The document discusses complications that can occur with stapes surgery for otosclerosis. Some common intraoperative complications include tears in the tympanic membrane flap, dislocation of the incus, and overhanging of the facial nerve. Postoperative complications include otitis media, vertigo, facial palsy, sensorineural hearing loss, conductive hearing loss, and reparative granulomas. Rare complications include cerebrospinal fluid leaks. Revision stapes surgery carries higher risks and lower success rates than initial surgery due to postoperative fibrosis and other challenges.

1. Complications of Stapes
surgery
Dr Safika Zaman
Dept of ENT and HNS
RKMSP,VIMS

2. Introduction
 Otosclerosis is a disease of altered bone
metabolism, unique to human temporal bone.
 Prevalence of otosclerosis varies amongst races,
more common in Caucasians
 More common in women.
 The operative procedure was divided into
stapedectomy (total footplate removal and
opening all the oval window) and stapedotomy
(small-hole creation on the footplate).

3. Government
History of Otosclerosis and Stapes SurgeryRonen Nazarian, MD
John T. McElveen Jr., MDAdrien A. Eshraghi, MD, MSc – Otolarngologic clinics

4. Otosclerosis
 Primarily a disease of the bone that encases the
cochlea and labyrinth.
 Characterized by progressive focal dysplasia
with destruction, remodelling, and finally
sclerosis of the endochondral bone of the
labyrinthine capsule.
 Mostly starts in the anterior part of the oval
window, the so-called fissula ante fenestram
and extends to the annular ligament and stapes.
 Bony ankylosis of the stapes, which results in
increased stiffness of the ossicular chain and
conductive hearing loss

5. Histopath
appearance

6. Types of
stapedial
otosclerosis

7. History
 Insidious onset progressive hearing loss
 Better hearing in noisy environment
 Tinnitus
 Vertigo
 Monotonous well modulated , soft speech

8. Examination
 Intact TM
 Schwartze Sign
 Negative Rinne test
 Weber lateralized to Ear with greater conductive
loss
 Good speech discrimination

9. Investigations
 Speech audiometry shows a normal increase in
speech discrimination when sound intensity
increases.
 Tympanometry – A type / AS type
 The stapedial reflex is absent
 PTA- conductive or mixed loss

10. Pure tone
audiometry
Otosclerosis
Th. Somers*, F. Declau**, R. Kuhweide*** and Th.
Robillard****

11. HRCT
 HRCT is currently the radiologic method of choice in assessing
the labyrinthine windows and otic capsule. On HRCT images,
otosclerotic foci are visualized as hypodense or radiolucent foci
Otosclerosis Temporal Bone PathologyAlicia M. Quesnel,
MDa,b,c,*, Reuven Ishai, MDb,c, Michael J. McKenna, MDa,b

12. Differentials
 Sequelae of otitis media with intact eardrum:
ossicular chain discontinuity, tympanosclerosis
 Post-traumatic stapes fixation
 Malleus head fixation
 Minor malformations of the middle ear:
monopodic stapes, aplasia of stapes
superstructure
 Abnormal perilymph pressure
 Paget’s disease
 Osteogenesis imperfecta

13. Treatment
options
 Observation – if hearing loss is less than 30 Db
 Hearing aid – patients with mod CHL , unwilling
to undergo surgery
 Cochlear otosclerosis with progressive
sensorineural hearing loss one may also
consider the use of sodium fluoride, calcium
and vitamin D.
 Surgery- stapedectomy or stapedotomy
 Cochlear implant – in profound HL with
cochlear involvement

14. Surgery
 Stapes surgery is most appreciated by patients
who experience hearing problems in everyday
life. This is mostly the case when Rinne’s test is
“negative” and air conduction thresholds are at
30 dB HL or worse
 In bilateral cases, the operation should be
carried out on the ear with the highest degree
of hearing loss.
 The worst ear- based on the patient’s
statement and not necessarily on the
audiogram, should be chosen for surgery

15. Contraindications
 Poor physical health
 Balance problems, such as active
endolymphatic hydrops or a fluctuating hearing
loss
 Pre-existing tympanic membrane perforation
 Active external or middle ear infection
 Inadequate air-bone gap confirmed by an
audiogram and the 512 Hz tuning fork test
 Inner ear malformations as visible on HRCT
Otosclerosis
Th. Somers*, F. Declau**, R. Kuhweide*** and Th.
Robillard****

16. Overview of
surgery

17. Cont ..

18. Cont..

19. Cont..

20. Complications
 Tears in the tympano-meatal flap
 Subluxation and dislocation of incus
 Overhanging facial nerve
 Obliterative otosclorosis of oval window
 Round window otosclerosis
 Persistent stapedial artery
 Malleus ankyloses
 Perilymph gushers
 Floating or depressed footplate
Intraoperative complications
Surgery of the ear- Shamaugh

21. Complications
 Chorda tympani dysfunctions
 Otitis media
 Vertigo
 Facial palsy
 SNHL
 CHL
 Reparative granuloma
postoperative complications
Surgery of the ear- Shamaugh

22. TM flap
tear
 Reason – elevation of small
flap
 Elevating flap without annulus
 Repair with fascia or
perichondrium

23. Dislocation
of
Incus
 Subluxation and dislocation of the
incus occurs most often during
curettage of the bony annulus or
separation of the incudo-stapedial
joint.
 Malleus attachment prosthesis.

24. Overhanging
facial
nerve
 Can lead to complete or partial oliteration of
footplate
 If partial, often surgery can be completed
 If total or near total - surgery can be completed by
drilling a small fenestra that includes the inferior
aspect of the annular ligament.

