otosclerosis.... stapedectomy vs stapedotomy complication of otosclerotic surgery management of otosclerotic surgery complications techniques latest trends

1. OTOSCLEROSIS
Dr zeeshan ali

2. History
 1704 valsalva discribed stapes
fixation
 1857 toynbee linked HL to fixation
 1890 katz microscopic evidence
 1923 father of fenestration Gunner
homgren
 Julius lampart single stage
fenestration
 1953 sameul rosen

3. History
 1956 john shea 1st
stapedectomy

4. Facts
 Females
 Male:female 1:2
 Onset 20-30 years
 Bilateral (uni 15%)
 Autosomal dominant
 Family history 50%
 Common in whites and indians

5. Etiology
 Expression of COL1A1 gene
 Measles
 Autoimmunity type II
 Lamellar bone replaced by immature spongy
bone …endochondral layer of otic capsule
 BLUE MANTLES on H&E stains

6. Clinical
 Slowly progressive conductive hearing loss
 Female
 Bilateral
 Aggravated in pregnancy
Vertigo , tinnitus, SNHL

7. Site
 FISSULA ANTE FENESTRUM
 Posterior oval window
 On foot plate
 Round window
 Otic capsule

9. Differential diagnosis
 Serous otitis media
 Adhesive otitis media
 Tympanosclerosis
 Attic fixation of malleus head
 Ossicular discontinuity
 Congenital stapes fixation
 Meniere’s disease
 SCC dehiscence
 Enlarged endolymphatic sac syndrome

10. Examination
 NormalTM
 SHWARTZ SIGN 2-10% flamingo pink
 PARACUSIS WILLISII…people raise there
voices(above threshold of patients hearing) in
noisy places while the background noise act
as masking

11. Audiological findings
 CARHART’S NOTCH
 As curve (<0.5 dapa)
 Absent stapedial reflex

12. Clinical OPD tests
 Tunning forks
 Rinne test 256,512,1024
 Weber
‘ABSOLUTE BONE CONDUCTIONTEST’ PLUS
‘FREE FIELDTESTING’
a clinical alternative to speech discrimination
It should be equal or near equal

13. ULTIMATE DIAGNOSTIC TOOL
EXPLORATORYTYMPANOTOMY!
One should be prepared to do stapedotomy ,deal with a
fixed malleus on spot
or
Find a nonoperable congenital malformation like a large
persistant stapedial artery or facial nerve going
through the crura of the stapes

14. Patient counsel
 Problem hereditary (care of children)
 Alley anxiety
 Hearing aid viable option
 Risks of surgery
 Total hearing loss
 Taste distubances
 Dizziness
 Facial paralysis

15. Selection criteria
 Mentally sound patient
 Hearing threshold < 30dB or worse
 Av air bone gap 15dB
 Rinne negative 256 and 512
 Speech discrimination > 60%
 Operate the worst ear
 6 months between operations

16. Contraindication
 Only hearing ear
 Meniere’s disease
 Young children (ET dysfunction)
 Professional athletes,divers,pilot
 Noisy construction worker
 Otitis externa,TM perforation,exostosis
 Active otosclerosis
 pregnancy
Van der hoef syndrome is not a contraindication

17. Avoid surgery in congenital
stapes fixation
 A child with unilateral conductive loss since
birth should raise the suspicion
 Vary of X linked progressive SNHL
 Increase risk of GUSHER!

18. IMAGING
 Obilerative type

19. IMAGING
 Mondini malformation

20. IMAGING
 Enlarged endolymphatic sac

21. IMAGING
 Dehiscent SCC

22. IMAGING
 Intralabyrinthine neuroma

23. Types of prosthesis
SHAETeflon MCGEE platinium
HOUSE wire prosthesis

24. Homma’s study
Measurements of ossicle resonances demonstrated that they show two
modes of vibration.
 Mode 1:The peak occurs around 1200 Hz.This vibration is caused by
hinging movement of ossicles due to air conduction stimulus at the level
of umbo of ear drum.
 Mode 2:This mode has a peak around 1700 Hz.This is caused by pivoting
motion of malleus and incus complex.
https://entscholar.wordpress.com/article/carharts-notch/

