CO Laser Assisted Stapedotomy Combined With a`Wengen ...

Otology & Neurotology
30:1071Y1078 Ó 2009, Otology & Neurotology, Inc.

CO2 Laser<Assisted Stapedotomy Combined With
a`Wengen Titanium Clip Stapes Prosthesis: Superior

Short-Term Results

*†Glen E. J. Forton, ‡§Floris L. Wuyts, *Kathelijne G. Delsupehe,
*Jan Verfaillie, and *Robert Loncke

*Department of Otorhinolaryngology and Head and Neck Surgery, Heilig Hart General Hospital Roeselare,
Roeselare; ÞDepartment of Neurosciences, Faculty of Medicine, University of Antwerp; þAntwerp University
Research centre for Equilibrium and Aerospace, Department of Otorhinolaryngology and Head and Neck Surgery,
Antwerp University Hospital; and §Department of Biomedical Physics, University of Antwerp, Antwerp, Belgium

Objective: To report on the short-term results of CO2-laser as- thesis. The mean postoperative air-bone gap 3 months postop-
sisted stapedotomy combined with the a`Wengen titanium clip eratively was 5.1 T 0.5 dB (standard deviation [SD], 4.1 dB; 0.5,
stapes prosthesis. A comparison with published series using 1, 2, 4 kHz). Air-bone gap closure less than or equal to 10 dB
other prostheses and/or different stapedotomy techniques is made. was achieved in 54 cases (87%). Air-bone gap closure less
Study Design: Retrospective case series. than 20 dB was achieved in all cases. The average gain was
Patients: Patients with a history and audiologic data matching 27.8 T 1.5 dB (SD, 12 dB; 0.5, 1, 2, 4 kHz). The average bone-
stapes fixation and computed tomographic imaging excluding conduction threshold shift or Boverclosure[ on 2,000 Hz was
other anomalies such as malleus fixation, dehiscent superior 13.6 T 1.3 dB (SD, 10 dB). There was no postoperative percep-
semicircular canal, and large vestibular aqueduct that may tive hearing loss exceeding 15 dB on any measured frequency.
mimic stapes fixationYlike hearing loss. The Amsterdam Hearing Evaluation Plots have also been used
Intervention: All patients underwent CO2 laserYassisted stape- to evaluate our data. These data were statistically analyzed and
dotomy (Lumenis Co. Israel CO2 laser, Acuspot 712, Surgi- compare favorably to other published series.
Touch 870 scanner) and subsequent reconstruction by means Conclusion: The authors conclude that the combination of CO2
of the a`Wengen titanium clip stapes prosthesis by Heinz Kurz laserYassisted stapedotomy and the a`Wengen titanium clip
Medizintechnik GmbH (Germany). stapes prosthesis is a combination likely to yield superior re-
Outcome Measures: Comparison and statistical analysis of sults in experienced hands. Key Words: a`Wengen stapes clip
preoperative and postoperative audiologic data. prosthesisVCO2 laserVOtosclerosisVStapedotomy.
Results: Sixty-two stapedotomies were performed (61 patients)
using the CO2 laser and a`Wengen titanium clip stapes pros- Otol Neurotol 30:1071Y1078, 2009.

Since the introduction of the Bsmall-hole[ stapedotomy microdrill has a relatively low rotation speed of 7,000 rpm
by Shea et al. (1) in the United States and by Marquet (2) in and has low noise intensity. Several studies have confirmed
Europe in the early 1960s, little has changed as to the prin- this tool to be safe and reliable (3Y6), although not nec-
ciples of otosclerosis surgery. What has changed over time essarily superior to the old-fashioned manual pick or
are the tools to perform the actual stapedotomy and the perforator.
prosthesis that can be used.
As the laser found its way into the operating theater,
The introduction of the skeeter microdrill (Skeeter Oto- several types of laser have been put to the test in otologic
logic Drill System; Medtronic Xomed Surgical Products, surgery. In his excellent survey of various lasers used in
Jacksonville, FL, USA) enabled otologic surgeons to create stapes surgery, Frenz (7) concludes that lasers seem to
a neatly calibrated 0.7-mm hole in the stapes footplate. This have a high potential in ear, nose, and throat surgery, es-
pecially in middle ear surgery. They permit nontactile,
Address correspondence and reprint requests to Glen E. J. Forton, mechanically atraumatic, and very precise cutting of tis-
M.D., Ph.D., ENT Department, Heilig Hartziekenhuis Roeselare, Wil- sues, including bone. None of the available laser devices,
genstraat 2, 8800 Roeselare, Belgium; E-mail: [email protected] however, is ideal: argon laser radiation is poorly absorbed
in bone and perilymph, but it can be transmitted through
Presented at the annual meeting of the Dutch-Flemish Otological
Society, Bruges (Belgium), March 2Y3, 2007.

