Otosclerosis <ul><li>Dr  S.K. PRADHAN </li></ul><ul><li>I.M.S.BHU </li></ul>
 
Introduction <ul><li>Otosclerosis  </li></ul><ul><ul><li>Primary metabolic bone disease of the otic capsule and ossicles. ...
History of Otosclerosis and Stapes Surgery <ul><li>1704 –  Valsalva  first described stapes    fixation </li></ul><ul><li>...
History of Otosclerosis and Stapes Surgery <ul><li>Gunnar Holmgren  (1923) </li></ul><ul><ul><li>Father of fenestration su...
History of Otosclerosis and Stapes Surgery <ul><li>Julius Lempert </li></ul><ul><ul><li>Popularized the single staged fene...
History of Otosclerosis and Stapes Surgery <ul><li>Fenestration procedure for otosclerosis </li></ul><ul><ul><li>Fenestrat...
History of Otosclerosis and Stapes Surgery <ul><li>Samuel Rosen </li></ul><ul><ul><li>1953 – first suggest mobilization of...
History of Otosclerosis and Stapes Surgery <ul><li>John Shea </li></ul><ul><ul><li>1956 – first to perform stapedectomy </...
Epidemiology <ul><li>Prevalence </li></ul><ul><li>histologic otosclerosis- 3.5%  </li></ul><ul><li>clinically significant ...
Aetiology <ul><li>Autosomal dominant </li></ul><ul><li>Hereditary in 70% of cases </li></ul><ul><li>1% Caucasians with sym...
Aetiology- Measles?
Pathophysiology <ul><ul><li>Inciting event unknown </li></ul></ul><ul><ul><ul><li>Hereditary, endocrine, metabolic, infect...
Pathology <ul><li>Two phases of disease </li></ul><ul><ul><ul><li>Active (otospongiosis phase) </li></ul></ul></ul><ul><ul...
Pathology <ul><li>Sites involved- </li></ul><ul><ul><ul><li>Anterior to oval window  ( Fissula ante fenestrum ) 90% </li><...
Non-clinical foci of otosclerosis
Anterior footplate involvement
Annular ligament involvement
Bipolar involvement of the footplate
Round Window
Biscuit footplate
Pathophysiology of <ul><li>Conductive hearing loss-  oval window sclerosis. </li></ul><ul><li>SNHL - Hyalinization of  spi...
Hyalinization of the spiral ligament
Erosion into inner ear
 
 
Organ of Corti
Cochlear Otosclerosis <ul><ul><li>Pure sensorinural hearing impairment without any conductive component. </li></ul></ul><u...
Diagnosis  of Otosclerosis
Clinical features <ul><ul><li>Conductive or Mixed hearing loss </li></ul></ul><ul><ul><ul><li>Onset </li></ul></ul></ul><u...
History  <ul><li>Family history </li></ul><ul><ul><li>2/3 have a significant family history </li></ul></ul><ul><li>Prior o...
Physical Exam <ul><li>Pneumatic otoscopy </li></ul><ul><li>Otomicroscopy </li></ul><ul><ul><li>Most helpful in ruling out ...
Physical Exam <ul><li>Tuning forks </li></ul><ul><ul><ul><li>Rinne- </li></ul></ul></ul><ul><ul><ul><ul><li>256 Hz – negat...
Differential Diagnosis <ul><li>Ossicular discontinuity </li></ul><ul><li>Congenital stapes fixation </li></ul><ul><li>Mall...
Audiometry <ul><li>Impedance  Audiometry </li></ul><ul><li>Tympanometry </li></ul><ul><li>Acoustic Reflexes </li></ul><ul>...
Tympanometry <ul><li>Jerger (1970) – classification of tympanograms </li></ul><ul><ul><li>Type A </li></ul></ul><ul><ul><u...
 
Acoustic Reflexes <ul><li>Otosclerosis has a predictable pattern of abnormal reflexes over time </li></ul><ul><ul><li>Redu...
