|Year : 2012 | Volume
| Issue : 3 | Page : 122-124
A comparison between conventional stapedectomy and KTP-532 laser stapedectomy
Rohit Singh, Dipak Ranjan Nayak, Produl Hazarika, Sajilal Manonmani, Deviprasad Dosemane, Prabhjot Randev
Department of ENT, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||12-Nov-2012|
Dipak Ranjan Nayak
Department of ENT and Head and Neck Surgery, Kasturba Medical College, Manipal University, Manipal 576104, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Otosclerosis is a primary and exclusive disease of the otic capsule, known to affect spontaneously only humans. The most classical manifestation is conductive hearing loss secondary to stapedial fixation. Perkins introduced argon laser stapedotomy in 1980 because it appeared that laser offered some technical advantage over conventional techniques. Materials and Methods: This is a retrospective study of 20 cases of stapedial otosclerosis (10 cases in each group) operated during a period of 5 years. Our study compares a series of potassium titanyl phosphate (KTP) 532 laser stapedectomy (LS) with a series of conventional stapedectomy (CS) with respect to technical advantages, hearing results, and complications. Paired students t test was used for statistical analysis of the data. Results and Conclusion: (i) KTP LS using 0.6mm fibre is a safe and efficient technique. (ii) LS is technically less difficult, produces an atraumatic, bloodless opening in the footplate of stapes without mechanical manipulation of the stapes. (iii) The air-bone gap closure is better in laser group.
Keywords: KTP laser, Stapedectomy, Stapedial otosclerosis
|How to cite this article:|
Singh R, Nayak DR, Hazarika P, Manonmani S, Dosemane D, Randev P. A comparison between conventional stapedectomy and KTP-532 laser stapedectomy. Indian J Otol 2012;18:122-4
|How to cite this URL:|
Singh R, Nayak DR, Hazarika P, Manonmani S, Dosemane D, Randev P. A comparison between conventional stapedectomy and KTP-532 laser stapedectomy. Indian J Otol [serial online] 2012 [cited 2020 Feb 22];18:122-4. Available from: http://www.indianjotol.org/text.asp?2012/18/3/122/103437
| Introduction|| |
Otosclerosis is a primary and exclusive disease of the otic capsule (bony labyrinth) and the ossicles that are known to affect spontaneously only humans. If the location of the bony changes; as stapedial fixation and their secondary effects; as conductive hearing loss is clinically evident, the term clinical otosclerosis is used. If the bony changes are not translated into clinical manifestation, the term histological otosclerosis is used. Perkins introduced argon laser stapedotomy in 1980 and reported some technical advantages over conventional techniques. We compared a series of potassium titanyl phosphate (KTP) 532 laser stapedectomy (LS) and conventional stapedectomy (CS).
| Aim|| |
To determine - (1) Whether the KTP LS offered any technical advantages over CS. (2) Whether the LS produced similar or better hearing results over CS. (3) To determine the peri- and postoperative complications of laser and nonlaser group.
| Materials and Methods|| |
A retrospective study of 20 cases who were operated during the period of 5 years. Out of these 20 cases, 10 underwent KTP LS and 10 cases underwent CS.
The patients were evaluated and diagnosed based on the history of hearing loss with intact tympanic membrane; with or without tinnitus by tuning fork tests and pure tone audiometry. The postoperative hearing improvement was evaluated by pure tone audiometry on 1 st month, 3 rd month, and 6 th month after surgery. Pre- and postoperative air and bone conductive thresholds were obtained at the speech frequencies 500, 1000, and 2000 Hz. The result was termed "excellent" if the air-bone gap (ABG) was reduced to <10 dB.
