Avoidance and Management of Complications of Otosclerosis Surgery

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Chapter 26 Avoidance and Management of Complications of Otosclerosis Surgery

Joseph B. Roberson, Jr.

image Videos corresponding to this chapter are available online at www.expertconsult.com.

Otosclerosis surgery is one of the most exciting and rewarding procedures an otologic surgeon performs. The physical demands of the operation are among the most refined of the surgical disciplines, and includes an extremely small tolerance for error even when the case goes along well with perfect equipment and perfect performance of support personnel. Small deviations from the surgical techniques illustrated in the remainder of this text regularly prove necessary to avoid complication. The knowledge base and technical skills needed to handle these deviations add difficulty to an already challenging undertaking seen with routine cases. With this difficulty comes a large reward, however, as patients experience improvement of their hearing with a successful outcome—frequently to the normal range.

As with other difficult procedures, the learning curve for otosclerosis surgery is not steep. Complete preparedness for each potential surgical obstacle or complication is necessary to achieve results approaching those of experienced surgeons in centers of excellence located throughout the world. The atmosphere in the operating room is usually one of excitement and potentially slight tension with this procedure, especially for surgeons just beginning their careers. Thorough knowledge of and ability to deal with potential complications and surgical deviations help reduce anxiety and allow the operating surgeon to focus on and complete the job at hand.

Reliable correction of otosclerotic conductive hearing impairment requires discipline, precision, knowledge, preparation of the operating facility, and judgment. Cognitive preparation should be complete before undertaking stapes surgery as the primary surgeon. Expert training and steady experience provide mastery of technical skill and development of operative judgment. Only then can the fullest potential as a stapes surgeon be reached. This chapter provides knowledge based on my own experience and that of other contributors to the field who have courteously shared their experience as colleagues, professors, mentors, and authors. The focus is on the preoperative, operative, postoperative, and reoperative situations a surgeon faces when he or she seeks to prevent or rectify complications.

PREOPERATIVE EVALUATION

Medical Conditions

A written or mental checklist is useful to avoid overlooking an important medical feature during preoperative evaluation. It is helpful (and recommended) to have any and all family members in the office present in the examination room during the interview. A useful practice is to write the names of the individuals present on the chart during the interview. In addition to a complete history and physical examination with attention to medical conditions germane to any surgical procedure, the prudent surgeon attempts to identify the following conditions.

Fluctuating hearing loss, episodic vertigo, and low-frequency sensorineural hearing loss (SNHL) may indicate endolymphatic hydrops. Care must be taken to avoid confusing the early conductive hearing loss of prior audiograms (which may falsely appear as SNHL) with endolymphatic hydrops. Patients with endolymphatic hydrops who undergo stapes surgery have a higher rate of SNHL (presumably from dilation of the saccule that contacts the stapes footplate where it is at risk during stapedectomy or stapedotomy) and chronic dizziness. This condition may be a contraindication to surgery.1

Surgeons should insist that acoustic reflex testing be performed and reviewed before entering the operating room because superior semicircular canal dehiscence manifests with conductive hearing impairment, which may be confused with impairment caused by otosclerosis on pure tone audiometry. This practice helps avoid the situation where a mobile and normal stapes is found intraoperatively after entering the middle ear. Clinical history also is very helpful if the patient has symptoms of vertigo with loud sounds. Diagnosis is established or refuted with a computed tomography (CT) scan in the plane of the superior semicircular canal. Patient symptoms such as vertigo with impulse noise may also alert the operating surgeon to the presence of this otosclerosis look-alike.

A history of multiple fractures or blue sclera may allow the diagnosis of osteogenesis imperfecta to be made preoperatively.2

Lifelong hearing loss in one ear should alert the surgeon to the possibility of congenital footplate fixation. Congenital footplate fixation carries a higher than usual risk of gusher and SNHL.3 A CT scan should be performed preoperatively in patients with suspected congenital footplate fixation to look for abnormal cerebrospinal fluid (CSF)–perilymph connections that predispose to gusher. If a high risk of a gusher is found, amplification is recommended. A genetic pedigree focused on hearing loss is helpful in identifying patients with X-linked progressive mixed deafness. Patients with this disorder are rare and unique in that a conductive hearing loss is seen on the audiogram with intact stapedial reflexes.4,5 During surgery, a stapes gusher is encountered with the attendant risk of SNHL. Although males are typically affected, heterozygous females may exhibit milder audiologic abnormalities.6

Imbalance may occur after otosclerosis surgery despite a well-done surgical procedure and an excellent hearing result. Professional athletes, high-rise steelworkers, and painters might be best advised to avoid surgery until the completion of their careers. In similar fashion, patients who depend on their sense of taste for employment (e.g., workers in the wine industry, coffee tasters, and professional chefs) may choose to avoid surgery. Changes in chorda tympani function considered minor to most patients may be a source of disability in such professions. Commercial airline pilots usually are allowed to have stapes surgery without affecting their employability, but the operating surgeon or patient should secure written documentation of the patient’s employer’s policy before undertaking surgery. Military personnel who fly aircraft should consult with a flight surgeon.

A history of or exhibited characteristics of severe anxiety, neuropsychiatric disease, claustrophobia, restless legs syndrome, and other conditions that would make the procedure difficult under sedation with an awake patient should be sought. When such patients have surgery, it should be performed under general anesthesia.

