Revision Stapedectomy with Necrosis of the Long Process of the Incus: Does the Degree of Necrosis Matter? A Retrospective Clinical Study

Abstract

OBJECTIVE:To discuss the different modalities for managing necrosis of the long process of the incus in revision stapedectomy on the basis of the degree of necrosis and compare the results with those reported in the literature. MATERIALS and METHODS:Thirty-six patients underwent revision stapedectomy with the necrosis of the long process of the incus from 2009 to 2016. The patients were divided into three groups on the basis of the degree of necrosis. For group A (minimal necrosis), augmentation technique with bone cement was performed. For group B (partial necrosis), the cement plug technique was performed. For group C (sever necrosis), malleus relocation with malleovestibulopexy was performed using reshaped necrosed incus. Air and bone conduction thresholds at frequencies of 500-3000 Hz were reviewed pre-and postoperatively using conventional audiometry. The air-bone gap (ABG) and bone conduction thresholds were measured. RESULTS:Postoperative ABG was reduced to <10 dB in 28 cases (77.8%) and <20 dB in all cases (100%). There was no significant change in postoperative bone conduction thresholds. The mean patient follow-up duration was 23 (range, 18-36) months. The cement plug technique was used in 75% of cases. CONCLUSION:Managing necrosis of the long process of the incus in revision stapedectomy should be considered according to the degree of necrosis. The cement plug technique is considered to be a reasonable option in most cases. Malleus relocation with malleovestibulopexy is an effective alternative to prosthesis.

Audiologic and surgical outcomes in endoscopic revision stapes surgery

“…Importantly, success in revision stapes surgery is correlated with an accurate diagnosis of the cause of failure . For example, the extent of incus necrosis dictates repair options and ultimately clinical outcomes . A close analysis of the incus and accurate evaluation of the extent of necrosis requires excellent visualization of the ossicular chain.…”

Long Process Incus necrosis in Revision Stapedotomy: Retrospective Clinical Study

“…4,5,9,10,15,16,20,26 Today, less than 20-dB ABG results are achieved in 64% to 96.3%, and 0% to 2% of patients go on to have profound sensorineural hearing loss, or a dead ear, postoperatively. 8,27,29,34…”

“…The literature shows that the incidence of LPI necrosis in revision stapedectomy ranges from 5% to 49%. 5,8,12,15,17-24 Theories for why this occurs vary but include overly zealous crimping, loss of blood supply, or a poorly fit prosthesis causing inflammation and bone erosion over time. 12,37,35,36 All techniques of ossicular reconstruction should be considered in case of incus necrosis.…”

“…10 Common findings during revision stapedectomy include necrosis of the long process of the incus, prosthesis lateralization or displacement away from the oval window, re-fixation of prosthesis, loosening of the connection between the prosthesis and incus, and closure of the fenestra in the oval window. [10][11][12][13][14][15][16] The incidence of long process incus (LPI) necrosis in revision stapedectomy ranges from 5% to 49%, 5,8,12,15,[17][18][19][20][21][22][23][24][25] and in some studies, it was the first cause of failure. 5,25 Hearing results in revision surgery have been poorer than those of primary stapes surgery.…”

Traumatic Incudostapedial Disarticulation: Anatomical Reconstruction Using Ionomeric Bone Cement

“…Also, the application of different bone cements has been increased in ear surgery which was introduced as an excellent alternative to currently accepted methods especially; for IS rebridging [4][5][6]. Cement plug technique was performed in revision stapedectomy cases in which long process of incus shows necrosis, the prosthesis was reinserted first onto remaining part of incus long process and then a plug of cement is used to fix it in place [7]. And using cement for anatomical repositioning of disarticulated incus in-between stapes and malleus during trans-mastoid supralabyrinthine facial decompression after temporal bone fractures [8].…”