4. otosclerosis


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4. otosclerosis

  1. 1. Otosclerosis DR. RS MEHTA, BPKIHS
  4. 4.  Stapes becomes immobilized RT growth of bones or deposition of new bone over oval window, causing fixation of the stapes  Interferences of the transmission of vibration into the inner ear.  Chronic ear disease DR. RS MEHTA, BPKIHS
  5. 5. INTRODUCTION Otosclerosis is a disease of otic capsule in which new vascular spongy bone formation causes ankylosis or fixation of the foot plate of the stapes and progressive conductive deafness.  Otosclerosis can result in conductive and/or sensorineural hearing loss. This usually will begin in one ear but will eventually affect both ears with a variable course.  DR. RS MEHTA, BPKIHS
  10. 10. ETIOLOGY  Exact cause not known.  Heredity: Family history of deafness is present in 50% of cases.  Sex: females are affected twice as often as males. DR. RS MEHTA, BPKIHS
  11. 11.  Age of onset: usually occurs between 20-30 years of age and rarely starts before 10 or after 40 years.  Pregnancy: Otosclerosis may be initiated or aggravated by pregnancy but never caused by it. DR. RS MEHTA, BPKIHS
  12. 12.  Other factor: Metabolic disorder, endocrinal, vitamin deficiency, focal infection etc. DR. RS MEHTA, BPKIHS
  13. 13. TYPES Stapedial Otosclerosis: it causes stapes fixation and conductive deafness is common. Lesion start in “fissula ante fenestram”  Cochlear Otosclerosis: it involves region of round window and may cause senso-neural hearing loss due to liberation of toxic materials.  Histologic Otosclerosis: remains asymptomatic and cause neither conductive nor senso-neural hearing loss.  DR. RS MEHTA, BPKIHS
  14. 14. PATHOLOGY       Bony changes vary according to the duration of diseases First: the normal bone is absorbed and replaced by vascular, spongy osteoid tissue and advanced with blood vessels. Later: bone become thicker and less vascular Then: new bone formation takes place at annular ligament of the oval window fixing the stapes and leads to conductive deafness. Spread to footplates of the stapes Also affect the bony-capsule of the labyrinth, resulting sensory-neural deafness.MEHTA, BPKIHS DR. RS
  15. 15. SIGNS  Hearing loss: progressive deafness which is painless and is insidious.  Tinnitus  Vertigo: uncommon  Speech: patient has a monotonous, well modulated soft speech. DR. RS MEHTA, BPKIHS
  16. 16. DIAGNOSIS  Tuning fork test revels conductive deafness.  Audiometry test  H/O hearing loss DR. RS MEHTA, BPKIHS
  17. 17. DIFFERENTIAL DIAGNOSIS It should be differentiated from:  Serrous otitis media  Adhesive otitis media  Tympanosclerosis  Otitic fixation of head of malleus  Ossicular discontinuity DR. RS MEHTA, BPKIHS
  18. 18. Management Options Medical Amplification Surgery Combinations DR. RS MEHTA, BPKIHS
  19. 19. TREATMENT  Medical: 1. no medical treatment to cure otosclerosis. May use: sodium fluoride in a dose 20 mg BD for 2 years, with calcium , arrests the rapid progress of otosclerosis. DR. RS MEHTA, BPKIHS
  20. 20. Medical  Sodium fluoride  Mechanism Fluoride ion replaces hydroxyl group in bone forming fluorapatite Resistant to resorption Increases calcification of new bone Causes maturation of active foci of otosclerosis DR. RS MEHTA, BPKIHS
  21. 21. Amplification  Excellent alternative  Non-surgical candidates  Patients who do not desire surgery Hearing aids conditions: a. unfit for surgery b. elderly patients c. not willing to operation d. after surgery if not improve deafness DR. RS MEHTA, BPKIHS
  22. 22. Stapedectomy  Stapedectomy: removal of stapes and insertion of prosthesis.  Prosthesis may be a Teflon piston, stainless steel piston, platinum teflon or titanium teflon piston. DR. RS MEHTA, BPKIHS
