Dr. Sanjay Maharjan's document discusses the history and surgical treatment of otosclerosis. It covers three eras in the evolution of otosclerosis surgery:
1) The mobilization era in the late 1800s, which involved attempts to mobilize the stapes bone.
2) The fenestration era from the 1920s-1950s, marked by the development of techniques like fenestration of the semicircular canals.
3) The stapedectomy era from the 1950s onward, highlighted by the first successful stapedectomy performed by Shea in 1956 using a Teflon prosthesis.
The document provides details on indications, contraindications,
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Case report - discussion about presentation and managements of laryngoceles.
Published in Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 32, April 20; Page: 5586-5591
Abstract: Laryngoceles are rare, cystic dilatation of saccule of ventricle of larynx. Three types are recognized –internal, external and mixed types. Many of the laryngoceles are asymptomatic; few require surgical excision via internal/endoscopic or external approach. Contrast CT is the investigation of choice. A 40year old male presented to our OPD with a neck Scar, later diagnosed as laryngocele. Here is the case report about presentation, diagnosis and management of a large mixed layngocele.
KEYWORDS: Layngocele, Neck swelling, Saccule, Ventricle of larynx.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
otosclerosis....
stapedectomy vs stapedotomy
complication of otosclerotic surgery
management of otosclerotic surgery complications
techniques
latest trends
otosclerosis is also known as otospongiosis. otosclerosis is a condition causing bilateral progressive conductive hearing loss. it is characterized by cahart's notch in bone conduction PTA. treated by stapes surgery also known as stapedotomy/stapedectomy or fenestration surgery.
Case report - discussion about presentation and managements of laryngoceles.
Published in Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 32, April 20; Page: 5586-5591
Abstract: Laryngoceles are rare, cystic dilatation of saccule of ventricle of larynx. Three types are recognized –internal, external and mixed types. Many of the laryngoceles are asymptomatic; few require surgical excision via internal/endoscopic or external approach. Contrast CT is the investigation of choice. A 40year old male presented to our OPD with a neck Scar, later diagnosed as laryngocele. Here is the case report about presentation, diagnosis and management of a large mixed layngocele.
KEYWORDS: Layngocele, Neck swelling, Saccule, Ventricle of larynx.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
otosclerosis....
stapedectomy vs stapedotomy
complication of otosclerotic surgery
management of otosclerotic surgery complications
techniques
latest trends
otosclerosis is also known as otospongiosis. otosclerosis is a condition causing bilateral progressive conductive hearing loss. it is characterized by cahart's notch in bone conduction PTA. treated by stapes surgery also known as stapedotomy/stapedectomy or fenestration surgery.
A surgical procedure featuring a partial thickness scleral flap that creates a fistula between AC and subconjunctival space for filtration of aqueous and creation of conjunctival bleb in an effort to lower IOP
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. History :
• Surgery for otosclerosis has developed through three
distinct eras:
1) The mobilization era
2) The fenestration era
3) The stapedectomy era
3. • THE MOBILIZATION ERA:
In 1842, Prosper Meneire first reported mobilization of
stapes
In late 1800s, Kessel attempted stapes mobilization without
ossicular reconstruction
In 1891, Jack left oval window open after removing stapes
Several french otolaryngologists performed mobilization of
stapes, including Boucheron And Miot
Adam Politzer, Siebenmann And Moure, declared that stapes
surgery was useless, dangerous and unethical at 6th
international Otology Congress in London
4. • THE FENESTRATION ERA :
In 1897, Passov suggested promontory fenestration
In 1899, Floderus suggested opening of vestibular labyrinth
In 1913, Jenkins in London described this as fenestration of
lateral semicircular canal
In 1920s, Nylen in Sweden was first to use microscope for ear
surgery
In 1923, With advent of operating microscope, fenestration
era began
5. Gunnar Holmgren (Father of fenestration surgery); created
fistula in lateral semicircular canal and sealed it immediately
with periosteum
Popularized during 1930’s by Sourdille in France (developed
three stage technique)
Julius Lempert in New York developed One-stage technique
for horizontal semicircular canal fenestration
6. • THE STAPEDECTOMY ERA:
Started prior to end of fenestration era