1071

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1072 G. E. J. FORTON ET AL.

optical fibers, which is an advantage. Carbon dioxide laser functional results were encouraging (15), the gold pros-
radiation has a strong absorption in bone and perilymph but thesis has been reported to cause inner ear damage due
cannot be transmitted through optical fibers. A micromani- to material intolerance, which resulted in granulomatous
pulator such as the Lumenis Acuspot 712 mounted on the reactions, progressive postoperative sensorineural hear-
operation microscope has to be used in conjunction with a ing loss, and extrusion of the prosthesis (16Y18). In 1999,
scanning system such as the Lumenis SurgiTouch 870 titanium was introduced as well. Titanium prostheses are
scanner to direct the laser beam. Jovanovic et al. (8) has highly biocompatible (19), very light, and easy to handle.
studied the so-called Bone-shot CO2 laser stapedotomy[ The extrusion rate is extremely low, and the audiometric
and concludes that it is a safe procedure with a lower inci- results are reported to be very good (20Y22).
dence and severity of intraoperative and postoperative com-
plications than conventional stapes surgery. Garin et al. However, as Ugo Fisch once so eloquently pointed out,
concur (9). Somers et al. (10), however, have found that Bthese new technologies will not make good surgeons out
there is no statistically significant difference between the of bad ones,[ but they might help good surgeons to obtain
Bskeeter[ microdrill technique and laser stapedotomy as far even better results.
as transient postoperative cochlear dysfunction or bone
threshold shift are concerned. To the best of our knowledge, this is the first report
on the short-term results of the combination of CO2
Since Shea fabricated his first Teflon prosthesis, re- laser stapedotomy and reconstruction by means of the
sembling a real human stapes, in 1956, a multitude of a`Wengen titanium clip stapes prosthesis (Heinz Kurz
stapes prostheses have been designed. After an episode Medizintechnik).
during which he used a polyethylene tube, Shea de-
signed a prosthesis entirely made of Teflon, and so did MATERIALS AND METHODS
Marquet (11). In 1960, Schuknecht (12) developed his
steel wireYadipose tissue prosthesis, which led to the Subjects
well-known steel wireYTeflon prosthesis (13). In the Sixty-one patients (35 women; 26 men) ranging in age from
1990s a soft-band piston made of pure gold was intro- 29 to 79 years underwent a CO2 laserYassisted stapedotomy and
duced by Pusalkar and Steinbach (14). Although the subsequent reconstruction by means of the a`Wengen titanium
clip stapes prosthesis (Heinz Kurz Medizintechnik) between

FIG. 1. Box-and-whisker plot depicting total functional gain (dB) on 125, 250, 500, 1,000, 2,000, 4,000, and 8,000 Hz obtained
3 mo postoperatively.
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STAPEDOTOMY COMBINED WITH STAPES PROSTHESIS 1073

