Otolaryngology http://oto.sagepub.com/ -- Head and Neck Surgery
Fenestration in Congenital Conductive Hearing Loss Rinze A. Tange Otolaryngology -- Head and Neck Surgery 2011 144: 648 DOI: 10.1177/0194599810397587 The online version of this article can be found at: http://oto.sagepub.com/content/144/4/648.1
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Otolaryngology– Head and Neck Surgery 144(4) 648–650 © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2011 Reprints and permission: sagepub.com/journalsPermissions.nav http://otojournal.org
Letters to the Editor
Fenestration in Congenital Conductive Hearing Loss
Rinze A.Tange, MD, PhD Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands Email:
[email protected]
DOI: 10.1177/0194599810397587
In the October issue of Otolaryngology–Head and Neck Surgery, Ashtiani et al1 published an interesting article on their experience with the classic fenestration of the lateral semicircular canal (LSCC) in cases of congenital conductive hearing loss. The classic fenestration procedure was invented in 1922 by Holmgren (Sweden), introduced in the United States by Sourdille (France) in 1937, and popularized by Lempert (United States) in 1938. In 1948, Holmgren2 stated, “The improvement in hearing is far from always permanent. In a large number of cases it regresses after a short or long period, and then usually returns to the pre-operative condition.” According to Jones,3 the greatest failure was a bony regrowth that closes the artificial window. No method has been devised that ensures against closure. Any surgeon reporting according to accepted standards who attains a 60% hearing improvement by his surgery may assure himself that he is getting excellent results.3 The closure of the fenestration fistula was the important issue in the high times of the fenestration era. Lempert invented the Nov-ovalis approach with later the cartilage “stopple”4 to attack with moderate success the problem of reclosure of the LSCC fenestration. The application of the fenestration of the LSCC for congenital conductive hearing loss is far from new as a solution for the mentioned dilemma. Ombredanne from Paris5 described in 1947 the fenestration of LSSC for congenital conductive hearing loss, and later in the 1960s, he reported more than 600 cases. In the 1950s, reports appear also on the experience with the fenestration in congenital conducting hearing loss. Unfortunately, the authors were unable to present this information in the recent article. Essential for the Lempert fenestration is the removal of the incus and the malleus head. It is not clear from the present article if this procedure has been followed. The color pictures do not solve this dilemma. It is surprising in this article that in the follow-up, there is no case of chronic otorrhea or at last closure of the fenestration after the surgery. The hearing results are extraordinarily positive when we compare the results with the data described by the masters of the fenestration of LSSC after 25 years of experience with this type of ear surgery in congenital conductive hearing loss. It might be possible that not performing a partial ossiculectomy is the reason for the good results in this study.
References 1. Ashtiani MK, Yazdani N, Satri SD, Mokhtari Z, Kouhi A. Lateral semicircular canal fenestration for congenital conducting hearing loss: solution for a dilemma. Otolaryngol Head Neck Surg. 2010;143(4):516-520. 2. Holmgren G. Present-day surgery of otosclerosis. Acta Otolaryngologica. 1948;36:19-25. 3. Jones MF. Critical survey of the Lempert endaural fenestration operation. Laryngoscope. 1947;57(4):263-271. 4. Lempert J. Lempert fenestra nov-ovalis with mobile stopple. Arch Otolaryngol. 1945;41:1-41. 5. Ombredanne M. Chirurgie de la surdite; Fenestration dans les aplasies de l’oreille avec imperforation de conduit: Results. Otorhinolaryngol. 1947;31:229-236.3
Lateral Semicircular Canal Fenestration for Congenital Conductive Hearing Loss: Solution for a Dilemma DOI: 10.1177/0194599810397588
We appreciate the comments made by Dr Tange regarding our article. We agree that recurrence of conductive hearing loss was the main negative point of the classic lateral semicircular canal fenestration procedure, as we stated in the article. As Dr Tange mentioned, the main reason for failure of this technique is bony regrowth that can result in complete occlusion of the fenestration and therefore regressing to the preoperative hearing level. The important point is that we had made a modification to the classic technique, which is putting a split-thickness skin graft on the fenestration directly instead of a fascia graft. As described in the article, a hole is made in the fascia graft and put on the fenestration site. The osteogenesis-inhibitory effect of the squamous epithelium is well understood in the cholesteatoma, and we used this to inhibit neo-osteogenesis on the fenestration site. We believe the good, long-standing hearing results are due to this modification. The classic fenestration procedure was described mainly for otosclerosis; therefore, the incus and malleous heads were removed. But our patients had middle ear anomalies that precluded oval window fenestration. Therefore, although we
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