Stapedectomy / Stapedotomy for Otosclerosis

Introduction

Stapedectomy and stapedotomy are surgical procedures designed to restore hearing in patients suffering from otosclerosis, a condition where abnormal bone growth fixes the stapes bone in the oval window. Consequently, sound cannot travel efficiently from the middle ear to the inner ear, leading to conductive hearing loss. Therefore, the surgeon either removes the entire stapes (stapedectomy) or creates a small hole in its footplate (stapedotomy) and replaces it with a prosthetic piston. This prosthesis bypasses the fixed bone and allows sound vibrations to reach the cochlea again.

For MBBS students, remember that stapedotomy has largely replaced stapedectomy in modern practice because it creates a smaller opening and reduces the risk of complications. However, both procedures share the same fundamental principle: restoring the ossicular chain’s mobility.

Patient Selection (Indications / Eligibility Criteria)

Patients selected for stapes surgery should meet the following criteria:

1. Patients with social hearing handicap (air conduction threshold ≥ 30 dB)
2. Air-bone gap of at least 15 dB
3. Rinne negative test results at 256 and 512 Hz
4. Speech discrimination score ≥ 60%

Surgical Procedure (Steps of Stapedectomy / Stapedotomy)

The surgery is preferably done under local anaesthesia

1. Typanomeatal Flap Elevation: An incision is made in the ear canal, and the tympanomeatal flap is elevated.

2. Exposure of Stapes and Disconnection: The surgeon exposes the stapes, separates it from the incus, and cuts the stapedius tendon.

3. Removal of Stapes Suprastructure: The superstructure of the stapes is fractured and removed carefully, away from the facial nerve. However, it is better to first divide the posterior crus with laser/ crurotomy scissors to reduce the risk of mobilising the footplate.

4. Measurement for Prosthesis Length: The distance between the incus and footplate is measured. The prosthesis selected needs to be 0.25 mm longer than the distance from the underside of the incus to the footplate.

5. Footplate Fenestration (Stapedotomy) / Footplate Removal (Stapedectomy):

• Stapedotomy (Modern Preferred Technique): A small hole (fenestration) measuring 0.6 to 0.8 mm in diameter is created in the posterior third of the footplate using a laser (CO2 or KTP) or a microdrill with a diamond burr. The posterior third is chosen because it is farthest from the saccule and utricle, reducing the risk of inner ear trauma.
• Stapedectomy (Older Technique): Part or all of the footplate is removed using picks and hooks. However, this technique creates a larger opening and increases the risk of perilymph leak and sensorineural hearing loss. Therefore, stapedotomy is now preferred by most surgeons.

6. Insertion and Fixation of Prosthesis: A prosthesis, slightly longer than the measured distance, is inserted and secured.

7. Flap Repositioning and Completion: The tympanomeatal flap is repositioned, and the surgery is complete.

Diagram: Steps of a Stapedotomy in the Right Ear

Diagram-Based Explanation (Steps of Stapedotomy in Right Ear)

• Image 1: Elevation of Tympanomeatal Flap and Scutum Curettage
  The procedure begins with the elevation of the tympanomeatal flap. This is followed by curetting the scutum to ensure adequate exposure. The exposure is considered sufficient when the facial nerve, pyramidal process, and round window are clearly visualised.
• Image 2: Measurement and Joint Separation
  Next, the surgeon takes precise measurements from the medial aspect of the incus to the footplate. This is followed by the separation of the incudo-stapedial joint and the sectioning of the stapedial tendon.
• Image 3 and 4: Crura Drilling and Superstructure Down-Fracture
  The surgeon then drills the posterior crura of the stapes, making the footplate visible. Following this, the remaining stapes superstructure is carefully down-fractured. During this step, the surgeon must monitor the footplate closely to prevent dislocation.
• Image 5: Fenestration of the Footplate
  Once the superstructure is removed, a fenestration (small opening) is created in the footplate.
• Image 6: Insertion and Crimping of the Piston
  Finally, a piston is inserted into the fenestration. The procedure concludes with crimping the piston to the incus, ensuring proper placement and function.

