Jean-Philippe Guyot, Kenan Sakbani
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Geneva, Switzerland
Nowadays, it is widely accepted that patients must be informed about the risks associated with any type of surgical procedure. Usually, the information provided consists of quoting a list of risks and their probability of occurrence based on data from the literature, and, more appropriately, the figures reflecting the surgeon's personal experience. As a rule, such data are sufficient to hold up in court in the event of a lawsuit, but may be insufficient to help patients make the most appropriate choice. We report two cases that presented complications following stapedotomy. Both cases had a sensorineural hearing loss and a vestibular deficit. This paper aims at describing the important psychological and social consequences of these complications. The potential impact of such complications on the quality of life and the projects for the future of these young patients was predictable. In order to better assist patients in choosing amongst options, we have taken action and modified our approach in advising our patients eligible for stapedotomy procedures.
Copyright © 2007 S. Karger AG, Basel
The efficiency of the surgical techniques used for the correction of the conductive hearing loss caused by otosclerosis, the so-called stapedectomy  or stapedotomy , has been extensively reported in the literature: the benefits of the procedure can be quantified in terms of hearing gain [3, 4] as well as improvement in quality of life . Complications are rare, consisting of a sen-sorineural hearing loss, vertigo or imbalance, dysgeusia, facial nerve paralysis, or meningitis. Sensorineural hearing loss may be immediate or delayed. The rate varies among series between 0 and 7% (mean: 0.9%) . Whilst transitory postoperative vertigo is often reported as a complication, persistent imbalance resulting from a total vestibular loss is not even mentioned in some papers and occurs in up to 7% in others . The cause of these deficits is unknown and therefore such complications may occur in any center! The other complications are much rarer, and generally result from surgical technique defaults.
In general, the preoperative counseling of the patient consists of quoting a list of benefits as well as risks and their probability of occurrence. The information is based on data from the literature or more appropriately, on figures reflecting the surgeon's own experience. As a rule, such data are sufficient to hold up in court in the event of a lawsuit, but may be insufficient to help patients make the most appropriate choice.
The purpose of this paper was to describe the psychological and social consequences of a total loss of auditory and vestibular function following stapes surgery in 2 patients, and to critically review the way to better assist patients eligible for stapedotomy procedures in choosing amongst options.
A 48-year-old male was referred to our department with a progressive left hearing loss. He was a native of Portugal and had been living in Geneva for 10 years, working in a large company as a bricklayer. Otoscopy was normal. The Weber test was lateralized to the left, the Rinne negative on the left. The pure-tone audiogram showed a 40-dB left conductive hearing loss, and the stapedial reflex was absent except to the right in response to an ipsilateral stimulation. On March 6, 1998, the patient underwent a stapedotomy. The procedure was standard, as described by Schuknecht . It was performed as an outpatient procedure, under local anesthesia and using a transcanal approach through the ear speculum. A posterior tym-panomeatal flap was elevated, the stapedius tendon cut, and the crural arch fractured and removed. A 0.8-mm perforation of the footplate was carried out with a motor-driven sharp-cutting bur, and a 0.6-mm Teflon wire piston inserted. The oval window was sealed with a piece of perilobar fat tissue. The tympanomeatal flap was replaced and the external ear packed with silk strips and cotton soaked in neomycin, polymyxin and hydrocortisone (Corticosporin®). The procedure was uneventful.
Three days after surgery, the patient experienced a violent vertigo of sudden onset. Clinical examination revealed a spontaneous right-beating nystagmus. The packing was removed. There was complete hearing loss. The surgical exploration showed no displacement of the prosthesis, and no abnormal middle ear tissue. Four weeks after revision surgery, the patient mentioned he was having nightmares and could not sleep well. He was obviously suffering from an acute depressive episode. He was referred to a psychiatrist who diagnosed the resurgence of a past psychological disorder in reaction to the horrors the patient had witnessed as a soldier during the war in Angola, back in the seventies. Vertigo gradually subsided over months. Unfortunately, there was no hearing recovery. A 2-year psychological treatment was necessary to improve the mood of the patient.
A 37-year-old male was seen 6 months after a stapedotomy complicated by a cochleovestibular deficit. He was suffering from a progressive bilateral hearing loss. He was an electronic engineer, working as technical vice director of a small company. He was planning to create his own company in the near future, and wanted the operation in order to facilitate communication with his future employees. On October 1, 2001, he underwent a left stapedotomy, by a renowned otologist. Surgery was performed as an outpatient procedure, under local anesthesia and through the external auditory canal. According to the patient and the documents we had access to, the procedure was uneventful.