Physical Examination

Various findings have an impact on upcoming surgery, including the following:

• Otitis externa must be completely treated for at least 1 month before undertaking surgery.
• Serous otitis media contains bacteria in approximately 50% of patients. Entrance into the vestibule in this situation puts the patient at risk for bacterial labyrinthitis, SNHL, and meningitis.7–9
• Tympanic membrane perforation or chronic otitis media must be repaired with a separate procedure before stapes surgery to reduce the bacteria present within the operative field as much as possible. Six to 12 months should pass after the first-stage repair for eustachian tube function to manifest, and for the hyperemia attendant with the primary procedure to fade.
• Exostosis, common in cold water swimmers, should be corrected and allowed to heal before attempting stapes surgery. Occasionally, small exostoses or osteomas may be removed at the same time as stapes surgery.
• A small or unusually angled ear canal should be noted in the clinic preoperatively. In extreme circumstances, enlargement may be necessary. More commonly, the case is simply made more difficult.
• Limited neck rotation or obesity may require rotation of the surgical table to allow correct positioning of the ear for the procedure. If this rotation is more than about 15 degrees, patients having surgery under local anesthesia with sedation are concerned about sliding on the operating room table. Such situations are better handled with general anesthesia so that the patient can be positioned more securely on the table.
• Congenital auricular or periauricular anomalies may indicate congenital malformation of the middle ear structures.
• Abnormalities of the ossicles or of the chorda tympani nerve noted at otomicroscopy are markers for congenital abnormalities.
• Severe myringosclerosis or an area of bimeric tympanic membrane (where the fibrous layer of the eardrum is missing, leaving only a mucosal lining and an epithelial surface) increases the chance of tympanic membrane perforation occurring as a result of tympanomeatal flap elevation. Note to the patient should be made of the finding with an explanation of the procedure for correction intraoperatively or during a second procedure. Myringosclerosis may be an indicator of tympanosclerosis involving the stapes footplate (see later for tympanosclerosis management).
• Tuning forks should confirm a conductive hearing loss with Weber or Rinne testing consistent with the audiogram. Overestimation of the conductive hearing loss using some audiologic techniques occurs. Lack of a “flipped tuning fork” may not be a contraindication to surgery when bilateral disease is present.10
• Careful examination may reveal evidence of prior otologic surgery not mentioned by the patient.

Informed Consent

Medicolegal situations over complications that are expected to occur in a small percentage of patients are avoided by obtaining written informed consent before the procedure. The reader is referred to other chapters for more information on the subject.

OPERATING ROOM

Surgical Technique Prerequisites for Residents

When surgeons are in training, much effort is put toward using proper methodology in the operating room. The technical difficulty associated with stapes surgery requires the surgeon to be facile with several key techniques. Residents and fellows should enter the operating room with previously demonstrated abilities in several areas. Preparation becomes more of an issue as the number of cases of surgically correctable otosclerosis decreases in most training programs.11 Limitation of hospital privileges may become more of an issue in the future if case availability precludes ascent to an acceptable level on an individual’s own learning curve. The following list is put forth for surgeons in training to use as preparation for successful performance of stapes surgery, while minimizing the risk of complications for the patient.

