The Laryngoscope V C 2013 The American Laryngological, Rhinological and Otological Society, Inc. CO 2 Laser Revision Stapedotomy Andreas E. Albers, MD; Uwe Sch€ onfeld, PhD; Kostas Kandilakis, MD; Sergije Jovanovic, MD, PhD Objectives/Hypothesis: To evaluate the safety and efficacy of the one-shot noncontact technique in stapedotomy for re- vision stapes surgery with a CO 2 laser combined with a scanning system. Study Design: Prospective study. Methods: Intraoperative findings and hearing results of 106 patients who underwent revision CO 2 laser stapedotomy because of conductive or sensorineural hearing loss or vertigo were analyzed. Results: Leading pathologies were displacement of the prosthesis, incus erosion, fibrous adhesions, and bony reoblitera- tion or a too long or too short prosthesis. Surgery was successfully performed in all cases with a noncontact technique result- ing in significantly improved postoperative air and bone conduction. The rate of permanent complications was 0.9%. A com- parison of the effect of higher laser energies used for the perforation of bony stapes footplates and lower energies for neomembranes revealed no significant difference in hearing results, underscoring the safety of the technique. Conclusions: To avoid any manipulation of the conductive hearing chain that may cause sensorineural hearing loss, we adapted the noncontact technique previously introduced by us for use in revision stapedotomy. This technique was success- fully applied to improve conductive and sensorineural hearing loss as well as vertigo in first and second revision stapedot- omy cases. Because the rate of postoperative complications was comparable to what is achieved with other laser systems, we conclude that the method has at least an equal level of safety. In conclusion, we advocate the use of a noncontact technique as suitable for an early revision of failed stapedotomy. Key Words: CO 2 laser, revision stapedotomy, scanner, otosclerosis, one-shot stapedotomy, hearing results. Level of Evidence: 2b. Laryngoscope, 000:000–000, 2013 INTRODUCTION Successful restoration of hearing in revision stape- dotomy involves precise identification and correction of the underlying abnormality without impairment of the inner ear function. Possible reasons for conductive hear- ing loss after primary stapedotomy include a displaced, fixed, or loose prosthesis; a subluxated, fixed, or eroded malleus or incus; and fibrosis or regrowth of otosclerotic bone in the oval window niche. 1,2 For a correct diagno- sis, it is necessary to visualize the malleus and incus and to clear the oval window niche from connective tis- sue until the margins of the footplate are visible and finally to verify the position of the piston in the stape- dotomy opening. In the past, conventional surgical procedures fre- quently resulted in unsatisfactory hearing and inner ear injuries. Numerous studies have shown that successful closure of the air-bone gap (10 dB) is achieved in less than half of patients who undergo a revision stapedot- omy, 3 and 8% to 33% of revision patients complain of poor hearing. The incidence of significant postoperative sensorineural hearing loss is 3% to 20%, with up to a 14% incidence of severe hearing loss. 2–5 Damage to the inner ear can be caused by the re- moval of connective tissue occluding the oval window niche and/or manipulation of the prosthesis that results in tearing the neomembrane covering the oval window. Histopathologic studies of petrous bone specimens from stapedectomized patients have demonstrated that adhe- sions often exist between the prosthesis and the neomembrane of the oval window and the inner ear (utricle and saccule). 6 These observations can explain why tearing forces during surgical manipulations may lead to rupture of utricle and saccule, resulting in ver- tigo and labyrinthine damage. This matter has been reviewed with instructive drawings by Lesinski et al. 7 Because of the relative high frequency of hearing loss and vertigo, several authors have discouraged revision attempts using conventional surgical techniques. 2–5 This dogma has been challenged by the introduction of otologic lasers in stapes surgery. Since their introduc- tion, they have enhanced the revising surgeon’s ability to safely identify and treat the causes for conductive hearing loss following stapes surgery, even after multiple revisions. The risk of profound postoperative sensorineu- ral hearing loss in several large series of laser revision cases is less than 1%, independent of the laser system From the Department of Otorhinolaryngology, Head and Neck Surgery (A.E.A., U.S., K.K., S.J.), Charit e – Universit€ atsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; and DRK Kliniken Berlin (S.J.), Park-Sanatorium Dahlem, Berlin, Germany. Editor’s Note: This Manuscript was accepted for publication October 10, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Andreas E. Albers, MD, Department of Otorhinolaryngology, Head and Neck Surgery, Charit e – Universit€ atsme- dizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. E-mail: andreas.albers@charite.de or to Sergije Jovanovic, MD, PhD. E-mail: sergije.jovanovic@gmx.de DOI: 10.1002/lary.23864 Laryngoscope 000: Month 2013 Albers et al.: CO 2 Laser for Revision Stapedotomy 1