11 surgery for otosclerosis.ppt copy

Surgery for Otosclerosis

History of Otosclerosis and Stapes Surgery

1878 – Kessel tried mobilisation of footplate byapplying pressure in various dir butthen removed the footplate

1888 – Boucheron reported 60 mobilisationswith best results in early ankylosis

1890 – Miot reported 200 stapes mobilisationswith improvement in bone conduction

1892 – Blake coined ‘Stapedectomy’

1893 – Jack reported series of cases ofextraction of stapes

1920 - Fenestration of lat. SCC began by accidentby Holmgren.

Gunnar HolmgrenFather of fenestration surgery

1924 - Maurice Sourdille

developed three stage

exteriorised fenestration

operation



• Julius Lempert

– Popularized the single staged fenestration procedure


• Samuel Rosen

– 1953 – first suggest mobilization of the stapes• Immediate improved

hearing

• Re-fixation


• John Shea

– 1956 – first to perform stapedectomy• Oval window vein graft

• Nylon prosthesis from incus to oval window

• 1980 - 81 - First LASER stapedotomy by Rod Perkins

Surgery

“Restoration of the impedance transfer ofthe ossicular chain and the acousticimpedance of the annular ligament of thestapes footplate in order to achievenormal physiologic vibration of the innerear fluid.”

Goals : • Open the oval window for sound transmission• Reconstruct sound conducting mechanism• without complication

Biophysics of Stapes surgery

• Acoustic Impedance transfer of the ossicular chain

Biophysics of Stapes Surgery

• Acoustic impedance of Annular ligament

Resistance

Mass

Rigidity & Elasticity

Indications for surgery

1. BC level 0 – 25 dB in the speech range & AC 45 – 65dB, AB gap at least 15 dB & SDS 60% or more.

2. In profound cochlear hearing loss with stapesfixation prior to prescribing hearing aid ( providedSpeech discrimination is good)

Contraindications of surgery

1. CHL from causes other than Stapes fixation.

(tympanosclerosis)

-High incidence of SNHL

2. Patients with only hearing ear

3. Stapedial & Cochlear Otosclerosis with poor AB gap

4. History of Vertigo, clinical e/o labyrinthine hydrops in

recent months.

5. Active stage – positive schwartze sign

Contraindications of surgery

6. Pregnancy – delayed till 12 months after delivery

7. Physical strain – Sports men, airmen

» ↑ risk of perilymph fistula

8. Extremes of age : Old age (70yrs)– SD score becoming worse in 40% of cases

- Risk of fistula is more

9. Otitis externa / TM perforation

10. Unilateral Otosclerosis

11. General medical illness

12. Poor ET function

Pre – operative Patient Counselling

• Options for treatment

Advantages and disadvantages of each

• Best surgical candidate

- Previously un-operated ear

- Good health

- Unacceptable ABG (Min of 20 dB ABG)

- Excellent Speech discrimination Score (> 60%)

Surgical steps - Stapedectomy

Incision and T M Flap elevation

Identifying & Separating Chorda tympani nerve

Curettage of canal wall

Measurement for prosthesis

Separating the IS Joint

Fenestra created in footplate

Removal of Stapes superstructure

Methods for removal of Stapes superstructure

Fracture downward using a sharp pick

Microcrurotomy burr / Microcrurotomy scissors

LASER : Argon / CO2 Laser

Excising the footplate

Polythene strut interposition

Surgical Technique

• Total Stapedectomy

• Partial Stapedectomy

Stapedotomy

• Originally for obliterated or solid footplates (1970-80)

• Micro drill/Micro pick/Laser

• Advantages– Less trauma to the vestibule

– Less incidence of prosthesis migration

– Less fixation of prosthesis by scar tissue

Drill Fenestration Technique

• 0.7mm diamond burr

Avoids smoke production

Avoids surrounding heat production

Marquet’s Microhook Technique

Fisch Stapedotomy

Classic Stapedotomy

1. Stapes superstructure removed

2. Fenestration of footplate

3. Prosthesis placement

Modified Stapedotomy


2. Stapes superstructure removal


Modified Stapedotomy



3. Stapes superstructure removal

Stapedotomy with stapes tendon preservation

• Stapes tendon attached to the stapes neck

• Stapes tendon attached to the lenticular process

• Reconstruction of the stapes tendon by placing it on a polycel pedestal

• Linear Stapedotomy without prosthesis (STAMP)

