History Of Stapes Surgery And Recent Concepts

Dr Yasha GuptaLADY HARDINGE MEDICAL COLLEGE

History of Otosclerosis and Stapes Surgery

• 1704 – Valsalva first described stapes fixation

• 1857 – Toynbee linked stapes fixation to hearing loss• 1890 – Katz was first to find microscopic evidence of otosclerosis• 1893 – Politzer described the clinical entity of “Otosclerosis”

History of Otosclerosis and Stapes Surgery

• 1878 – Kessel reported transtympanic mibilization and removal of stapes

• Blake(1892) and Jack(1893) removed stapes and observe hearing improvement

• At this time no attempt was made to seal oval window or reconstruct ossicular chain

• At 6th international otologic congress held in london (1899) these surgeries were condemned

History of Otosclerosis and Stapes Surgery

• Gunnar Holmgren(1930)– Father of fenestration

surgery– Single stage technique

• Sourdille– Holmgren’s student– Multistage procedure– 64% satisfactory results

History of Otosclerosis and Stapes Surgery

• Julius Lempert– Popularized the single

staged fenestration procedure

History of Otosclerosis and Stapes Surgery

• Samuel Rosen(1952)

• reintroduced mobilization of the stapes

• Immediate improvement in hearing

• Re-fixation

History of Otosclerosis and Stapes Surgery

• John Shea(1956)

• First to perform stapedectomy and introduced concept of ossicular chain reconstruction

• Oval window vein graft• Teflon prosthesis

History of Otosclerosis and Stapes Surgery

• Portman and Claverie(1957)suprastructure of stapes for bridging the gap

Types of OtosclerosisA. Stapedial

B. Cochlear: otosclerotic focus over-

Round window

Promontory

C. Mixed: Stapedial + Cochlear

D. Malignant: rapidly progressing cochlear lesion with severe

sensori-neural deafness.

Types of Stapedial Otosclerosis1. Anterior focus (commonest): anterior to oval window

2. Posterior focus: behind oval window

3. Circumferential: involves footplate margin only

Types of Stapedial Otosclerosis4. Biscuit type: footplate involved, margin is free

5. Obliterative: obliterates oval window completely

STAPES SURGERY

Stapedectomy StapedotomySTAMP (STApedotomy Minus Prosthesis) or Stapedioplasty

SURGERY• Indications: - Air bone gap 25dB or more at 250 Hz to 1 kHz and

negative rinne at 512- B/l worse ear operated first

• Contraindication:- Patients with vestibular symptoms and

meniers disease(relative contraindication)- Infected middle or external ears- Perforation of TM- Only hearing ear

STAPEDECTOMY

Stapedectomy• Indications– Floating footplate– Comminuted fracture of the footplate– Footplate inadvertentaly removed– Revision surgery

• Disadvantages– Increased post-op vestibular symptoms–More technically difficult– Increased potential for prosthesis migration

Oval window seal

• Tragal perichondrium• Vein (hand or wrist)• Temporalis fascia• Blood• Fat

Prosthesis

• Recentaly introduced shape memory alloy recoverable technology(SMART) piston prosthesis makes use of the elastic memory of a nitilon metallic wire that coils around incus in response to heating

• Platinum ribbon type most commonly used prosthesis

Placement of the Prosthesis

• Prosthesis is chosen and length picked

• Some prefer bucket handle to incorporate the lenticular process of the incus

Stapedotomy

STAPEDOTOMY

Drill Fenestration

• Size of fenestra is dependent on prosthesis

• Diamond burr

Laser Fenestration• First laser stapedotomy performed by

Perkins in 1978– Cut and coagulate with great precision– Less trauma to the vestibule– Less incidence of prosthesis migration– Less fixation of prosthesis by scar tissue