Pure Tone Audiometry <ul><li>Most useful audiometric test for otosclerosis </li></ul><ul><ul><li>Characterizes the severit...
 
Imaging <ul><li>Computed tomography (CT) of the temporal bone </li></ul><ul><ul><ul><li>Pre-op </li></ul></ul></ul><ul><ul...
 
 
 
Paget’s disease
Management Options <ul><li>Medical  </li></ul><ul><li>Amplification </li></ul><ul><li>Surgery </li></ul><ul><li>Combinatio...
Medical <ul><li>Sodium Fluoride </li></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><ul><li>Fluoride ion replaces hydro...
Medical <ul><li>Sodium Fluoride </li></ul><ul><ul><li>Reduces tinnitus, reverses Schwartze’s sign, resolution of otospongi...
Medical <ul><li>Bisphosphonates </li></ul><ul><ul><li>Inhibits bone resorption by inhibiting osteoclastic activity. </li><...
Amplification <ul><ul><li>Conventional hearing aids  </li></ul></ul><ul><ul><li>Bone-anchored hearing aids </li></ul></ul>
Surgery <ul><li>Best surgical candidate </li></ul><ul><ul><li>Air conduction level 45 – 65 dB </li></ul></ul><ul><ul><li>B...
Surgery <ul><li>Other factors </li></ul><ul><ul><li>Age of the patient </li></ul></ul><ul><ul><ul><li>Elderly </li></ul></...
Canal Injection <ul><li>2-3 cc of 2% lidocaine with  1:100,000 epinephrine </li></ul><ul><li>4 quadrants </li></ul><ul><li...
Raise Tympanomeatal Flap <ul><li>6 and 12 o’clock positions </li></ul><ul><li>6-8 mm lateral to the annulus </li></ul><ul>...
Separation of chorda tympani nerve from malleus <ul><li>Separate the chorda from the medial surface of the malleus to gain...
Curettage of Scutum <ul><li>Curettage a trough lateral to the scutum, thinning it </li></ul><ul><li>Then remove the scutum...
Middle ear examination <ul><li>Mobility of ossicles </li></ul><ul><ul><li>Confirm stapes fixation </li></ul></ul><ul><ul><...
 
Measurement for prosthesis <ul><li>Measurement </li></ul><ul><ul><li>Lateral aspect of the long process of the incus to th...
Drill Fenestration <ul><li>0.7mm diamond burr </li></ul><ul><ul><li>Motion of the burr removes bone dust </li></ul></ul><u...
Laser Fenestration <ul><li>First laser stapedotomy performed by  Perkins  in 1978 </li></ul><ul><ul><li>Less trauma to the...
Stapedotomy
Oval window seal <ul><li>Vein (hand or wrist) </li></ul><ul><li>Temporalis fascia </li></ul><ul><li>Blood </li></ul><ul><l...
Total Stapedectomy <ul><li>Indications </li></ul><ul><ul><li>Extensive fixation of the footplate </li></ul></ul><ul><ul><l...
 
 
 
 
Reconstructing the annular ligament
Stapedectomy  vs.  Stapedotomy <ul><li>Better low frequency hearing gain. </li></ul><ul><li>Better high frequency hearing ...
Postoperative <ul><li>Water precautions </li></ul><ul><li>No valsalva </li></ul><ul><li>Post-op audio </li></ul>
Special Considerations and Complications in Stapes Surgery
Overhanging Facial Nerve <ul><li>Usually dehiscent(10%) </li></ul><ul><li>Consider aborting the procedure </li></ul><ul><l...
Floating Footplate <ul><li>Footplate dislodges from the surrounding OW niche </li></ul><ul><ul><li>Incidental finding </li...
Diffuse Obliterative Otosclerosis <ul><li>Occurs when the footplate, annular ligament, and oval window niche are involved ...
Perilymphatic Gusher <ul><li>Associated with patent cochlear aqueduct </li></ul><ul><li>Increased incidence with congenita...