• Parfocal setup of the operating microscope: This allows the surgeon to change magnification without losing focus in the operative field. Safety, accuracy, and speed all are improved.
• Appropriate microscope triangulation intraoperatively to allow depth of field perspective: To achieve depth of field information, the plane of view must be off-axis from the surgical instrument by several degrees. Movement of the microscope off-axis establishes a virtual triangle with its apex at the point of surgical interest (usually the tip of an instrument or an anatomic structure). The two points of the base of the triangle are formed by the microscope lens and the intersection of an imaginary line drawn perpendicular to the line of vision from the microscope where it intersects another imaginary line extending from the handle of the instrument (Fig. 26-1). Very small movements of the microscope can mean the difference between success and failure with delicate manipulations mandatory with stapedotomy.
• Appropriate use of magnification balancing depth of field with surgical detail: Increasing magnification decreases depth of field and vice versa. The surgeon must balance the need for high magnification (e.g., needed with footplate work) with the need for depth of field (e.g., needed when securing the tympanomeatal flap with absorbable gelatin sponge [Gelfoam]).
• Laser safety, use, beam sizing, and focus coincident with parfocal microscope: Delivery of laser energy is a function of laser wavelength, generated power from the laser base unit, and power density as determined by the size of the working spot size in the operative field. If the laser is scope mounted, it should remain focused precisely with the vision at the working magnifications in which it would be needed. The surgeon should also be familiar with beam defocusing. This technique can be useful with measures such as stopping bleeding and shrinking tissue. Hand-held lasers diverge from the fiberoptic tip. In this instance, laser power can be manipulated by moving the probe tip to or away from the intended target.
• Two-handed technique: It is crucial that the operative surgeon be able to use two hands to perform surgical maneuvers. This skill is learned and starts with the use of two hands for otologic procedures beginning with tympanostomy tubes. Likewise, vision with two eyes is necessary to allow depth perception. Instruments must be grasped and used in a way that neither the right nor the left eye’s visual pathway from the microscope is obstructed. Observer side arms are monocular, and the surgeon in training may not realize when binocular vision is missing when using the binocular microscope unless instructed. Professors of otologic surgery can ensure binocular vision while looking through the monocular side arm by watching the video monitor and the side arm in succession. Typically, the side arm is what the operating surgeon sees through one eye, while the video shows what is seen through the other eye.
• Lack of significant tremor: Although many fine surgeons have rhythmic variation in fine muscle control, delicate otologic surgery and significant tremor are mutually exclusive. Nervousness and anxiety make tremor worse. The surgeon and the professor of surgery should attempt to create and maintain an atmosphere of relaxed concentration and focus. Responsible surgeons would determine if caffeine avoidance on the morning of surgery is prudent.
• Canal injection for hemostasis: Local anesthetic provides anesthesia for the patient under sedation and is crucial to procedure success. The mucosa of the middle ear receives innervation from deeper nerves and is not affected by the canal injection. A drop or two of local anesthesia instilled into the middle ear provides nearly instant relief. Anesthetic should be promptly removed from the middle ear to prevent absorption into the inner ear, avoiding the coincident severe vertigo, nausea, and vomiting. A high percentage of epinephrine in the canal injection (e.g., 1:20,000) provides a maximal amount of vasoconstriction with a minimum of volume of injection. Turning the needle such that the bevel is against the bone allows delicate instillation of solution under thin skin. Most innervation proceeds down the canal, but small nerves traverse the fissures of Santorini in the anteroinferior canal adjacent to the annulus. These nerves are more of an issue when dissection is carried out in this area, but they may also need to be surrounded with local anesthetic to provide a comfortable patient under sedation. Use of identical syringes for each procedure allows the surgeon to develop the feel necessary to perform excellent injections (we suggest a glass dental-type syringe holding 3 mL of solution). A perfect injection is an art that comes only with practice. Surgeons in training should perform and demonstrate proficiency with injections in cases where it is not as critical to the outcome of the procedure (e.g., tympanoplasty) before being allowed to inject for stapedotomy. Creation of large blebs cannot be rectified easily, and markedly increases case difficulty.
• Tympanomeatal flap design and elevation: A recurring mistake of inexperienced surgeons occurs when the tympanomeatal flap is too short to reach anatomic position after curetting to expose the oval window niche (Fig. 26-2). One should avoid suctioning the elevated skin to prevent flap tears. Positioning the suction behind the round knife during flap elevation keeps the field dry and prevents inadvertent suctioning of the elevated skin. The vertical incisions of the flap should be kept 1 to 2 mm lateral to the annulus to reduce the likelihood of tearing the tympanic membrane.
• Chorda tympani nerve identification and preservation: Surgeons should be able to identify and mobilize this nerve at the iter chordae posterius and from the posterior surface of the malleus to maximize the chance of its preservation.
• Curetting: Proficiency must be shown in removing the posterosuperior canal wall to expose the facial nerve and pyramidal process, while preserving the chorda tympani nerve.
• Incudostapedial joint identification and division: Correct identification of the joint is necessary to prevent removal of the lenticular process of the incus. This becomes more of an issue when a bucket handle prosthesis is used. Slight anterior pressure on the incus while focusing on the joint under high power allows correct identification of this plane.
• Prosthesis sizing: Understanding of the measurements used (Fig. 26-3) improves results. Measurement from the lateral surface of the footplate to the medial side of the incus is taken. To this figure is added 0.5 mm and an amount equal to the thickness of the stapes footplate. Footplate thickness may vary from 0.2 mm to several millimeters. The prosthesis should extend 0.5 mm beyond the medial surface of the footplate into the vestibule (Figs. 26-4 and 26-5).
• Suction sizing to usage and risk: Proper two-handed technique turns the suction into an instrument. Suction size must be scaled to use. Damage to middle and inner ear structures may occur with use of too large a suction or with improper use of any suction. Intraoperative electronystagmographic studies performed on stapedectomy patients in the prelaser era implicate suctioning over the vestibule, drilling near the oval and round windows, and manipulation of the stapes footplate as the great offenders for vestibular and presumably for cochlear damage.12
• Crus division and stapes superstructure removal: Fracture of the stapes superstructure with both crura intact and a fixed footplate is frequently possible. Division of the posterior crus before fracture decreases the chance of stapes footplate fracture, mobilization, and transmission of potentially damaging energy to the inner ear. Various methods are available for division of the posterior crus. Our preferred method is laser vaporization, which carries with it a much reduced risk for the inner ear. Although some techniques advocate laser vaporization of the anterior crus, there is no indication that fracture of a single crus with a fixed footplate carries any risk of footplate mobilization.
• Prosthesis preparation and loading: For surgeons using a vein-clad technique, vein preparation, sizing, and vein-clad prosthesis preparation are steps in which small variations can produce postoperative conductive hearing loss. The stapedotomy, prosthesis, and attached vein should be approximately 0.9 mm, 0.6 mm, and 0.2 mm. Variations in the thickness of the attached vein may cause the surgeon to vary the size of the stapedotomy. For this reason, the vein-clad prosthesis should be prepared before creation of the stapedotomy. In situations in which a vein is not attached to the prosthesis, the stapedotomy should exceed the size of the prosthesis by 0.2 to 0.3 mm. Bucket handle prostheses should be inserted with the bail inferior to the incus to allow it to be swung superiorly and secured with small pieces of tissue. Shepherd’s crook pistons should be grasped with smooth forceps in a way that the open end of the wire hook can be placed directly over the incus.
• Footplate removal: The surgeon must be able to create a round and concentrically located stapedotomy by melding multiple round individual laser bursts. The tiny movements used to move the laser are more reliably produced by moving the microscope with pressure from a hand or nose than with the joystick, although both methods work. Vaporization of the footplate with a laser leaves a small meshwork of char. This char does not need to be removed before prosthesis placement. Large fragments of footplate that enter the vestibule can give patients symptoms of positional vertigo. For this reason, all bony fragments within the stapedotomy that may mobilize with prosthesis placement should be vaporized. One should never attempt to “fish out” a fragment that has entered the vestibule. Use of a microdrill creates a round stapedotomy. Significant pressure on the footplate must be avoided to prevent drill overinsertion in the vestibule.
• Prosthesis placement: Resident surgeons should practice crimping techniques in the laboratory before undertaking the maneuver on a patient. Likewise, placement of a bucket handle prosthesis should be performed in the temporal bone laboratory setting first. Excess vein from operative procedures can be taken to the laboratory to create a realistic practice model.
• Prosthesis removal: Frequently with revision surgery, a prior prosthesis must be removed. It is also sometimes necessary, especially early in one’s career, to remove a prosthesis that is the wrong size during primary surgery. This is best accomplished for a prosthesis attached to the incus with a wire by inserting a right angle hook and rotating the hook to open the wire loop. In this way, traction forces on the incus are avoided. Laser ablation of the tissue surrounding the oval window segment of the prosthesis is a first step before removal to avoid traction damage of structures within the vestibule.
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FIGURE 26-1

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FIGURE 26-3

Surgeons who have performed stapes surgery frequently understand that each individual step of the procedure itself must be performed to perfection, or the ill effects become additive. (For example, an imperfect injection makes every remaining portion of the procedure more difficult if blood continues to enter the operative field. Likewise, inadequate curetting limits exposure of the footplate.) A small amount of compromise in each step of the procedure quickly adds up to overall failure. This “law of additive inadequacy” has proven useful as a teaching concept. Viewing the procedure in this way emphasizes the need for perfection in each step before moving forward in the operation.

Similar to a preflight checklist, every skill must be checked off before allowing performance of a stapedotomy. Surgeons who never master the listed techniques probably should not perform stapes surgery as part of their surgical practice—just as not every otolaryngologist is able to perform procedures such as blepharoplasty, partial laryngectomy, and laryngotracheal reconstruction.

Attending physicians are reticent to allow significant participation of residents and fellows if this means that several inadequacies have already summed to put the senior surgeon in a tough spot while completing the procedure. Residents and fellows gain the confidence of their attending surgeons as these skills are mastered allowing greater and greater participation. It is the duty of those of us who teach surgical technique to deliver to the next generation a cadre of well-trained individuals suited to stapes surgery without sacrificing success and safety for our current patients.

