Introduction
Ossicular pathology from varying cause, including ossicular erosion from cholesteatoma, disarticulation from trauma and congenital malformation can produce conductive hearing loss.Reference Young and Ng1 Ossiculoplasty refers to the surgical restoration of the middle ear’s sound-transmitting mechanism, via restoring ossicular continuity with various techniques and prostheses.Reference Young and Ng1 The surgical aim is to improve air conduction thresholds and reduce air–bone gap (ABG), thereby improving hearing secondary to conductive hearing loss.Reference Jung, Son, Kwon, Kwon and Lee2
Hearing outcomes following an ossiculoplasty can be influenced by numerous factors. The main disease-related factor that has been more extensively looked at in the literature is the presence of cholesteatoma.Reference Kálmán, Horváth, Dános, Tamás and Polony3, Reference Mishiro, Sakagami, Adachi and Kakutani4 Prosthesis-related factors include predominantly the type of prosthesis (partial or total ossicular replacement prosthesis [PORP/TORP]) and material (metals, plastics, biomaterials)Reference Park, Lim, Lim, Park, Rah and Choi5 The main surgical factors include single or staged procedures and primary versus revision cases. Surgeon factors can also be related to surgical experience, skill and choice of techniques; however, such factors are more difficult to be addressed and certainly quantified.Reference Cox, Trinidade, Russell and Dornhoffer6
While several of the above factors have been assessed in the literature, the precise impact of the presence of an intact stapes on the hearing outcomes remains, at least to some extent, a controversy. Thus, our objective was to determine if the presence of the intact stapes superstructure affects the success of an ossiculoplasty in terms of auditory outcomes based on detailed data collected from consecutive cases. Our secondary objectives were to assess the impact of the presence of cholesteatoma and primary versus revision surgery on the hearing results.
Materials and methods
Study design and patient selection
We carried out a retrospective cohort study in a single, academic, tertiary referral centre with a catchment area of approximately 1.2 million population. Ethical approval was granted by the NHS Health Research Authority decision tool.7 Caldicott approval was additionally sought from the Health Board to obtain clinically relevant information.
We included all consecutive adult patients (age > 16 years old) who underwent an ossiculoplasty procedure under the senior author over a seven-year period (including the period of coronavirus disease 2019 [Covid-19] pandemic).
The main underlying indications for surgery were chronic middle ear disease including cholesteatoma and ossicular disorders contributing to conductive hearing loss. Each patient was operated in a standardised manner, using the same middle ear instrumentation and surgical microscope with all operations performed by the same surgeon. All cases were single stage procedures.Reference Park, Lim, Lim, Park, Rah and Choi5
The prosthesis of choice if the stapes superstructure was absent was the adjustable centred Alto Total with integrated footplate shoe (Grace Medical®, Memphis, TN, traded by Severn Health Technologies Ltd, Berkshire, UK),8, 9 and, if present, either the adjustable centred Alto Byte Partial or for cases where a prosthesis shorter than 2 mm was deemed suitable the Frisbee Partial at 2 mm, 1.5 mm and 1 mm, depending on the case (all by Grace Medical).8, 9 Subsequently, reconstruction of the neotympanum was performed with cartilage and a split layer of perichondrium overlying the prosthesis.
All patients underwent the same post-operative clinical follow up with the hearing assessment as described in this paper at three to six months with pure tone audiometry (PTA).
Patient electronic results were retrieved for patient demographics (age, gender), key operative information (presence of cholesteatoma, initial/revision surgery, type of prosthesis used) and audiological metrics (pre- and post-operative PTA results). We excluded any patients with inadequate data, mostly due to failure to attend post-operative appointments within the three- to six-month period.
Audiological outcomes
PTA was conducted as per British Society of Audiology (BSA) recommended procedure guidelines, with the pure tone average thresholds obtained for air and bone conduction at 500, 1000, 2000 and 4000 Hz.10 This was performed at least twice, once pre-operatively and another post-operatively. The first post-operative audiogram is our outcome marker of choice. We also documented the ABG as well as the ABG closure. Traditionally, closure of the ABG to less than or equal to 20 dB is a marker of a successful outcome of ossiculoplasty, although, we further divided this to ABG closure less than 15 dB and less than 10 dB.Reference Cox, Trinidade, Russell and Dornhoffer6
Statistical methods
R statistical computing software (version 4.4.2; The R Foundation)11 was used for data analysis. For continuous variables, e.g., audiometric outcomes in dB, normality was first checked with the Shapiro–Wilk test. For normal distribution, the independent T-test was used between groups, and if normal distribution was not observed, the Mann–Whitney U-test was used. Categorical variables, for example, gender was calculated with Fisher’s exact test.
