69.2%) had a very good and three (2%) had a good result. One case of postoperative SNHL, a loss of 21.25 dB compared with the preoperative mean BC value, was found at longterm follow-up audiometry (Table 1, Fig. 4). There was no significant difference in either preoperative or postoperative ABG between incudostapedeotomy and malleostapedotomy. 3.3. Comparison hearing results between congenital stapes fixation and juvenile otosclerosis There was no significant difference in either the preoperative and 1 year postoperative BC and ABG values or the last postoperative follow-up AC, BC, and ABG values between congenital stapes fixation and juvenile otosclerosis. However, there was a significant difference in both preoperative and early postoperative BC values between congenital stapes fixation and juvenile otosclerosis (p = 0.035 and 0.041, respectively; Table 2). In early postoperative audiometric outcomes, six of 18 ears (44.4%) with congenital stapes fixation had a very good result and 15 ears (83.3%) had either a very good or good result, whereas four of six ears (66.7%) with juvenile otosclerosis had a very good result and six ears (100%) had either a very good or good result. ABG closure after stapedotomy was more likely in juvenile otosclerosis than in congenital stapes fixation, but the finding was not significant (p = 0.546; Fig. 5).
Fig. 4. The audiometric outcomes in the preoperative and postoperative periods. ‘‘Very good’’ was defined as an air-bone gap (ABG) 10 dB; ‘‘Good’’ was defined as an ABG of 11–20 dB; ‘‘Acceptable’’ was defined as an ABG of 21–30 dB; and ‘‘Bad’’ was defined as ABG higher than 30 dB.
3.4. Comparison of hearing results between congenital isolated stapes fixation and congenital stapes fixation with ossicular anomaly There was no significant difference in either the preoperative ABG or BC values between stapes fixation with ossicular anomaly and isolated stapes fixation. However, there was a significant difference in preoperative AC values between stapes fixation with ossicular anomaly and isolated stapes fixation (p = 0.001). There was no statistical difference in the early postoperative, 1 year postoperative, and last postoperative follow-up AC, BC, and ABG values between stapes fixation with ossicular anomaly and isolated stapes fixation (Table 3).
Table 2 Comparison of hearing results between congenital stapes fixation and juvenile otosclerosis. Congenital stapes fixation
Preoperative BC Preoperative AC Preoperative ABG Early postop BC Early postop AC Early postop ABG 1 year postop BC 1 year postop AC 1 year postop ABG Last follow-up postop BC Last follow-up postop AC Last follow-up postop ABG
Juvenile otosclerosis
p value
No. of ears
Hearing (dB)
No. of ears
Hearing (dB)
22 22 22 18 18 18 16 16 16 9 9 9
14.9 7.9 50.9 9.8 36.0 10.9 11.0 3.8 23.5 7.6 12.5 7.7 11.5 4.4 24.0 5.5 12.5 7.1 13.7 7.1 28.3 18.8 14.6 4.6
6 6 6 6 6 6 6 6 6 4 4 4
22.4 3.9 55.2 7.5 32.8 8.4 14.9 3.6 23.5 9.0 8.7 6.0 12.7 4.2 20.8 4.6 8.2 3.6 12.6 4.9 17.2 4.8 4.6 3.3
0.035* 0.330 0.515 0.041* 0.999 0.277 0.570 0.226 0.169 0.786 0.277 0.136
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last follow-up, postoperative results more than 18 months. * p < 0.05.
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Fig. 5. Postoperative audiometric outcomes (air-bone gap) for pediatric stapedotomy for congenital stapes fixation and juvenile otosclerosis.