In 1952, Samuel Rosen from New York, tested mobility of
stapes using transcanal approach before semicircular canal
fenestration
On 1st May 1956 John Shea Jr., in collaboration with Treace,
an engineer, created stapes prosthesis made of Teflon & used
it for first time
In 1960s, Plester suggested technique of partial
stapedectomy in which only posterior third of foot plate was
removed
7. In 1961, the piston concept was introduced in which a cup or
piston prosthesis was used with connective tissue graft of
vein to seal oval window
In 1962, Shea et al and Marquet and Martin made small
opening in middle of footplate into which prosthesis piston
fitted exactly
This initiated era of “stapedotomy” which has continued till
present time
Reverse Stapedotomy was popularized by Fisch and involved
insertion of a prosthesis before removal of suprastructure of
stapes
8. INDICATIONS :
• An air-bone gap of 25 dB or more at frequencies of 250 Hz to
1 kHz and a negative Rinne at 512 Hz are considered to be
good indicators
• In cases of bilateral involvement, worse hearing ear is usually
operated first
9. CONTRAINDICATIONS:
• ABSOLUTE CONTRAINDICATIONS:
1. Only hearing ear
2. Active middle ear or external ear
infections
3. When otosclerotic patient presents
with symptoms of hydrops and has
vertigo and tinnitus
4. Severe middle ear atelectasis
10. • RELATIVE CONTRAINDICATIONS:
1. Unfit for GA
2. When patient presents positive Schwartz sign
3. Pregnancy
4. Whose professional activities put them at risk, such as
boxers, professional wrestlers, and those who indulge in
severe physical strain
11. PREOPERATIVE COUNSELING :
• Should be informed about
amplification as alternative
mode for improved hearing
• Informed consent must
include description of
procedure and discussion of
all potential risks:
12. a) Failure of procedure to correct conductive component of
hearing loss
b) Partial or complete SNHL (occurs in approximately 1% )
c) Vestibular disturbances
d) Perforation of tympanic membrane
e) Facial nerve injury
f) Development of Perilymphatic fistula (PLF)
g) Delayed failure after initial good result
h) Disturbance of taste
13. OPERATIVE NOTE :
• The operative note must include:
1. Shape and mobility of incus and malleus
2. Presence of otosclerosis, fixation of stapes, patency of
round window
3. Location of and bone covering facial nerve
4. Status of chorda tympani at end of procedure
5. Unusual perilymphatic flow
6. Type and size of prosthesis
14. ANESTHESIA :
• Choice of anesthesia depends on patient's and surgeon's
preferences and nature of surgery planned
A. Local anesthesia; saves time
• Intraoperative patient reports of vestibular stimulation may
be used as safety measure to prevent excessive inner ear
irritation
B. General anesthesia;
• provides assurance against pain and head movement
17. • Transcanal approach
• Dotted line represents canal
incision of tympanomeatal
flap
• Flap is longer superiorly to
cover scutectomy defect
• For flap to properly fold on
itself exposing posterior
superior quadrant it is best
to carry incision slightly
beyond malleus
18. • Using twisting motion
incision is created with
circular knife
• Tunnel is created under the
“vascular strip,”
19. • Flap is raised to the level of
tympanic annulus
• To avoid disturbance to
ossicles middle ear is first
entered inferiorly
• Bony prominence is often
encountered slightly lateral
to tympanic membrane level
20. • Continuous pressure with
knife against bony canal
should be maintained
• Tympanic mucosa is lysed
with a curved needle
21. • Using back of annulus elevator, flap pushed against anterior
canal wall where surface tension will adhere it
22. • Elevation of annulus
superiorly done with curved
needle
• chorda tympani nerve
identified and dissected free
• Elevation needs to be carried
superiorly until flap is free
from notch of Rivinus
23. • Scutum has to be removed
to provide full access to oval
window
• Done with either a curette
or microdrill or combination
24. • Curette is firmly braced
against speculum to create a
fulcrum effect
• Motion is rotational and
outward, inward leads to
incus dislocation
• Considerable force is needed
to fracture pieces of bone
25. • Curetting is complete
when facial nerve is in
full view superiorly and
junction of stapes
tendon and pyramid are
visible posteriorly
26. • It is important to have
sufficient room to bring
instruments into action from
superior, posterior, and
inferior directions
27. • Palpation of the stapes
superstructure to confirm
fixation
28. • For sizing of prosthesis,
measuring done from lateral
aspect of incus to footplate
• To achieve proper angle,
instrument shaft has to lean
on anterior wall of speculum
• Correct measurement is
between center and
posterior third of footplate
• 4.5 mm in majority of cases
29.