Contraindications of stapes surgery:

Absolute Contraindications:

1. Otosclerosis in the only hearing ear.
2. Age > 70 years.
3. Young children- Recurrent eustachian tube dysfunction may displace the prosthesis or cause acute otitis media.
4. Sportspersons, snorkelling, parachuting, construction workers at high altitudes, scuba divers and frequent air travellers have a risk of postoperative vertigo.
5. Patients having occupational noise exposure are susceptible to sensorineural hearing loss after surgery. 
6. Pregnancy

Relative contraindications:

1. Diabetes, active otosclerosis and eustachian tube dysfunction.
2. Active infection in the outer or middle ear, tympanic membrane perforation and exostosis 

Complications of stapes surgery:

• Conductive Hearing Loss: This can result from prosthesis displacement, incus erosion, or new bone growth.
• Sensorineural Hearing Loss (SNHL): This may occur due to surgical trauma, barotrauma, or inflammation (labyrinthitis).
• Facial Nerve Injury: Caused by overheating from the drill or incorrect local anaesthesia.
• Vertigo: Often temporary and resolves within a week.
• Incus Dislocation: This can happen during surgery or later due to pressure changes or infections.
• Taste Disturbances and Dry Mouth: Due to injury to the chorda tympani nerve.
• Dead Ear: In rare cases, permanent total hearing loss may occur, often due to reparative granuloma after surgery.

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High-Yield Points for NEET PG and University Exams

These points are frequently tested and deserve special attention.

1. Stapedotomy is preferred over stapedectomy because it creates a smaller fenestration, reducing the risk of perilymph leak and sensorineural hearing loss.
2. The posterior third of the footplate is chosen for fenestration because it is farthest from the saccule and utricle, minimising inner ear trauma.
3. The prosthesis should be 0.25 mm longer than the measured distance from the incus to the footplate to ensure adequate contact without excessive pressure.
4. Schwartze sign (reddish blush on the promontory) indicates active otosclerosis and is a relative contraindication to surgery.
5. The most common site of otosclerosis is the fissula ante fenestram, just anterior to the oval window.
6. A dead ear after stapes surgery is most often caused by reparative granuloma.
7. The chorda tympani nerve is most vulnerable during elevation of the tympanomeatal flap.
8. The facial nerve is at greatest risk during footplate manipulation because of its close proximity to the oval window.
9. Postoperative nose blowing is strictly prohibited because it can cause prosthesis displacement or perilymph leak.
10. The most common cause of recurrent conductive loss years after surgery is incus erosion from prosthesis crimping.

NEET PG-Style MCQs

1. The most common site of otosclerosis is: A. Round window B. Fissula ante fenestram C. Oval window D. Cochlear apex. Answer: B
2. A patient is being evaluated for stapedotomy. Which finding would be an absolute contraindication? A. Air-bone gap of 20 dB B. Only hearing ear C. Age 65 years D. Speech discrimination score of 70%. Answer: B
3. The ideal prosthesis length should be how much longer than the measured distance from incus to footplate? A. 0.1 mm B. 0.25 mm C. 0.5 mm D. 1.0 mm. Answer: B
4. During stapedotomy, the fenestration is created in which part of the footplate? A. Anterior third B. Posterior third C. Center D. Any part is equally safe. Answer: B
5. A patient develops profound sensorineural hearing loss 3 weeks after stapedotomy. The most likely cause is: A. Surgical trauma during footplate removal B. Reparative granuloma C. Prosthesis displacement D. Incus erosion. Answer: B
6. Which nerve is most commonly injured during tympanomeatal flap elevation? A. Facial nerve B. Chorda tympani C. Glossopharyngeal nerve D. Vagus nerve. Answer: B
7. Schwartze sign on otoscopy indicates: A. Inactive otosclerosis B. Active otosclerosis C. Cochlear otosclerosis D. Otitis media. Answer: B
8. Which of the following is an absolute contraindication for stapes surgery? A. Diabetes mellitus B. Active middle ear infection C. Age 60 years D. Air-bone gap of 15 dB. Answer: B
9. The most common cause of recurrent conductive hearing loss years after successful stapedotomy is: A. Prosthesis displacement B. Reparative granuloma C. Incus erosion D. Footplate refixation. Answer: C
10. A patient reports metallic taste on the anterior tongue after stapedotomy. Which structure is most likely injured? A. Facial nerve B. Glossopharyngeal nerve C. Chorda tympani nerve D. Hypoglossal nerve. Answer: C