Salient differences in the surgical steps between two groups are as follows:
Under 6Χ magnification, endomeatal incision was placed from 10 O' clock to 6 O' clock position over the posterior canal wall with a circular knife in CS. This was done with KTP laser using 0.6 mm fiber at 5 W as continuous supply, in LS. Stapes supra structure removal: In CS, stapedial tendon was severed, incudostapedial joint dislocated and supra structure was fractured with pick and removed. In LS, the incudostapedial joint was dislocated, stapedial tendon and crurae of the stapes vaporized using 0.2 mm laser fiber at 0.2 second pulse mode of 2 W. Creation of fenestra: Under 10Χ magnification; in CS, straight pick was used for fenestration of the footplate. In LS, stapedial footplate fenestration was made using 0.6 mm laser fiber at 0.2 second pulse mode of 2 W.
| Results|| |
Majority of the patients in both the groups were females, aged between 30 and 50 years with duration of hearing loss less than 10 years. Nineteen of the 20 patients had bilateral hearing loss. Family history was present in only one patient, who underwent LS, and did not have excellent results. In 18 out of 20 patients, no seal was used. Fat seal was used in one case of CS whereas gel foam was used as seal in one case of LS and had excellent results. Most commonly used length of all Teflon pistons was 4 mm with 66% excellent results in both laser and nonlaser groups. There were no significant complications during the procedure except that tympanic membrane had a tear in one case of each group and one case in the CS group had perilymph leak.
The pure tone average for each surgery was calculated on follow up at 1, 3, and 6 months. Nearly 40% of LS patients had an ABG closure within 10 dB at 1 month, which increased to 70% at the 6 th month. All patients (100%) had ABG closure within 20 dB at the end of the 6 th month. Nearly 10% of CS patients had an ABG closure within 10 dB at 1 month, which increased to 50% at the 6 th month. All patients had ABG closure within 20 dB at the end of the 6 th month.
The ABG gain in LS and CS groups was comparable at each frequency with better gain at low frequencies. There was a statistically significant (P < 0.001) reduction in ABG following surgery in both groups at frequencies 500, 1000, and 2000 Hz. Paired students t test was used for statistical analysis. [Table 1].
The air conduction gain was higher in laser group compared with nonlaser group at frequency 500, 1000, and 2000 Hz. The air conduction gain in laser and CS groups was comparable at each frequency, with better gain at higher frequencies in laser group and better gain at lower frequencies in nonlaser group. There was a statistically significant (P < 0.001) reduction in air conduction gain following surgery in both groups at frequencies 500, 1000, and 2000 Hz [Table 2].
|Table 2: Comparison of air conduction (AC) gain at different frequency between the two groups|
Click here to view
On the whole, 70% of the cases had excellent results with LS compared with 55% in the nonlaser group.
However, in statistical terms, no significant difference was noted in the hearing results of both groups.
| Discussion|| |
Lasers have been used in otology for the past two decades as a surgical tool that can vaporize, cut or coagulate.  These three properties make lasers useful in middle ear operation. McGee claims that use of laser significantly reduce trauma and increases accuracy, making microsurgery easier to perform.  LS is proved to be safe, bloodless operation without causing significant cochlear trauma. ,, Results of our LS surgery are encouraging but follow up of only 6 months is not adequate when compared with the Western literature. In this series, Causse Teflon piston of 0.6 mm diameter of variable lengths were used, because it is nonwettable, pressure applied over the incus long process is more diffuse and shape of the piston can be modified according to the situation. 