Surgical Equipment, Decisions, and Techniques

Prosthesis Type, Size, and Availability

Three general prosthesis types exist: piston/wire, bucket handle, and polytef (Teflon) varieties. Few comparative data exist to compare the different types, but bucket handle prostheses may have a smaller incidence of incus necrosis in long-term follow-up. Piston/wire and Teflon varieties are probably easier to place. Self-crimping prostheses offer a new option in design, which may reduce the need for manual crimping.13 Long-term results with attention to incus necrosis would be of interest because the metal nitinol used in these prostheses contains a small percentage of nickel—a known cause of hypersensitivity reactions in other uses in humans such as jewelry.

Prostheses come in several different diameters, ranging from 0.3 to 0.8 mm most commonly. Experienced surgeons have indicated that 0.6 mm gives optimal results.14 Several studies have looked at alternative sizes, and there seems to be no degradation of results in the speech range down to 0.4 mm piston diameter.15 Prostheses measuring 0.3 mm show worse hearing results compared with prostheses measuring 0.4 mm.16 Lighter prostheses perform better in higher frequencies in situ in temporal bone studies.

Prosthesis length varies from patient to patient. Availability of the correct prosthesis is crucial to successful outcome. We prefer to use nonferromagnetic materials, in particular titanium bucket handle prostheses. Table 26-1 outlines the prostheses stocked in our operating suite. Note the inclusion of the incus replacement prosthesis (see the later discussion on incus necrosis).

TABLE 26-1 Prosthesis Type and Size Stocked in Operating Suite

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Laser Stapedotomy versus Drill Stapedotomy

It is generally agreed among most surgeons that use of the laser reduces the risk of mechanical transmission of vibratory energy to the inner ear, making it a safer technique. Comparative data from primary stapedotomy question this tenet, viewing both techniques as effective and safe.17 Use of a laser does improve results in revision cases.18 In all cases, proper use of the laser reduces bleeding associated with tissue ablation, which is an advantage. Both techniques are accepted within the standard of care.

Stapedectomy versus Stapedotomy

For most otologists, the procedure of choice for otosclerosis has become stapedotomy. Compared with stapedectomy, the limited fenestra improves results in the high frequencies, and most authors report a reduction in SNHL as a result of the procedure.19–21 Stapedotomy carries a smaller rate of postoperative vestibular complaints. Stapedectomy remains a valuable alternative in the experience of some surgeons. Occasionally, a stapedotomy needs to be converted to a complete stapedectomy.

Stapedotomy Site

The stapedotomy should be placed posteroinferiorly in the central footplate region (see Fig. 26-2). This area does not overlay the saccule or utricle and gives the most margin for overpenetration on the medial side of the footplate. It is possible, and frequently necessary, to move the stapedotomy to other areas of the footplate because of anatomic concerns of the incus or structures surrounding the oval window niche.

Footplate/Vestibular Relationships

Almost all patients have a minimum safe distance of 1 mm between the medial surface of the footplate and the utricle or saccule. Penetration of the vestibule by more than 1 mm with instruments or the prosthesis may impinge the structures of the membranous labyrinth, producing vertigo with prosthesis movement. Perforation of the saccule or utricle may induce SNHL, vertigo, or both.22,23

Laser Type

Controversy regarding laser type, efficacy, and safety has arisen since the first laser stapedotomy performed by Perkins.24 Visible wavelength lasers have the added advantage of absorption by blood, providing hemostasis. Appropriate adjustment of the CO2 laser also can provide hemostasis. Visible wavelength lasers have the technologic advantage of being able to use the laser light as the aiming beam; this avoids needing to produce a visible wavelength light that also serves as the aiming beam, which may not accurately reflect where the therapeutic beam is aimed (as can occur with the helium-neon aiming beam with CO2 lasers). Theoretical concerns regarding absorption of energy from the KTP or argon laser by the inner ear have been voiced by several authors (visible wavelength lasers are transmitted through clear fluid). Several studies have proven equal safety of visible wavelength and CO2 lasers for laser stapedotomy.25,26

Local versus General Anesthesia

Local anesthesia for laser stapedotomy is cost-effective, safe, and comfortable for patients. Under sedation, a patient can supply feedback to the surgeon if any event that stimulates the vestibular system occurs. Such feedback may help to prevent damage to inner ear structures. Additionally, the patient’s assessment of hearing ability after prosthesis placement and tympanomeatal flap replacement is helpful. Movement, which could be disastrous, is rarely experienced in the appropriately psychologically prepared and medicated patient. General anesthesia is used in patients unable to comply with the demands of local anesthesia with sedation, including claustrophobic patients, pediatric patients, or non–English-speaking patients. General anesthesia has appeal for teaching cases, where operative time may be long.

Stapedotomy in Children

Stapedotomy can be performed safely in children with surgical results as least as good as the results expected in adults.27 Children should be beyond the age of otitis media, and surgery should be attempted only under general anesthesia. Congenital footplate fixation requires special considerations, as discussed later.

Prosthesis Ballottement

After prosthesis placement, careful and gentle palpation of the incus reveals the degree of freedom of movement of the prosthesis. Gentle, nonsudden movements are tolerated well by the patient and usually heard only as low-volume and low-frequency stimuli if performed appropriately, carrying minimal risk of injury to the inner ear. If a prosthesis is too long and touches the membranous labyrinth (which could produce vestibular symptoms with loud sounds postoperatively), gentle motion of the reconstruction induces vertigo in sedated patients allowing prosthesis replacement with a shorter variant during the original procedure. Prosthesis ballottement can be a useful measure for experienced surgeons to assess the function of the reconstruction on the operating table.

Prosthesis Displacement at Stapedotomy

After prosthesis placement, a gentle posterior-to-anterior force applied to the shaft of the prosthesis at the footplate helps identify a prosthesis of inappropriate length. A prosthesis well situated and of appropriate length within a stapedotomy fenestra would not displace, whereas a too-short prosthesis would be moved from the stapedotomy. Because prosthesis displacement is the most common reason for failure of surgical success, proper sizing and positioning should receive special attention.