In early postoperative audiometric outcomes, five of eight ears (62.5%) with congenital isolated stapes fixation had a very good result and six ears (75.0%) had a very good or good result whereas four of 10 ears (40.0%) with congenital stapes fixation with ossicular anomaly had a very good result and nine ears (90.0%) had a very good or good result. ABG closure to within 10 dB after stapedotomy was more likely in congenital isolated stapes fixation than in congenital stapes fixation with ossicular anomaly but the finding was not significant (p = 0.319; Fig. 6). 4. Discussion Although there are many reports of the surgical outcomes of stapes surgery in adults, reports of the results of this surgery in children are rare. Preadolescents are usually strongly motivated to undergo surgery between the ages of 10 and 12 years and stapes surgery is uncommon under this age. However, recent studies [1–6] demonstrate that there is good potential to achieve satisfactory hearing improvements in children undergoing stapes surgery. Otosclerosis is one of the most common causes of adult-onset hearing loss in the Caucasian population, with a prevalence of 0.3– 0.4% [7]. The incidence of otosclerosis is different between ethnic groups. Otosclerosis incidence is high in Caucasians, but low in East Asians, people of African descent, and Native Americans. Recently the incidence of otosclerosis seems to be increasing amongst Japanese people. Ohtani reported that the incidence of histologic otosclerosis among Japanese people seemed to be similar to that among Caucasians [8]. In 2012, at the Asan Medical Center, otological surgeries were performed on 1157 ears. Among these ears, tympanomastoid
Fig. 6. Postoperative audiometric outcomes (air-bone gap) for pediatric stapedotomy for isolated stapes fixation and stapes fixation with ossicular anomaly.
surgeries were performed on 643 ears compared to stapes surgeries on 36 ears. Compared to the incidence of chronic otitis media, stapes fixation had a relative incidence of 5.6%. In our study, 121 patients (175 ears) underwent stapes surgery for conductive hearing loss with normal tympanic membrane from 1999 to 2012. Among 175 ears, only 28 ears (19.4%) were associated with patients less than 15 years old. In the 1980 pediatric stapedectomy series of House et al. [1], congenital stapes fixation was noted in 20 of 34 ears (58.8%) and juvenile otosclerosis in 14 (41.2%). In 2010, Denoyelle et al. [2] reported that congenital stapes fixation was diagnosed in 25 of 35 ears (71%) and juvenile otosclerosis in six of 35. In 2013, Carlson et al. [6] reported that congenital stapes fixation was diagnosed in 27 of 44 ears (61.4%) and juvenile otosclerosis in 17. We found that congenital stapes fixation occurred in 22 of 28 ears (79%) and juvenile osclerosis in six (21%). Denoyelle et al. [2] reported that 94% of the results of 35 stapedectomies in children were considered good or very good. They noted no significant differences between early postoperative, 1 year postoperative, and last follow-up audiometric results. We found that 87.5% of ears at the early postoperative period, 91% at 1 year after surgery, and 92.3% at last follow-up showed an improvement in hearing of less than 20 dB in ABG. The ABG did not widen significantly over time; however, one ear had a poor result in long-term follow-up necessitating revision surgery and incus fixation due to new bone formation, which was confirmed in revision explorative tympanotomy. Stapedotomy in children has been performed for correction of conductive hearing loss caused by congenital stapedial fixation or juvenile otosclerosis. Most studies report that juvenile otosclerosis is associated with more favorable audiometric outcomes than
Table 3 Comparison of hearing results due to existence of concomitant ossicular anomalies.
Preop BC Preop AC Preop ABG Early postop BC Early postop AC Early postop ABG (dB) 1 yr postop BC 1 yr postop AC 1 yr postop ABG Last follow-up postop BC Last follow-up postop AC Last follow-up postop ABG (dB)
Congenital isolated stapes fixation
Congenital stapes fixation with ossicular anomaly
No. of ears
Hearing (dB)
No. of ears
Hearing (dB)
12 12 12 8 8 8 10 10 10 6 6 6
12.2 8.8 45.3 9.4 33.1 12.0 9.7 3.8 20.8 8.3 11.1 10.1 11.2 5.3 22.6 5.2 11.4 8.1 14.0 8.6 30.2 23.0 16.2 14.7
10 10 10 10 10 10 6 6 6 3 3 3
18.2 5.5 57.6 4.9 39.5 8.7 12.1 3.6 26.8 6.5 12.4 3.7 11.9 2.6 26.3 5.7 14.3 4.7 13.1 3.9 24.6 7.5 11.5 4.1
p value
0.075 0.001* 0.182 0.177 0.173 0.736 0.762 0.211 0.443 0.450 0.756 0.938
ABG, air-bone gap; BC, bone conduction; AC, air conduction; early postop, postoperative results less than 4 months; 1 year, postoperative results 1 year 3 months; last, postoperative results more than 18 months. * p < 0.05.
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congenital stapedial fixation. House et al. [1] found that 77% (10/ 14) of ears had successful ABG closure (