SNHL <ul><li>1%-3% incidence of profound permanent SNHL </li></ul><ul><li>Temporary </li></ul><ul><ul><li>Serous labyrinth...
Reparative Granuloma <ul><li>Granuloma formation around the prosthesis and incus </li></ul><ul><li>2 -3 weeks post-op </li...
Vertigo <ul><li>Most commonly short lived (2-3 days) </li></ul><ul><li>More prolonged after stapedectomy compared to stape...
 
Recurrent Conductive Hearing Loss <ul><li>Slippage or displacement of the prosthesis </li></ul><ul><ul><li>Most common cau...
 
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Otosclerosis

  1. 1. Otosclerosis <ul><li>Dr S.K. PRADHAN </li></ul><ul><li>I.M.S.BHU </li></ul>
  2. 3. Introduction <ul><li>Otosclerosis </li></ul><ul><ul><li>Primary metabolic bone disease of the otic capsule and ossicles. </li></ul></ul><ul><ul><li>Results in fixation of the ossicles and conductive hearing loss. </li></ul></ul><ul><ul><li>May have sensorineural component if the cochlea is involved. </li></ul></ul>
  3. 4. History of Otosclerosis and Stapes Surgery <ul><li>1704 – Valsalva first described stapes fixation </li></ul><ul><li>1857 – Toynbee linked stapes fixation to </li></ul><ul><li>hearing loss </li></ul><ul><li>1890 – Katz was first to find microscopic </li></ul><ul><li>evidence of otosclerosis </li></ul>
  4. 5. History of Otosclerosis and Stapes Surgery <ul><li>Gunnar Holmgren (1923) </li></ul><ul><ul><li>Father of fenestration surgery </li></ul></ul><ul><ul><li>Single stage technique </li></ul></ul>
  5. 6. History of Otosclerosis and Stapes Surgery <ul><li>Julius Lempert </li></ul><ul><ul><li>Popularized the single staged fenestration procedure </li></ul></ul>
  6. 7. History of Otosclerosis and Stapes Surgery <ul><li>Fenestration procedure for otosclerosis </li></ul><ul><ul><li>Fenestration in the horizontal canal with a tissue graft covering </li></ul></ul><ul><ul><li>>2% profound SNHL </li></ul></ul><ul><ul><li>Rarely complete closure of the ABG </li></ul></ul><ul><ul><li>May exhibit vestibular disturbances </li></ul></ul>
  7. 8. History of Otosclerosis and Stapes Surgery <ul><li>Samuel Rosen </li></ul><ul><ul><li>1953 – first suggest mobilization of the stapes </li></ul></ul><ul><ul><ul><li>Immediate improved hearing </li></ul></ul></ul><ul><ul><ul><li>Re-fixation </li></ul></ul></ul>
  8. 9. History of Otosclerosis and Stapes Surgery <ul><li>John Shea </li></ul><ul><ul><li>1956 – first to perform stapedectomy </li></ul></ul><ul><ul><ul><li>Oval window vein graft </li></ul></ul></ul><ul><ul><ul><li>Nylon prosthesis from incus to oval window </li></ul></ul></ul>
  9. 10. Epidemiology <ul><li>Prevalence </li></ul><ul><li>histologic otosclerosis- 3.5% </li></ul><ul><li>clinically significant otosclerosis- 2% </li></ul><ul><li>Gender </li></ul><ul><ul><li>Histologic otosclerosis – 1:1 ratio </li></ul></ul><ul><ul><li>Clinical otosclerosis – 2:1 (W:M) </li></ul></ul><ul><ul><ul><li>Possible progression during pregnancy (10%-17%) </li></ul></ul></ul><ul><li>Age </li></ul><ul><ul><li>Most commonly-15-45 years </li></ul></ul>
  10. 11. Aetiology <ul><li>Autosomal dominant </li></ul><ul><li>Hereditary in 70% of cases </li></ul><ul><li>1% Caucasians with symptoms </li></ul><ul><li>Autoimmune diseases </li></ul><ul><li>Van der Hoeve syndrome </li></ul><ul><li>Measles </li></ul>
  11. 12. Aetiology- Measles?