  23. 23. SURGICAL INTERVENTION  Stapedotomy Less trauma to the oval window  Less possibility of damage to the inner ear  In addition, revision surgery, if required, is easier due to preserved anatomy  DR. RS MEHTA, BPKIHS
  24. 24. Placement of the Prosthesis Prosthesis is chosen and length picked  Some prefer bucket handle to incorporate the lenticular process of the incus  DR. RS MEHTA, BPKIHS
  25. 25. NURSING CARE         Operated ear: Upside for 24 hrs after OT Vital sign Caution in ambulation: as dizziness may occur Reassure dizziness is temporary Observe for S/S of bleeding, drainage, N/V Assess vertigo: quite, rest, sedative Antibiotic & Analgesic: to control infection & pain Observe: Nystagmus or S/S of facial palsy DR. RS MEHTA, BPKIHS
  26. 26.       Medicated ribbon gauze pack removed after 5-7 days Decongestentant: dilate Eustachian Tube Discharge advice: Avoid water in ear for 2 months, loud noise, blowing nose and mouth open when sneezing Avoid: straining, bending, heavy lifting, and infection. Antibiotic full course and as advised. DR. RS MEHTA, BPKIHS
  27. 27. Monitor and report complications  Facial nerve palsy  Giddiness  Vomiting  Sensory-neural deafness  Conductive deafness DR. RS MEHTA, BPKIHS
  28. 28. CONTRAINDICATIONS      The only hearing ear History of Meniere’s disease Young children Professional atheletes, high constructive workers, drivers, frequent air travellers. Pregnancy DR. RS MEHTA, BPKIHS
  29. 29. SELF CARE AT HOME(POSTOPERATIVE)         Take medicine as prescribed. Blow nose gently. Sneeze and cough with mouth open for few weeks after surgery. Avoid heavy lifting, straining and bending. Popping and crackling sensation are normal for 3-5 weeks after surgery. Temporary hearing loss is normal in operative ear. Change cotton ball in the ear as needed. Avoid getting in water for 2 weeks after surgery. DR. RS MEHTA, BPKIHS
  31. 31. Surgical Steps  Subtleties of technique and style Local vs. general anesthesia  Stapedectomy vs. partial stapedectomy vs. stapedotomy  Laser vs. drill vs. cold instrumentation  Oval window seals  Prosthesis  DR. RS MEHTA, BPKIHS
  32. 32. Total Stapedectomy  Uses Extensive fixation of the footplate  Floating footplate   Disadvantages Increased post-op vestibular symptoms  More technically difficult  Increased potential for prosthesis migration  DR. RS MEHTA, BPKIHS
  33. 33. Stapedotomy/Small Fenestra Less trauma to the vestibule  Less incidence of prosthesis migration  Less fixation of prosthesis by scar tissue  DR. RS MEHTA, BPKIHS
  34. 34. Drill Fenestration  0.7mm diamond burr    Motion of the burr removes bone dust Avoids smoke production Avoids surrounding heat production DR. RS MEHTA, BPKIHS
  35. 35. Laser Fenestration  Laser   Avoids manipulation of the footplate Argon and Potassium titanyl phosphate (KTP/532)      Wave length 500 nm Visible light Absorbed by hemoglobin Surgical and aiming beam Carbon dioxide (CO2)    10,000 nm Not in visible light range Surgical beam only   Requires separate laser for an aiming beam (red helium-neon) Ill defined fuzzy beam DR. RS MEHTA, BPKIHS
  36. 36. Placement of the Prosthesis   Prosthesis is chosen and length picked Some prefer bucket handle to incorporate the lenticular process of the incus DR. RS MEHTA, BPKIHS
  37. 37. COMPLICATIONS OF SURGERY      Overhanging facial nerve Floating footplate Diffuse obliterative otosclorosis Perilymphatics Guscher SNHL     Round window closure Recurrent CHL Regenerative granuloma Vertigo DR. RS MEHTA, BPKIHS
  38. 38. Oval window seal       Tragal perichondrium Vein (hand or wrist) Temporalis fascia Blood Fat Gelfoam (now discouraged) DR. RS MEHTA, BPKIHS
  39. 39. Reconstructing the annular ligament DR. RS MEHTA, BPKIHS