Oval Window Seal

A tissue seal at the oval window (we prefer vein taken from the dorsum of the hand) nearly eliminates the risk of perilymphatic fistula.28

MANAGEMENT OF COMPLICATIONS ENCOUNTERED AT PRIMARY SURGERY

Tympanic Membrane Perforation and Flap Tear

Skin or tympanic membrane tears can complicate elevation of the tympanomeatal flap. The case can be continued with an underlay graft of fascia or other collagen-containing tissue providing repair. With small tears, the defect heals if edges are approximated without an underlay graft. A similar repair can be used when the flap is made too short to cover the area of bone removal in the posterosuperior margin of the bony annulus. The flap incision should be at least 6 mm from the annular ligament to prevent inadequate flap length. The surgeon can estimate appropriate flap length to be twice the length of a large round knife.

Incus Dislocation

Dislocation of the incus precludes routine stapedotomy. The case should be halted and time given for the incus and malleus to reattach. In 4 to 6 months, the patient is taken back to the operating room. If sufficient reattachment has occurred, stapedotomy is performed in the usual fashion. If not, the incus is removed, and a malleus-to-footplate prosthesis is used.

Malleus and Incus Fixation

Routinely, every case should include a check of the mobility of the malleus and incus. Patients with otosclerosis have a higher incidence of hyalinization of the anterior malleal ligament, which may be the sole cause or a contributing factor in the conductive hearing impairment.29 This is best performed after division of the incudostapedial joint with gentle upward pressure on the undersurface of the handle of the malleus, while watching for movement at the lenticular process of the incus. Documentation of the state of function of the first two ossicles is crucial when evaluating and planning revision for patients who do not experience adequate improvement of hearing with the primary procedure. In addition, in approximately 1% of cases, fixation of the malleus and incus is discovered, allowing rectification during the primary procedure. A small or moderate amount of limitation of motion of the malleus and incus usually produces little in terms of conductive hearing loss, which is usually low frequency in nature. In cases where doubt exists about the severity of malleus and incus fixation with clearly appreciated footplate fixation, performance of the stapedotomy with postoperative testing before work on the malleus or incus or both shows good judgment.

Operative repair of the situation is best addressed with a mastoidotomy with extension into the root of the zygoma to allow exposure of the body of the incus and head of the malleus in the epitympanum (Fig. 26-6). Usually, fixation occurs at the superior malleolar ligament from the tegmen. The posterior process of the incus may also be involved, as can any suspensory ligament of the ossicular chain. Removal of offending bone and restoration of ossicular mobility can be performed with a laser.30 Larger wattages are necessary than those used on the stapes superstructure or footplate (we use the KTP laser with 5 to 8 W on continuous mode). A blood-soaked Gelfoam is placed as a “backstop” to protect the facial nerve with higher laser settings. Although a drill can remove bone as well, laser use minimizes the risk of transmission of damaging vibratory energy to the vestibule. If the stapes is also fixed, it is prudent to remove the stapes superstructure before mobilization of the malleus and incus. If the conductive hearing loss resides solely in the fixation of the malleus and incus, disarticulation of the incudostapedial joint to produce discontinuity is mandatory in cases where the laser is not used to remove the fixation (sometimes interposition of Gelfoam is necessary to keep the lenticular process of the incus from touching the capitulum of the stapes). Removal of bone in the mastoid can be performed comfortably in most patients under sedation if necessary.

If the suspensory ligaments cannot be reached safely, reconstruction can still be performed. Removal of the incus allows access to the head of the malleus through the mastoid. Removal of the head of the malleus superior to the lateral ligament is performed with a malleus nipper or a tiny diamond drill. The chorda tympani nerve should be mobilized from the medial surface of the neck of the malleus and pushed inferiorly to prevent its injury with this maneuver. Reconstruction with a malleus-to-stapes footplate prosthesis completes the repair. Complete closure of the air-bone gap is frequently impossible with this technique, and the decision for surgery should take this into account.

Persistent Stapedial Artery and Vascular Anomalies

Rarely, a persistent stapedial artery is encountered running from the facial nerve through the arch of the stapes to the carotid artery. Even less commonly, an aberrant carotid is seen. Although the persistent stapedial artery is not seen with otoscopy, an aberrant carotid is visible, and can be mistaken for a glomus tumor. Most vascular anomalies occur in women.31 If a persistent stapedial artery is small, fine bipolar cautery or laser coagulation may be used to remove the vessel from the field, allowing completion of the procedure. With larger arteries, it may be prudent to stop the procedure and prescribe amplification.

Tympanosclerosis

One may discover ossicular fixation secondary to tympanosclerosis of the stapes footplate. Fixation of this type is not as vascular as otosclerosis and has a softer texture. Stapedotomy may be performed safely. Excellent early results may be achieved with some attrition over time.32–34

Osteogenesis Imperfecta

Osteogenesis imperfecta is a congenital disorder of bone inherited via autosomal dominant or autosomal recessive patterns. The triad of blue sclera, multiple fractures, and conductive hearing loss is known as Van der Hoeve’s syndrome. The mean age of hearing impairment is in the early 20s.35 Footplate fixation accounts for the conductive hearing loss. Footplates are typically thick and frequently very soft with increased vascularity, whereas crura may be atrophic.36 Progressive SNHL can be seen in a few patients.37 Despite a small increase in risk of SNHL in some series, stapedotomy remains a viable treatment for conductive hearing loss associated with this disorder.38

Congenital Stapes Fixation

Complete absence of the annular ligament of the stapes without evidence of otosclerotic bone growth may be congenital stapes fixation. This entity is discussed at the beginning of the chapter.

Round Window Obliteration

Severe otosclerotic overgrowth may completely obliterate the round window membrane. No remedy is available for the excess bone, and complete closure of the air-bone gap is unlikely postoperatively.

Overhanging Facial Nerve

The facial nerve can provide obstruction to completing successful stapes surgery and is encountered regularly (Fig. 26-7). Recognition of an aberrant or dehiscent facial nerve prevents injury. Twenty-five percent to 40% of temporal bone specimens include dehiscence of the bony fallopian canal. Inconveniently located dehiscence may be sites of trauma secondary to surgical instrumentation. Local anesthetic agents may also penetrate these areas more readily, causing postoperative facial paralysis. The reader is referred to Chapter 29 for management options. In some situations, coupling the technique used for narrow oval window enlargement becomes necessary for prosthesis placement. A dehiscent facial nerve rarely prevents successful surgical repair.