In addition to bivariate analysis, to determine the independent predictors of post-operative ABG closure, a multiple linear regression model was performed. The dependent variable was ABG closure (in decibels) while predictor variables included presence of stapes, presence of cholesteatoma, presence of revision surgery, age, gender and pre-operative ABG (continuous). Model assumptions (normality of residuals, homoscedasticity and multicollinearity) were assessed and met.
To determine whether a larger pre-operative ABG is associated with greater ABG closure post-operatively, normality was first checked with the Shapiro–Wilk test, Pearson correlation is used if data are normally distributed and Spearman rank correlation if not. A linear regression line will be used for parametric correlation, and a LOESS (locally weighted scatterplot smoothing) curve will be used if non-parametric.
p-Values of less than 0.05 were considered statistically significant. Patient characteristics including age in years, and all percentages are expressed to one decibel point, p-values are expressed to three decimal points.
Results and analysis
A total of 100 patients (n = 100) were included in the study. Patient characteristics are presented in Table 1. The cohort had a mean age of 40.9 plus or minus 15.3 years (range: 16–75), consisting of 46 males (46 per cent) and 54 females (54 per cent). The overall mean ABG closure was 23.2 plus or minus 9.6 dB. No patient experienced a significant change in bone conduction thresholds (>10 db) upon their post-operative review. No extrusions were observed.
Patient characteristics (n = 100)
Table 1 Long description
The table summarizes demographics, clinical features, and hearing outcomes for 100 patients. Mean age was 40.9 years with a standard deviation of 15.3, ranging from 16 to 75 years. Gender distribution was 46% male and 54% female. The stapes was present in 71% and absent in 29%. Cholesteatoma was present in 48% and absent in 52%. Most cases were primary procedures at 59%, with 41% revisions. Hearing outcomes are reported in decibels: the mean pre-operative air–bone gap was 35.2 with a standard deviation of 10.9, and the mean post-operative air–bone gap was 12.1 with a standard deviation of 8.2, indicating a mean closure of 23.2 with a standard deviation of 9.6.
ABG = air–bone gap; dB = decibel; SD = standard deviation.
Table 2 compares the basic demographics as well as the hearing outcomes for the stapes present group versus the stapes absent group. An intact stapes superstructure was present in 71 cases (71 per cent) and absent in 29 cases (29 per cent). There was no significant difference in age or gender between the two groups (p = 0.145 and p = 0.512, respectively).
Stapes present versus stapes absent group
Table 2 Long description
The table compares baseline characteristics and hearing outcomes between surgeries with the stapes present using a partial prosthesis and surgeries with the stapes absent using a total prosthesis. Age and gender distribution were similar between groups, with no statistically significant differences. Revision surgery was more common when the stapes was absent, and cholesteatoma was also more frequent in that group; both differences were statistically significant. Before surgery, the stapes-absent group had a larger average air–bone gap than the stapes-present group, and this difference was statistically significant. After surgery, the stapes-present group had a much smaller average air–bone gap and a larger average closure than the stapes-absent group, with statistically significant differences. Hearing success thresholds favored the stapes-present group: nearly all were at or below 20 dB, and large majorities were at or below 15 dB and 10 dB, while the stapes-absent group had substantially lower proportions at each threshold; these differences were statistically significant. P-values and listed tests indicate statistical comparisons between groups, but the table does not adjust for potential confounders such as higher revision and cholesteatoma rates in the stapes-absent group.
ABG = air–bone gap; PORP = partial ossicular replacement prosthesis; SD = standard deviation; TORP = total ossicular replacement prosthesis
Patients with an intact stapes had a statistically significantly greater ABG closure (27.4 ± 13.4 dB vs. 21.1 ± 8.8 dB; p = 0.048), with better post-operative hearing outcomes (7.5 ± 6.2 dB vs. 19.7 ± 9.4 dB; p < 0.001). Using ABG closure to less than or equal to 20 dB as a marker of a successful procedure, a greater percentage of stapes present patients achieved such success relative to the stapes absent group (98.6 per cent vs. 62.1 per cent; p < 0.001).
