Preoperative considerations and indications for revision stapedectomy.

This is the fourth installment in a series of CLINICAL NUGGETS on stapedectomy and revision stapedectomy. These installments are based on more than 2,000 revision cases performed at the authors' practice.

* Do not perform revisions unless you are experienced with the laser. (1)

* If the hearing is equal in both ears, operate on the unoperated ear.

* Be reluctant to perform a revision if the primary surgery was done by an experienced surgeon and the hearing did not improve.

* Do not rely on the operative report unless the previous surgery was done by an experienced surgeon and the report was dictated immediately after the procedure.

* Beware of a patient who is anxious to tell you how terrible the previous surgeon was.

* Do not revise an ear within the first 3 months unless severe vertigo persists and no tissue graft was used, or if you know that the prosthesis is too long. (2)

* The ideal case to revise is one in which the hearing went up initially and then down at a later time. (1)

* Know that posterior crus technique cases are easy to revise. Just remove the suprastructure and the posterior footplate, place a tissue graft, and put in a prosthesis.

* "SMart" piston prosthesis cases are also often easy to revise. The prosthesis has a memory and just comes off the incus.

* Perform revision surgery in all patients who experience a sensorineural hearing loss with dizziness following a stapedectomy in which no tissue graft was used. A fistula will be present in 50% of these cases.

* Do not revise cases of sensorineural hearing loss if no dizziness is present. (3)

* Consider revision for patients with unsteadiness, memory loss, and a lack of concentration; they may well have a prosthesis that is too long ("long prosthesis syndrome"). (4)

* Perform revision surgery in patients who develop persistent dizziness and a fluctuating hearing loss. The fluctuating loss may be sensorineural or conductive. The symptoms may arise years after surgery, often initiated by an altitude descent. Look for a fistula. The best test for a fistula is to press on the tragus and look for nystagmus.

* If a patient complains of a persistent distortion or vibration in his or her voice or in the voices of others, the prosthesis is too short ("short prosthesis syndrome"). In tissue graft cases, just remove the prosthesis, place a new tissue graft on top of the first graft, and replace the prosthesis. This will correct the problem. (1,4)

* The results of the Rinne and Weber tests must be consistent with the conductive hearing loss.

* The air-bone gap must be at least 15 dB.

* The speech discrimination score must be at least 75% unless the patient has far advanced otosclerosis.

* Use local anesthesia with sedation. If a patient becomes dizzy during the revision, you will want to know.

References

(1.) Lippy WH, Battista RA, Berenholz L, et al. Twenty-year review of revision stapedectomy. Otol Neurotol 2003;24(4):560-6.

(2.) Lippy WH, Schuring AG, Ziv M. Stapedectomy revision. Am J Otol 1980;2(7 Pt 1):15-21.

(3.) Lippy WH, Schuring AG. Stapedectomy revision following sensorineural hearing loss. Otolaryngol Head Neck Surg 1984;92(5): 580-2.

(4.) Lippy WH. Special problems of otosclerosis surgery. In: Brackmann DE, Shelton CS, Arriaga MA, eds. Otologic Surgery. Philadelphia: W.B. Saunders; 1994.

William H. Lippy, MD, FACS; Leonard R Berenholz, MD, FACS