In a study of CS, hearing was improved in 33 of 34 ears (97%). The surgical revision rate was 3%. The average preoperative ABG (calculated as an average from 250, 500, and 1000 Hz) was 29.0 dB HL in the left ear group and 26.6 dB HL in the right ear group. The average postoperative ABG was 9.9 dB HL in the left ear group and 9.4 dB HL in the right ear group.  In a study of LS (for revision), approximately 56.5% of patients achieved closure of the postoperative ABG to within 10 dB; 91.3% of patients achieved a postoperative ABG within 20 dB.  In a 20-year review of revision stapedectomy, of the 522 revision cases, a total of 483 patients were operated on to improve hearing. Closure of the ABG to within 10 dB was achieved in 71% of patients (343 of 483). The mean pure-tone average improvement was 17.8 dB, with an average postoperative ABG of 7.3 dB. Since beginning the use of the Argon laser for surgical problems, the success rate has increased to 80%. A subgroup of 35 Argon laser revision stapedectomies resulted in a larger hearing gain (25.2 dB) and 91.4% closure of the ABG to less than 10 dB.  Our study suggests that LS yields better results as compared with conventional stapedectomy in treatment of otosclerosis in terms of 70% of the cases had excellent results with LS compared with 55% of CS. All patients (100%) in laser group had ABG closure within 10 dB at the end of 6 th month as compared with 50% at 6 th month in CS.
The potential adverse effects of lasers in the ear during stapes surgery extend beyond the vestibule. Delayed facial palsy appears to be more prevalent in lasers cases as compared with those in which other techniques are used and this probably is due to heating of the facial nerve during surgery, possibly resulting in reactivation of viruses within the nerve. , Bartels pointed out that clean gelfoam soaked with physiological salt solution forms a layer in the middle ear to protect more deeply located structures, on the surface of solution KTP laser does not absorb, that is, the penetration into deeper areas depends on the duration of laser exposure and laser power applied.  Various complications of CS have been reported, which include vertigo in the immediate postoperative period, vomiting, perilymph gusher, floating foot plate, tympanic membrane tear, dead labyrinth, perilymph fistula, and labyrinthitis. In our study, here were no significant complications during the procedure except that tympanic membrane had a tear in one case of each group and one case in the CS group had perilymph leak.
| Conclusions|| |
KTP-532 LS is a safe and efficient technique. It reduces the technical difficulty of stapes surgery when compared with conventional techniques opening into the vestibule through the footplate regardless of the thickness without any mechanical trauma to the inner ear.
The results of KTP-532 LS have been encouraging, with the main advantage being an atraumatic and bloodless surgery.
Though laser showed a better ABG closure in our study; its use is not that widespread. Hence, the intention of this study is not to make a judgment on the usage of newer surgical aids in middle-ear operations, but to highlight and present the current usage of such tools among the otolaryngologists.
| References|| |
|1.||McGee TM. Lasers in otology. Otolaryngol Clin North Am 1989;22:233-8. |
|2.||McGee TM. The argon laser for chronic ear diseases and otosclerosis. Laryngoscope 1983;93:1177-82. |
|3.||Lesinski SG, Palmer A. Carbon dioxide laser for otosclerosis: Safe energy parameters. Laryngoscope 1989;99:9-12. |
|4.||Bartels JJ. KTP laser stapedectomy: Is it safe? Otolaryngol Head neck Surg 1990;103:685-92. |
|5.||Somers T, Marquet T, Govaerts P. Statistical analysis of otosclerosis surgery performed by Jean Marquet. Annals Otol Rhinol Laryngol 1994;103:945-51. |
|6.||Hsu GS. Improving hearing in stapedectomy with intraoperative auditory brainstem response. Otolaryngol Head Neck Surg 2011;144:60-3. |
|7.||Stucken EZ, Brown KD, Selesnick SH. The Use of KTP Laser in Revision Stapedectomy. Otol Neurotol 2012;33:1297-9. |
|8.||Lippy WH, Battista RA, Berenholz L, Schuring AG, Burkey JM. Twenty-year review of revision stapedectomy. Otol Neurotol 2003;24:560-6. |
|9.||Bonkowsky, Kochanowski B, Strutz J, Pere P, Hosemann W, Arnold W. Delayed facial palsy following uneventful middle ear surgery: A herpes simplex virus type 1 reactivation? Ann Otol Rhinol Laryngol 1998;107:901-5. |
|10.||Shea J Jr, Ge X. Delayed facial palsy after stapedectomy. Otol Neurotol 2001;22:465-70. |
[Table 1], [Table 2]