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Intraoperative Monitoring of Hearing During Ossiculoplasty

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Intraoperative Monitoring of Hearing During Ossiculoplasty IntraoperativeIntraoperative MonitoringMonitoring ofof HearingHearing DuringDuring OssiculoplastyOssiculoplasty Krzysztof Morawski, MD, PhD1; Kazimierz Niemczyk, MD, PhD1; Fred Telischi, MEE, MD, FACS2 1Department of Otolaryngology, Medical University of Warsaw, Poland; 2Department of Otolaryngology, University of Miami Miller School of Medicine, FL, USA ABSTRACT INTRODUCTION METHODS AND PATIENTS RESULTS DISCUSSION Objective: To evaluate the utility of Though progress in middle ear surgery is still very dynamic hearing perichondrium (4 cases) in underlay technique. Second look surgery Twenty patients were monitored intraoperatively using RW-ECochG and One of the methods to improve postoperative hearing results during electrocochleography recorded from the round window improvement is still an important challenge for otologist. There are some was performed usually from 8 and 12 months after the first procedure. ABR. In general, this procedure prolongated surgery about 20-25 min. middle ear surgery is intraoperative monitoring. Intraoperative hearing (RW-ECochG) and auditory brainstem responses factors that should be considered in prediction of air-bone gap (ABG) In all included to this study patients no charge and correctly healed graft In 13 patients 20 to 40 dB improvement was calculated intraoperatively threshold assessment in patients under general anesthesia is (ABR) for assessment of hearing improvement during closing. Otorrhea, pre-operative ossicular and tympanic membrane status, was observed. Before surgery an ER2 insert earphone placed in the for click and frequency specific stimulation. These successful cases significantly limited. Only electrophysiological techniques are to be used ossicular reconstruction performed during second look presence of cholesteatoma, open or closed tympanoplasty or number of external ear canal of the operated ear. During intraoperative monitoring consisted of all patients (n=8) with preserved stapes suprastructure to evaluate hearing objectively as it is practiced in neonates. Strategy of operation. reoperations still remain factors which effect on postoperative hearing 0.5-, 1.0-, 2.0-kHz tone bursts and click were applied. Smart-EP evoked (Gr.A) and 5 with no suprastructure and preserved malleus (Gr.B). At measurements of ABG reduction should fulfilled some criteria. Time of Study Design: A prospective study of 20 patients results. Two-stage middle ear surgery, mostly in otitis media cholesteatoma, potential system (Intelligent Hearing Systems®, Miami, FL) was used least 6 months follow-up showed good correlation between intraoperative procedure should be no longer than 20-25 min. Easy is recognized as an optimal surgical strategy within the context of ABG undergoing two-stage canal wall-up tympanoplasty with for all recordings. Needle electrodes were fixed in the head apex intraoperative improvement of hearing and calculated ABG reduction. In interpretation of collected data and high sensitivity of method revealing closing and good long-term hearing results following ossiculoplasty. intraoperative RW-ECochG and ABR recording during (reference) and at hairs-forehead border (ground). Measuring needle one case three weeks after second look procedure a rapid hearing loss detection even 5-10 dB changes is also expected. ECochG measured Another factor effecting on ABG closing is optimally adjusted prosthesis to occurred. Revision surgery showed dislocation of the prosthesis. In all the second look operation to improve hearing results. the pre-operative status of the ossicles: type, size, material, electrode for RW-ECochG was placed via posterior tympanotomy into from the RW niche supported with simultaneous ABR recording seems Setting: This study was performed in a tertiary referral fixation/stabilization, post-ossiculoplasty tension of the acoustic energy the round window (RW) niche while for ABR on the apex of the mastoid. patients with no suprastructure and no malleus (Gr.C) intraoperative to fulfill this criteria. Evaluation of ABG reduction is possible on the center. transmitting middle ear system (membrane graft-prosthesis-stapes plate). During the second look surgery ossiculoplasty was performed. An improvement was between 5 to 15 dB. Also follow-up showed poor basis of measurements of ABR and RW-ECochG. Comparison of Subjects and Methods: Twenty patients 18 to 50 During the second look surgery following the first stage - canal wall up approach to the tympanum enabled placing and fixation needle postoperative hearing results. In 2 patients with preserved malleus and preoperative and postoperative thresholds during ossiculoplasty make years of age underwent two stage canal wall-up