March 2005 and September 2007. They all had a medical history the cutting function (4.5 W, 0.05 s). Extreme care was taken to
and audiologic data matching stapes fixation. High-resolution not accidentally damage the chorda tympani orVworseVthe
computed tomographic imaging was performed in all cases to facial nerve. Whenever necessary, nontarget middle ear struc-
exclude other anomalies (such as malleus fixation, dehiscent tures were protected with saline-soaked swabs or gelatin sponges
superior semicircular canal, and large vestibular aqueduct) that (e.g., Spongostan). Subsequently, the anterior crus was frac-
might mimic stapes fixationYlike hearing loss, thus preventing tured using a microhook. We have always attempted to create
unnecessary surgery and complications. One patient had bilat- a 0.8-mm circular perforation of the footplate using a single
eral surgery during this period, so this study comprises 62 ears shot (24 W, 0.05 s). Whenever there was no perforation of
with confirmed stapes fixation. There were 38 left ears and 24 the footplate after the first shot, a second or even third pulse
right ears. was delivered. However, we have never administered additional
laser shots as soon as the vestibulum was opened. Therefore,
Surgical Technique whenever there was an opening in the footplate after the first
All patients were operated by the same surgeon (G.F.) at the shot, but the desired diameter was not yet achieved, the opening
ear, nose, and throat Department of the Heilig Hart General was manually enlarged using microhooks. In cases where the
Hospital (Roeselare, Belgium). In all cases, the CO2 laser oval window was too narrow to accommodate a 0.6-mm piston,
(Lumenis Co. Yokneam, Israel) was used in conjunction with the laser spot settings were changed to a 0.6-mm diameter, and a
the Lumenis Acuspot 712 micromanipulator and the Lumenis 0.4-mm prosthesis was used. After creating the calibrated hole,
SurgiTouch 870 scanner. The device and the microscope (Zeiss we inserted either the 0.6-mm or the 0.4-mm a`Wengen titanium
Opmi Sensera S7) focus length were both set to 300 mm. The clip stapes prosthesis (Heinz Kurz Medizintechnik) as described
approach to the middle ear cleft was invariably endaural using a by a`Wengen (20). The desired length was established immedi-
slightly modified Rosen incision. Before even starting with the ately after removing the superstructure. We use no vein interpo-
actual stapedotomy, the mobility of the ossicular chain was sition or additional sealing, following Marquet’s example (11).
assessed by gently moving the malleus handle and the lenticular
process with a microhook. During the latter maneuver, the Audiometry and Statistics
incudostapedial joint was closely observed to evaluate synchro- All patients had at least 2 preoperative hearing tests, deter-
nous movement of the stapes. Finally, after having convinced mining pure-tone thresholds in the frequency range from 125
ourselves that malleus and incus were mobile, the stapes was to 8,000 Hz by air and bone conduction (Madsen Orbiter II;
gently palpated and fixation was ascertained. Only then was the Madsen, Denmark). All patients were tested again preferably
stapedius tendon cut with a few single laser pulses. The incu- 2 weeks, 6 weeks, and 3 months postoperatively, again by air
dostapedial joint was conventionally severed in all cases. The and bone conduction. These tests were performed by qualified
posterior crus was vaporized with several pulses, again using audiologists at our department. The data were stored in an Excel

FIG. 2. Box-and-whisker plot depicting postoperative air-bone gap (dB) on 250, 500, 1,000, 2,000, and 4,000 Hz measured
3 mo postoperatively.

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1074 G. E. J. FORTON ET AL.

spreadsheet (Microsoft Corp., Redmond, Wash, USA). The on demand. The postoperative air-bone gap is defined as
audiologic data used for our calculations and reported in this
article were all collected 3 months postoperatively. We have cal- the postoperative air-conduction threshold minus the
culated the preoperative and postoperative air-bone gap on 250,
500, 1,000, 2,000, and 4,000 Hz. A mean preoperative and post- postoperative bone-conduction threshold, as recom-
operative air-bone gap using the calculated values for 500, 1,000,
2,000, and 4,000 Hz was also defined (23). According to mended by the Committee on Hearing and Equilibrium
continental habit, 3,000 Hz was not used in our calculations.
Furthermore, the bone-conduction threshold shift was also in 1994 (23).
calculated for these frequencies to evaluate the overclosure
phenomenon or to assess postoperative perceptive hearing Obviously, the goal of stapes surgery is improvement
loss. Finally, total air-conduction gain was calculated for all
the frequencies. Statistical analysis was performed using SPSS of functional hearing. Consequently, the total gain in
Statistics software. All values are presented using a box-and-whis-
ker plot (featuring maximum, minimum, average, median, first-, the frequency domain between 500 and 4,000 Hz has
and third-quartile values) as proposed by Govaerts et al. (24), and
we have also used the Amsterdam Hearing Evaluation Plots as the greatest impact on speech discrimination. Figure 1
defined by De Bruijn et al. (25). This way, we have endeavored
to facilitate interpretation and comparison with other reports. illustrates the total functional gain we have obtained at