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FIGURE 26-7

Narrow Oval Window Niche

Anatomic abnormalities or impingement on the oval window area by the facial nerve can produce narrowing so that prosthesis placement is difficult or impossible. Enlargement of the inferior margin of the oval window niche at the midpoint of the footplate just anterior to the junction of the subiculum and promontory can facilitate surgical success.39 Intermittent laser pulses produce char that is then removed with a rasp. Significant extra space can be gained with this technique because the bone is quite thick in this area. Care must be taken to prevent caloric overstimulation of the vestibule. In addition, the stapedotomy can be shifted inferiorly to the margin of the oval window to facilitate prosthesis placement. Overlapping the margin of the oval window can be dangerous because Reissner’s membrane and the basilar membrane occupy this area in the cochlear hook region.40

Congenitally Ectopic Facial Nerve

The facial nerve may be congenitally malpositioned entirely on the promontory side of the footplate, split with a portion on either side of the footplate, or pass through the arch of the stapes.41,42 The stapes crura are not attached to the footplate a high percentage of the time with abnormalities in the course of the facial nerve. If prosthesis placement can proceed without iatrogenic injury to the nerve, the case can be completed with the prosthesis placed above, between, or around the aberrant nerve. (Alternatively, few hearing devices produce facial paralysis!)

Biscuit Footplate

Manipulation of a biscuit footplate puts the patient at increased risk for footplate mobilization and SNHL (Fig. 26-8). Use of the laser allows removal of bone and performance of a footplate fenestra without significant energy transfer to the tenuous footplate. Care should be used to prevent heat transfer to the vestibule, which may put the inner ear at risk. Cases performed under local sedation allow the surgeon to sense when caloric stimulation begins for the patient as vertigo frequently begins. Cessation of laser use for several minutes allows cooling of the footplate and vestibule, allowing resumption of the bone removal process. Patients operated on under general anesthesia should have no more than 8 to 10 laser pulses in a row without allowing time for cooling. Excellent results are obtainable for the patient and surgeon.

Obliterative Otosclerosis

Obliteration of the oval window niche occurs from otosclerotic bone growth in some cases (Fig. 26-9). The area should not be drilled out using a diamond burr because reactivation and reformation of the otosclerotic growth may be stimulated, and a higher rate of SNHL may be realized. Bleeding is also frequently produced with such a technique.43–45 Footplate fenestration may be accomplished as with a biscuit footplate outlined previously.

Perilymphatic Gusher

The normal anatomic arrangement of the human ear allows flow of CSF into the perilymphatic space. Normally, extremely small connections between these two spaces exist. With enlarged connections (usually through the fundus of the internal auditory canal, through the modiolus of the cochlea, and possibly through an enlarged cochlear aqueduct), a rapid outpouring of perilymph occurs when the stapes footplate is removed as a barrier in either a stapedectomy or a stapedotomy. Known as a “gusher,” such an event can be associated with SNHL.46 Conditions known to increase the chance of this condition include enlarged vestibular aqueduct syndrome, X-linked progressive mixed deafness, congenital footplate fixation, and Mondini’s dysplasia.

Successful repair is most easily accomplished with a bucket-type piston over a vein graft seal of the stapedotomy. The bucket-type prosthesis is recommended because of the possible CSF pressure extrusion of a piston-shepherd’s crook–type prosthesis. If a watertight seal can be obtained, no further treatment is necessary except restricted activity for 1 week.

Several authors recommend creation of a small control hole in the footplate before removal of the footplate if the technique of stapedectomy is used. It is much easier to handle this complication through a small footplate hole than with the entire footplate out. In the event a gusher is encountered that cannot be controlled with a vein and prosthesis, more extensive management becomes necessary. In this situation, management is similar to that of a CSF leak. Tissue is used to provide a seal for the oval window fenestra, preferably with a prosthesis providing tamponade (which is not always possible). A lumbar drain is placed to decrease the cerebrospinal and perilymph pressure. Postoperatively, the head of the bed is elevated at least 30 degrees, and bed rest is employed. Fluids are restricted, and oral acetazolamide may be prescribed. Prophylactic antibiotics are given.47 The patient is discharged 24 hours after the lumbar drain is clamped with no further fluid leak as judged by CSF rhinorrhea. Bed rest at home is recommended for another week.

Fractured Footplate

Fragmentation occasionally occurs. Free-floating surface fragments should be removed, and the surgery should be converted to a partial or complete stapedectomy. A tissue seal is mandatory in this setting.

Footplate Fragments in the Vestibule

No attempt should be made to remove any footplate fragments in the vestibule. Although positional vertigo is rarely a sequela of these fragments, most cause no harm. Attempted removal with an instrument in the vestibule carries a high rate of SNHL.

Blood within the Vestibule

A bloodless field increases safety by allowing the surgeon to see all structures clearly. In addition, blood in the vestibule is associated with an increase in risk for sensorineural hearing impairment in animal studies and human experience.48 The ultimate surgical technique employs a completely bloodless oval window before entrance into the vestibule through the stapes footplate.

Sensorineural Hearing Loss

SNHL is perhaps the most disappointing and devastating complication for the patient and the surgeon. Complete or partial hearing loss can result from the most meticulously and appropriately performed stapes procedure. Most cases probably are due to surgical trauma, however. Intraoperative electronystagmographic studies performed during stapedectomy in the prelaser era implicate suctioning over the vestibule, drilling near the footplate or oval window niche, and manipulation of the footplate as the great offenders for vestibular and presumably for cochlear damage.49

COMPLICATIONS AFTER PRIMARY SURGERY

Medical Management

Acute Otitis Media

Acute otitis media occurs in the postoperative period in patients who have had stapes surgery. The infection is usually successfully treated without sequelae. Entrance of pathogenic organisms into the perilymph can produce SNHL and vestibular damage. Progression into the CSF has been reported with meningitis.8,50–52 Prophylactic antibiotics have not been shown to reduce the incidence of this complication and carry some risk, and are not recommended.

