Stapedectomy

Stapedectomy 101 - Stirrup Solutions

Surgical procedure: stapes removal (stapedotomy/stapedectomy) & prosthesis insertion for conductive hearing loss (CHL).

• Primary Indication:
  • Otosclerosis: fixed stapes causing CHL.
• Key Contraindications:
  • Only hearing ear.
  • Active middle/external ear infection.
  • Poor cochlear reserve (significant SNHL).
  • Meniere's disease (active/uncontrolled).
  • Pregnancy (relative; often deferred).

⭐ Otosclerosis classically affects young adults (20-40 yrs), causing bilateral progressive CHL, often with family history & Carhart's notch (dip at 2000 Hz) on audiogram.

Pre-Op Assessment - Case Unmasking

• History & Exam: Exclude other CHL. Family Hx. Schwartze's sign (active otospongiosis). Rinne -ve.
• Audiometry:
  • PTA: CHL/Mixed HL. Air-bone gap > 20-25dB.
  • Carhart's notch: BC dip, classically at 2kHz.
  • Tympanometry: Type A/As. Good SDS.
• HRCT Temporal Bone:
  • Confirms diagnosis: footplate thickening, 'halo sign'.
  • Rules out anomalies; assesses round window.

⭐ The 'halo sign' or 'double ring sign' on HRCT around the stapes footplate is highly suggestive of fenestral otosclerosis.

• Patient Selection:

Surgical Steps - Microscopic Marvels

• Approach & Exposure: Endaural/Postaural incision. Tympanomeatal (TM) flap elevated for middle ear access.
• Stapes Preparation: Posterior scutum curettage. Incudostapedial (IS) joint disarticulated. Stapedius tendon divided. Stapes superstructure removed.
• Footplate Management:
  • Stapedotomy: Preferred. Small fenestra (0.6-0.8 mm) created in fixed footplate.
  • Stapedectomy: Partial or total removal of stapes footplate.
• Reconstruction: Prosthesis (e.g., Teflon, Titanium; length 4.0-5.0 mm) placed between incus long process and oval window (fenestra).
• Sealing & Closure: Oval window sealed (vein graft, fascia, perichondrium). TM flap repositioned. Ear canal packed.

⭐ Stapedotomy (small hole in footplate) is preferred over stapedectomy (total footplate removal) due to ↓ risk of sensorineural hearing loss and labyrinthine complications.

Prosthesis Parade - Piston Picks

Aftermath & Alerts - Healing & Hazards

• Post-op Care:

  • Bed rest 24-48 hours, head elevated.
  • Avoid straining, vigorous nose blowing, air travel, heavy lifting for 4-6 weeks.
  • Keep ear dry (water precautions); prophylactic antibiotics, analgesia.
  • Hearing improvement is gradual as gelfoam/packing dissolves.

• Complications Table:

  Timing	Complication	Key Signs	Management Snippet
  Intraop	Perilymphatic Fistula (PLF)	Sudden SNHL, vertigo	Immediate seal (fat/fascia), bed rest
  	Facial Nerve Injury	Ipsilateral facial weakness	Steroids, observation; ?decompression
  Early Postop	Dysgeusia, Vertigo	Altered taste, dizziness	Reassurance, anti-vertigo medication
  	Graft/Prosthesis Displacement	Conductive Hearing Loss (CHL)	Observation, ?revision surgery
  Late Postop	Reparative Granuloma	Progressive SNHL, otalgia	Steroids, surgical excision
  	Prosthesis Migration/Necrosis	Recurrent CHL	Revision stapedectomy

⭐ Most common cause for stapedectomy revision: Prosthesis displacement or migration.

High‑Yield Points - ⚡ Biggest Takeaways

• Primary Indication: Otosclerosis causing conductive hearing loss (CHL) with a characteristic Carhart's notch.
• Key Contraindications: Active ear infection, Meniere's disease, or if it's the patient's only hearing ear.
• Prosthesis Materials: Commonly Teflon, stainless steel, titanium, or platinum.
• Most Common Complication: Persistent CHL; Sensorineural hearing loss (SNHL) is a serious adverse event.
• Carhart's Notch: Audiometric dip in bone conduction (typically at 2000 Hz), which disappears after successful surgery.
• Other Serious Risks: Vertigo, facial nerve injury, and perilymphatic fistula (PLF).