Within the stapes present group (Table 3), patients without cholesteatoma had better ABG closure (30.9 ± 12.5 dB vs. 21.2 ± 12.7 dB; p = 0.003) and a smaller post-operative ABG (6.3 ± 6.2 dB vs. 9.6 ± 5.7 dB; p = 0.027). In the stapes absent group (Table 4), there was no statistically significant difference in primary outcomes between the cholesteatoma versus no cholesteatoma and the primary versus revision subgroups.
Stapes present, primary versus revision, presence of cholesteatoma
Table 3 Long description
The table reports mean air–bone gap values before surgery, after surgery, and the amount of air-bone gap closure for patients with stapes present, comparing primary versus revision surgery and comparing cases with versus without cholesteatoma. For primary versus revision surgery, pre-operative ABG was 35.4 (SD 10.9) versus 33.9 (SD 11.8), post-operative ABG was 6.8 (SD 6.0) versus 8.9 (SD 6.4), and ABG closure was 28.6 (SD 13.3) versus 24.9 (SD 13.5). None of the primary versus revision comparisons reached statistical significance, with p-values 0.491, 0.172, and 0.279. For no cholesteatoma versus cholesteatoma, pre-operative ABG was 37.3 (SD 10.0) versus 30.8 (SD 12.1), post-operative ABG was 6.3 (SD 6.2) versus 9.6 (SD 5.7), and ABG closure was 30.9 (SD 12.5) versus 21.2 (SD 12.7). All three cholesteatoma comparisons were statistically significant, with p-values 0.013, 0.027, and 0.003. Overall, revision status did not show clear differences, while cholesteatoma was associated with higher post-operative ABG and smaller closure; results are based on group means and do not describe individual outcomes.
ABG = air–bone gap; SD = standard deviation.
Stapes absent, primary versus revision, presence of cholesteatoma
Table 4 Long description
The table compares hearing outcomes, reported as mean air–bone gap with standard deviation, for patients with absent stapes across two groupings: primary versus revision surgery, and cholesteatoma absent versus present. In the primary versus revision comparison, pre-operative air–bone gap was higher in revision cases (45.1, SD 9.5; n 17) than primary cases (34.8, SD 12.8; n 12), and this difference was statistically significant (p 0.027; t-test). Post-operative air–bone gap was 17.2 (SD 9.5) for primary and 21.5 (SD 9.1) for revision, with no statistically significant difference (p 0.238; t-test). Air–bone gap closure averaged 17.5 (SD 8.1) in primary and 23.7 (SD 8.7) in revision, not statistically significant (p 0.062; t-test). In the cholesteatoma comparison, pre-operative air–bone gap was 38.1 (SD 15.5; n 7) without cholesteatoma and 41.7 (SD 10.8; n 22) with cholesteatoma (p 0.588; t-test). Post-operative air–bone gap was 18.5 (SD 8.4) without cholesteatoma and 20.1 (SD 9.8) with cholesteatoma (p 0.683; t-test). Air–bone gap closure was 19.6 (SD 9.2) without cholesteatoma and 21.6 (SD 8.9) with cholesteatoma, with no statistically significant difference (p 0.777; Mann–Whitney U-test). Overall, the only clear group difference is worse baseline air–bone gap in revision cases; other comparisons do not reach statistical significance and should be interpreted cautiously given small subgroup sizes.
ABG = air–bone gap; SD = standard deviation.
Multiple linear regression analysis (Table 5) showed that the presence of the stapes superstructure (β = 9.93; p < 0.001) and pre-operative ABG (β = 0.87; p < 0.001) were independently associated with greater ABG closure. Other variables listed did not achieve statistical significance. The model demonstrated good fit with an adjusted R2 of 0.683, indicating that approximately 68 per cent of the variability in ABG closure could be explained by the included predictors.
Multiple linear regression
Table 5 Long description
The table reports a multiple linear regression assessing how six predictors relate to the study outcome. Stapes present shows the largest positive association, with an estimated increase of 9.93 and a 95 percent confidence interval from 6.49 to 13.37, with a p-value below 0.001. Higher pre-operative air–bone gap is also positively associated, with an estimated increase of 0.87 per unit and a 95 percent confidence interval from 0.73 to 1.00, with a p-value below 0.001. Cholesteatoma, revision surgery, age, and male gender have small negative estimates and p-values above 0.05, and their confidence intervals include zero, indicating no clear evidence of an association in this model. Overall model fit is moderate to strong, with about 0.683 of outcome variation explained. Results are associations from a regression model and do not by themselves establish causation.