Barotrauma

Iatrogenic rearrangement of the normal anatomy may increase a patient’s chance of experiencing barotrauma of the inner ear after stapes surgery. We allow patients to fly in pressurized aircraft 2 days after surgery when a vein graft has been placed. No restrictions are placed for snorkeling or scuba diving after healing has occurred, provided that patients are able to self-insufflate through an open eustachian tube (as all patients should have for these activities even without previous ear surgery). A wide range of practices regarding postoperative restrictions exists among otologists. No significant differences have been shown in the prevalence of barotrauma based on individual physicians’ recommendations for these activities.53

Dysgeusia

Approximately 20% of patients note taste changes in the postoperative period when asked. Chorda tympani nerve dysfunction is usually transient, and less than 5% of patients experience permanent deficits. “Second ears” and patients with a vocation involving taste warrant special consideration. The risk of economic hardship to a patient who works as a sommelier or coffee taster may not be worth the risk of surgery. Revision cases frequently involve a nerve adherent to the posterior surface of the tympanic membrane. Mobilization of an adherent nerve is best accomplished with a small sharp blade (e.g., a No. 5910 Beaver blade designed for corneal incisions).

Delayed Facial Nerve Paralysis

A few cases of delayed facial nerve paralysis have occurred. Typically, the onset of paralysis occurs 7 to 10 days after surgery and is associated with pain. Treatment with a tapering dose of steroids (initial dosing of prednisone, 30 mg twice daily tapering over 2 weeks) has brought about resolution in all cases.54

Hyperacusis

Almost all patients have some degree of phonophobia postoperatively. Reassurance is adequate treatment, with only a few patients experiencing a persistent problem.55

Binaural Diplacusis

The same tone is perceived as different pitches in each ear in one third of patients after stapes surgery. By 6 weeks postoperatively, the condition fades without treatment.56

Otosclerotic Inner Ear Syndrome

Balance disturbance may result from ongoing growth of the otosclerotic focus postoperatively. Patients complain of brief episodes of motion not severe enough to be termed spinning or of diffuse, persistent unsteadiness. Such complaints are hard to distinguish from perilymphatic fistula and other causes of postoperative vestibular complaints. A high percentage of patients respond to the administration of fluoride when the complaint is due to ongoing otosclerosis.57 We currently use calcium fluoride (Monocal), 2 tablets twice daily. Sodium fluoride (Flurocal) has been associated with gastric intolerance in a higher percentage of patients.58

Sensorineural Hearing Loss Progression

Otosclerosis induces a progressive SNHL in many patients.59–65 Otosclerosis can be a cause of SNHL without a conductive component.66 It can be extremely disappointing to see an excellent surgical result deteriorate because of progressive SNHL, leaving the patient with functionally significant hearing impairment. Convincing data exist that establish the role of fluoride in stabilizing SNHL associated with otosclerosis.67–73 We place patients with SNHL present at the time of surgery on calcium fluoride (2 tablets orally twice daily with meals) for 1 to 2 years after surgery. If hearing remains stable at that time, the treatment is stopped. Any further progression prompts further treatment. Patients who exhibit new-onset SNHL in the postoperative period are treated similarly. Patients whose otosclerosis produces severe to profound sensorineural hearing loss can be expected to do well with cochlear implants, although there is a higher incidence of facial nerve stimulation in such applications.74

Serous Labyrinthitis

Patients who experience the onset of constant dysequilibrium several days after surgery are thought to have an inflammatory response in the inner ear. Frequently, a short course of steroids improves symptoms and alleviates dizziness.

Vestibular Complaints

Vertigo with and after stapedotomy is less frequent than with stapedectomy. Approximately 1 or 2 in 10 patients experience some balance complaint immediately after laser stapedotomy. Standard sedative vestibular suppressants provide relief allowing the problem to resolve on its own. Patients rarely have symptoms for more than 2 days postoperatively.

Wound Infection

Antibiotic-soaked Gelfoam is placed against the tympanomeatal flap incision after return of the eardrum and skin to anatomic position. It is unnecessary to fill the ear canal. The packing is removed 5 to 10 days after surgery. Antibiotic eardrops are prescribed once daily for 2 weeks. Water precautions are followed until 3 weeks postoperatively. With such a regimen, wound infections occur extremely rarely.

Upper Respiratory Infection

Infection in the postoperative period with influenza virus has been associated with an increase in SNHL.75

Surgical Management

Adhesions

Postoperative adhesions form in virtually every surgical case. Significant conductive hearing loss is rarely a result of adhesions for stapedotomy patients, unless the healing process has displaced the prosthesis. When the middle ear is re-examined after primary surgery in these patients, a source of conductive hearing loss apart from adhesions must be sought. Stapedectomy patients have a higher tendency to form adhesions around the prosthesis foot in the oval window. Severe fibrosis in this area can displace or severely limit motion of the prosthesis producing conductive loss.

One of the most useful features of the laser for use in revision surgery is removal of adhesions with little to no bleeding. For insignificant adhesions, laser vaporization allows identification of the real cause of recurrent conductive hearing impairment without troublesome bleeding. In the case of oval window fibrosis, therapeutic removal of the adhesions with maintenance of a thin membrane separating the vestibule allowing prosthesis placement is possible.

Acute Facial Nerve Paralysis

As opposed to delayed facial nerve paralysis, which is a medically treated condition, acute paralysis may require surgical intervention. Adequate time (approximately 2 hours) should elapse after surgery to preclude a local anesthetic effect. Cases of persistent paralysis should be re-explored. Referral or including a colleague for objectivity and future support and collaboration may be a prudent decision.

Conductive Hearing Loss

Return of conductive hearing loss is the most commonly experienced postoperative complication of stapedotomy, accounting for 50% to 70% of revision surgical procedures.76–80 Although exact rates are difficult to determine, 10% to 20% of cases require revision sometime during the patient’s lifetime. With the decrease in primary surgery, many experienced stapes surgeons perform revision surgery a significant percentage of the time.

Prosthesis Displacement

Hearing deterioration may be acute, as the prosthesis becomes dislodged, or chronic, as it is gradually displaced out of position (Fig. 26-10). This complication may be encountered many years after stapes surgery. The diagnosis is definitively made at reoperation, but may be suspected based on history and tuning fork and audiometric testing.

