The future of stapes surgery.

The future of stapes surgery has been a matter of concern and conjecture since the 1970s. Reflecting on this subject in preparation for a lecture to the Otosclerosis Study Group presented on September 18, 2004, I queried distinguished senior otologists, using a questionnaire. They included Otosclerosis Study Group members Drs. John Shea, Jr., John Emmett, John House, Bill Lippy, Jack Hough, and Joe Nadol, and fellow Jack Wazen. This editorial summarizes our vision of the current state and future of stapes surgery.

Primary stapes surgery incidence

I believe the number of primary stapes cases seen by surgeons who do stapes surgery has decreased, for two main reasons: There is no longer the large backlog of unoperated patients as in the 1960s, and today more surgeons are performing the procedure. Joe Nadol and John Shea believe the measles vaccine has contributed to this decrease. In fact, Vrabec and Coker (1) recently published a convincing article indicating that the number of patients with otosclerosis is decreasing, perhaps because of the measles vaccine. However, four of the surgeons surveyed believed that the number has remained constant. In our practice, the number of cases has remained fairly constant over the past 20 years.

Revision stapes surgery

Three of the seven surgeons surveyed felt the total number of revision cases is increasing. Incus erosion caused by a prosthesis appears to be the most common reason for failure. Three felt that incus necrosis increases with the passage of time. Joe Nadol estimated that he sees about 15% revision cases per year. John Shea believes incus necrosis occurs in 10 to 15% but is increasing. He also said 20 to 25% of his cases are now revisions. Our surgical cases are now averaging about 16% revisions per year. John House believes incus necrosis is the most common cause of failure but the incidence is low. I am seeing more incus necrosis in cases in which a platinum ribbon has been crimped around the incus. Joe Nadol believes the opposite and feels that the ribbon causes less damage than the crimped wire.

Only two out of seven felt the wire was more damaging to the incus than Teflon. I disagree; I believe using the Causse Teflon prosthesis results in a lower incidence of incus necrosis over the long term. Jean Bernard Causse, who used a Teflon piston, stated that the rate of necrosis was very low. Two other surgeons use prostheses that are cup-shaped and do not need crimping. They rarely see necrosis. Bill Lippy uses a stainless steel cup, and John Shea uses a Teflon cup. I believe there will be new prostheses developed that will attach easily to an incus that has been damaged and foreshortened by a prosthesis. Regarding long-term results, only one out of seven felt the prosthesis would eventually fail if the patient lived long enough.

Otosclerosis prevention

Three of seven surgeons surveyed felt that preventive treatment, such as genetic therapy, may someday prevent otosclerosis. John Shea feels the incidence is already so low that prevention won't be necessary.

Training surgeons to do stapes surgery

This will be a great challenge for all of us involved in teaching, since fewer cases are being done by each resident. Training may need to be reserved for only those highly interested in otology. Six of the seven surgeons surveyed believe we should train fewer residents. Joe Nadol disagreed. Four of seven felt the Temporal Bone Lab is an essential tool in training. Three of seven felt close supervision was a "must" in training, and two felt that one must do 20 to 25 cases to become competent. (My two current fellows agree: Drs. Avron Marcus and Sam Hill.) Only two felt fellowship training is essential in stapes surgery, and two felt it is helpful. I feel that a fellowship gives young surgeons the added expertise to make them more competent in performing this procedure.

The challenges of stapes surgery

Stapes surgery is the most difficult otologic procedure we do. It requires the utmost of skill, leaving very little room for error. Five of the seven surgeons surveyed agree with this idea, but two believe that cholesteatoma removal can be more difficult.

Development of the laser for stapes surgery by Perkins and others has made the procedure safer and easier and has all but eliminated the floating footplate. (2) It also makes teaching stapes surgery easier for the instructor. Stapedotomy will replace stapedectomy. We have been preserving the stapedius tendon when possible, (3) which makes the incus more stable during prosthesis insertion and may help maintain the blood supply to the incus. The new Smart Piston makes wire crimping much easier. The long-term effects of this prosthesis are not known; it may cause incus necrosis, as seen with other wire prostheses. Mobilizing the stapes (laser STAMP) (4,5) with a laser in minimal otosclerosis will eliminate prosthesis problems.