R2 = 0.683
ABG = air–bone gap; CI = confidence interval.
This strong correlation between a larger pre-operative ABG and greater ABG closure (Spearman’s ρ = 0.723; p < 0.001) across all cases is also confirmed by the LOESS curve (Figure 1 and Table 6). For the stapes present group, a larger pre-operative ABG is very strongly associated with larger ABG closure (Spearman’s ρ = 0.886; p < 0.001). The stapes present group demonstrates a greater increase in ABG closure compared to the stapes absent group for the same pre-operative ABG value, and particularly so at higher pre-operative ABG values (Figure 1).
Pre-operative air–bone gap (ABG) versus ABG closure correlation.
Figure 1 Long description
Preoperative ABG versus ABG Closure A scatter plot with three fitted lines and a legend. The x-axis label is Preoperative ABG (dB). The x-axis shows tick labels at 20, 30, 40, 50 and 60. The y-axis label is ABG Closure (dB). The y-axis shows tick labels at 0, 10, 20, 30, 40 and 50. The legend lists: Stapes Absent (TORP), Stapes Present (PORP), Linear Regression (Stapes Absent), LOESS Curve (Stapes Present), LOESS Curve (All Cases). Scatter points appear across the plot area. Points extend from about x equals 18 to x equals 60 and from about y equals 0 to y equals 55. A straight fitted line labeled Linear Regression (Stapes Absent) rises from about (20, 10) to about (60, 30). A shaded band surrounds this line. A curved line labeled LOESS Curve (Stapes Present) rises from about (18, 8) to about (60, 55), with a steeper rise after about x equals 35. A curved line labeled LOESS Curve (All Cases) rises from about (18, 8) to about (60, 40), staying between the other two fitted lines over most of the x-range.
Pre-operative ABG versus ABG closure correlation
Table 6 Long description
The table reports normality test results and the strength of association between pre-operative air–bone gap and subsequent air–bone gap closure for three groups: stapes absent, stapes present, and all cases. For stapes absent, Shapiro–Wilk p-values are 0.094 for pre-op and 0.091 for closure, so Pearson correlation is used; the correlation coefficient is 0.63 with a p-value below 0.001. For stapes present, Shapiro–Wilk p-values are 0.004 and 0.028, so Spearman correlation is used; the coefficient is 0.886 with a p-value below 0.001. For all cases combined, Shapiro–Wilk p-values are 0.001 and 0.005, so Spearman correlation is used; the coefficient is 0.723 with a p-value below 0.001. Across groups, the association is positive and statistically significant, and it is strongest in the stapes-present group. Because different correlation methods are used based on distribution testing, coefficients should be compared with that context in mind.
ABG = air–bone gap.
Discussion
Main findings
Our study, based on powered data and multivariate analysis, indicates the presence of the stapes remained a strong and independent predictor of post-operative ABG closure, even after adjusting for confounders. There is a significantly better post-operative hearing outcome both in terms of absolute values (7.5 ± 6.2 dB vs. 19.7 ± 9.4 dB; p < 0.001) and percentage of clinically meaningful closure thresholds of less than or equal to 20 dB (98.6 per cent vs. 62.1 per cent; p < 0.001). This could be explained by an intact stapes superstructure providing a more secure platform for the prosthesis to rest on, relative to a total prosthesis, which may have a less stable contact point to the footplateReference Yu, He, Ni, Wang, Lu and Li12; an alternative, popular explanation would be that the absence of stapes is usually linked to more severe middle ear disease and potentially worse middle ear ventilation, which are considered as negative prognostic factors for good hearing outcome.Reference Kim and Wiet13 While the absence of an intact stapes cannot guarantee the success rates similar to an intact one, a favourable hearing outcome can still be achieved, and surgical hearing restoration should be considered.
Presence of the stapes superstructure
These results are corroborated by multiple other studiesReference Mishiro, Sakagami, Adachi and Kakutani4, Reference Schmerber, Troussier, Dumas, Lavieille and Nguyen14–Reference Gluth, Judd, Gurgel, Dornhoffer, Kutz and Carlson17 in the contemporary literature, including a meta-analysis.Reference Yu, He, Ni, Wang, Lu and Li12 For example, Vincent et al. in a large series has shown excellent results in the presence of an intact stapesReference Vincent, Rovers, Mistry, Oates, Sperling and Grolman18 While the technique used is different to ours (a silastic banding technique utilising TORP attached to the intact stapes rather than a partial prosthesisReference Vincent, Sperling, Oates and Osborne19), it still highlights that a mobile, intact stapes is a positive prognostic factor of favourable hearing outcome.
