SURGICAL MANAGEMENT SURGICAL MANAGEMENT OF OTOSCLEROSISOF OTOSCLEROSIS

DR. PRIYANKA SHASTRI

HISTORYHISTORY1704 – Valsalva first described

stapes fixation1857 – Toynbee linked stapes

fixation to hearing loss1890 – Katz was first to find

microscopic evidence of otosclerosis

1893 – Politzer described the clinical entity of “otosclerosis”

The first ever stapes surgery was attempted by Kessel in 1876. He tried to mobilise the stapes by applying pressure to its head in various directions and then if fixed, removed it.

History of Otosclerosis and Stapes History of Otosclerosis and Stapes SurgerySurgeryGunnar Holmgren

◦ Father of fenestration surgery

◦ Single stage technique

Sourdille◦ Holmgren’s student◦ 3 stage procedure◦ 64% satisfactory

results

Julius Lempert◦ Popularized the

single staged fenestration procedure

John House◦ Further refined the

procedure Popularized blue lining

the horizontal canal

Samuel Rosen◦ 1953 – first

suggest mobilization of the stapes Immediately

improved hearing Problem with re-

fixation

History of Stapes SurgeryHistory of Stapes SurgeryJohn Shea

◦ 1956 – first to perform stapedectomy Oval window vein

graft Nylon prosthesis

from incus to oval window

Schuknecht 1960Wire adipose

tissue prosthesis

INDICATIONSINDICATIONSThe majority of the patient with a conductive

deafness caused by otosclerosis can be treated surgically.

Air bone gap of 25dB or more at frequencies of 250kHz to 1kHz

There should be a speech discrimination score of 60% or more for a good hearing improvement.

Patient with hearing losses in the 90-100 db range and no measurable cochlear reserve on speech discrimination may still be a canditate for operative treatment.

Surgical interventionsSurgical interventionsThe best surgical candidate

◦ good health with a socially unacceptable ABG,

◦a negative Rinne test, ◦excellent discrimination, ◦the desire for surgery after an

appropriate period of time for deliberation.

◦Younger patients are more likely to develop re-ossification of the stapes footplate over their lifetime.

CONTRAINDICATIONSCONTRAINDICATIONSIf the patient has only one hearing ear.In stapedial and cochlear otosclerosis

with a poor air-bone gap.The presence of vertigo and clinical

evidence of labyrinthine hydrops.Active foci with positive shwartze signOtits externa/ perforationConductive loss because of any other

causePoor eustachian tube function.

General medical disease.Old age-above 70 years there is a 40%

chance of discrimination becoming worse and the risk of fistula formation is greater.

In pregnancyRevision stapedectomy Second ear stapedectomy : risk of

immediate and delayed SNHL.

OUTCOMES AND BENEFITOUTCOMES AND BENEFIT Belfast rule of thumb and

Glasgow benefit plot (GBP). The Belfast rule of thumb :

patient likely to report a significant benefit if the postoperative hearing level was 30 dB or better and the interaural difference reduced to less than 15 dB

In GBP, the ear that has a hearing level better than 30 dB is considered normal or "socially acceptable", and an interaural difference of less then 10 dB is classified as symmetric

Stapes SurgeryStapes SurgeryInformed consentFailure of procedure to correct the CHL◦ Total sensorineural hearing loss occurs

0.2% of cases Less than 2% chance of further hearing loss

◦ Dizziness may occur post-operatively Usually transient and brief May persist for short time Rarely could be permanent

◦ Possible facial paralysis/palsy◦ Tinnitus ◦ Recurrent conductive hearing loss

PROCEDUREPROCEDURE

STAPEDECTOMYSTAPEDECTOMY

Total StapedectomyTotal StapedectomyFloating footplateComminuted fracture of footplatefootplate inadvertently removedRevision surgeries

STAPEDOTOMYSTAPEDOTOMY

StapedotomyStapedotomyFenestration :

posterior 1/3rd of footplate

Fisch PerforatorMicrodrillLASER

Microdrill◦ 0.7mm diamond burr

Motion of the burr removes bone dust Minimizes smoke production/surrounding

heat production

Laser◦Avoids manipulation of the footplate◦Reduced risk of resultant floating footplate◦Can fenestrate a mobile footplate◦Minimal inner ear irritation and trauma◦Reduces the risk of subluxating footplate

or fragments into vestibulum

◦ Argon and Potassium titanyl phosphate (KTP/532) Wave length 514 : argon; 532 nm for KTP Visible light Can be delivered via fibreoptic handpiece Light energy disperses rapidly allowing for

both coagulation and cutting Absorbed by hemoglobin Surgical and aiming beam

◦ Carbon dioxide (CO2) 10,000 nm Not in visible light range Readily absorbed by perilymph, collagen :

risk of heating of perilymph Less risk of inner ear trauma : loss of

energy is rapid : longer wavelength Surgical beam only

Requires separate laser for an aiming beam (red helium-neon)