RESULTS 3 months postoperatively. In our series, the mean total
All raw preoperative and postoperative audiometric functional gain T standard error (SE; 500, 1,000, 2,000,
data are available to the reader on request but have not and 4,000 Hz) amounts to 27.8 T 1.5 dB. The mean pre-
been included in this article. Postoperative gain per fre- operative hearing loss (air conduction) was 64.3 T 2.1 dB
quency, bone-conduction threshold shift (i.e., overclo- (standard deviation [SD], 16 dB).
sure or inner ear damage), and postoperative air-bone
gap have all been calculated and are likewise available Figure 2 illustrates the postoperative air-bone gap. Our

mean postoperative air-bone gap (500, 1,000, 2,000, and
4,000 Hz) is 5.1 T 0.5 dB (SD, 4.1 dB). The mean air-
bone gap of all our patients is smaller than 20 dB. Of our

62 ears, 54 (87%) have a mean postoperative air-bone

gap of 10 dB or less. The mean preoperative air-bone gap
was 27.3 T 1.3 dB (SD, 10 dB).

Finally, we have evaluated postoperative bone-

conduction threshold changes. Figure 3 illustrates the so-

called overclosure phenomenon, which occurs most

prominently at 2,000 Hz due to the elimination of

FIG. 3. Box-and-whisker plot illustrating postoperative bone-conduction threshold shift (overclosure) on 250, 500, 1,000, 2,000, and
4,000 Hz measured 3 months postoperatively.
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STAPEDOTOMY COMBINED WITH STAPES PROSTHESIS 1075

FIG. 4. Amsterdam Hearing Evaluation Plot 1. Preoperative bone-conduction values are plotted against postoperative bone-conduction
values for each operated ear. The 2 diagonal lines enclose the area where the postoperative bone-conduction threshold has not changed
more than 10 dB with respect to the preoperative bone-conduction threshold. Iatrogenic cochlear damage is indicated by every point above
the uppermost diagonal line. Significant overclosure is indicated by every point below the lower diagonal line.

Carhart notch. At 2,000 Hz, the improvement of the In Figures 4 and 5, we have depicted our results using
bone-conduction threshold was 13.6 T 1.3 dB (SD, 10 the Amsterdam Hearing Evaluation plots, as suggested
dB) with a median of 15 dB. None of our patients by De Bruijn et al. (25). The first graph shows preopera-
tive bone-conduction values plotted against postopera-
has a loss exceeding 15 dB on either of the measured tive bone-conduction values for each operated ear. The

frequencies.

FIG. 5. Amsterdam Hearing Evaluation Plot 2. The horizontal axis represents the postoperative change in air-conduction threshold, and
the vertical axis represents the preoperative air-bone gap. The lower diagonal line indicates total closure of the air-bone gap. Conse-
quently, every point below this diagonal line indicates a gain in air-conduction threshold that is larger than one might expect from total air-
bone gap closure. Such a result can be regarded as a very successful result with overclosure. An unsuccessful result is considered to be a
negative change in air-conduction threshold or a positive change that fails to reduce the air-bone gap to less than 20 dB. A point above the
uppermost diagonal line indicates such an unsuccessful result.

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1076 G. E. J. FORTON ET AL.