However, there is no firm consensus. Lahlou et al., in a similar study, showed that there is no difference in ABG closure whether the stapes is present or not, but the post-operative ABG was better in the stapes present group.Reference Lahlou, Sonji, de Seta, Mosnier, Russo and Sterkers20 De Vos et al.Reference De Vos, Gersdorff and Gérard21 shows that the best hearing outcomes are obtained from a present malleus and absent stapes superstructure. Dornhoffer and GardnerReference Dornhoffer and Gardner22 found no significant statistical difference in ABG outcomes whether the stapes superstructure was present or not. In fact, the Ossiculoplasty Outcome Parameter Staging (OOPS) that is widely used does not consider the status of the stapes. Dornhoffer and Gardner suggest that, in select cases, there may even be a role in removal of the intact stapes superstructure.Reference Dornhoffer and Gardner22 Our results show the contrary: that preserving the stapes superstructure should be a priority in ossiculoplasty whenever feasible, as it leads to better post-operative hearing outcomes.
A recent meta-analysis comparing results from 40 studies found post-operative ABG less than 20 dB in 70.7 per cent of patients with intact stapes and 57.1 per cent of patients with absent stapes treated with titanium middle ear prostheses.Reference Kortebein, Russomando, Greda, Cooper, Ledbetter and Kaylie23 While the main objective of that meta-analysis focused on cases where titanium prostheses were used, it did highlight the difference in the achieved hearing outcome with better results in patients with an intact stapes superstructure. Our series used titanium prostheses for reconstruction in all cases. Our study did not investigate the different partial prosthesis used, mostly because of the numbers but also due to the high success rates in patients with present stapes, which would indicate that the type of prosthesis used was not a decisive factor.
Pre-operative ABG, cholesteatoma and revision surgery
The strong positive association between the size of the pre-operative ABG and ABG closure is demonstrated (β = 0.87; p < 0.001, Spearman’s ρ = 0.723; p < 0.001). This correlation is more pronounced when the stapes is present (Spearman’s ρ = 0.886; p < 0.001), a new finding in the literature. Although greater ABG closure does not equate to a successful post-operative ossiculoplasty hearing outcome, this shows that patients presenting with a more pronounced pre-operative ABG can stand to gain more (e.g., less reliance on hearing aids), particularly those with a present stapes superstructure, an additional factor reinforcing the decision to operate. A counter point that well explains this result is that of a ceiling effect, whereby patients with small pre-operative ABG have less room for maximal measurable improvement.
At first glance, the presence of cholesteatoma seems to negatively impact the post-operative hearing outcomes, with reduced ABG closure (21.2 ± 12.7 dB vs. 30.9 ± 12.5 dB; p = 0.003) noted in the presence of the stapes superstructure. However, on the multivariate analysis, it is not a significant factor overall (β = –2.92; p = 0.101). This is a mixed finding within the existing literature, where it is suggested that the improvement in ABG is not significant in the presence of cholesteatoma whether with the use of partial or total prosthesesReference Kálmán, Horváth, Dános, Tamás and Polony3, Reference Gluth, Judd, Gurgel, Dornhoffer, Kutz and Carlson17, Reference Wood, Yawn, Lowery, O’Connell, Haynes and Wanna24 Given the great variety of cholesteatoma size and behaviour, expansion and impact on the ossicular chain, it is a challenging factor to standardise throughout the literature.
Revision ossiculoplasty can be challenging, amongst other factors, due to scar tissue and altered anatomy. A high proportion of our study cohort are revision cases (41 per cent), highlighting the nature of our tertiary referral centre. We found ABG closure was similar between revision and primary cases overall (24.4 dB vs. 26.4 dB; p = 0.554); on multivariate analysis, revision surgery was not a significant factor (β = –1.42; p = 0.392). This is mixed in the contemporary literature with some in concordance,Reference Schmerber, Troussier, Dumas, Lavieille and Nguyen14, Reference Lahlou, Sonji, de Seta, Mosnier, Russo and Sterkers20 but others showed that primary ossiculoplasties with the use of both partial and total prostheses were significantly more successful than revision cases,Reference Kálmán, Horváth, Dános, Tamás and Polony3 and for multiple revisions.Reference Gluth, Judd, Gurgel, Dornhoffer, Kutz and Carlson17 Perhaps this could relate to our patient selection and predominantly on the nature of the underlying cause for the disruption of the ossicular chain. We make the case that revision surgery still provides adequate functional improvement and should not be a contraindication when making the decision to operate.
