Stapedectomy - Indications, Contraindications, Surgical Procedure, and Complications

Introduction:

Stapes is a “U” shaped, tiny bone present in the middle ear and is most close to the inner ear. This minute “U” shaped bone functions to transfer sound waves from the middle ear to the inner ear and thus helps in the hearing mechanism. Any damage to the stapes results in hearing loss, thereby affecting the quality of life of a person. Otosclerosis is a condition in which abnormal growth of the bones takes place around the stapes, thereby blocking the vibratory function of the stapes resulting in conductive hearing loss. The most commonly involved sites of otosclerosis are anterior to the oval window (seen in 95 percent of cases), round window niche (seen in 25 to 30 percent of cases), Stapes footplate (around 10 to 12 percent of cases), and posterior to oval window (in 5 percent of cases).

Otosclerosis is of two types :

1. Fenestral (Stapedial): It is seen in 80 percent of the cases. It affects the stapes footplate and oval window resulting in conductive (disruption in sound conduction mechanism) hearing loss.

2. Retro-Fenestral (Cochlear): It is seen in 20 percent of cases and mostly involves the cochlear capsule or sac resulting in sensorineural (disruption in the transfer of electrical signal by a hearing nerve) hearing loss.

What Is the Prevalence of Otosclerosis Disorder?

• Otosclerosis disorder accounts for 12% of the general population, with 0.3% of people presenting symptoms.

• Females are more frequently affected than males. It mostly affects people in the age group of 20 to 30 years.

What Are the Causes of Otosclerosis Disorder?

The exact cause of otosclerosis is unknown, but some factors supposed to cause otosclerosis are:

• Genetic Mutation: Due to mutation of chromosome COL1A1.

• Hereditary: It can run in families.

• Viral infections: These can be associated with viral infections like measles.

What Are the Indications of Stapedectomy Surgery?

Partial or complete surgical removal of stapes is advised in a person with hearing loss in one or both ears due to otosclerosis, traumatic damage, and birth abnormalities of the stapes.

What Are the Contraindications of Stapedectomy Surgery?

Surgical removal of the stapes should not be performed if :

• A person is having active middle ear infections (surgery is delayed until the infection subsides).

• Only one hearing ear is there in person.

• Patient with a recent history of vertigo (spinning sensation in the head like in Meniere's disease).

What Are the Signs and Symptoms of Abnormal Bone Formation on Stapes?

Signs and symptoms that occur due to otosclerosis disorder are:

• Loss of balance.

• Pressure changes in the ear.

• Ear pain.

• Hearing loss in one or both ears.

• Vertigo (spinning sensation in the head).

• Tinnitus (ringing sensation in the ears).

• Headaches.

• Dizziness.

What Diagnostic Tests Are Performed Before a Stapedectomy Procedure?

Various diagnostic tests performed to rule out otosclerosis before the stapedectomy procedure are:

• History and Physical Examination: A detailed history of the clinical symptoms like hearing impairment, tinnitus, vertigo, and if positive family history of otosclerosis should be noted. An otoscope (a small instrument with attached light used to examine the ears) is used by the doctor to examine the ears for the presence of any chronic ear infections.

• Audiometry (Hearing Test): It is done to rule out the severity of hearing loss in the patient by producing different pitches of sounds in the ear with a tiny earphone, and the response is recorded on the graph (audiogram).

• Computed Tomography (CT) Scan: These scans are the gold standard for diagnosis. It shows the thickening of the stapes and involvement of the cochlea (demineralization of the otic capsule).

• Tuning Fork Test: This test is done to check hearing loss. In this test, a tuning fork is just kept near the middle ear first and then behind the ear near the mastoid bone to detect if a person can hear the sound more through the ears or the bone.

How Is Stapedectomy Surgery Done?

Stapedectomy surgery is performed under local or general anesthesia. It usually takes one to two hours for the surgery. A surgeon cuts the tympanic membrane, and a flap (outer tissue cover) is elevated to expose the middle ear bones. After the stapes are visualized, it is removed along with the footplate (stapes base), and the created space is replaced by a prosthesis (artificial device). After placing an artificial device eardrum is placed back into place along with the flap, and stitches are given. After the surgical procedure is done, the patient is prescribed antibiotics and painkillers.

What Is Revision Stapedectomy?

Revision stapedectomy is a similar operation done for the removal of stapes. It is indicated to treat hearing loss complications in the patient after the surgical procedure or in patients in which previous surgery failed. It is performed in a similar ear in which previous surgery was done.

Is It Safe to Do Stapedectomy Surgery in Children?

Yes, it is safe to do stapedectomy surgery in children.

Can a Stapedectomy Surgery Be Performed in Both Ears at the Same Time?

No, Stapedectomy surgeries are performed in one ear at a time. A gap of a minimum of six months should be there for performing second ear surgery.

What Are the Instructions That Need to Be Followed After Stapedectomy Surgery?

Instructions to be followed after surgery are:

• Follow-up with the doctor for the dressing of the surgical site.

• Avoid blowing your nose for two weeks.

• Avoid entry of water in treated ears till the doctor advises.

• Avoid strenuous activities for two weeks.

• Avoid driving for two weeks if you feel dizzy after surgery.

• Avoid traveling from the plane for a minimum of four weeks as it can lead to sudden pressure changes in the ears. After four weeks, cotton plugs should be used to prevent the entry of air into the ears while traveling.

• Keep your head elevated by using two pillows while sleeping.

• Avoid popping your ears by holding your nose.

• Any severe complications faced should be reported to the doctor immediately.

What Are the Complications of Stapedectomy Surgery?

Risk factors or complications associated with stapedectomy surgery are:

• Pain in ears.

• Discharge from ears.

• Nerve damage (chorda tympani nerve-a branch of the facial nerve).

• Tympanic membrane perforation during surgery.

• Spinning sensations in the head (vertigo).

• Ringing sensation in ears (tinnitus).

• Hearing loss.

• Perilymphatic fistula (an abnormal opening between the middle and inner ear).

• Loss of taste sensation.

• Infection at the surgical site.

• Scarring at the surgical site.

What Are the Differences Between Stapedectomy and Stapedotomy?

Stapedectomy surgery involves the removal of the complete stapes footplate followed by replacement with a tiny prosthesis (artificial device) but in the case of stapedotomy, a laser is used to make a fine hole in the stapes footplate followed by placement of prosthesis through the precise hole made. Stapedotomy is an easier and safer procedure than stapedectomy with minimal post-surgical complications.

Conclusion:

Otosclerosis (an abnormal formation of bone around the stapes), traumatic damage, and birth defects related to the stapes are the reasons resulting in the dysfunction of the stapes (a tiny bone in the middle ear) affecting the quality of life of a person tremendously.

Stapedectomy is a surgically challenging procedure done for the removal of the stapes to treat the underlying symptoms like headaches, ear pain, dizziness, spinning sensation in the head, ringing sensation in the ears, and balance loss. Early diagnosis of the symptoms is crucial for a better surgical outcome and to minimize the risk factors/complications associated with the stapedectomy procedures.