1. LASER ASSISTED SMALL FENESTRA STAPEDOTOMY TECHNIQUE & ANALYSIS Dr V.V.Raut, Dr J.Halik Dept. of Otolaryngology Toronto

2. N= 135 (Primary cases) Markham Stouffville Hospital M:F = 54: 81(1: 1.5) Age Range: 20-78 yrs Second Ear surgery: 35 Follow-up: 4 months –24 months(avg 10 months)

3. Technique Local anaesthesia with IV sedation Argon Laser 2.5 watt (coherent) Otoprobe –20 deg. Angled, 0.2 mm tip diameter Halik footplate perforators:0.3,0.4,0.5, 0.6mm diameter (Richards) Cawthorne piston: 0.3 x 5mm Teflon prosthesis with notch at 3 o’clock(Modified Halik)

7. Laser Settings Stapedial Tendon and Crurae 0.2 sec at 2.0 watts Footplate 0.1 sec at 1.0 watts

18. COST Laser - $ 45,000(cdn) Otoprobe-$190(cdn)-Single use- offset against cost of prosthesis which is cheap

19. Results N=135 Avg A-B gap closure(Post op air minus pre-op bone) A-B gap0.5,1,2 KHz0.5,1,2,4 KHz < 10dB118/135(87.4%)107/135(79.3%) <20dB13/135(9.6%)24/135(17.7%) >20dB4/135(3%)

20. Over Closure of Air-Bone Gap N=135 40/135(29.6%) Range 5-40dB Average over closure = 13dB

21. Improvement in High Frequency Hearing (post-op air minus pre-op air) 4 KHz8 KHz Improved110/135(81.4%) (17dB) 82/135(60.7%) (15dB) Same14/135(10.3%)26/135(19.3%) Worse11/135(8.1%) (9dB) 27/135(20%) (13dB)

22. Post-op SRT< 30dB=111 Pre-op possible SRT<30db=107 %Improvement=111/107 (103%)

23. A-B gapBauch et al 0.5,1,2kHz N=39 Hodgson et al 0.5,1,2kHz N=62 Raut/Halik 0.5,1,2kHz N=135 Raut/Halik 0.5,1,2kHz N=135 <10 dB31 (79.5%)54(87%)118(87.4%)107(79.7%) < 20dB4(10.3%)5(8%)13(9.6%)24(17.7%) > 20dB4(10.3%)3(5%)4(3%)

24. Complications N=135 Minor Taste:29 cases(21%)-resolved in 3 months Tinnitus:9cases(6%)- 2 persisted beyond 3 months Vertigo: 6 cases(4%)-1 persisted beyomd 3 months

25. Major Immediate SNHL-nil Delayed SNHL-nil Perilymph fistula- 1 case ( young female perilymph gusher- reexplored, prosthesis removed,OW sealed with fat,ME sealed with tisseal, no SNHL, persistent cond loss ) Persistent conductive loss-4 cases

26. Advantages of Small Fenestra Stapedotomy Lower incidence of perilymph fistula Lower incidence of immediate SNHL Long term hearing loss progresses more slowly* 4kHz & Speech Discrimination scores show less significant deterioration* * Smyth,Hassard & El Kordy, 1980

27. Advantages of Laser Precision Least traumatic Better control of bleeding Technically easier Floating footplate Results-Over closure Decreased post-operative morbidity- Day surgery

28. Step-reordering (1998) Laser (2001) Day Surgery87118 Inpatient765

29. Conclusion Safe Minimal Vestibular upset Acceptable A-B gap closure with significant improvement in hearing at 4kHz & 8kHz Significant over closure rate (29.6%) Functionally excellent results(10%SRT<30dB) An easier ear to aid than conventional techniques Neurolept anaesthesia- out patient procedure Surgery on second ear can be offered