Medicine:Stapedectomy

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Short description: Surgical procedure of the middle ear

Stapedectomy is a surgical procedure in which the stapes bone is removed from the middle ear and replaced with a prosthesis.

If the stapes footplate is fixed in position, rather than being normally mobile, the result is a conductive hearing loss. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the temporal bone called otosclerosis. The second is a congenital malformation of the stapes.[1][2][3]

In both of these situations, it is possible to improve hearing by removing the stapes bone and replacing it with a micro prosthesis – creating a small hole in the fixed stapes footplate and inserting a tiny, piston-like prosthesis. The results of this surgery are generally most reliable in patients whose stapes has lost mobility because of otosclerosis. Nine out of ten patients who undergo the procedure will come out with significantly improved hearing while less than 1% will experience worsened hearing acuity or deafness. Successful surgery usually provides an increase in hearing acuity of about 20 dB. However, most of the published results of success fall within the speech frequency of 500 Hz, 1000 Hz and 2000 Hz; poorer results are typically obtained in the high frequencies, but these are normally less hampered by otosclerosis in the first place.[4]

Stapedectomy process and results

Stapedectomy has success rates ranging from 80% to 95%.[5][6]

Stapedectomy closes what is called the "air bone gap" very efficiently, meaning it restores efficient conduction of sound coming through the air close to the level of the best ability of the nerve cells to perceive the sound.[7]

It takes 30 minutes to 90 minutes depending on skills and experience of the surgeon and the presence of difficult or easy anatomical access to the stapes.[8]

Stapedectomy is performed under either local or general anesthesia depending on the preference of the surgeon.[6]

Most surgeons do not make any skin incisions, especially when the surgery is performed with an endoscope.[9] However, sometimes the ear canal is so small that an incision is needed.[9]

Indications

Indications of stapedectomy:

  1. Conductive hearing loss (due to fixation of stapes).
  2. Air bone gap of at least 30 dB.
  3. Presence of Carhart's notch in the audiogram of a patient with conductive hearing loss (relative)
  4. Good cochlear reserve as assessed by the presence of good speech discrimination.[10]

Contraindications

Contraindications for stapedectomy:

  • Poor general condition of the patient.
  • Only hearing ear.
  • Poor cochlear reserve as shown by poor speech discrimination scores
  • Patient with tinnitus and vertigo
  • Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign.
  • Conductive deafness due to Ehlers–Danlos Syndrome (EDS)[10]

Complications

Complications of stapedectomy:

  • Facial palsy
  • Vertigo in the immediate post op period
  • Vomiting
  • Perilymph gush
  • Floating foot plate
  • Tympanic membrane tear
  • Dead labyrinth
  • Perilymph fistula
  • Labyrinthitis
  • Granuloma (Reparative)
  • Tinnitus[11][12]

When a stapedectomy is done in a middle ear with a congenitally fixed footplate, the results may be excellent but the risk of hearing damage is greater than when the stapes bone is removed and replaced (for otosclerosis). This is primarily due to the risk of additional anomalies being present in the congenitally abnormal ear. If high pressure within the fluid compartment that lies just below the stapes footplate exists, then a perilymphatic gusher may occur when the stapes is removed. Even without immediate complications during surgery, there is always concern of a perilymph fistula forming postoperatively.

In 1995, Glasscock et al. published a 25-year single-centre review of over 900 patients who underwent stapedectomy and stapedotomy and found complications rates as follows: reparative granuloma 1.3%, tympanic membrane perforation 1.0%, total sensorineural hearing loss 0.6%, partial sensorineural hearing loss 0.3%, and vertigo 0.3%. In this series, there was no incidence of facial nerve paralysis or tinnitus.[6]

Stapedotomy

A modified stapes operation, called a stapedotomy, is thought by many otologic surgeons to be safer and reduce the chances of postoperative complications. In stapedotomy, instead of removing the whole stapes footplate, a tiny hole is made in the footplate – either with a microdrill or with a laser,[7] and a prosthesis is placed to touch this area, oval window. This procedure can be further improved by the use of a tissue graft seal of the fenestra, which is now common practice.[5]

Laser stapedotomy is a well-established surgical technique for treating conductive hearing loss due to otosclerosis. The procedure creates a tiny opening in the stapes (the smallest bone in the human body) in which to secure a prosthetic. The CO2 laser allows the surgeon to create very small, precisely placed holes without increasing the temperature of the inner ear fluid by more than one degree, whilst decreasing the risk of footplate fracture, making this an extremely safe surgical solution.[8] The hole diameter can be predetermined according to the prosthesis diameter. Treatment can be completed in a single operation visit using anesthesia, normally followed by one or two nights' hospitalization with subsequent at-home recovery time a matter of days or weeks.

