Stapes mobilization revisited: Primum non nocere.

Unavoidably, much medical practice is based on impression and experience rather than evidence. When evidence is available, we are usually more comfortable with our practice decisions. However, we should also remember that utilization of evidence-based data includes interpretation and judgments. It seems healthy to review the assumptions underlying such judgments periodically. The widespread decision to abandon stapes mobilization in favor of stapedectomy warrants reconsideration.

Most otologists stopped performing stapes mobilization years ago because of its high failure rate. I have continued to perform stapes mobilization electively (following a comprehensive consent discussion with my patients) throughout my practice. having learned the procedure from my father, Joseph Sataloff, who performed approximately 10,000 stapes operations, many of them mobilizations. This decision is not because of a disagreement with any of the data that were utilized by the otologists who advocated abandoning stapes mobilization in favor of stapedectomy. Rather, it is based on a different stratification of priorities, which resulted in a judgment in favor of stapes mobilization, based on the same data.

In 1979, Brooklet published an article reviewing 120,132 stapedectomy cases. (1) He identified sensorineural hearing loss reported in 0.97% (approximately 1%) of cases. It was not possible to separate "dead" ears from less severe sensorineural hearing loss in all of these cases. Most active otologists agree that the incidence is at least 1 to 2% commonly, and probably higher in less experienced hands. I have reviewed many of the published articles on stapes mobilization, totaling 10.811 cases. (2-16) These articles revealed a 0.036% incidence of sensorineural hearing loss and a 0.064% incidence of "dead" ears. This results in a total sensorineural hearing loss incidence of approximately 0.1% among stapes mobilization patients, a tenfold decrease in comparison with stapedectomy.

The reported long-term success rate of stapes mobilizations gleaned from these articles was about 55%. This number has remained accepted for decades, perhaps because no one has tried to improve it. However, if we were to initiate research to advance the techniques and outcomes of stapes mobilization surgery (to be reviewed at greater length in a future issue of ENT JOURNAL), it is conceivable that better outcomes might prove possible. Nevertheless, this editorial assumes a "failure" rate of about 50%.

There is something intrinsically unappealing about a procedure with a failure rate that approaches 50%, but we still must ask whether it is worth paying the price necessary to achieve a "success" rate closer to 98% by performing stapedectomy instead of stapes mobilization. At the beginning of my career, I decided that it was not, and that judgment has not changed.

If we accept as our guiding principle Primum non nocere ("First do no harm"), then perhaps stapes mobilization has a place in otologic surgery. If we have a patient with bilateral 70-dB conductive hearing loss, have a stapes mobilization fail, and have to proceed with stapedectomy, little is lost other than a few minutes in the operating room. However, if we perform a stapedectomy on that patient and end up with a 70-dB hearing loss in one ear and a dead ear on the other side, we have not done the patient a service. Hence, I would submit that anything we can do to decrease the incidence of dead ears or severe sensorineural hearing loss should be considered seriously.

My personal experience has been similar to that in the literature. I care for patients for whom I performed stapes mobilization 25 years ago, and patients operated on by my father 50 years ago, who still have normal hearing and who achieved it with minimal risk of sensorineural hearing loss. Of course, I also care for others who are returned to the operating room to undergo stapedectomy within a few months following stapes mobilization. Our stapedectomy results in patients who have undergone stapes mobilization do not differ from results in patients who have never undergone stapes surgery, and the procedure has been particularly trouble-free since the advent of laser stapedotomy.

Stapes mobilization and stapedectomy are both excellent operations. Their risks and benefits vary and are worthy of reconsideration. The judgment of the field of otology to select stapedectomy in order to eliminate the high failure rate associated with stapes mobilization is certainly understandable. However, even if half of the patients who undergo stapes mobilization fail and require stapedectomy, the successful half has achieved good hearing with a 0.1% risk instead of a 1% risk of irreversible sensorineural impairment. Furthermore, if half return for secondary stapedectomy, that would mean that only half of our otosclerosis patients are subjected to the 1% (or greater) risk of sensorineural hearing loss associated with stapedectomy, and that would cut the overall risk in our surgical otosclerosis patients nearly in half. It appears worth considering any procedure that decreases the incidence of one of our worst complications by tenfold in half of our patients, and by half in the population as a whole. We also may want to reprioritize our criteria for "success." From my perspective, a good hearing result that required two trips to the operating room seems like a success; a dead ear surely does not.

ROBERT T. SATALOFF, MD, DMA 

Editor-in-Chief

Ear, Nose & Throat Journal

References

(1.) Brookler KH. Otosclerosis surgery: Reassessment of its value in 1978. Laryngoscope 1979;89(7 Pt 1):725-9.

(2.) Bellucci RJ. Survey of stapes surgery: Five-year study. Arch Otolaryngol 1969;89:408-11.

(3.) Derlacki EL, Shambaugh GE Jr., Harrison WH. The evolution of a stapes mobilization technique. Laryngoscope 1957;67:420-47.

(4.) Goodhill V, Holcomb AL. A study of 500 stapes mobilizations. Laryngoscope 1957;67:615-42.

(5.) Harrison WH, Shambaugh GE Jr., Derlacki EL, Clemis JD. Perilymph fistula in stapes surgery. Laryngoscope 1967;77:836-49.

(6.) Holmgren L. Mobilization and stapediolysis. Primary and long-term results. Acta Otolaryngol Suppl 1960;158:316-27.

(7.) House HP. Trends in mobilization surgery. Laryngoscope 1959;69:1805-7.

(8.) Kinney CE. Statistical analysis of the stapes mobilization procedure. Laryngoscope 1956;66:1339-45.

(9.) Kos CM, Shapley JL, lies PB. Results of nine-hundred and thirty-nine stapes mobilization operations. Ann Otol Rhinol Laryngol 1960;69:206-21.

(10.) Kraus RN, Elliott LL, Moore EW. Stapes mobilization. Experience in the United States Air Force. Rep US Navy Exp Diving Unit 1961;88:1-11.

(11.) Lewis DK. Some unsolved problems of stapes mobilization. Ann Otol Rhinol Laryngol 1960;69:222-35.

(12.) Meurman Y, Meurman O. Stapes mobilization in otosclerosis; primary results and a review of sixty-three cases. AMA Arch Otolaryngol 1955;62:164-72.

(13.) Myers D, Ronis BJ. Improvement of hearing in otosclerosis by means of stapes-mobilization operation; report of results and experience. AMA Arch Otolaryngol 1956;64:307-23.

(14.) Rosen S. Results of mobilization of fixed stapedial foot plate in otosclerotic deafness. JAMA 1956;161:595-9.

(15.) Sataloff J, Menduke H. Mobilization of the stapes in older patients with otosclerosis. J Am Geriatr Soc 1960;8:277-83.

(16.) Scheer AA. Observations of five hundred cases of transtympanic mobilization of the stapes. AMA Arch Otol 1957;65:245-54.