25. Obliterative
otosclerosis
of O. window
 Fenestration can be achieved after
first saucerizing the obliterated niche
and thinning the obstructing bone.
 After blue lining the vestibule, the
fenestration can be made with a 0.7-
mm diamond burr.
 measurements for prosthesis length
are made just prior to fenestration.
 If obliterative otosclerosis is found in
one ear, there is 50% chance of the
same finding to be present in the
other ear

26. Round
window
otosclerosis
 Even a minute opening to the round window membrane
can be associated with good hearing.
 if the round window is found to be obliterated, the
procedure should be completed and the finding noted in
the operative note.
 If a residual conductive loss is present following surgery
revision surgery is not recomended as the likely cause is a
obliterated round window

27. Persistent
stapedial
artery
 A persistent stapedial artery cannot
be safely coagulated with bipolar
cautery or laser.
 Often, it occupies only the anterior
half of the footplate and
fenestration
 can be completed in the posterior
half.
 The procedure should be
completed only if the space left by
the artery is clearly sufficient for
safe fenestration.

28. Malleus
fixation
 Malleus fixation may result from ossification of the
superior and anterior suspensory ligaments

29. CSF
Gusher
 Gusher" is a rare phenomenon
that consists in sudden exit of
peri-lymphatic fluid during the
course of the surgery
stapedotomy or stapedectomy
 Etiology is a congenital
malformation that causes
abnormal communication
between the peri-lymphatic
space and the subarachnoid
space.

30. CSF
Gusher
 1. Elevation of the head
 2. Lumbar spinal drain to remove as much CSF as possible
 3. Small fenestra stapedotomy
 4.Tissue seal over the fenestra is mandatory.
 Some experts recommend that a prosthesis be placed to
keep the seal over the fenestra in place
Management

31. Floating or
depressed
footplate
 Fenestration can made with a LASER.
 Footplate too thick for the laser to penetrate, a small bur
hole can be created inferior to the annular ligament
 Footplate can be elevated with a small hook.
 Footplate is depressed into the vestibule it should not be
extracted
 Opening should be sealed with a tissue graft, before
placing appropriately sized prosthesis

32. Facial
palsy
 Temporary paralysis lasts for few hours , often due to local
anaesthesia.
 If paralysis persists more than 3 hour – traumatic injury is
likely.
 Nerve can be injured by -
1. Bone curette or drill during removal of the bony annulus,
2. Fracturing the stapes toward the nerve rather than away
toward the promontory,
3. By injuring an anomalous nerve
Nerve repair to be done in cases of nerve injury

33. Otitis
media
 Acute otitis media in postoperative period carries risk of
suppurative labyrinthitis and meningitis.
 Treatment – Broad spectrum intravenous antibiotics
 Hospitalization
 Supportive care

34. Vertigo
 Vertigo during surgery- insult to labyrinth , or result of air
entry in the vestibule. - Resolves within 48 hours.
 Blood causes chemical irritation and resolves in a matter
of days.
 Persistant vertigo is associated with SNHL, can be due to
peri – lymphatic fistula

35. Chorda
tympani
dysfunction
 Presents with taste disturbance
 Some- time sacrificed during the surgery
 Stretched nerve produce more symptoms than a sacrificed
nerve.

36. SNHL
 Slight transient depression (<5 dB) in bone conduction
immediately following the procedure is a common
occurrence and attributable to mild serous labyrinthitis.
 Permanent SNHL is attributable to surgical trauma.
 Delayed SNHL should raise the suspicion of a PLP.
 A delayed fluctuating low-frequency loss may indicate
post-traumatic hydrops.

37. Reparative
granuloma
 Mass of exubareant granulation tissue developing in
reaction to surgery , foreign body or perilymph.
 Presents with signs of labyrinthitis
 Appears after an early period of hearing gain
 Audiometry – mixed hearing loss
 Management – re-exploration and removal of granulation
tissue with prosthesis

38. CHL
 Malfunctioning prosthesis, eg, one that is too short,
 Unrecognized malleus fixation
 Unrecognized round window obliteration
 Middle ear effusion
 Presence of unrecognized SSCD.
 Revision surgery may be considered after waiting for
several months.
Common causes are

39. Peri-lymph
Fistula
 Common cause of
sensorineural hearing loss
following stapedectomy.
 Causes are -inadequate
closure of the fenestra in the
footplate by the seal, too long
a prosthesis, or possibly
increased perilymph pressure.
 symptoms are fluctuating
sensorineural hearing loss,
roaring tinnitus, and vertigo
accompanied by fullness in
the ear.

40.  Otosclerosis Temporal
Bone PathologyAlicia
M. Quesnel,
MDa,b,c,*, Reuven
Ishai, MDb,c, Michael
J. McKenna, MDa,b

41. Complications
<Name of Song>
Otosclerosis Temporal Bone PathologyAlicia M. Quesnel, MDa,b,c,*, Reuven Ishai,
MDb,c, Michael J. McKenna, MDa,b

42. Revision
stapes
surgery
 Technically more challenging
 Higher incidence of complications
 Lower success rates
 Often done under general anaesthesia

43. Revision
stapes
surgery
 Prosthesis dislocation from oval window
 Incus erosion and incus-prosthesis detachment
 Short prosthesis
 Postoperative fibrosis in the middle ear and re-ankyloses
 Peri-lymphatic fistula
 Insufficient fenestra and too tight prosthesis
 Footplate re-sclerosis, incus subluxation, facial nerve
dehiscence and prosthesis friction, reparative granuloma
Yetiser S. Revision surgery for otosclerosis: An overview. World J Otorhinolaryngol 2015; 5(1): 21-29 [DOI:
10.5319/wjo.v5.i1.21]
Common causes