Laser Fenestration• TYPES –– Argon and Potassium titanyl phosphate

(KTP)• Wave length 500 nm• Convenient not required separate aiming beam

– Carbon dioxide (CO2)• 10,000 nm• Not absorbed in perilymph• Separate aiming beam• Requirement of microscope attached delivery

system• Recently hand held, flexible CO2 delivery

system

Stapedectomy vs Stapedotomy

• Better low frequency hearing gain

• Occurrence, duration and severity of vestibular symptoms are greater

• Better high frequency hearing gain

• Decreased perilymphatic fistula

• Decreased SNHL• Decreased Vertigo

STAMP

• Preservation of the stapedius tendon– Reduction in hyperacusis– Reduction in risk for long-term

postoperative inner ear injuries

• No prosthesis complications• Difficult technique

STAMP

COMPLICATIONS OF SURGERY

• Overhanging facial nerve

• Floating footplate• Diffuse

obliterative otosclorosis

• Perilymphatics Gusher

• SNHL

• Round window closure

• Recurrent CHL• Regenerative

granuloma• Vertigo

DR. RS MEHTA, BPKIHS

Overhanging Facial Nerve• Usually dehiscent• Consider aborting the procedure• Facial nerve displacement (Perkins, 2001)– Facial nerve is compressed superiorly with No.

24 suction (5 second periods)– 10-15 sec delay between compressions– Perkins describes laser stapedotomy while

nerve is compressed• Wire piston used– Add 0.5 to 0.75 mm to accommodate curve

around the nerve

Floating Footplate• Footplate dislodges from the

surrounding OW niche– Incidental finding– More commonly iatrogenic

• Prevention– Laser– Footplate control hole

• Management– Abort– H. House favors promontory

fenestration and total stapedectomy– Perkins favors laser fenestration

Diffuse Obliterative Otosclerosis

• Occurs when the footplate, annular ligament, and oval window niche are involved

• Laser not efficient • Fenestration can be

achieved after saucerizing the obliterated niche

• Refixation commonly occurs

Perilymphatic Gusher• Associated with patent cochlear aqueduct• Increased incidence with congenital

stapes fixation• Increases risk of SNHL• Management– Rapid placement of the oval window seal then

the prosthesis– Head of bed elevated, bed rest, avoid Valsalva,

+/- lumbar drain

Round Window Closure• No effect on

hearing unless 100% closed

• Opening has a high rate of SNHL so contraindicated

• Residual conductive hearing loss

SNHL• 1%-3% incidence of profound permanent SNHL

– Surgeon experience– Extent of disease

• Cochlear– Prior stapes surgery

• Temporary– Serous labyrinthitis– Reparative granuloma

• Permanent– Suppurative labyrinthitis– Extensive drilling– Basilar membrane breaks– Vascular compromise– Sudden drop in perilymph pressure

Reparative Granuloma• Granuloma formation in reaction to surgery, a

foreign body(e.g surgical glove powder, gelfoam, prosthesis)

• 5th to 15th day after surgery• Initial good hearing results followed by an increase

in the high frequency bone line thresholds• Associated tinnitus, nystagmus and vertigo• Otoscopy – edema, thickening and hyperemia of

the skin flaps and tympanic membrane• Treatment

– Immediate reexploration– Removal of granulation tissue and prosthesis– Steroids

• Prognosis – return of hearing with early intervention

Vertigo• Most commonly short lived (2-3 days)• More prolonged after stapedectomy

compared to stapedotomy– Due to serous labyrinthitis

• Medialization of the prosthesis into the vestibule–With or without perilymphatic fistula

• Reparative granuloma

Conductive Hearing Loss– Immediate conductive loss:

• Malfunctioning prosthesis• Unrecognized malleous fixation• Unrecognized round window obliteration• Middle ear effusion• Unrecognized SSCD

– Recurrent conductive HL• Slippage from incus narrowing or erosion(64%)• Malpositioned prosthesis(41%)• Bony or fibrous regrowth at oval window area(14%)• Round window obliteration(23%)