Less trauma to the vestibule

Annular ligament is not disrupted

Advantages of Stapedotomy over Stapedectomy

Advantages of Stapedotomy over Stapedectomy

Stapedectomy Stapedotomy

Principle Removal of footplate

+ Seal + prosthesis

Small fenestra +

prosthesis

Energy transfer to cochlea

Better Mech. system Better results at 4 kHz

Better compressionalBC

Effects on sensory apparatus

Overstimulation Less damage to high freq. receptors

Excess energy to cochlea- Hair cell damage

Mech. factors

Technique Risk of damage to inner ear

Incidence is less

Stapedectomy Stapedotomy

Technique More chance of prosthesis migration

Less

Results Immediate SNHL 1.5%

Delayed SNHL9.5 dB / decade 3.5 dB / decade

Complications More Less

LASER in Stapes Surgery

• Indications

• Ideal qualities reqd

• Lasers commonly used : CO2, Argon, KTP, Erbium

• Technique

Laser in Stapes Surgery

• Advantages :

Precision

Avoid trauma to inner ear

Lowers incidence of floating footplate

Good hemostasis

Good long term results

Less difficult technically

Post–op Care

• Nurse pt with operated ear up

• Analgesics

• Antipyretics

• Antiemetics

• Avoid straining

Special Problems During Surgery

Narrow ear canal

Fixed incus and/or malleus

Dehiscent /Prolapsed facial nerve (0.5%) Go to

Floating footplate Go to

Obliterative Otospongiosis Go to

Biscuit footplate

Perilymph gusher (0.03 – 0.3%) Go to

Persistent stapedial artery (0.2%)

Adhesions in oval window niche

Special Problems During Surgery

Complications of Stapedectomy

I. Complications during TM flap elevation

• Ear drum perforation (2-5%)

• Facial nerve palsy (0.02 – 0.5%)

• Chorda tympani lesions

• Incus luxation (Anterior/posterior/lateral)


II. Complications during removal of stapes

Sensorineural hearing loss (3.5 – 4%) Go to

Floating footplate


Complications after stapedectomy

Reparative granuloma Go to

Perilymph fistula (0.9% - 2.6%) Go to

Delayed SNHL

Delayed facial nerve palsy

Cholesteatoma

Labyrinthitis / Meningitis

Conductive Hearing loss after stapedectomy

Refixation of mobilised footplate

Adherence of prosthesis to edge of OW

Osseous closure of OW

Aseptic necrosis of long process of incus

Slippage of prosthesis

Loosening of wire attachment to incus

Ankylosis of incus/malleus to attic wall

Conductive Hearing Loss Mechanism: After Stapedectomy

• Collagen tissue seal contracts

• Neomembranelateralizes

• Erosion of incus causing loosening of wire loop

Conductive Hearing Loss Mechanism: After Stapedotomy

• Collagen tissue seal contracts

• Prosthesis lifts out of stapedotomy

• Prosthesis migrates to fixed stapes footplate

Results of Surgery

• Initial successful results are not likely to be maintained indefinitely

• Despite modifications – how long and how well the good results withstand the passage of time ?

• Pts require assistance with amplification 10 yrs. or more after surgery.

Problems During Stapes Surgery

Floating Footplate• Footplate dislodges from surrounding oval window niche

– Usually iatrogenic– Incidental finding less common

• Prevention– Laser– Footplate control hole

• Management– Abort– Proceed

• Total stapedectomy• Laser fenestration/microdrill fenestration• Back

Problems During Stapes Surgery

Perilymph Gusher - profuse flow of perilymph immediately upon opening vestibule

• Rare – 0.03% incidence• Associated with congenital footplate fixation• Possibly due to:

– Widened cochlear aqueduct– Defect in IAC fundus

• Management– Head end elevation– Tissue graft over oval window– Complete procedure if possible– Bed rest, stool softeners, avoid Valsalva– Consider lumbar drain Back

Overhanging Facial Nerve

• Usually dehiscent• Consider aborting the procedure• Facial nerve displacement (Perkins, 2001)

– Facial nerve is compressed superiorly with No. 24 suction (5 second periods)

– 10-15 sec delay between compressions– Perkins describes laser stapedotomy while nerve is

compressed

• Wire piston used– Add 0.5 to 0.75 mm to accommodate curve around the

nerveBack

Obliterative Otosclerosis

• Occurs when the footplate, annular ligament, and oval window niche are involved

• Drill out procedure

• Stapedotomy

– Bone is thinned with a small cutting burr

– Blue lined at anteroposterioredges first

– Seepage of perilymphBack

11 surgery for otosclerosis.ppt copy

Health & Medicine

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