If the stapes footplate is fixed in position, rather than being normally mobile, the result is a conductive hearing loss. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the temporal bone called otosclerosis. The second is a congenital malformation of the stapes.[1][2][3]
In both of these situations, it is possible to improve hearing by removing the stapes bone and replacing it with a micro prosthesis – creating a small hole in the fixed stapes footplate and inserting a tiny, piston-like prosthesis. The results of this surgery are generally most reliable in patients whose stapes has lost mobility because of otosclerosis. Nine out of ten patients who undergo the procedure will come out with significantly improved hearing while less than 1% will experience worsened hearing acuity or deafness. Successful surgery usually provides an increase in hearing acuity of about 20dB. However, most of the published results of success fall within the speech frequency of 500Hz, 1000Hz and 2000Hz; poorer results are typically obtained in the high frequencies, but these are normally less hampered by otosclerosis in the first place.[4]
Stapedectomy process and results
Stapedectomy has success rates ranging from 80% to 95%.[5][6]
Stapedectomy closes what is called the "air bone gap" very efficiently, meaning it restores efficient conduction of sound coming through the air close to the level of the best ability of the nerve cells to perceive the sound.[7]
It takes 30 minutes to 90 minutes depending on skills and experience of the surgeon and the presence of difficult or easy anatomical access to the stapes.[8]
Stapedectomy is performed under either local or general anesthesia depending on the preference of the surgeon.[6]
Most surgeons do not make any skin incisions, especially when the surgery is performed with an endoscope.[9] However, sometimes the ear canal is so small that an incision is needed.[9]
Indications
Indications of stapedectomy:
Conductive hearing loss (due to fixation of stapes).
Air bone gap of at least 30dB.
Presence of Carhart's notch in the audiogram of a patient with conductive hearing loss (relative)
Good cochlear reserve as assessed by the presence of good speech discrimination.[10]
Contraindications
Contraindications for stapedectomy:
Poor general condition of the patient.
Only hearing ear.
Poor cochlear reserve as shown by poor speech discrimination scores
Patient with tinnitus and vertigo
Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign.
When a stapedectomy is done in a middle ear with a congenitally fixed footplate, the results may be excellent but the risk of hearing damage is greater than when the stapes bone is removed and replaced (for otosclerosis). This is primarily due to the risk of additional anomalies being present in the congenitally abnormal ear. If high pressure within the fluid compartment that lies just below the stapes footplate exists, then a perilymphatic gusher may occur when the stapes is removed. Even without immediate complications during surgery, there is always concern of a perilymph fistula forming postoperatively.
In 1995, Glasscock et al. published a 25-year single-centre review of over 900 patients who underwent stapedectomy and stapedotomy and found complications rates as follows: reparative granuloma 1.3%, tympanic membrane perforation 1.0%, total sensorineural hearing loss 0.6%, partial sensorineural hearing loss 0.3%, and vertigo 0.3%. In this series, there was no incidence of facial nerve paralysis or tinnitus.[6]
Stapedotomy
A modified stapes operation, called a stapedotomy, is thought by many otologic surgeons to be safer and reduce the chances of postoperative complications. In stapedotomy, instead of removing the whole stapes footplate, a tiny hole is made in the footplate – either with a microdrill or with a laser,[7] and a prosthesis is placed to touch this area, oval window. This procedure can be further improved by the use of a tissue graft seal of the fenestra, which is now common practice.[5]
Laser stapedotomy is a well-established surgical technique for treating conductive hearing loss due to otosclerosis. The procedure creates a tiny opening in the stapes (the smallest bone in the human body) in which to secure a prosthetic. The CO2 laser allows the surgeon to create very small, precisely placed holes without increasing the temperature of the inner ear fluid by more than one degree, whilst decreasing the risk of footplate fracture, making this an extremely safe surgical solution.[8] The hole diameter can be predetermined according to the prosthesis diameter. Treatment can be completed in a single operation visit using anesthesia, normally followed by one or two nights' hospitalization with subsequent at-home recovery time a matter of days or weeks.