Four days after surgery, the patient experienced an intense rotatory vertigo with nausea and vomiting. He refused surgical exploration of the ear and was given oral corticosteroids for 5 days. The vertigo gradually subsided in 4-5 days but the patient noticed a total loss of hearing and a persisting imbalance. He was able to return to work only 6 months after surgery.
At the last visit, 3 years after surgery, there is no hearing recovery, and a slight imbalance persists. The patient wears a hearing aid on the contralateral ear. He complains of intense fatigue and considers himself inefficient at work. He was downgraded from vice director to employee, with obvious financial consequences. His project to start his own company is definitely cancelled. In his own words, his life has been radically changed by the surgery. He states the obvious negative impacts, but also positive aspects such as a reduction of his ambient stress that resulted from the decrease in his ambitions.
These cases illustrate that patients' lives may require radical modifications due to stapedectomy complications. The first case demonstrates how vertigo is a frightening experience. Vertigo weakens patients physically and mentally, allowing the reactivation of sometimes already successfully treated past psychological disorders. This has been shown in many other instances, in particular in large series of patients suffering from Meniere's disease [8, 9]. The second case illustrates that the complications of stapedectomy have sometimes major professional and financial consequences. Although in the long run patients cope with the new physical condition, it is at the price of a tremendous effort in professional, family, mental, and emotional adaptation, the result of surgery being the opposite of the expectation, a hearing loss rather than gain and persisting imbalance!
In 1998, a debate on the ethics of stapedectomy was published [10-16]. As wearing a hearing aid would give functional results comparable to those achieved by surgery, when should surgery be performed? Due to the risks of serious complications, all the authors considered stapedectomy ethical after the patient has given a fully informed consent, one adding that patients should undergo surgery only after a trial of hearing aid use . However, the risk of persisting imbalance was not even mentioned in this debate, which raises the question on the definition of an informed consent! Knowing every possible outcome, would our patients have chosen surgery over a hearing aid?
Eriksson-Mangold et al.  have shown that patients confronted with the significant impact of stapes surgery on their life report conflicting feelings of both added responsibility and anxiety, resulting in emotional turmoil. Their choice between a hearing aid versus surgery is thus based on rational, but also many irrational considerations. Indeed, patients may choose an operation to make others aware that the situation is serious and to gain sympathy, which 'may promote adaptation to the handicap', or to the contrary, 'impede adaptation to the necessary hearing aids' . The opinions of the people in contact with the patient are important, as hearing deficit is the single greatest handicap in communicating with others [Degive, C., pers. commun.]. In the population, deafness is associated with mental deficiency, and hearing aids with aging and/or poor communication. Obviously, wearing a hearing aid makes the handicap visible. In spite of this, we think that it is also the responsibility of surgeons to promote nonsurgical solutions to a problem. In addition, from an ethical point of view, to dispel preconceptions about hearing aids is also the role of doctors. As a consequence, today, our patients are clearly informed of all the benefits and risks of the operation, and informed that a hearing aid would provide satisfactory results. Finally, a period is given for them to fully assimilate the information, which appears essential before a proper decision can be made.
Many doctors consider that information regarding the benefits and risks of an operation is given to the patients in order to hold up in court in the event of a lawsuit . Such a conception weakens the patient-doctor relationship as the physician's role is reduced to merely implementing a treatment with a looming threat of punishment in case of problems, whereas the lawyer's role is elevated, as he establishes the rules and controls their application. Conversely, if the information is dispensed with the intention of helping the patient choose the best course of action, the patient-doctor relationship is strengthened as the responsibility is evenly shared between both actors. The trust thus forged would certainly diminish the number of lawsuits , which have a negative impact on not only the surgeon, but also the patient who, due to the length of the proceedings, takes a longer time to accept the functional loss, and often goes as far as presenting a major depressive event.
As a renowned myopic surgeon, would you accept an operation to cure your myopia which presents as little as a one-percent chance of total visual loss, or wear glasses? And what information would you need to make your choice? These are the kinds of questions we have in mind when giving information to a patient suffering from otosclerosis with a conductive hearing loss, being a candidate for a stapedotomy.
The authors are grateful to Colette Degive, Psychologist, Department of Psychiatry, and Prof. Alex Mauron, Chair of Ethics, University Hospital, Geneva, Switzerland, for their assistance in preparing the manuscript.
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Prof. Jean-Philippe Guyot, MD
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital 24, rue Micheli-du-Crest CH-1211 Geneva 14 (Switzerland)
Tel. + 41 22 372 82 42, Fax +41 22 372 82 40, E-Mail [email protected]
Teaching of Stapes Surgery
Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 353-360
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