30. • Slight outward pressure on incus
with incudostapedial joint knife
demonstrates thin gray line of
joint
• Joint is cut with gentle
“worming” motion in anterior
direction
• gentle outward lifting of incus is
best while strictly avoiding
downward pressure on stapes
capitulum
34. • Removal of stapes
superstructure through down
fracture toward promontory
• Should always be conducted
away from facial nerve
• Curved needle should contact
both crura, but preferentially
apply force to anterior crus
• Excessive pressure on posterior
crus will potentially lead to
transverse footplate fracture
35.
36. • Creation of small fenestra
stapedotomy with diamond
burr
• Slightly larger than intended
prosthesis (eg: 0.7 mm for 0.6-
mm piston)
• Quick, subtle inward drilling
motion with goal of having burr
penetrate to its meridian (ie:
widest point) and not beyond
37.
38. • Optimal position of fenestra
is in posterior central region
of footplate as vestibule is
deepest in this region
• Contact with footplate
should be brief
• This procedure is delicate
and potentially dangerous, a
mere extra 1 mm of
penetration can kill the ear
39. • Using smooth alligator
prosthesis is seated in
position
• It is important to have both
shepherd’s crook engage
incus as well as the piston
the fenestra
• If wire misses incus, piston
can penetrate vestibule too
deeply
40.
41. • Crimper must be stabilized
on the wall of speculum
• Must be aligned perfectly
with the wire
42.
43.
44.
45. • Once prosthesis is seated
and crimped, its mobility is
tested both by gently
moving either incus or
malleus handle
• Shallowly placed prosthesis
will pop out when subjected
to stress
• If this occurs, prosthesis is
replaced with one 0.25 mm
longer
46. TOTAL STAPEDECTOMY:
• In certain situations, stapedotomy is not possible and
stapedectomy is performed
Floating footplate
Comminuted fracture of footplate
Footplate inadvertently removed during suprastructure
dislocation through anterior crus attachment
Some revision surgeries
When instruments required to create small fenestra are
lacking
47. • Gap between prosthesis and oval window opening to
vestibule must be sealed with tissue graft, such as fat
50. LASERS IN OTOSCLEROSIS :
Offer precision
Avoids use of manual mechanical force
Offer excellent hemostasis
• These qualities are desirable for:
1. Fenestrating thin footplate with reduced risk of resultant
floating footplate
2. Having the ability to fenestrate mobile footplate
3. Creating fenestra with minimal movement of footplate or
perilymph
51. • TYPES OF LASERS:
• Visible green light lasers (argon or potassium titanyl
phosphate [ktp-532])
• Invisible or infrared light lasers (Carbon Dioxide, CO2)
52. • ADVANTAGES OF VISIBLE LASERS:
1. Convenience of handheld probe for use of lasers during
surgery
2. Spot size can be chosen accurately
• DISADVANTAGES:
1. The visible light lasers depend on char formation
2. Char absorbs laser energy and creates heat
3. The laser energy can pass through either directly or by
scatter and injure neural tissue of utricle or saccule
53. • ADVANTAGE OF CARBON DIOXIDE LASERS:
• Not absorbed in perilymph, thus potentially reducing risk to
structures within vestibule
• DISADVANTAGES:
• Need for separate aiming beam
• Requirement of microscope-attached delivery system
Recently, special flexible cable developed by OmniGuide
allows CO2 laser beam to be precisely delivered through
handheld probe
58. TYPES OF PROSTHESIS :
1. Robinson prosthesis:
• Metal stem prosthesis designed to
fit under lenticular process of incus
• Advantage does not require
crimping, relatively easy to insert
• Self-centering
• A narrow stem prosthesis is also
available that can be used for
posterior half footplate removal
59. 2. Causse prosthesis:
• Made of teflon and is designed to
attach to long process of incus.