Stapedectomy vs. stapedotomy
Comparisons have shown stapedotomy to yield either as good[13] or better[14] results than stapedectomy (measured by hearing improvement and reduction in the air-bone hearing gap, and especially at higher sound frequencies), and to be less prone to complications.[15] In particular, stapedotomy procedure greatly reduces the chance of a perilymph fistula (leakage of cochlear fluid).[5]
Stapedotomy, like stapedectomy, can be successful in the presence of sclerotic adhesions (tissue growths abnormally linking the bones to the tympanic cavity), provided the adhesions are removed during surgery. However, the adhesions may recur over time. The stapedotomy method is not applicable in those relatively rare cases that involve sclerosis of the entire ossicular chain.
Endoscopic view of the stapedotomy in the footplate of the stapes boneEndoscopic view of the piston inserted into the stapedotomy and on to the long processof the incus
Because it is a simpler and safer procedure, stapedotomy is normally preferred to stapedectomy in the absence of predictable complications. However, the success rate of either surgery depends greatly on the skill and the familiarity with the procedure of the surgeon.[5] Furthermore, a major success factor in both surgeries is correctly determining the length of the prosthesis.[16]
Endoscopic Stapedotomy
In 1999, Professor Tarabichi described his experience with stapedotomy performed using the endoscope without the need for bone removal or skin incision (endaural approach).[9] Since then, endoscopic stapedotomy has been gaining popularity especially amongst younger endoscopically trained surgerons. It allows for better view of the footplate of the stapes without the need to remove bone which is very common when doing the procedure with microscope.[17] Professor Patel and his Australian team published a relatively large cohort of patients undergoing endoscopic stapedotomy procesure with closure of air-bone gape within 20dB in 98.6%.[18]
History
The world's first stapedectomy is credited to Dr. John J.Shea Jr. who performed it in May 1956 on a 54-year-old housewife who could no longer hear even with a hearing aid.[19] Significant contributions to modern stapedectomy techniques were then made by the late Dr. Antonio De La Cruz of the House Ear Institute in Los Angeles; by the late Professor Henri André Martin of the Hôpital Edouard Herriot in Lyon, France, including calibrated platinotomy (stapes footplate rather than whole surgery) and trans-footplate piston surgery that also paved the way for modern stapedotomy;[20] and by the late Dr. Jean-René Causse of the eponymous clinic in Béziers, France, who pioneered the use of Teflon piston prostheses (also critical progress for stapedotomy) and, with his late son Dr. Jean-Bernard Causse, the reattachment of the stapedius muscle alongside the use of veinous grafts.[21][22] in 1999, Professor Tarabichi of the Tarabichi Stammberger Ear and Sinus Institute, reported his experience performing the surgery using endoscope which lessens the need to remove bone to obtain access to the stapes.[9]
↑ Raman R (1983). "Poor High Frequency Results Following Total Stapedectomy Theoretical Considerations". Indian Journal of Otolaryngology and Head & Neck Surgery. 35 (1): 9–11. doi:10.1007/BF02992304.
1 2 3 4 De Souza C, Glasscock ME (2004), Otosclerosis and Stapedectomy, New York, NY: Thieme, ISBN1-58890-169-6
↑ Dawes, J. D. K.; Welch, A. R. (1985), Marquet, Jean F. E. (ed.), "Complications of stapedectomy", Surgery and Pathology of the Middle Ear: Proceedings of the International Conference on ‘The Postoperative Evaluation in Middle Ear Surgery’ held in Antwerp on June 14–16, 1984, Dordrecht: Springer Netherlands, pp.201–205, doi:10.1007/978-94-009-5002-3_49, ISBN978-94-009-5002-3, retrieved 2022-03-27
↑ Sedwick JD, Louden CL, Shelton C (February 1997). "Stapedectomy vs stapedotomy. Do you really need a laser?". Archives of Otolaryngology–Head & Neck Surgery. 123 (2): 177–80. doi:10.1001/archotol.1997.01900020059008. PMID9046285.