  12. 13. Pathophysiology <ul><ul><li>Inciting event unknown </li></ul></ul><ul><ul><ul><li>Hereditary, endocrine, metabolic, infectious, vascular, autoimmune, hormonal </li></ul></ul></ul><ul><ul><li>Resorption and formation of new bone </li></ul></ul><ul><ul><li>Limited to the temporal bone and ossicles </li></ul></ul>
  13. 14. Pathology <ul><li>Two phases of disease </li></ul><ul><ul><ul><li>Active (otospongiosis phase) </li></ul></ul></ul><ul><ul><ul><ul><li>Active resorption of bone </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dilation of vessels </li></ul></ul></ul></ul><ul><ul><ul><li>Mature (sclerotic phase) </li></ul></ul></ul><ul><ul><ul><ul><li>Deposition of new bone (sclerotic and less dense than normal bone), Chalky white </li></ul></ul></ul></ul>
  14. 15. Pathology <ul><li>Sites involved- </li></ul><ul><ul><ul><li>Anterior to oval window ( Fissula ante fenestrum ) 90% </li></ul></ul></ul><ul><li>Round window 30% </li></ul><ul><li>Cochlear labyrinth 25% </li></ul><ul><li>Stapes footplate 12% </li></ul><ul><li>Posterior to oval window 5-10% </li></ul>
  15. 16. Non-clinical foci of otosclerosis
  16. 17. Anterior footplate involvement
  17. 18. Annular ligament involvement
  18. 19. Bipolar involvement of the footplate
  19. 20. Round Window
  20. 21. Biscuit footplate
  21. 22. Pathophysiology of <ul><li>Conductive hearing loss- oval window sclerosis. </li></ul><ul><li>SNHL - Hyalinization of spiral ligament , toxins. </li></ul><ul><li>Vestibular symptoms- degeneration of scarpa’s ganglion . Soluble toxic substances </li></ul><ul><li>Direct invasion. </li></ul>
  22. 23. Hyalinization of the spiral ligament
  23. 24. Erosion into inner ear
  24. 27. Organ of Corti
  25. 28. Cochlear Otosclerosis <ul><ul><li>Pure sensorinural hearing impairment without any conductive component. </li></ul></ul><ul><ul><li>Incidence is quite low. </li></ul></ul><ul><li>Histiologic studies </li></ul><ul><ul><li>Cases of documented otosclerosis and a large sensory loss have shown large foci of otosclerosis in the otic capsule without stapes fixation. </li></ul></ul>
  26. 29. Diagnosis of Otosclerosis
  27. 30. Clinical features <ul><ul><li>Conductive or Mixed hearing loss </li></ul></ul><ul><ul><ul><li>Onset </li></ul></ul></ul><ul><ul><ul><li>Slowly progressive, </li></ul></ul></ul><ul><ul><ul><li>Bilateral (80%) </li></ul></ul></ul><ul><ul><ul><li>Asymmetric </li></ul></ul></ul><ul><ul><li>Tinnitus (75%) </li></ul></ul><ul><ul><li>Paracusis willisii </li></ul></ul><ul><ul><li>Vestibular symptoms(25%) </li></ul></ul>
  28. 31. History <ul><li>Family history </li></ul><ul><ul><li>2/3 have a significant family history </li></ul></ul><ul><li>Prior otologic surgery </li></ul><ul><li>History of ear infections </li></ul>
  29. 32. Physical Exam <ul><li>Pneumatic otoscopy </li></ul><ul><li>Otomicroscopy </li></ul><ul><ul><li>Most helpful in ruling out other disorders </li></ul></ul><ul><ul><ul><li>Middle ear effusions </li></ul></ul></ul><ul><ul><ul><li>Tympanosclerosis </li></ul></ul></ul><ul><ul><ul><li>Tympanic membrane perforations </li></ul></ul></ul><ul><ul><ul><li>Cholesteatoma or retraction pockets </li></ul></ul></ul><ul><ul><li>Schwartze’s sign </li></ul></ul><ul><ul><ul><li>Reddish hue over the promontory </li></ul></ul></ul><ul><ul><ul><li>10% of cases </li></ul></ul></ul>