Clinical Case Scenarios for Practical Exams and Viva

Case 1. A 35-year-old woman presents with progressive hearing loss in both ears over 5 years, worse on the left side. She has no history of ear infections or trauma. Otoscopy reveals normal tympanic membranes with a faint reddish blush on the left promontory. Tuning fork tests show bilateral Rinne negative at 256 Hz. Pure tone audiometry reveals an air-bone gap of 25 dB on the left and 15 dB on the right, with bone conduction thresholds within normal limits. Speech discrimination is 85% bilaterally. Most likely diagnosis: Bilateral otosclerosis with active disease on the left (Schwartze sign). Best next step: Offer left stapedotomy after confirming no contraindications. However, because the Schwartze sign indicates active disease, some surgeons may delay surgery until the disease becomes inactive. Management: Left stapedotomy under local anesthesia with preoperative counseling about risks, especially dead ear (0.5-1%).

Case 2. A 50-year-old male scuba diver reports hearing loss and tinnitus in his right ear for 3 years. Audiometry shows an air-bone gap of 30 dB with normal bone conduction. He asks about stapes surgery so he can continue diving. Most likely diagnosis: Otosclerosis. Best next step: Explain that scuba diving is an absolute contraindication to stapes surgery due to the risk of prosthesis displacement and vertigo from pressure changes. Management: Recommend a hearing aid instead of surgery. If he insists on surgery, he must permanently stop diving.

Case 3. A 28-year-old woman who is 4 months pregnant presents with progressive hearing loss and a confirmed air-bone gap of 20 dB. She desires surgical correction. Most likely diagnosis: Otosclerosis exacerbated by pregnancy. Best next step: Defer surgery until after delivery because pregnancy increases vascularity and bleeding risk. Moreover, anesthesia poses fetal risks. Management: Recommend hearing aids during pregnancy and reassess 6 months postpartum for possible stapedotomy.

Case 4. A 60-year-old man underwent uncomplicated left stapedotomy 6 months ago and had excellent hearing improvement. He now presents with a 2-week history of recurrent hearing loss in the same ear after a upper respiratory infection with forceful nose blowing. Audiometry shows a recurrent air-bone gap of 15 dB. Most likely diagnosis: Prosthesis displacement or incus dislocation due to barotrauma from forceful nose blowing. Best next step: Surgical exploration and revision stapedotomy. Management: At revision surgery, the surgeon may find a displaced prosthesis, which requires repositioning or replacement.

Case 5. A 45-year-old woman complains of persistent vertigo, fluctuating hearing loss, and a sensation of fullness in her ear 4 weeks after stapedotomy. Otoscopy reveals a normal eardrum, but the patient becomes dizzy when the ear canal is pressed (Hennebert sign positive). Most likely diagnosis: Perilymph leak from an inadequately sealed footplate fenestration. Best next step: Exploratory tympanotomy to confirm and repair the leak. Management: The surgeon will place a fat or fascia graft over the fenestration to seal the leak. Bed rest and head elevation are also prescribed.

Frequently Asked Questions in Viva

• What is the success rate of stapedotomy for otosclerosis? Stapedotomy successfully closes the air-bone gap to within 10 dB in approximately 90-95% of patients, providing significant hearing improvement.
• What is the difference between stapedectomy and stapedotomy? Stapedectomy removes the entire stapes footplate, while stapedotomy creates a small hole (fenestration) in the footplate. Stapedotomy is now preferred because it reduces complications.
• How long does it take to recover from stapes surgery? Most patients return to normal activities within 1 to 2 weeks. However, heavy lifting, straining, and air travel should be avoided for 4 to 6 weeks.
• Can stapedotomy cause complete hearing loss? Yes, in approximately 0.5% to 1% of cases, a dead ear (profound sensorineural hearing loss) can occur, most often due to reparative granuloma.
• Which prosthesis is best for stapedotomy? Teflon, platinum, and titanium prostheses are all effective. The choice depends on surgeon preference and patient anatomy.
• Is stapes surgery performed under local or general anesthesia? Most surgeons prefer local anesthesia with sedation because it allows monitoring of hearing and facial nerve function during surgery.
• Why can’t scuba divers have stapes surgery? Pressure changes during diving can displace the prosthesis or cause perilymph leak, leading to severe vertigo and hearing loss.

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of Surgery of the Ear.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Rob and smith, Textbook of Operative surgery.
• Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Gordon B. Hughes, Myles L. Pensak, H. B. Broidy. Textbook of Clinical Otology.
• Mario Sanna. Textbook of Color Atlas of Endo-Otoscopy Examination–Diagnosis–Treatment.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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