↑ Motta G, Ruosi M, Motta S (April 1996). "[Stapedotomy vs stapedectomy. Comparison of hearing results]". Acta Otorhinolaryngologica Italica (in Italian). 16 (2 Suppl 53): 36–41. PMID8928670.
↑ Thamjarayakul T, Supiyaphun P & Snidvongs K, "Stapes fixation surgery: Stapedectomy versus stapedotomy", Asian Biomedicine, 4(3): 429–434, 2010.
↑ Pauw BK, Pollak AM, Fisch U (December 1991). "Utricle, saccule, and cochlear duct in relation to stapedotomy. A histologic human temporal bone study". The Annals of Otology, Rhinology, and Laryngology. 100 (12): 966–70. doi:10.1177/000348949110001203. PMID1746843. S2CID20656876.
The LION Foundation's Live International Otolaryngology Network offers annual symposia geared for continuing education of practicing surgeons, and subsequently available via streaming internet.
Overview of Otosclerosis and Stapedectomy
Balasubramanian T (2006). "Stapedectomy". Retrieved 2007-07-03. - details of the procedure with pictures
Amanda Jenner, Lynne Shields PhD ccc-slp "Speech and Language Issues"
M. Hawthorne, FRCS-ENT Surgeon. "Hearing Impairment and EDS"
Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Cholesteatomas are not cancerous as the name may suggest, but can cause significant problems because of their erosive and expansile properties. This can result in the destruction of the bones of the middle ear (ossicles), as well as growth through the base of the skull into the brain. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal.
The stapes or stirrup is a bone in the middle ear of humans and other animals which is involved in the conduction of sound vibrations to the inner ear. This bone is connected to the oval window by its annular ligament, which allows the footplate to transmit sound energy through the oval window into the inner ear. The stapes is the smallest and lightest bone in the human body, and is so-called because of its resemblance to a stirrup.
A cochlear implant (CI) is a surgically implanted neuroprosthesis that provides a person who has moderate-to-profound sensorineural hearing loss with sound perception. With the help of therapy, cochlear implants may allow for improved speech understanding in both quiet and noisy environments. A CI bypasses acoustic hearing by direct electrical stimulation of the auditory nerve. Through everyday listening and auditory training, cochlear implants allow both children and adults to learn to interpret those signals as speech and sound.
Otosclerosis is a condition of the middle ear where portions of the dense enchondral layer of the bony labyrinth remodel into one or more lesions of irregularly-laid spongy bone. As the lesions reach the stapes the bone is resorbed, then hardened (sclerotized), which limits its movement and results in hearing loss, tinnitus, vertigo or a combination of symptoms. The term otosclerosis is something of a misnomer: much of the clinical course is characterized by lucent rather than sclerotic bony changes, so the disease is also known as otospongiosis.
Otology is a branch of medicine which studies normal and pathological anatomy and physiology of the ear as well as their diseases, diagnosis and treatment. Otologic surgery generally refers to surgery of the middle ear and mastoid related to chronic otitis media, such as tympanoplasty, or ear drum surgery, ossiculoplasty, or surgery of the hearing bones, and mastoidectomy. Otology also includes surgical treatment of conductive hearing loss, such as stapedectomy surgery for otosclerosis.
Microtia is a congenital deformity where the auricle is underdeveloped. A completely undeveloped pinna is referred to as anotia. Because microtia and anotia have the same origin, it can be referred to as microtia-anotia. Microtia can be unilateral or bilateral. Microtia occurs in 1 out of about 8,000–10,000 births. In unilateral microtia, the right ear is most commonly affected. It may occur as a complication of taking Accutane (isotretinoin) during pregnancy.