YAG laserErbium yttrium aluminium garnet Shorter wavelengthRestricted optical penetration depth in

waterlimited thermal effect on surrounding tissue

Creater pressure waves : immediated bone conduction loss

Measurement◦ Lateral aspect of

the long process of the incus to the footplate

Average 4.5 mm

Oval window sealOval window sealVein (hand or wrist)Temporalis fasciaBloodFatTragal perichondriumGelfoam (now discouraged)

Classic Stapes Surgery Classic Stapes Surgery ApproachApproach1. Stapes superstructure removed2. Fenestration of footplate3. Prosthesis placement

Modified Stapes Surgical Modified Stapes Surgical ApproachApproach1. Fenestration of footplate2. Stapes superstructure removal3. Prosthesis placement

Modified Stapes Surgical Modified Stapes Surgical ApproachApproach1. Fenestration of footplate2. Prosthesis placement3. Stapes superstructure removal

Stapedectomy –vs- Stapedectomy –vs- StapedotomyStapedotomy

Stapedectomy Uses

◦ Extensive fixation of the footplate

◦ Floating footplate◦ Comminuted fractures of

footplate◦ Inadvertent removal of

footplate◦ Better gain in lower

frequencies Disadvantages

◦ Increased post-op vestibular symptoms

◦ More technically difficult◦ Increased potential for

prosthesis migration

Stapedotomy Originally for

obliterated or solid footplates

Advantages ◦ Less trauma to the

vestibule◦ Less incidence of

prosthesis migration◦ Less fixation of

prosthesis by scar tissue◦ Better high frequency

gain◦ Better postoperative

speech discrimination scores

STAMPSTAMPLaser stapedotomy minus prosthesisCases where otosclerosis affects only

the anterior part of footplatePartial mobilization of stapes footplate

with anterior crurotomy and exclusion of anterior located otosclerotic foci

Hough and Portmann

Procedure Procedure Handheld fibre

optic probe 200um attached to argon laser , bent to 30 degree ange

Laser used to vaporize anterior crus of stapes

Complete transection of crus confirmed by passing 1.5mm light angle pick

Linear stapedotomy : 0.5mm in width created acroos anterior 1/3rd of footplate

Ensure complete mobility of posterior 2/3rd of footplate

2x 3 mm ear lobe adipose tissue placed over footplate to seal perilymph space

Advantages Advantages Normal anatomyLong term high frequency hearing

improvement with little evidence of refixationPreservation of the stapedius tendon

◦ Reduction in hyperacusis◦ Reduction in risk for long-term postoperative

inner ear injuriesNo prosthesis complications3% : refixation

Stapedial tendon Stapedial tendon preservationpreservationSilverstein : 1998Decreased

hyperacusisLower complication

rates Improved

discrimination scores Increased tolerance

to high amplitude sounds : stapedial reflex

Elevated UCL after surgery

NeostapedotonyNeostapedotonyNeo-stapedotomy is the Stapes surgery in

otosclerosis with anatomical preservation of the stapedius tendon and incudostapedial joint. In the cases on whom it is possible to preserve the incudostapedial joint, which becomes a difficult job sometimes, it is named as "Classical Neostapedotomy

After finishing the stapedotomy, the head of the superstructure of stapes is brought back and kept attached with the lenticular process of the incus - stapedius tendon being attached in its original position

PROSTHESISPROSTHESIS

Vary in design Material : teflon,

steel, gold, titanium, alloys ( nitinol )

DiameterAnchorage to

long process of incus

Larger diameter of piston : greater hearing improvement in lower frequencies ( 0.4 : 0.6:0.8mm )

Heavier pistons better results in lower frequencies, lighter pistons ( teflon ) better in higher frequencies

Loose wire syndrome ( LWS )Inaccurate crimping Hearing loss, poor speech

discrimination, distortion of sound

Improvement temporarily with middle ear inflation

At revision surgery loose attachment of prostheis is found

Problems of prosthesisProblems of prosthesisErosion of incusMost likely

mechanism : fixation of prostheis to solid otic capsule bone or residual footplate

Continuous vibration of biological bone against fixed prosthesis

Prosthesis migration : Contraction of sealing material with a lifting of prosthesis from the fenestration

Contraction from adhesions

Faulty crimping of incus

Shorter prosthesis

Conductive Hearing Loss Conductive Hearing Loss Mechanism: After StapedotomyMechanism: After Stapedotomy

Collagen tissue seal contractsProsthesis lifts out of stapedotomyProsthesis migrates to fixed stapes footplate