25. Tondroff hypothesis
When skull is vibrated by bone conduction, sound is
transferred to cochlea via three routes. i.e.
 By direct vibration of skull
 By vibration of ossicular chain which is
suspended within the skull
 By transmission via external auditory canal
(normal route)
In conductive hearing loss routes 2 and 3 are affected, but can be
regained following successful stapes surgery. Hence bone
conduction thresholds improve around 2 KHz frequency range

26. STAPEDECTOMY

39. LASER STAPEDOTOMY

40. Advantage of CO2
 Less penetrance as visible spectrum laser like
KTP and argon penetrate more
 Less heat generation

41. CO2 Laser setting
 1.5W
 1/10 second
one shot technique used currently

45. Site of fenestra
 Avoid utricle and saccule
 Post 2/3 ant 1/3
 Some say center

46. Post op care
 Dizziness for few hours
 Don’t blow nose
 Sneeze with mouth open
 Avoid straining 2 weeks
 Remove ear dressing next day
 Can fly after 3 days (swallow on decent)
 PTA after 3 weeks
 PTA changes are permanent after 3 months

47. INTRAOPERATIVE PROBLEMS

48. Chorda tympani
 Free properly and move up or down

49. Round window closure
 Leave it as such
 Don’t drill it!

50. Perilymph gusher
 Don’t suction
 Put fascia or vein graft in
 Put in the prosthesis
 Apply gel foam on sides and pack middle ear
completely
 Head end elevated after operation
 Mastoid dressing applied

51. TM perforation
 Replace with facial graft

52. Malleus fixed
 If malleus fixed and stapes mobile
 Further stapes surgery abandoned
 Remove incudostapedial joint
 Sever malleus neck with snipper

54. Malleus fixed
 If malleus and stapes fixed
 Incus replacement prosthesis used
 If normal prosthesis length in general is 4.5mm
than add 1mm to it …..5.5mm

55. Dehiscent low facial nerve
 Lift the nerve upwards
 Do not bent the prosthesis
 Rubbing of facial nerve against the prosthesis
doesn’t cause paresis

56. Floating footplate
 Night mare for surgeon
 Ameuture should abandon it
 If fenestra made then place the graft and
prosthesis over it…leave it
 If stapedectomy…. the experience surgeon
will only lift it by drilling from the side of
promontary and lifting It towards the
fallopian canal

57. Obliterated footplate
 It is known by the decrease length
measurment of the prosthesis
 It is opaque white footplate
 Best is to use laser to make fenestra
 Other option is drill out
 Be patient

58. Dislocated incus
 During raising theTM flap
 Best is leave as such as incudomalleal joint
will heal
 Wiser to place a slightly longer prosthesis ..
0.25mm longer as incus lateralise

59. Partial eroded incus
 Robinson prosthesis

60. Persistant stapedial artery
 Bipolar cautry it
 Laser coagulate it
 Large artery stop procedure

61. tympanosclerosis
 Not vascular
 Proceed with stapedotomy

62. Early SNHL (uneventful
surgery)
 Perilabyrinthine fistula
 Head elevation
 Diamox
 Steriod for 2 weeks
 Explore if fails
If some thing went wrong in surgery then don’t
explore ,save time and counsel patients!

63. POSTOPERATIVE PROBLEMS

64.  Acute otitis media– antibiotic
 Barotrauma-- ??? Book say nothing can be
done in presence of functional ET
 Dysgeusia– 20% of op cases
 Delayed facial paralysis—steriod 99% recover
 Hypercusis—reassurance
 Binaural diplacusis– wait 6 weeks

65. Dizziness
 Perilabyrinthine fistula / active otosclerotic
foci / serous labyrinthitis/slippage of
prosthesis
 Labyrinthine sedatives
 Antibiotics
 Flouride
SOME OPEN EAR EARLIER ..SOME DON’T!

66. Progressive SNHL
 Otoscelerotic foci toxins
 Raparative granuloma
 Cochlear implant works well in severe cases

67. NEW TECHNIQUE

68. Current literature
 Focuses on improving imaging
 ONE SHOT LASERTECHNIQUES
 Comparative studies comparing laser vs
perforator
 Endoscopic techniques

69. Intraoperative audiometery
 Greatest airbone gap frequency taken
 Look for gain not for complete improvement
 Even a 5 dB gain is good enough
 Complete improvement will be visible after 3
weeks

70. NITIBOND

71. THANK YOU