TABLE 1. Comparison of postoperative air-bone gap

Forton Vincent Zuur Grolman and Garin Rondini-Gilli Lundman
et al.
et al. (30) et al. (21) Tange (22) et al. (9) Fisch (31) et al. (32) et al. (33) Shea (34)

Stapedotomy CO2 laser Argon laser Micropick Micropick CO2 and Micropick Microdrill Microdrill Micropick and
Prosthesis Kurz a`Wengen Teflon
K-Piston Kurz a`Wengen argon laser Teflon argon laser

9 wk Mean, 25.4 wk Wire-Teflon Wire-Teflon 18 mo Teflon Teflon
58 23 127
79.0 56.5 90.0 platinum wire
18.0 43.0
Observation time 3 mo 3Y11 mo 97.0 Median, 7 mo 12 mo 5.0 5 yr 1 yr 6Y10 yr
62 1,838 NA 100.0 54 170 95.0%a
n 87.0 95.6 NA 72.0 123 4,137
e10 dB, % 13.0 NA 22.0 58.0 10
10Y20 dB, % 100.0 NA 94.0 NA 77.0 95.1, 89.9
e20 dB, % 1.6 9 NA
5 NA 18.0 NA
Mean postoperative
95.0 NA
AB gap, dB
7 NA

AB indicates air bone; NA, not applicable.

2 diagonal lines enclose the area where the postoperative clip stapes prosthesis combined have, to the best of our
bone-conduction threshold has not changed more than knowledge, not yet been published. Because all data
10 dB with respect to the preoperative bone-conduction were collected 3 months postoperatively, the authors wish
threshold. Iatrogenic cochlear damage is indicated by to emphasize that theirs are short-term results, whereas
every point above the uppermost diagonal line. Con- some of the published series we refer to are long-term
versely, significant overclosure is indicated by every results. Comparison of functional results over time indeed
point below the lower diagonal line. In the second is difficult because perceptive hearing loss might increase
graph, the horizontal axis represents the postoperative due to presbyacousis or cochlear otospongiosis on the
change in air-conduction threshold, and the vertical one hand and the air-bone gap tends to enlarge again with
axis represents the preoperative air-bone gap. The 0.9 dB per year, as demonstrated by Aarnisalo et al. (29),
lower diagonal line indicates total closure of the air- on the other hand.
bone gap. Consequently, every point below this diagonal
line indicates a gain in air-conduction threshold that is In Table 1, our results pertaining to air-bone gap clo-
larger than one might expect from total air-bone gap sure 3 months postoperatively are compared with other
closure. Such a result can be regarded as a very success- published results. The methods used by the respective
ful result with overclosure. An unsuccessful result is surgeons are also given. Comparison between published
considered to be a negative change in air-conduction series is often difficult because all required parameters
threshold or a positive change that fails to reduce the (e.g., SE or SD) are rarely reported, and methodology
air-bone gap to less than 20 dB. A point above the upper- varies greatly. In addition, as mentioned earlier, some
most diagonal line indicates such an unsuccessful result. studies discuss long-term results. To facilitate compa-
rison, we have also included the follow-up time in our
DISCUSSION tables. To make a sensible comparison, we have included
Several articles confirming the safety and usefulness only the short-term (3Y11 months’ follow-up) section of
of CO2 laserYassisted stapedotomy and skeeter microdrill the collection of Vincent et al. (30). Among the articles
have been published in contemporary literature (3Y10, we have quoted, only Vincent et al. (30) and Shea (34)
26Y28). We have also found several studies reporting report a percentage of patients with a postoperative air-
on metallic stapes prosthesis in general and the a`Wengen bone gap less than or equal to 10 dB that is statistically
titanium clip stapes prosthesis in particular (15,19Y22). significantly higher than ours. Considering the number of
However, the results of CO2 laserYassisted stapedotomy patients, our results are statistically significantly better
with reconstruction by means of the a`Wengen titanium than those reported by Grolman and Tange (22) and
Fisch (31). Table 2 shows the average functional gain

TABLE 2. Comparison of postoperative gain

Forton et al. Vincent et al. (30) Grolman and Rondini-Gilli
Tange (22) Marquet (11) et al. (32) Lundman et al. (33)

Stapedotomy CO2 laser Argon laser Micropick Micropick Microdrill Microdrill
Prosthesis Kurz a`Wengen Teflon Kurz a`Wengen Teflon Teflon Teflon platinum wire
3Y11 mo Mean, 25.4 wk 18 mo
Observation time 3 mo 1,838 Mean, 59 mo 127 5 yr
51.3 23 1,681 NA 123
n 62 25.8 49 NA NA 57
25.5 28 NA 24 26
Mean preoperative threshold, dB 64 21 32 31

Mean postoperative threshold, dB 37

Gain, dB 28

NA indicates not applicable.

