surgical management of otosclerosis

1. • Dr. SANJAY MAHARJAN
• PG, ENT – HNS
• MCOMS, Pokhara.
Surgical treatment of
otosclerosis

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

15. SURGICAL TECHNIQUE:
• POSITIONING:
Head turned towards contralateral shoulder and tilted
downward 10 to 15 degrees

16. • EXPOSURE AND EXPLORATION:

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

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

32. • Stapedial muscle tendon divided using microscissors

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

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

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

41. • Crimper must be stabilized
on the wall of speculum
• Must be aligned perfectly
with the wire

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

48. STAPEDECTOMY VS STAPEDOTOMY :

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

56. • COMPLICATIONS OF LASERS:

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

63. INTRAOPERATIVE COMPLICATIONS:
A. TEARS IN TYMPANOMEATAL FLAP:
• Elevation of flap in limited segment
• Elevating TM without annulus.

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

69. D. OBLITERATIVE OTOSCLEROSIS:

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

71. E. PERSISTENT STAPEDIAL ARTERY:
• Incidence  1 of 5000 to 10,000 ears

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