Stapedectomy vs. stapedotomy

Comparisons have shown stapedotomy to yield either as good[13] or better[14] results than stapedectomy (measured by hearing improvement and reduction in the air-bone hearing gap, and especially at higher sound frequencies), and to be less prone to complications.[15] In particular, stapedotomy procedure greatly reduces the chance of a perilymph fistula (leakage of cochlear fluid).[5]

Stapedotomy, like stapedectomy, can be successful in the presence of sclerotic adhesions (tissue growths abnormally linking the bones to the tympanic cavity), provided the adhesions are removed during surgery. However, the adhesions may recur over time. The stapedotomy method is not applicable in those relatively rare cases that involve sclerosis of the entire ossicular chain.

Endoscopic view of the stapedotomy in the footplate of the stapes bone
Endoscopic view of the piston inserted into the stapedotomy and on to the long processof the incus

Because it is a simpler and safer procedure, stapedotomy is normally preferred to stapedectomy in the absence of predictable complications. However, the success rate of either surgery depends greatly on the skill and the familiarity with the procedure of the surgeon.[5] Furthermore, a major success factor in both surgeries is correctly determining the length of the prosthesis.[16]

Endoscopic Stapedotomy

In 1999, Professor Tarabichi described his experience with stapedotomy performed using the endoscope without the need for bone removal or skin incision (endaural approach).[9] Since then, endoscopic stapedotomy has been gaining popularity especially amongst younger endoscopically trained surgerons. It allows for better view of the footplate of the stapes without the need to remove bone which is very common when doing the procedure with microscope.[17] Professor Patel and his Australian team published a relatively large cohort of patients undergoing endoscopic stapedotomy procesure with closure of air-bone gape within 20 dB in 98.6%.[18]

History

The world's first stapedectomy is credited to Dr. John J.Shea Jr. who performed it in May 1956 on a 54-year-old housewife who could no longer hear even with a hearing aid.[19] Significant contributions to modern stapedectomy techniques were then made by the late Dr. Antonio De La Cruz of the House Ear Institute in Los Angeles ; by the late Professor Henri André Martin of the Hôpital Edouard Herriot in Lyon, France , including calibrated platinotomy (stapes footplate rather than whole surgery) and trans-footplate piston surgery that also paved the way for modern stapedotomy;[20] and by the late Dr. Jean-René Causse of the eponymous clinic in Béziers, France , who pioneered the use of Teflon piston prostheses (also critical progress for stapedotomy) and, with his late son Dr. Jean-Bernard Causse, the reattachment of the stapedius muscle alongside the use of veinous grafts.[21][22] in 1999, Professor Tarabichi of the Tarabichi Stammberger Ear and Sinus Institute, reported his experience performing the surgery using endoscope which lessens the need to remove bone to obtain access to the stapes.[9]