  30. 33. Physical Exam <ul><li>Tuning forks </li></ul><ul><ul><ul><li>Rinne- </li></ul></ul></ul><ul><ul><ul><ul><li>256 Hz – negative test indicates at least a 20 dB ABG. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>512 Hz – negative test indicates at least a 30 dB ABG. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>1024 Hz- negative test indicates at least a 45 dB ABG </li></ul></ul></ul></ul><ul><ul><ul><li>Weber- </li></ul></ul></ul><ul><ul><ul><li>ABC- </li></ul></ul></ul>
  31. 34. Differential Diagnosis <ul><li>Ossicular discontinuity </li></ul><ul><li>Congenital stapes fixation </li></ul><ul><li>Malleus head fixation </li></ul><ul><li>Paget’s disease </li></ul><ul><li>Osteogenesis imperfecta </li></ul><ul><li>Adhesive otitis media </li></ul>
  32. 35. Audiometry <ul><li>Impedance Audiometry </li></ul><ul><li>Tympanometry </li></ul><ul><li>Acoustic Reflexes </li></ul><ul><li>Eustachian tube function test </li></ul><ul><li>Pure tones Audiometry </li></ul>
  33. 36. Tympanometry <ul><li>Jerger (1970) – classification of tympanograms </li></ul><ul><ul><li>Type A </li></ul></ul><ul><ul><ul><li>Type A </li></ul></ul></ul><ul><ul><ul><li>Type As </li></ul></ul></ul><ul><ul><ul><li>Type Ad </li></ul></ul></ul><ul><ul><li>Type B </li></ul></ul><ul><ul><li>Type C </li></ul></ul>
  34. 38. Acoustic Reflexes <ul><li>Otosclerosis has a predictable pattern of abnormal reflexes over time </li></ul><ul><ul><li>Reduced reflex amplitude </li></ul></ul><ul><ul><li>Elevation of ipsilateral thresholds </li></ul></ul><ul><ul><li>Elevation of contralateral thresholds </li></ul></ul><ul><ul><li>Absence of reflexes </li></ul></ul>
  35. 39. Pure Tone Audiometry <ul><li>Most useful audiometric test for otosclerosis </li></ul><ul><ul><li>Characterizes the severity of disease </li></ul></ul><ul><ul><li>Frequency specific </li></ul></ul><ul><li>Low frequencies affected first(Below 1000 Hz) </li></ul><ul><li>Air line flattens with disease progression </li></ul><ul><li>Carhart’s notch </li></ul><ul><ul><li>Hallmark audiologic sign of otosclerosis </li></ul></ul><ul><ul><li>Decrease in bone conduction thresholds </li></ul></ul><ul><ul><ul><li>5 dB at 500 Hz </li></ul></ul></ul><ul><ul><ul><li>10 dB at 1000 Hz </li></ul></ul></ul><ul><ul><ul><li>15 dB at 2000 Hz </li></ul></ul></ul><ul><ul><ul><li>5 dB at 4000 Hz </li></ul></ul></ul>
  36. 41. Imaging <ul><li>Computed tomography (CT) of the temporal bone </li></ul><ul><ul><ul><li>Pre-op </li></ul></ul></ul><ul><ul><ul><ul><li>Characterize the extent of otosclerosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe or profound mixed hearing loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Evaluate for enlarge cochlear aqueduct </li></ul></ul></ul></ul><ul><ul><ul><li>Post-op </li></ul></ul></ul><ul><ul><ul><ul><ul><li>prosthesis dislocation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vertigo </li></ul></ul></ul></ul></ul>
  37. 45. Paget’s disease
  38. 46. Management Options <ul><li>Medical </li></ul><ul><li>Amplification </li></ul><ul><li>Surgery </li></ul><ul><li>Combinations </li></ul>