• Teflon ring is spread open and
prosthesis is snapped onto incus
• Teflon has a long memory and does
not require crimping
• Can be adjusted easily
• Can be used in small fenestra
stapedectomy
60. 3. Fisch/McGee-type piston prosthesis:
• Consists of malleable ribbon-like crook
connected to metal or teflon stem
• Crook is attached to long process of
incus and must be crimped into
position.
• Distal end of prosthesis is scored
checking exact length of prosthesis
that is required easy
• Can be used in small fenestra
stapedectomy.
61. 4. House wire prosthesis:
• One end is shepherd crook-like
arrangement
• At other end is a loop
• Crook is attached and crimped to
long process of the incus
• Technically more difficult to attach
than other prostheses
• Used in total stapedectomy
62. POSTOPERATIVE CARE :
• Patients are instructed
to keep their ears dry
to avoid strenuous physical activities (eg, heavy lifting,
Valsalva maneuvers)
to avoid nose blowing, and to sneeze with an open mouth
Air travel is permissible a couple of days after operation
Oral antibiotics are continued for a week
Audiometric evaluation is performed after 6 to 8 weeks
64. • Repaired by placement of
tragal perichondrium or
fascia graft
• Underlay technique
• Small tears in vicinity of
annulus closed with piece
of Gelfoam
• Small linear tears in canal
skin flap typically need no
repair
65. B: SUBLUXATION OF THE INCUS:
• During curettage of bony annulus
• Separation of incudo-stapedial joint
• Manipulation around oval window
• Crimping
• If disarticulation or complete disruption of joint best to
remove incus and use malleus attachment prosthesis
66. C: OVERHANGING FACIAL NERVE:
• Can be dehiscent of its covering bone, but usually does not
extend significantly out of fallopian canal
• If prolapsed nerve abuts the promontory inferior to oval
window, surgery should not be completed
• Drilling small fenestra that includes the inferior aspect of the
annular ligament
• Prosthesis must be longer than usual to accommodate
bending inferiorly to avoid the nerve
70. • Fenestration made by saucerizing the obliterated niche and
thinning the obstructing bone
• After blue lining the vestibule, with a 0.7-mm diamond burr
72. • It cannot be safely coagulated with bipolar cautery or laser
• Often occupies only anterior half of footplate and
fenestration can be completed in the posterior half
73. F. PERILYMPH GUSHERS AND OOZERS:
• Incidence 0.03%
• Flow of cerebrospinal fluid
• Oozers steady trickle of fluid, associated with persistent
cochlear aqueduct
• Gusher strong and forceful flow originating from defect
in cribrose area of fundus of internal auditory canal
• Rapid drainage of inner ears fluids can threaten
sensorineural hearing
74. • Fenestra is packed with
tissue graft or a cotton
pledget
• Placing lumbar drain can be
useful
75. G. FLOATING OR DEPRESSED FOOTPLATE:
• Footplate that is irretrievably depressed into vestibule will
almost certainly cause vertigo
• Fenestration by laser reduces chances of footplate
disarticulation
• Assessing movement of footplate before completing
fracturing and disengaging suprastructure
76. H. OTOSCLEROSIS INVOLVING THE ROUND WINDOW:
• Attempts at removing this obstruction have resulted in SNHL
• Hence contraindicated
77. POSTOPERATIVE COMPLICATIONS:
1. PERILYMPH FISTULA: PLF
• Most common single complication of stapedectomy
• Potentially dangerous d/to risk of meningitis
• May give rise to dysequilibrium and hearing loss
• Types:
• Primary or early PLF
• Secondary or aquired PLF
78. A. PRIMARY OR EARLY PLF :
• Occurs when fistula created at time of surgery persists and
fails to seal off vestibule
• Use of gelatin sponge (gelfoam) as a seal for oval window
fenestra is associated with high incidence
(1) It may be resorbed before neomembrane has formed
(2) Gelatin sponge will get softened by perilymph and
prosthesis will penetrate through it
(3) Neomembrane that forms with gelatin sponge is very thin
• Vein graft shows less incidence
79. • SIGNS AND SYMPTOMS:
Vary with size of leak
Large fistulas rapid hearing loss, tinnitus, and vertigo