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STAPEDOTOMY COMBINED WITH STAPES PROSTHESIS 1077

TABLE 3. Comparison of postoperative bone-conduction ween our results and both aforementioned series are sta-
threshold shift tistically significant (p G 0.05). Vincent et al. (30) define
overclosure as Ban improvement of the four frequency
Forton et al. Zuur et al. Grolman and Tange average bone conduction threshold greater than 10 dB[.
(21) (22) They report a thus defined overclosure rate of 4%.
Conversely, they report 0.5% of their cases to have a
Stapedotomy CO2 laser Micropick Micropick postoperative sensorineural loss of 15 dB or worse.
Prosthesis Kurz a`Wengen K-Piston Kurz a`Wengen Rondini-Gilli et al. (32) wrote that 90% of their patients
had no postoperative perceptive loss, 4% had experi-
n 62 58 23 enced an improvement of at least 10 dB, and 3% had
0 j2 a perceptive loss exceeding 30 dB (but no deafness).
250 Hz 1 2 j3 Lundman et al. (33) report an improvement of more
2 j2 than 10 dB in 24% of their cases and only 1% of wor-
500 Hz 4 6 sening greater than 20 dB. In our series, 8 of our 62 had
5 an improvement of their average bone-conduction thresh-
1,000 Hz 6 j2 j1 old (500, 1,000, 2,000, and 4,000 Hz) greater than 10 dB,
which amounts to no less than 13%. Again, the difference
2,000 Hz 13 with the quoted series is statistically significant ( p G 0.05).
We had no postoperative sensorineural hearing loss ex-
4,000 Hz j2 ceeding 15 dB on any of the measured frequencies.