  39. 47. Medical <ul><li>Sodium Fluoride </li></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><ul><li>Fluoride ion replaces hydroxyl group in bone forming fluorapatite. </li></ul></ul></ul><ul><ul><ul><li>Resistant to resorption </li></ul></ul></ul><ul><ul><ul><li>Increases calcification of new bone </li></ul></ul></ul><ul><ul><ul><li>Causes maturation of active foci of otosclerosis </li></ul></ul></ul>
  40. 48. Medical <ul><li>Sodium Fluoride </li></ul><ul><ul><li>Reduces tinnitus, reverses Schwartze’s sign, resolution of otospongiosis seen on CT </li></ul></ul><ul><ul><li>Dose – 20-120mg </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Non-surgical candidates </li></ul></ul></ul><ul><ul><ul><li>Surgical candidates with + Schwartze’s sign </li></ul></ul></ul><ul><ul><ul><ul><li>Treat for 6 months pre-op </li></ul></ul></ul></ul><ul><ul><li>Hearing results </li></ul></ul><ul><ul><ul><li>50% stabilize </li></ul></ul></ul><ul><ul><ul><li>30% improve </li></ul></ul></ul><ul><ul><li>Re-evaluate for 2 yrs with CT and for Schwartze’s sign to resolve </li></ul></ul>
  41. 49. Medical <ul><li>Bisphosphonates </li></ul><ul><ul><li>Inhibits bone resorption by inhibiting osteoclastic activity. </li></ul></ul><ul><ul><li>Often supplement with Vitamin D and Calcium. </li></ul></ul><ul><ul><li>Studies conducted on otosclerosis patients with neurotologic symptoms report the majority of patients with subjective improvement or resolution. </li></ul></ul>
  42. 50. Amplification <ul><ul><li>Conventional hearing aids </li></ul></ul><ul><ul><li>Bone-anchored hearing aids </li></ul></ul>
  43. 51. Surgery <ul><li>Best surgical candidate </li></ul><ul><ul><li>Air conduction level 45 – 65 dB </li></ul></ul><ul><ul><li>Bone conduction level 0 – 25 dB </li></ul></ul><ul><ul><li>Air-Bone Gap 15 dB </li></ul></ul><ul><ul><li>Discrimination score >60% </li></ul></ul><ul><li>Factors affecting stapes surgery </li></ul><ul><ul><li>Audiometric profile </li></ul></ul><ul><ul><li>Skill of the surgeon </li></ul></ul><ul><ul><li>Facilities </li></ul></ul><ul><ul><li>Medical condition of the patient </li></ul></ul>
  44. 52. Surgery <ul><li>Other factors </li></ul><ul><ul><li>Age of the patient </li></ul></ul><ul><ul><ul><li>Elderly </li></ul></ul></ul><ul><ul><ul><li>Congenital stapes fixation (44% success rate) </li></ul></ul></ul><ul><ul><li>Occupation </li></ul></ul><ul><ul><ul><li>Diver, Pilot </li></ul></ul></ul><ul><ul><li>Vestibular symptoms </li></ul></ul><ul><ul><ul><li>Meniere's disease </li></ul></ul></ul><ul><ul><li>Concomitant otologic disease </li></ul></ul><ul><ul><ul><li>Cholesteatoma </li></ul></ul></ul>
  45. 53. Canal Injection <ul><li>2-3 cc of 2% lidocaine with 1:100,000 epinephrine </li></ul><ul><li>4 quadrants </li></ul><ul><li>Bony cartilaginous junction </li></ul>
  46. 54. Raise Tympanomeatal Flap <ul><li>6 and 12 o’clock positions </li></ul><ul><li>6-8 mm lateral to the annulus </li></ul><ul><li>Take into account curettage of the scutum </li></ul>
