title: A systematic review of the effect of piston diameter in stapes surgery for otosclerosis on hearing results.
abstract: OBJECTIVE
  To evaluate the effect of piston diameter in primary stapedotomy for otosclerosis patients measured by hearing outcome.
  
  
  METHODS
  PubMed, Embase, and the Cochrane Library.
  
  
  METHODS
  A systematic search was conducted. Studies reporting original data on the effect of piston diameter on pure-tone audiometric results in patients undergoing primary stapedotomy for otosclerosis were included. Relevance and risk of bias of the selected articles were assessed. Studies with low relevance, high risk of bias, or both were excluded. Absolute risks and risk differences, means and mean differences, and 95% confidence intervals were extracted.
  
  
  RESULTS
  Twelve studies with moderate to high relevance and moderate risk of bias were included for data extraction. Air-bone gap closure to 10 dB or less was assessed in six studies, the majority of which did not show a statistically significant or clinically relevant difference between two pistons with a different diameter. More importantly, the differences that were found were not consistently in favor of smaller-diameter pistons or larger-diameter pistons. Mean postoperative air-bone gap ranged from 3 dB in favor of a smaller-diameter piston to 3 dB in favor of a larger-diameter piston across four studies. Permanent sensorineural hearing loss was assessed in eight studies and occurred in only one study. In this study, no difference was found between a 0.4-mm-diameter piston and a 0.6-mm-diameter piston.
  
  
  CONCLUSIONS
  There is not sufficient evidence to support the superiority of the use of a larger-diameter piston compared to a smaller-diameter piston for primary stapedotomy in otosclerosis patients.
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.|Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Inge
authors.initials: I
authors.lastname: Wegner
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Jessica J
authors.initials: JJ
authors.lastname: Verhagen
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.|Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Inge
authors.initials: I
authors.lastname: Stegeman
authors.affiliation: Causse Ear Clinic, Traverse de Béziers, Colombiers, France.
authors.forename: Robert
authors.initials: R
authors.lastname: Vincent
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.|Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Wilko
authors.initials: W
authors.lastname: Grolman
mesh_terms: D001301:Audiometry, Pure-Tone; D034381:Hearing Loss / Q000534:rehabilitation*; D006801:Humans; D010040:Otosclerosis / Q000601:surgery*; D013201:Stapes Surgery / Q000295:instrumentation
keywords: Otosclerosis; conductive hearing loss; diameter; hearing loss; piston; prosthesis; pure-tone audiometry; stapedotomy; stapes surgery