of our data compared with other series. In addition, the Our results therefore confirm that single-shot CO2
average air-conduction gain in our series proves to be laserYassisted stapedotomy is a safe and atraumatic pro-
superior to the gain mentioned by Vincent et al. (30), cedure if the required safety measures are observed. The
Grolman and Tange (22), and Rondini-Gilli et al. (32). a`Wengen titanium clip prosthesis, is in our opinion, an
However, they are inferior to the results obtained by excellent prosthesis that allows optimal air-bone gap clo-
Marquet, as reported by Somers et al. (35) and those of sure. The combination of both surgical devices seems to
Lundman et al. (33). These comparisons could only be yield superior results, as illustrated by our data.
made by taking the standard variation (SE) of the respec-
tive data into account, thus allowing us to apply the ap- Finally, it has been frequently put forward that one
propriate t test. However, the SD values are lacking in should use as large a prosthesis diameter as possible. Our
the series of Vincent et al. (30), Grolman and Tange (22), data corroborate this maxim. In our series, the 0.6-mm-
Somers et al. (35), and Rondini-Gilli et al. (32). To solve diameter prosthesis yields statistically significant better
this problem, we have assumed a safe standard deviation results than the 0.4-mm-diameter titanium prosthesis (as
of 15 dB for these series. Our analysis shows that our systematically used by Grolman et al. [22]). Our average
gain is statistically significantly better ( p G 0.05) than the gain (500, 1, 2, and 4 kHz) is 31.3 T 2.1 dB (SD, 11; n =
gain reported by Vincent et al., Grolman & Tange and 28) with the 0.6-mm prosthesis and 24.9 T 2.0 dB (SD, 12;
Rondini-Gilli et al. The difference with Lundman et al. n = 34) with the 0.4-mm prosthesis. The difference once
(33) was not statistically significant, while the gain again is statistically significant ( p = 0,038). The observa-
obtained by Somers et al. (35) was statistically signifi- tions of Marchese et al. (36) agree with these findings. We
cantly better than ours ( p G 0.05). Even when we changed therefore conclude that, whenever possible, one should en-
the assumed SD to 12.7 or 11.6 dB, these conclusions did deavor to create a 0.8-mm stapedotomy and use a 0.6-mm-
not change. Therefore, we can safely assume that our con- diameter prosthesis.
clusions are valid from a statistical point of view.
CONCLUSION
Additionally, while contemplating gain, one should The small-hole stapedotomy, followed by reconstruc-
take into account that the average preoperative air-bone tion by means of a stapes prosthesis, is a well-established
gap in the older reports is significantly larger than the aver- and standardized procedure. In experienced hands, the
age air-bone gap in contemporary series. Consequently, the results are usually very good. However, further improve-
maximum gain that could possibly be obtained at that time ment of our results seems to be possible thanks to mod-
is much larger than at the present time. ern technology such as laser-assisted stapedotomy and
more refined prostheses, such as the a`Wengen titanium
We have also taken a closer look at the results of the clip stapes prosthesis (Heinz Kurz Medizintechnik).
Colombiers group (30) because their mean postoperative With this article, we present the first report on the short-
air-bone gap is statistically significantly smaller than term results of the combination of CO2 laser stapedotomy
ours ( p G 0.05), whereas our total gain is statistically and reconstruction by means of the a`Wengen titanium clip
significantly larger than theirs ( p G 0.05). The only pos- stapes prosthesis (Heinz Kurz Medizintechnik).
sible explanation for this phenomenon is that we have Our short-term results seem to be superior to other
consistently obtained more important Boverclosure.[ short-term results obtained with laser-assisted stapedot-
omy, followed by reconstruction with another prosthesis,
To ascertain this assumption, we have sought to com-
pare our preoperative and postoperative bone-conduction
thresholds to those of other studies. However, there are
disappointingly few reports that mention detailed pre-
operative and postoperative bone-conduction thresholds.
Nevertheless, we seem to have obtained more significant
overclosure: Table 3 compares our overclosure data to
those of Grolman and Tange (22) and those of Zuur et al.
(21), both short-term result series. The difference bet-

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1078 G. E. J. FORTON ET AL.

and those obtained by manual or skeeter drill stapedot- 17. Kwok P, et al. Safety of gold in stapes surgery. Biomaterials
omy, followed by reconstruction with either a conven- 2005;26:7132Y5.
tional or the a`Wengen titanium clip stapes prosthesis
(Heinz Kurz Medizintechnik). However, it remains to be 18. Tange RA, Schimanski G, Van Lange JW, et al. Reparative gran-
seen whether this will also be the case in the long run. uloma seen in cases of gold piston implantation after stapes surgery
for otosclerosis. Auris Nasus Larynx 2002;29:7Y10.
Based on these short-term results, we advocate the com-
bination of CO2 laserYassisted stapedotomy and recon- 19. Schwager K. Epithelisierung von Titanprothesen im Mittelohr
struction with the a`Wengen titanium clip stapes prosthesis des Kaninchens. Modelvorstellungen zur Mukosaentwicklung.
(Heinz Kurz Medizintechnik). Laryngorhinootologie 1998;77:38Y42.

Finally, our data also confirm that a 0.6-mm-diameter 20. a`Wengen D. A new self-retaining titanium clip stapes prosthesis.
prosthesis is to be preferred to a 0.4-mm-diameter pros- In: Arnold W, Ha¨usler R, eds. Otosclerosis and Stapes Surgery.
thesis whenever feasible. Basel, Switzerland: Karger, 2007;65:184Y9.

Acknowledgments: The authors wish to thank S. Sinnaeve 21. Zuur CL, de Bruijn AJG, Tange RA. A retrospective analysis of
and P. Carton, audiologists of our department, for diligent work. early postoperative hearing results obtained after stapedotomy with
implantation of a new titanium stapes prosthesis. Otol Neurotol
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