Anatomy gallery

  • Location of the ossicular chain in the ear

  • Right-ear stapes

  • Stapes: Relative size

See also

Footnotes

  1. ↑ Ishida, Hiroki; Okano, Takayuki; Hayashi, Yasuyuki; Nishimura, Koji; Sakamoto, Tatsunori; Yamamoto, Norio; Omori, Koichi (2020-01-01). "Two cases of congenital stapes malformation: Implications for development of the stapes footplate and the oval window". Acta Oto-Laryngologica Case Reports 5 (1): 91–95. doi:10.1080/23772484.2020.1798765. 
  2. ↑ "Congenital Stapes Fixation | Dallas Ear Institute". https://www.dallasear.com/conditions-congenital-stapes-fixation.html. 
  3. ↑ Henriques, Vânia; Teles, Rafaela; Sousa, Ana; Estevão, Roberto; Rodrigues, Jorge; Gomes, Alexandra; Silva, Francisco; Fernandes, Ângelo et al. (2016). "Abnormal Congenital Location of Stapes' Superstructure: Clinical and Embryological Implications". Case Reports in Otolaryngology 2016: 2598962. doi:10.1155/2016/2598962. ISSN 2090-6765. PMID 27648330. 
  4. ↑ "Poor High Frequency Results Following Total Stapedectomy Theoretical Considerations". Indian Journal of Otolaryngology and Head & Neck Surgery 35 (1): 9–11. 1983. doi:10.1007/BF02992304. 
  5. ↑ 5.0 5.1 5.2 5.3 Otosclerosis and Stapedectomy, New York, NY: Thieme, 2004, ISBN 1-58890-169-6 
  6. ↑ 6.0 6.1 6.2 "Twenty-five years of experience with stapedectomy". The Laryngoscope 105 (9 Pt 1): 899–904. September 1995. doi:10.1288/00005537-199509000-00005. PMID 7666721. 
  7. ↑ 7.0 7.1 "Laser stepedotomy for otosclerosis". The Laryngoscope 90 (2): 228–40. February 1980. doi:10.1288/00005537-198002000-00007. PMID 7354691. 
  8. ↑ 8.0 8.1 "The Use of Lasers in Stapes Surgery". Ear, Nose, & Throat Journal 100 (1_suppl): 73S–76S. February 2021. doi:10.1177/0145561320937828. PMID 32603217. 
  9. ↑ 9.0 9.1 9.2 9.3 "Endoscopic middle ear surgery". The Annals of Otology, Rhinology, and Laryngology 108 (1): 39–46. January 1999. doi:10.1177/000348949910800106. PMID 9930539. 
  10. ↑ 10.0 10.1 Stapedectomy: Background, Indications, Contraindications. 2021-12-23. https://emedicine.medscape.com/article/2094916-overview. 
  11. ↑ Savić, D.; Djerić, D. (May 1991). "[Complications of stapedectomy involving the middle ear structures"]. Srpski Arhiv Za Celokupno Lekarstvo 119 (5–6): 130–133. ISSN 0370-8179. PMID 1792562. https://pubmed.ncbi.nlm.nih.gov/1792562/. 
  12. ↑ Dawes, J. D. K.; Welch, A. R. (1985), Marquet, Jean F. E., ed., "Complications of stapedectomy" (in en), Surgery and Pathology of the Middle Ear: Proceedings of the International Conference on ‘The Postoperative Evaluation in Middle Ear Surgery’ held in Antwerp on June 14–16, 1984 (Dordrecht: Springer Netherlands): pp. 201–205, doi:10.1007/978-94-009-5002-3_49, ISBN 978-94-009-5002-3, https://doi.org/10.1007/978-94-009-5002-3_49, retrieved 2022-03-27 
  13. ↑ "Stapedectomy vs stapedotomy. Do you really need a laser?". Archives of Otolaryngology–Head & Neck Surgery 123 (2): 177–80. February 1997. doi:10.1001/archotol.1997.01900020059008. PMID 9046285. 
  14. ↑ "[Stapedotomy vs stapedectomy. Comparison of hearing results]" (in Italian). Acta Otorhinolaryngologica Italica 16 (2 Suppl 53): 36–41. April 1996. PMID 8928670. 
  15. ↑ Thamjarayakul T, Supiyaphun P & Snidvongs K, "Stapes fixation surgery: Stapedectomy versus stapedotomy", Asian Biomedicine, 4(3): 429–434, 2010.
  16. ↑ "Utricle, saccule, and cochlear duct in relation to stapedotomy. A histologic human temporal bone study". The Annals of Otology, Rhinology, and Laryngology 100 (12): 966–70. December 1991. doi:10.1177/000348949110001203. PMID 1746843. 
  17. ↑ "Endoscopic stapedotomy: Merits and demerits". Journal of Otology 13 (3): 97–100. September 2018. doi:10.1016/j.joto.2017.11.002. PMID 30559773. 
  18. ↑ Vaughan, Casey; Fox, Richard; Jufas, Nicholas; Kong, Jonathan H. K.; Patel, Nirmal P.; Saxby, Alexander J. (October 2020). "Endoscopic Stapedectomy: Collective Experience From a Large Australian Center" (in en). Otology & Neurotology 41 (9): 1198–1201. doi:10.1097/MAO.0000000000002762. ISSN 1531-7129. PMID 32925837. https://journals.lww.com/10.1097/MAO.0000000000002762. 
  19. ↑ "John J. Shea, Jr". Shea Ear Clinic. http://www.sheaclinic.com/doctors_1.asp. 
  20. ↑ "Necrology: Henri André Martin, 01/21/1918 - 10/16/2004" (in French). 2004. p. 332. http://www.ent-review.com/detail_en.lasso?id=8c6c2eb03f52a797&-session=rvl:42F942AF11ccc2F96Fimq196FE0F. 
  21. ↑ "Stapedotomy technique and results". The American Journal of Otology 6 (1): 68–71. January 1985. PMID 3976862. 
  22. ↑ Obituaries: Jean-Rene Causse, MD, February 6, 1910 - December 10, 2001; Jean-Bernard Causse, MD, May 13, 1944 -– December 13, 2001, Ear, Nose & Throat Journal, February 2002, http://findarticles.com/p/articles/mi_m0BUM/is_2_81/ai_83516024/ 

External links

  • The LION Foundation's Live International Otolaryngology Network offers annual symposia geared for continuing education of practicing surgeons, and subsequently available via streaming internet.[1]
  • Overview of Otosclerosis and Stapedectomy [2]
  • Balasubramanian T (2006). "Stapedectomy". http://www.drtbalu.com/staped.html.  - details of the procedure with pictures
  • Amanda Jenner, Lynne Shields PhD ccc-slp "Speech and Language Issues" [3]
  • M. Hawthorne, FRCS-ENT Surgeon. "Hearing Impairment and EDS" [4]



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