Strengths and limitations
One could argue that we only assessed two key subgroups – presence of cholesteatoma and revision/primary surgery. Other factors, such as those mentioned in the OOPSReference Dornhoffer and Gardner22 including, but not limited to type of surgery, malleus status, presence of fibrotic mucosa were not assessed, any of these which could have been significant. However, the focus of our paper was on assessing the effect of the status of the stapes; we standardised many of these confounding factors such as same surgeon, same prosthesis manufacturer and limited range and one-stage operation to eliminate any potential bias.
It could be seen as a limitation that our focus is on the presence of the stapes superstructure and not the use of total versus partial prosthesis. However, studies comparing such types of prostheses are not an accurate measure of the presence or absence of stapes superstructure as total prostheses are being used while the stapes is present by many surgeons.Reference Yu, He, Ni, Wang, Lu and Li12, Reference Vincent, Rovers, Mistry, Oates, Sperling and Grolman18, Reference Vincent, Sperling, Oates and Osborne19, Reference Baker, O’Connell, Nguyen and Lambert25 Our study does not seek to address the question on what type of prostheses is best when the stapes superstructure exists.
Our primary outcome uses the short-term post-operative PTA results. Long-term results were not collected as this cohort was not routinely followed up for the long term (> 5 years). However, there is evidence to show that short-term and long-term correlation in maintenance of ABG is good in majority of cases.Reference Cox, Trinidade, Russell and Dornhoffer6
Finally, it is important to note that clinician decision-making, as well as informed patient choice to perform an ossiculoplasty are key factors that can alter results. Our mitigation is in selecting the most experienced clinician in our department and standardisation. Although the data were obtained from consecutive patients, the decision to operate will always be multifactorial and selective in nature.
Despite the above limitations, this is a powered, single centre, well set-up study, including standardisation of several potential confounding factors and thorough analysis, that provides high quality overview of the hearing outcomes. Our detailed statistical analysis including both bivariate and multivariate analyses is new and provides a more nuanced interpretation of factors around the presence of the stapes superstructure.
• Hearing outcomes following ossiculoplasty vary according to disease, surgical and prosthesis-related factors, with the effect of an intact stapes superstructure debated
• In our study of 100 consecutive adult titanium ossiculoplasties, presence of the stapes superstructure is strongly associated with better hearing outcomes after ossiculoplasty, with significantly lower post-operative air–bone gap (ABG) and greater ABG closure
• Stapes-present (partial ossicular replacement prosthesis [PORP]) reconstructions achieve a much higher rate of good hearing outcomes, with nearly all patients achieving post-operative ABG less than or equal to 20 dB compared with only around 2/3 in the stapes-absent (total ossicular replacement prosthesis [TORP]) group
• A strong positive correlation between pre-operative ABG and ABG closure, particularly in stapes-present ears, indicating that patients with larger pre-operative conductive losses may derive the greatest absolute hearing gains
Conclusions
Our study demonstrates that the presence of an intact stapes superstructure is a significant and independent predictor of improved post-operative hearing outcomes following ossiculoplasty, resulting in substantially better ABG closure. While the presence of cholesteatoma negatively impacts hearing outcomes in the presence of the stapes superstructure, it is not independently significant after controlling for confounders. Revision ossiculoplasty provides comparable hearing improvement to primary surgery. Overall, these results reinforce the clinical practice of preserving the stapes superstructure when feasible, highlight the prognostic importance of pre-operative ABG and support informed patient counselling in ossiculoplasty planning.
Acknowledgements
I acknowledge the use of OpenAI’s ChatGPT26 to support the efficiency and clarity of manuscript preparation in terms of data visualisation and editorial refinement. However, final interpretations, conclusions, and responsibility for the content remain solely with the authors.
Funding statement
No funding was received for this paper.
Competing interests statement
To the best of our knowledge, the named authors have no conflict of interest, financial or otherwise.