technique, in majority of cases otologist meets with relatively comfortable electrode on the niche of the RW and measuring RW-ECochG. As a no suprastructure with poor intraoperative hearing improvement and possible to change position of prosthesis. These recordings let adjust tympanoplasty and followed for at least 6 months. situation. Pathological changes of the middle ear are removed, usually no two-channel system was used ABRs were recorded from the same ABG reduction less than 10 dB revison surgery was performed during various intraoperative maneuvers of the otologist to achieve the best During the second look operation RW-ECochG and charge in cavum tympani, healed and stabilized graft. In such a clinical stimulation. RW-ECochG and ABR were measured and compared which fibrosis around stapes plate and its reduced move ability was hearing results. Good correspondence of intraoperatively assessed ABR were measured intraoperatively. Needle electrode situation the last procedure to be done is correctly adjusted and performed before and after final ossiculoplasty. observed. There are some intraoperative circumstances that make hearing thresholds to the follow-up hearing results suggest that hearing for RW-ECochG was placed at RW niche via posterior ossiculoplasty. Three situations for ossiculoplasty were evaluated: (A) both the malleus impossible intraoperative monitoring of hearing. The most often clinical monitoring during ossiculoplasty is a good strategy to improve long-term tympanotomy. Various options of ossiculoplasty were What could improve the hearing results in the second stage surgery? One and stapes suprastructure preserved (n=8); (B) the malleus preserved situation is intraoperative microbleeding to the tympanum. Wet middle hearing results. Impossibility to monitor hearing in bleeding conditions is evaluated. Auditory thresholds defined by N1-peak in of the factors that should significantly improve ABG closing is and no stapes suprastructure (n=7; (C) no malleus and no stapes ear with slow but continuously increasing blood from cortical bone and the only limitation for this intraoperative monitoring of hearing RW-ECochG and ABR wave V were evaluated for intraoperatively monitored hearing during ossiculoplasty. There are only few suprastructure (n=5). Prosthesis was elaborated using autologous from mucosa changes in very short time conditions for monitoring. At CONCLUSIONS various prostheses types and orientations. papers demonstrating an idea of an electrophysiological intraoperative ossicles (incus – 12 cases; mastoid bone – 8). Functional effectiveness the beginning of monitoring hearing is always better than few minutes Intraoperative evoked potentials using RW-ECochG and, to some extent, Results: Intraoperatively measured thresholds monitoring of hearing during middle ear surgery for better ossicular of ossiculoplasty was evaluated by auditory thresholds defined as N1- later. Even little amount of blood in tympanum reduces intraop ABR were found to be good predictors of postoperative hearing after reconstrauction and, finally, hearing improvement. Majority of authors use demonstrated a good improvement for click and tone- peak of RW-ECochG and ABR wave V. Final intraoperative ABG calculated threshold 15-30 dB, mostly at 0.5 and 1.0 kHz. Decreasing second stage ossicular reconstruction and a good tool for intraoperative auditory evoked potentials from brainstem (ABR) as a hearing monitoring bursts. RW-ECochG appeared more sensitive than closing was evaluated comparing pre- and post-ossiculoplasty systemic blood pressure by anesthesiologist was found to be more evaluation of ossicular reconstruction efficacy. Bleeding from mucosa tool. According to the authors knowledge, till now there is only one paper in effective than placing cotton with epinephrine on the bleeding place. limited intraoperative application of both RW-ECochG and ABR. ABR during ossicular prostheses manipulations. The which electrocochleography (ECochG) recorded intraoperatively from electrophysiological thresholds. largest changes in measurements occurred during promontory was used to monitor an effect of ossicular reconstruction during TORP placement procedures. In two cases stapedectomy. According to Wazen et al. (1997) this strategy was found to intraoperative bleeding from tympanic mucosa made be successful and appeared “to be effective for verifying the functional impossible effective testing. For all the others a good integrity of ossicular reconstructions”. correspondence between intraoperative recordings and Aim: To evaluate the utility of electrocochleography recorded from the postoperative hearing results were achieved. round window (RW-ECochG) and auditory brainstem responses (ABR) for Conclusions: Intraoperative evoked potentials using assessment of hearing improvement during ossicular reconstruction RW-ECochG
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