  47. 55. Separation of chorda tympani nerve from malleus <ul><li>Separate the chorda from the medial surface of the malleus to gain slack </li></ul><ul><li>Avoid stretching the nerve </li></ul><ul><li>Cut the nerve rather than stretch it </li></ul>
  48. 56. Curettage of Scutum <ul><li>Curettage a trough lateral to the scutum, thinning it </li></ul><ul><li>Then remove the scutum (incus to the round window) </li></ul>
  49. 57. Middle ear examination <ul><li>Mobility of ossicles </li></ul><ul><ul><li>Confirm stapes fixation </li></ul></ul><ul><ul><li>Evaluate for malleus or incus fixation </li></ul></ul><ul><li>Abnormal anatomy </li></ul><ul><ul><li>Dehiscent facial nerve </li></ul></ul><ul><ul><li>Overhanging facial nerve </li></ul></ul><ul><ul><li>Deep narrow oval window niche </li></ul></ul><ul><ul><li>Ossicular abnormalities </li></ul></ul>
  50. 59. Measurement for prosthesis <ul><li>Measurement </li></ul><ul><ul><li>Lateral aspect of the long process of the incus to the footplate </li></ul></ul>
  51. 60. Drill Fenestration <ul><li>0.7mm diamond burr </li></ul><ul><ul><li>Motion of the burr removes bone dust </li></ul></ul><ul><ul><li>Avoids smoke production </li></ul></ul><ul><ul><li>Avoids surrounding heat production </li></ul></ul>
  52. 61. Laser Fenestration <ul><li>First laser stapedotomy performed by Perkins in 1978 </li></ul><ul><ul><li>Less trauma to the vestibule </li></ul></ul><ul><ul><li>Less incidence of prosthesis migration </li></ul></ul><ul><ul><li>Less fixation of prosthesis by scar tissue </li></ul></ul><ul><li>TYPES - </li></ul><ul><ul><li>Argon and Potassium titanyl phosphate (KTP) </li></ul></ul><ul><ul><ul><li>Wave length 500 nm </li></ul></ul></ul><ul><ul><ul><li>Surgical and aiming beam </li></ul></ul></ul><ul><ul><li>Carbon dioxide (CO2) </li></ul></ul><ul><ul><ul><li>10,000 nm </li></ul></ul></ul><ul><ul><ul><li>Ill defined fuzzy beam </li></ul></ul></ul>
  53. 62. Stapedotomy
  54. 63. Oval window seal <ul><li>Vein (hand or wrist) </li></ul><ul><li>Temporalis fascia </li></ul><ul><li>Blood </li></ul><ul><li>Fat </li></ul><ul><li>Tragal perichondrium </li></ul><ul><li>Gelfoam (now discouraged) </li></ul>
  55. 64. Total Stapedectomy <ul><li>Indications </li></ul><ul><ul><li>Extensive fixation of the footplate </li></ul></ul><ul><ul><li>Floating footplate </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Increased post-op vestibular symptoms </li></ul></ul><ul><ul><li>More technically difficult </li></ul></ul><ul><ul><li>Increased potential for prosthesis migration </li></ul></ul>
  56. 69. Reconstructing the annular ligament
  57. 70. Stapedectomy vs. Stapedotomy <ul><li>Better low frequency hearing gain. </li></ul><ul><li>Better high frequency hearing gain. </li></ul><ul><li>Decreased perilymphatic fistula. </li></ul><ul><li>Decreased SNHL </li></ul><ul><li>Decreased Vertigo </li></ul>
  58. 71. Postoperative <ul><li>Water precautions </li></ul><ul><li>No valsalva </li></ul><ul><li>Post-op audio </li></ul>
  59. 72. Special Considerations and Complications in Stapes Surgery
  60. 73. Overhanging Facial Nerve <ul><li>Usually dehiscent(10%) </li></ul><ul><li>Consider aborting the procedure </li></ul><ul><li>Facial nerve displacement (Perkins, 2001) </li></ul><ul><ul><li>Facial nerve is compressed superiorly with No. 24 suction (5 second periods) </li></ul></ul><ul><ul><li>10-15 sec delay between compressions </li></ul></ul><ul><ul><li>Perkins describes laser stapedotomy while nerve is compressed </li></ul></ul>
