Stapedectomy is a surgical procedure in which the

stapes The ''stapes'' or stirrup is a bone in the middle ear of humans and other tetrapods which is involved in the conduction of sound vibrations to the inner ear. This bone is connected to the oval window by its annular ligament, which allows the f ...

bone is removed from the

middle ear The middle ear is the portion of the ear medial to the eardrum, and distal to the oval window of the cochlea (of the inner ear). The mammalian middle ear contains three ossicles (malleus, incus, and stapes), which transfer the vibrations ...

and replaced with a

prosthesis In medicine, a prosthesis (: prostheses; from ), or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through physical trauma, disease, or a condition present at birth (Congenital, congenital disord ...

. If the stapes footplate is fixed in position, rather than being normally mobile, the result is a

conductive hearing loss Conductive hearing loss (CHL) is a type of hearing impairment that occurs when sound waves are unable to efficiently travel through the outer ear, tympanic membrane (eardrum), or middle ear structures such as the ossicles. This blockage or dysfun ...

. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the

temporal bone The temporal bone is a paired bone situated at the sides and base of the skull, lateral to the temporal lobe of the cerebral cortex. The temporal bones are overlaid by the sides of the head known as the temples where four of the cranial bone ...

called

otosclerosis Otosclerosis is a condition of the middle ear, middle and inner ear where portions of the dense enchondral layer of the bony labyrinth Tissue remodeling, remodel into one or more lesions of irregularly-laid spongy bone. As the lesions reach the s ...

. The second is a

congenital malformation A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...

of the stapes. 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

. 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 Deafness has varying definitions in cultural and medical contexts. In medical contexts, the meaning of deafness is hearing loss that precludes a person from understanding spoken language, an audiological condition. In this context it is writte ...

. 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.

Stapedectomy process and results

Stapedectomy has success rates ranging from 80% to 95%. 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. 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. Stapedectomy is performed under either local or general anesthesia depending on the preference of the surgeon. Most surgeons do not make any skin incisions, especially when the surgery is performed with an endoscope. However, sometimes the ear canal is so small that an incision is needed.

Indications

Indications of stapedectomy: # Conductive hearing loss (due to fixation of stapes). # Air bone gap of at least 30 dB. # Presence of Carhart's notch in the audiogram of a patient with conductive hearing loss (relative) # Good cochlear reserve as assessed by the presence of good speech discrimination.

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 Ehlers–Danlos syndromes (EDS) is a group of 14 genetic connective-tissue disorders. Symptoms often include loose joints, joint pain, stretchy velvety skin, and abnormal scar formation. These may be noticed at birth or in early childhood. Co ...

(EDS)

Complications

Complications of stapedectomy: *

Facial palsy Facial nerve paralysis is a common problem that involves the paralysis of any structures innervated by the facial nerve. The pathway of the facial nerve is long and relatively convoluted, so there are a number of causes that may result in facial ...

* Vertigo in the immediate post op period * Vomiting * Perilymph gush * Floating foot plate * Tympanic membrane tear * Dead labyrinth * Perilymph fistula *

Labyrinthitis Labyrinthitis is inflammation of the labyrinth, a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve (the nerve in the ear that sends messages related to motion and position to the brain) ...

* Granuloma (Reparative) *

Tinnitus Tinnitus is a condition when a person hears a ringing sound or a different variety of sound when no corresponding external sound is present and other people cannot hear it. Nearly everyone experiences faint "normal tinnitus" in a completely ...

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

perilymph Perilymph is an extracellular fluid located within the inner ear. It is found within the scala tympani and scala vestibuli of the cochlea. The ionic composition of perilymph is comparable to that of plasma and cerebrospinal fluid. The major ca ...

atic 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.

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 A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word ''laser'' originated as an acronym for light amplification by stimulated emission of radi ...

, and a

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. 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. 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 or better 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. In particular, stapedotomy procedure greatly reduces the chance of a perilymph fistula (leakage of cochlear fluid). Stapedotomy, like stapedectomy, can be successful in the presence of sclerotic adhesions (tissue growths abnormally linking the bones to the

tympanic cavity The tympanic cavity is a small cavity surrounding the bones of the middle ear. Within it sit the ossicles, three small bones that transmit vibrations used in the detection of sound. Structure On its lateral surface, it abuts the external audit ...

), 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 Stapedotomy

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. Furthermore, a major success factor in both surgeries is correctly determining the length of the prosthesis.

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). 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. 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%.

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. 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 Los Angeles, often referred to by its initials L.A., is the List of municipalities in California, most populous city in the U.S. state of California, and the commercial, Financial District, Los Angeles, financial, and Culture of Los Angeles, ...

; by the late Professor Henri André Martin of the Hôpital Edouard Herriot in

Lyon Lyon (Franco-Provençal: ''Liyon'') is a city in France. It is located at the confluence of the rivers Rhône and Saône, to the northwest of the French Alps, southeast of Paris, north of Marseille, southwest of Geneva, Switzerland, north ...

France France, officially the French Republic, is a country located primarily in Western Europe. Overseas France, Its overseas regions and territories include French Guiana in South America, Saint Pierre and Miquelon in the Atlantic Ocean#North Atlan ...

, including calibrated platinotomy (stapes footplate rather than whole surgery) and trans-footplate piston surgery that also paved the way for modern stapedotomy; and by the late Dr. Jean-René Causse of the eponymous clinic in

Béziers Béziers (; ) is a city in southern France. It is a Subprefectures in France, subprefecture of the Hérault Departments of France, department in the Occitania (administrative region), Occitanie Regions of France, region. Every August Béziers ho ...

, who pioneered the use of

Teflon Polytetrafluoroethylene (PTFE) is a synthetic fluoropolymer of tetrafluoroethylene, and has numerous applications because it is chemically inert. The commonly known brand name of PTFE-based composition is Teflon by Chemours, a spin-off from ...

piston prostheses (also critical progress for stapedotomy) and, with his late son Dr. Jean-Bernard Causse, the reattachment of the

stapedius muscle The stapedius is the smallest skeletal muscle Skeletal muscle (commonly referred to as muscle) is one of the three types of vertebrate muscle tissue, the others being cardiac muscle and smooth muscle. They are part of the somatic nervous syste ...

alongside the use of veinous grafts. 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.

Anatomy gallery

Image:Place-des-osselets-Schema.jpg, Location of the ossicular chain in the ear Image:Etrier schéma.png, Right-ear stapes Image:Stapes human ear.jpg, Stapes: Relative size

Footnotes

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 interne

* Overview of Otosclerosis and Stapedectom

* - details of the procedure with pictures * Amanda Jenner, Lynne Shields PhD ccc-slp "Speech and Language Issues

* M. Hawthorne, FRCS-ENT Surgeon. "Hearing Impairment and EDS

{{Operations and other procedures on the ear Ear surgery Ear procedures