Surgeons who aren't equipped with enough knowledge to handle difficult problems probably should not be doing the procedure. They should send patients in need of stapes surgery to the most experienced surgeons.

Future needs

A prosthesis that attaches easily to the eroded incus is needed, as is a nontoxic bone cement. Since lawsuits have arisen when there is a poor result, I believe more cases are being sent to experienced surgeons. I also believe the "occasional" stapes procedure will be a thing of the past.

Hearing aids vs. stapes surgery

Although hearing aids work well for conductive deafness, all surgeons surveyed agreed that the hearing obtained after successful stapes surgery is much better. I don't think most patients who are surgical candidates will opt for a hearing aid instead. All agreed that our happiest patients are those who have had a successful stapes procedure.

Influence of insurance companies and audiologists

Two surgeons surveyed felt that insurance companies' refusal to pay for stapes surgery because "a hearing aid could correct the hearing loss" may be a deciding factor for patients considering surgery. All agreed that if the audiologist becomes the "gatekeeper," fewer patients will be referred for surgery. Four of the group believed that patients will still be referred but less often. It seems to me that it is important for the surgeons to continue to hold a strong hand in the deal, and not let audiologists dictate whether surgery is a viable alternative.

Fees and liability

We have seen a steady decline in reimbursement for stapes surgery. As with any change, emotions have run the gamut. At first there was shock--our fees were reduced by as much as 70%. Then there was depression, followed by anger. Eventually, we accepted our fate. And since most of us love doing this challenging procedure and reaping the benefits of a patient's first smile, and perhaps tears, upon finally being able to hear again, we bite the bullet and continue to do the surgery.

Perhaps a larger question we face is, Will the procedure (like acoustics) become so cost-prohibitive--i.e., the fee so low and the risk so high--that we will begin to ask ourselves, "Is it really worth it?" and say, "What the heck, let's just give them a hearing aid and get on with our lives." Three of the group agreed that this may very well happen. John Shea mentioned, "If you can't assure the patient of a 90% success rate, then a hearing aid is in order." Four others thought differently. They believed that because they can provide better results than can be expected with a hearing aid, this will not happen.

I believe the pendulum has already swung far to one side. I think the entropic laws will lessen the litigation potential and that reimbursement will stay the same or even improve. Am I an optimist? Yes, but I also believe that if this is going to happen, tort reform is a definite must.

Looking ahead

In summary, I feel stapes surgery is here to stay, at least in the near future. Small fenestra stapes surgery will prevail over stapedectomy or even partial stapedectomy. When there is minimal otosclerosis, the stapes can be mobilized with or without a laser, avoiding the need for a prosthesis. Piston prostheses and laser techniques will continue to be used. The Smart Piston will be used more frequently. New prostheses for the eroded incus will be developed. Prostheses that do not need to be crimped around the incus will reduce the incidence of incus necrosis. Preservation of the stapedius tendon (5) may help maintain the blood supply to the incus. Since fewer surgeons will be trained in the procedure, more specialists will evolve, such as those with a fellowship or specialized residency.

In the long term, perhaps gene therapy or another cure may arise and put stapes surgery in the history books, but I don't see this happening anytime soon.

References

(1.) Vrabec JT, Coker NJ. Stapes surgery in the United States. Otol Neurotol 2004;25:465-9.

(2.) Perkins RC. Laser stepedotomy [sic] for otosclerosis. Laryngoscope 1980;90:228-40.

(3.) Silverstein H, Hester TO, Rosenberg SI, Deems DA. Preservation of the stapedius tendon in laser stapes surgery. Laryngoscope 1998;108:1453-8.

(4.) Silverstein H. Laser stapedotomy minus prosthesis (laser STAMP): A minimally invasive procedure. Am J Otol 1998;19:277-82.

(5.) Silverstein H, Jackson LE, Conlon WS, et al. Laser stapedotomy minus prosthesis (laser STAMP): Absence of refixation. Otol Neurotol 2002;23:152-7.

HERBERT SILVERSTEIN, MD, FACS 

President and Founder

Silverstein Institute

Sarasota, Florida