A bone-anchored hearing aid (BAHA) is a type of hearing aid based on bone conduction. It is primarily suited for people who have conductive hearing losses, unilateral hearing loss, single-sided deafness and people with mixed hearing losses who cannot otherwise wear 'in the ear' or 'behind the ear' hearing aids. They are more expensive than conventional hearing aids, and their placement involves invasive surgery which carries a risk of complications, although when complications do occur, they are usually minor.
The round window is one of the two openings from the middle ear into the inner ear. It is sealed by the secondary tympanic membrane, which vibrates with opposite phase to vibrations entering the inner ear through the oval window. It allows fluid in the cochlea to move, which in turn ensures that hair cells of the basilar membrane will be stimulated and that audition will occur.
A perforated eardrum is a hole in the eardrum. It can be caused by infection, trauma, overpressure, inappropriate ear clearing, and changes in middle ear pressure. An otoscope can be used to view the eardrum to diagnose a perforation. Perforations may heal naturally, or require surgery.
Functional endoscopic sinus surgery (FESS) is a procedure that is used to treat sinusitis and other conditions that affect the sinuses. Sinusitis is an inflammation of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose.
A mastoidectomy is a procedure performed to remove the mastoid air cells, air bubbles in the skull, near the inner ears. This can be done as part of treatment for mastoiditis, chronic suppurative otitis media or cholesteatoma. In addition, it is sometimes performed as part of other procedures or for access to the middle ear. There are classically 5 different types of mastoidectomy:
Neurotology or neuro-otology is a subspecialty of otolaryngology—head and neck surgery, also known as ENT medicine. Neuro-otology is closely related to otology, clinical neurology and neurosurgery.
Tympanosclerosis is a condition caused by hyalinization and subsequent calcification of subepithelial connective tissue of the tympanic membrane and middle ear, sometimes resulting in a detrimental effect to hearing.
In the auditory system, the columella contributes to hearing in amphibians, reptiles and birds. The columella form thin, bony structures in the interior of the skull and serve the purpose of transmitting sounds from the eardrum. It is an evolutionary homolog of the stapes, one of the auditory ossicles in mammals.
In medicine, an ossicular replacement prosthesis is a device intended to be implanted for the functional reconstruction of segments of the ossicles and facilitates the conduction of sound waves from the tympanic membrane to the inner ear. There are two common types of ossicular replacement prostheses, the total ossicular replacement prosthesis (TORP) and partial ossicular replacement prosthesis (PORP). A TORP replaces the entire ossicular chain while a PORP replaces only the incus and malleus but not the stapes. Indications for use of an ossicular replacement prosthesis include:
A persistent stapedial artery (PSA) is a rare anomaly in human anatomy where the stapedial branch of posterior auricular artery, or simply stapedial artery, remains within the ear of a fetus after the first ten weeks of pregnancy. Whilst not problematic for the majority of people with the anomaly, it can cause difficulties with hearing.
Endoscopic ear surgery (EES) is a minimally invasive alternative to traditional ear surgery and is defined as the use of the rigid endoscope, as opposed to a surgical microscope, to visualize the middle and inner ear during otologic surgery. During endoscopic ear surgery the surgeon holds the endoscope in one hand while working in the ear with the other. To allow this kind of single-handed surgery, different surgical instruments have to be used. Endoscopic visualization has improved due to high-definition video imaging and wide-field endoscopy, and being less invasive, EES is gaining importance as an adjunct to microscopic ear surgery.
Eustachian tube dysfunction (ETD) is a disorder where pressure abnormalities in the middle ear result in symptoms.
Muaaz Tarabichi is a Syrian otolaryngologist, lecturer, researcher, and author. He is recognized around the world as the father of endoscopic ear surgery. He is the co-founder of Tarabichi Stammberger Ear and Sinus Institute. He was elected as the chairman of the International Advisory Board of the American Academy of Otolaryngology–Head and Neck Surgery.
A middle ear implant is a hearing device that is surgically implanted into the middle ear. They help people with conductive, sensorineural or mixed hearing loss to hear.
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