In early PLF when leak is small hearing loss may initially
appear as CdHL and then has sensorineural component and
then progresses to total SnHL
Minute fistula failure of good closure of an air–bone gap,
mild fluctuation in hearing, and small decrease in speech
discrimination scores
80. B. SECONDARY OR AQUIRED FISTULA :
• Usually due to barotrauma, (flying, mountaineering, lifting
heavy objects, coughing, sneezing, and head injury) which
breaks fragile seal
• Characteristics symptom change of hearing after
successful operation; as/w fullness, tinnitus and
dysequilibrium
• Can occur anytime after surgery
81. • MANAGEMENT OF A PERILYMPH FISTULA:
Surgical closure of fistula is treatment of choice
Fistulous track is excised and prosthesis removed with great
care
Mucosa over footplate is elevated completely
Fresh soft tissue seal is placed over adequately created
fenestra
New adequate prosthesis is placed over seal
Patient is advised total rest in bed for 48 hours
82. 2. CHORDA TYMPANI DYSFUNCTION:
• Injury to nerve may result in
a. Hypogeusia and dysgeusia
b. Atrophy of fungiform papillae in denervated area
c. Temporary symptoms, which will improve in course of 3 to
6 months
83. 3. FACIAL PALSY:
• Immediate facial paralysis is related to local anesthesia or
intraoperative trauma to the nerve
• Can be damaged by
a. Bone curette or drill during removal of bony annulus
b. By fracturing stapes toward nerve rather than toward
promontory
c. By injuring anomalous nerve
84. 4. VERTIGO:
• Vertigo may appear during surgery, immediately following it,
or in a delayed manner
• During surgery insult to membranous labyrinth or may be
result of air entering vestibule
• Pneumolabyrinth generally resolves in 24 to 48 h
• Blood causes chemical irritation and resolves in days
• Vertigo extending beyond that time suggests more serious
insult to inner ear and is often associated with SNHL
• Delayed vertigo can be result of BPPV or PLF
85. 5. REPARATIVE GRANULOMA:
• Mass of exuberant granulation tissue developing in reaction
to surgery, foreign body or to perilymph
• Manifests in 5th to 15th POD
• Symptoms and signs of labyrinthitis appear after an early
period of hearing gain
• Otoscopy reveals edema, thickening, and hyperemia of skin
flaps and tympanic membrane
• Immediate reexploration; granulation tissue and prosthesis
are removed, and fenestra is sealed with tissue graft
• Steroids may be useful
86. 6. SENSORINEURAL HEARING LOSS:
• Slight transient SnHL immediately common occurrence
and d/to mild serous labyrinthitis
• Permanent SNHL can occur immediately following surgery or
appear weeks or months after
• Early loss, especially at high tones surgical trauma
• Delayed SNHL PLF
• Delayed fluctuating low-frequency loss post-traumatic
hydrops
• Up to 1% of patients suffer partial or even complete SNHL
87. 7. CONDUCTIVE HEARING LOSS:
• Can appear immediately or more commonly delayed after
initial good result
• Common reasons for immediate conductive loss:
(1) Malfunctioning prosthesis, eg: one that is too short
(2) Unrecognized malleus fixation
(3) Unrecognized round window obliteration
(4) Middle ear effusion, and
(5) Presence of unrecognized SSCD
88. • CdHL after good initial closure
or reduction of airbone gap
1. Erosion of incus at site of
prosthesis attachment (64%)
2. Malpositioned prosthesis
(41%)
3. Bony (14%) or fibrous
regrowth at oval window
area
4. Round window obliteration
(23 %)
89. SUMMARY:
• Surgery for otosclerosis requires specific acquired skills
• Most common procedure to correct stapedial fixation is
small fenestra stapedotomy with incus attachment
prosthesis
• Successful surgery reduces air-bone gaps to less than 10 db
and is achieved in 90% of patients
• Noteworthy complications include SNHL(1%), chorda tympani
nerve dysfunction, and vestibular injury
• Revision surgery associated with lower success rates and
slightly higher complication rates
90. REFERENCES:
• Shambaugh - Ear surgery 6th edn
• Scott – Browns otolaryngology 6th edn
• De Souza – Otosclerosis
• Evolution of Stapes Surgery, P Karthikeyan, D Thomas