Conductive Hearing Loss Conductive Hearing Loss Mechanism: After Mechanism: After StapedectomyStapedectomy

Collagen tissue seal contracts

Neomembrane lateralizes

Erosion of incus causing loosening of wire loop

Post operative carePost operative careKeep ears dryAvoid strenuous activities avoid air travelOral antibiotics

Problems found at Problems found at operationoperationTympanic membrane tearDamage to the chorda tympani nerveAbnormalities of the facial nerve-

dehiscences of the facial nerve.Persistent stapedial artery-found in

0.2% of operationPerilymph floodingFloating and submerged footplatePresence of blood in the vestibuleObliterative otosclerosisNarrowed oval window niche

Problems During Stapes Problems During Stapes SurgerySurgeryExposed overhanging facial nerveOccurs ~9% of stapes proceduresMay block footplate access making

completion impossibleProsthesis touching facial nerve

generally does not create problem◦May displace nerve superiorly while

performing stapedotomy

In partial obstruction the bone of the adjacent promontory can be drilled with an 8-mm diamond drill and a stapes prosthesis can be inserted.

If the nerve abuts the promontory inferior to oval window, surgery should not be completed.

Sx can be completed by drilling a small fenestra that includes inferior aspect of annular ligament

Floating FootplateFloating FootplateFootplate that is irretrievably depressed into

vestibule◦ Usually iatrogenic◦ Incidental finding

Prevention◦ Laser◦ Footplate control hole

Management◦ Abort◦ Proceed

Total stapedectomy Laser fenestration/microdrill fenestration Burr hole created inferior to annular ligament and

footplate elevated with hook Opening sealed with tissue graft

Diffuse Obliterative Diffuse Obliterative OtosclerosisOtosclerosis Occurs when footplate,

annular ligament, and oval window niche are involved

Laser not efficient Fenestration achieved by

first saucerizing the obliterated niche and thinning obstructing bone

Fenestration made with 0.7mm microdrill

Closure of air-bone gap < 10 dB less common

Refixation commonly occurs

ROUND WINDOW OTOSCLEROSISROUND WINDOW OTOSCLEROSIS

About 1% complete(Shuknecht)

If complete: Abandon surgery

If incomplete or not sure:Do not remove bone and proceed

Malleus ankylosisMalleus ankylosis

Rare problem 0.5%Malleus head can be ankylosed to the

wall or roof of epitympanumCan be associated with myringosclerosisMust always check mobility of each

ossicle independantlyRemove incus and head of head of

malleus, reconstruction ewith maleus attachment prosthesis

Perilymph GusherPerilymph Gusher Profuse flow of perilymph immediately upon

opening vestibule

Rare – 0.03% incidenceAssociated with congenital footplate fixationPossibly due to:

◦ Widened vestibular aqueduct◦ Defect in IAC fundus

Management◦ Tissue graft over oval window◦ Complete stapedectomy using vein tissue graft or

perichondrium◦ Consider lumbar drain

Persistent stapedial arteryPersistent stapedial arteryIf persistent : arises from internal

carotid artery Often occupies anterior half of

footplateFenestration done in posterior

half

Intraoperative vertigoIntraoperative vertigo

Causes◦Prosthesis too long◦Checking prosthesis mobility

Management ◦Shorter prosthesis (try 0.25mm

shorter piston)

Tympanic membrane Tympanic membrane perforationperforationMay occur during elevation of

tympanomeatal flap Does not preclude completion of

operationRepair involves myringoplasty or

tympanoplasty with either synthetic material or autologous tissue

Chorda Tympani damageChorda Tympani damageOccurs ~30% of cases due to

nerve stretching/mobilizationCauses temporary (3-4 months)

◦Dry mouth◦Tongue soreness◦Metallic taste

Symptoms less severe with sectioning of nerve

Post-operative Post-operative ComplicationsComplicationsSensorineural Hearing LossMost devastating complication of

stapes surgeryRanges from mild to total loss or may

be isolated to high frequencies<1% - 3% incidence of profound

permanent SNHL◦ Surgeon experience◦ Extent of disease

Cochlear, obliterative◦ Prior stapes surgery

Temporary◦ Serous labyrinthitis◦ Reparative granuloma

Permanent (0.2%)◦ Suppurative labyrinthitis◦ Adhesion formation in vestibulum◦ Acoustic trauma : extensive drilling/ bone

fragments◦ Vascular compromise◦ Sudden drop in perilymph pressure◦ Sudden release of enzymes into inner ear from

active foci

Immediate Average loss of

20dB or more1.5% :

stapedectomyExcessive

perilymph loss

Delayed1.Sudden onset2.Chronic

progressive

Conductive hearing lossConductive hearing lossImmediate Malfunctioning prosthesis : too