  40. 40. Special Considerations and Complications in Stapes Surgery DR. RS MEHTA, BPKIHS
  41. 41. 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 DR. RS MEHTA, BPKIHS
  42. 42. Floating Footplate  Footplate dislodges from the surrounding OW niche    Prevention    Incidental finding More commonly iatrogenic Laser Footplate control hole Management    Abort H. House favors promontory fenestration and total stapedectomy Perkins favors laser fenestration DR. RS MEHTA, BPKIHS
  43. 43. Diffuse Obliterative Otosclerosis    Occurs when the footplate, annular ligament, and oval window niche are involved Closure of air-bone gap < 10 dB less common. Refixation commonly occurs DR. RS MEHTA, BPKIHS
  44. 44. Perilymphatic Gusher      Associated with patent cochlear aqueduct More common on the left Increased incidence with congenital stapes fixation Increases risk of SNHL Management    Rough up the footplate Rapid placement of the OW seal then the prosthesis HOB elevated, stool softeners, bed rest, avoid Valsalva, +/lumbar drain DR. RS MEHTA, BPKIHS
  45. 45. Round Window Closure   20%-50% of cases 1% completely closed  No effect on hearing unless 100% closed  Opening has a high rate of SNHL DR. RS MEHTA, BPKIHS
  46. 46. SNHL  1%-3% incidence of profound permanent SNHL   Surgeon experience Extent of disease    Prior stapes surgery Temporary    Cochlear Serous labyrinthitis Reparative granuloma Permanent      Suppurative labyrinthitis Extensive drilling Basilar membrane breaks Vascular compromise Sudden drop in perilymph pressure DR. RS MEHTA, BPKIHS
  47. 47. Reparative Granuloma       Granuloma formation around the prosthesis and incus 2 -3 weeks postop Initial good hearing results followed by an increase in the high frequency bone line thresholds Associated tinnitus and vertigo Exam – reddish discoloration of the posterior TM Treatment     ME exploration Removal of granuloma Prognosis – return of hearing with early excision Associated with use of Gelfoam DR. RS MEHTA, BPKIHS
  48. 48. Vertigo   Most commonly short lived (2-3 days) More prolonged after stapedectomy compared to stapedotomy   Medialization of the prosthesis into the vestibule   Due to serous labyrinthitis With or without perilymphatic fistula Reparative granuloma DR. RS MEHTA, BPKIHS
  49. 49. Recurrent Conductive Hearing Loss  Slippage or displacement of the prosthesis   Most common cause of failure Immediate    Technique Trauma Delayed      Slippage from incus narrowing or erosion Adherence to edge of OW niche Stapes re-fixation Progression of disease with re-obliteration of OW Malleus or incus ankylosis DR. RS MEHTA, BPKIHS
  50. 50. Amplification  Excellent alternative Non-surgical candidates  Patients who do not desire surgery   Patient satisfaction rate lower than that of successful surgery Canal occlusion effect  Amplification not used at night  DR. RS MEHTA, BPKIHS
  51. 51. Medical  Bisphosphonates      Class of medications that inhibits bone resorption by inhibiting osteoclastic activity Dosing not standard Often supplement with Vitamin D and Calcium Studies conducted on otosclerosis patients with neurotologic symptoms report the majority of patients with subjective improvement or resolution. Future application of this treatment unclear, especially with new reports of bisphosphonate related osteonecrosis. DR. RS MEHTA, BPKIHS
  52. 52. Postoperative Water precautions No valsalva Postop audio DR. RS MEHTA, BPKIHS
  53. 53. Rare complications    Facial paralysis Acute otitis media Cholesteatoma DR. RS MEHTA, BPKIHS
  54. 54. Monitor and report complications  Facial nerve palsy  Giddiness  Vomiting  Sensory-neural deafness  Conductive deafness DR. RS MEHTA, BPKIHS
  55. 55. DR. RS MEHTA, BPKIHS
  57. 57. Thank-You DR. RS MEHTA, BPKIHS