  61. 74. Floating Footplate <ul><li>Footplate dislodges from the surrounding OW niche </li></ul><ul><ul><li>Incidental finding </li></ul></ul><ul><ul><li>More commonly iatrogenic </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>Laser </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Abort </li></ul></ul><ul><ul><li>total stapedectomy </li></ul></ul>
  62. 75. Diffuse Obliterative Otosclerosis <ul><li>Occurs when the footplate, annular ligament, and oval window niche are involved </li></ul><ul><li>Closure of air-bone gap < 10 dB less common. </li></ul><ul><li>Refixation commonly occurs </li></ul>
  63. 76. Perilymphatic Gusher <ul><li>Associated with patent cochlear aqueduct </li></ul><ul><li>Increased incidence with congenital stapes fixation </li></ul><ul><li>Increases risk of SNHL </li></ul><ul><li>Management </li></ul><ul><ul><li>Rapid placement of the OW seal then the prosthesis </li></ul></ul><ul><ul><li>Bed rest, avoid Valsalva . </li></ul></ul>
  64. 77. SNHL <ul><li>1%-3% incidence of profound permanent SNHL </li></ul><ul><li>Temporary </li></ul><ul><ul><li>Serous labyrinthitis </li></ul></ul><ul><ul><li>Reparative granuloma </li></ul></ul><ul><li>Permanent </li></ul><ul><ul><li>Suppurative labyrinthitis </li></ul></ul><ul><ul><li>Extensive drilling </li></ul></ul><ul><ul><li>Basilar membrane breaks </li></ul></ul><ul><ul><li>Vascular compromise </li></ul></ul>
  65. 78. Reparative Granuloma <ul><li>Granuloma formation around the prosthesis and incus </li></ul><ul><li>2 -3 weeks post-op </li></ul><ul><li>Initial good hearing results followed by an increase in the high frequency bone line thresholds </li></ul><ul><li>Associated tinnitus and vertigo </li></ul><ul><li>Exam – reddish discoloration of the posterior TM </li></ul><ul><li>Treatment </li></ul><ul><ul><li>ME exploration </li></ul></ul><ul><ul><li>Removal of granuloma </li></ul></ul><ul><li>Prognosis – Return of hearing with early excision </li></ul>
  66. 79. Vertigo <ul><li>Most commonly short lived (2-3 days) </li></ul><ul><li>More prolonged after stapedectomy compared to stapedotomy </li></ul><ul><ul><li>Due to serous labyrinthitis </li></ul></ul><ul><li>Medialization of the prosthesis into the vestibule </li></ul><ul><ul><li>With or without perilymphatic fistula </li></ul></ul><ul><li>Reparative granuloma </li></ul>
  67. 81. Recurrent Conductive Hearing Loss <ul><li>Slippage or displacement of the prosthesis </li></ul><ul><ul><li>Most common cause of failure </li></ul></ul><ul><ul><li>Immediate </li></ul></ul><ul><ul><ul><li>Technique </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><li>Delayed </li></ul></ul><ul><ul><ul><li>Slippage from incus narrowing or erosion </li></ul></ul></ul><ul><ul><ul><li>Adherence to edge of OW niche </li></ul></ul></ul><ul><ul><ul><li>Stapes re-fixation </li></ul></ul></ul><ul><ul><ul><li>Malleus or incus ankylosis </li></ul></ul></ul>
  68. 83. THANK YOU
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