short, improper crimpingUnrecognized malleus fixationUnrecognized round window

obliterationMiddle ear effusionUnrecognized sscd

Recurrent Conductive Recurrent Conductive Hearing LossHearing LossSlippage or displacement of the

prosthesis◦ Most common cause of failure◦ Immediate

Technique Trauma

◦ Delayed Slippage from incus narrowing or erosion Adherence to edge of oval window niche Stapes re-fixation Progression of disease with re-obliteration of oval

window Malleus or incus ankylosis

Recommendations ◦ Laser stapedotomy◦ Teflon/platinum stapedotomy prosthesis◦ Prosthesis 0.25mm longer than distance

between incus undersurface and footplate◦ Clotted blood oval window seal◦ Minimize mechanical trauma◦ Use tissue seal

Perilymph gusher Footplate fracture When stapedotomy too large

VertigoVertigoMore common with stapedectomy

than stapedotomy◦ Due to serous labyrinthits

Occurs ~5% of casesRarely prolonged or severeUsually lasts a few hours to one week

◦ Rapidly subsidesSupportive management

Intraoperative or immediately post-op:

lasts up to 1 week without intervention◦ Inner ear trauma

Prosthesis/instrument contact with membranous labyrinth (utricular macula)

Perilymph aspirationIsolated delayed vertigo

◦ Trauma to otolith organs creating BPPV-like picture

◦ Perilymphatic fistula

Perilymph FistulaPerilymph FistulaPrimary / secondaryRare complication after stapes

surgeryPresents with:

◦Vague unsteadiness◦Vertigo◦Tinnitus◦Fluctuant hearing impairement◦Positive fistula test◦Nystagmus with fast component away

from the affected ear

Mechanism of Post-operative Mechanism of Post-operative Perilymph Fistula: StapedotomyPerilymph Fistula: Stapedotomy

Incus medially displaced by contracture adhesions between incus and promontory

Prosthesis medializes into vestibule

Mechanism of Post-operative Mechanism of Post-operative Perilymph Fistula: Perilymph Fistula: StapedectomyStapedectomy

Prosthesis migration from center to edge of oval window

Vibration tears weaker shortened edge of membrane

PrimaryImmediateDysequilibrim

which is persisting in days following surgery

Breif episodes of vertigo continuing over long periods

SecondaryMonths to yrsChange of

hearing which occurs after an interval of months to yrs

Conductive loss

PreventionOval window

covered with vein graft

Avoid1.Nose blowing2.Mouth kept open

while sneezing3.Flying4.Swimming diving5.Lifting of heavy

weights

Management TympanotomyFistulous tract

excisedRemove prosthesis

carefully → tissue seal the oval window → prosthesis replaced

TinnitusPossibly related to serous

labyrinthitisManagement

◦Reassurance◦Routine tinnitus measures

Facial paralysis/palsyFacial paralysis/palsy

ImmediateLocal

anesthesia/Local trauma

Should recover within few hrs

Oral corticosteroids

Delayed0.5%5-20 days

following surgeryResolves in 1-2

mothsManagement :

similar to bells palsy

Reparative granulomaReparative granulomaVery rarePatient presentation

◦ Initial hearing improvement followed by gradual/sudden deterioration over 1 to 6 weeks

◦ Reddish discoloration in posterosuperior quadrant

◦ Vertigo, tinnitus◦ Nystagmus to nonoperated side◦ Mixed hearing loss with decreased speech

discrimination scores

EtiologyTissue reaction 1. to glove powder2. Sealing material3. ProsthesisOveruse of lasersOtoscopy : edmea,

thickening and hyperemia of skin flaps and TM

Management ◦ Granuloma

removal◦ Revision surgery◦ Conservative

management with steroids and antibiotics

Meningitis and suppurative Meningitis and suppurative labyrinthitislabyrinthitis

Creation of fistula introduces route for potential meningitis

Since the inner ear is opened during surgery, potential risk for microbial colonization

Loss of hearing with or without meningitis

Revision surgeryRevision surgeryDelayed or

immediate postop conductive hearing loss

Dizziness and unsteadiness being caused by excessively long prosthesis

Sypmtoms of perilymph fistula

Prosthesis malfunction

Prosthesis displacement from oval window

Short prosthesisMalleus fixation

Lenticular process/ long process eroded : replacement prosthesis : remnant of incus to the vestibule

If incus remnant not suitable : malleus grip prosthesis

Fixed malleus head : malleus attachment prosthesis : attached to manubrium : malleus head separated using malleus nipper

Lasers valuable in revision surgeries

Divide adhesions, mucosal folds and soft tissue surrounding the prosthesis

Lower succes rates : AB closure to 10dB : 60-80%

Cochlear implantationProfound b/l snhlAdvanced otosclerosis

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