Incus Necrosis

Division of the incudostapedial joint reduces the blood supply to the distal incus. Vessels from the stapes superstructure provide a little perfusion, whereas vessels coursing from the stapedial tendon bring most of the blood to the distal incus. Channels for blood flow exist within the interior of the long process of the incus. Necrosis of this incus leads to prosthesis displacement (Figs. 26-11 and 26-12). Prostheses that crimp onto the incus may reduce further the only remaining blood supply coming from the direction of the body of the incus, increasing the chance of this complication. For this reason, some surgeons prefer a bucket handle prosthesis. Incus necrosis still occurs, no matter which prosthesis is used.

image

FIGURE 26-13 Otosclerosis regrowth.

FIGURE 26-14. Adhesions from oval window to membranous labyrinth.

FIGURE 26-15. Excess prosthesis length, which contacts the membranous labyrinth.

If an adequate amount of incus remains, a shepherd’s crook prosthesis can be used by crimping the prosthesis more proximally on the incus during revision surgery. Occasionally, it becomes necessary to bend the prosthesis around the facial nerve ridge to establish footplate contact. The amount of bend affects the length of prosthesis needed. In selected cases, application of an otologic cement may aid in prosthesis stabilization after repositioning or replacement.81 In the event the remnant incus cannot be used, the tympanic membrane is elevated from the lateral surface of the malleus, and a malleus-to-stapes footplate prosthesis is placed. Table 26-1 lists sizes of our preferred malleus-to-footplate prostheses.

Prosthesis Extrusion

Prosthesis extrusion may rarely occur. Usually, contact of the prosthesis is first established by retraction of the eardrum. Over time, a perforation occurs, and prosthesis extrusion becomes evident. A prosthesis that has partially extruded through the eardrum can be left in place as long as adequate function is maintained, infection is not present, and skin is not growing into the middle ear. In this event, the ear should be kept dry. Persistent tympanic membrane perforations should be repaired before replacing the stapes prosthesis to reduce the bacterial content of the middle ear before opening the vestibule. Placement of a tympanostomy tube or positioning of autologous tissue over the prosthesis helps discourage future extrusion.

Otosclerotic Regrowth

Otosclerosis continues to grow in some patients, producing prosthesis fixation or displacement (Fig. 26-13). At revision surgery, the cause of the conductive hearing impairment is best handled with prosthesis removal, laser enlargement of the stapedotomy, and placement of a fresh prosthesis.

Wire Loop Prosthesis

The dominant prosthesis used for many years for stapes surgery was the wire loop prosthesis. The wire loop prosthesis was used only in the technique of total stapedectomy. Return of conductive hearing impairment prompting revision frequently shows displacement of the oval window portion of the prosthesis. Because tissue was used to seal the stapedotomy in most instances, a large amount of scar usually exists in the oval window (Fig. 26-14). A properly adjusted laser allows removal of scar surrounding the oval window loop of the prosthesis. The wire loop prosthesis should not be grasped and removed because it frequently is attached to vital structures of the vestibule, producing a high chance of inner ear injury. It is necessary when revising these cases to leave a small membrane of tissue, if possible, over the vestibule, or to insert autologous tissue with the new prosthesis.

Long Prosthesis Overinsertion

Overinsertion of the long prosthesis into the vestibule may cause a sensation of vertigo with loud sounds (Fig. 26-15). If this occurs, prosthesis removal and replacement with a shorter version usually fixes the difficulty. Palpation of the freshly placed prosthesis by putting gentle pressure on the incus in patients under sedation identifies a too-long prosthesis while still in the operating room. With a too-long prosthesis, the patient experiences vertigo with this maneuver. Care should be taken to avoid overstimulation of the vestibule, which could produce SNHL.

Loose Prosthesis Syndrome

Loose coupling of the prosthesis to the incus produces characteristic sensations of sound distortion (see Fig. 26-11).77 A large conductive hearing loss may not exist on the audiogram; tuning forks may also be normal. Occasionally, severe symptoms of this type prompt revision surgery. Tightening the crimp or changing to a different prosthesis can completely alleviate the difficulty.

Perilymphatic Fistula

Perilymphatic fistula is a cause of postoperative dysequilibrium and SNHL. The signs and symptoms of perilymphatic fistula may be indistinguishable from normal postoperative findings.78,79 In addition, a perilymphatic fistula may be discovered at revision surgery with an asymptomatic patient. Fistulas seem to be much less common after stapedotomy compared with stapedectomy. Progressive SNHL or unremitting vestibular complaints or both may prompt re-exploration. Repair of a symptomatic perilymphatic fistula relieves vestibular complaints in approximately half of patients.

Reparative Granuloma

Reparative granuloma is defined as a histologically confirmed formation of granulation tissue involving the prosthesis and oval window in a symptomatic patient after stapes surgery. The lesion does not involve granulomatous inflammation.80 This unusual complication occurs in approximately 0.1% of all cases. Presenting symptoms usually surface 1 to 6 weeks after surgery, and most commonly involve vertigo, but may include SNHL, progressive mixed hearing loss, sudden hearing loss, and tinnitus.82 Management includes either immediate surgery with removal and replacement of prosthesis and grafting material or nonsurgical management comprising steroids and antibiotics. Surgical intervention seems to give a better outcome.

Introduced Ectopic Tissue

Occasionally, material introduced into the operative field brings about a return of conductive hearing loss. Introduced squamous epithelium can produce a cholesteatoma,83 and perichondrium has been known to stimulate formation of cartilage.84

SURGICAL RISK REDUCTION IN REVISION SURGERY

Although variation occurs based on the adequacy and technique of primary surgery, revision stapes surgery is needed in a significant percentage of patients. Series from nations with centralized health care provide the best data because of controlled follow-up. A revision rate of 13% in one series of 4000 cases amassed by several surgeons has been reported.85 Revision may be necessary immediately after primary surgery or many years later, with an average time to revision of 8 to 12.5 years.86,87

Success rates for revision surgery have improved significantly over the past 20 years. Early reports found postoperative conductive hearing loss of 10 dB or less in less than half of patients.72,88 Modern results more closely approach those of primary surgery with closure to 10 dB or less in 90% of cases.

Use of a laser improves surgical outcome. Meta-analysis of revision stapes surgery comparing 11 studies without laser use (N = 1147 patients) with 4 studies that employed laser technique (N = 170 patients) showed a statistically significant (P = .0002) advantage in terms of safety and efficacy. Postoperative air-bone gaps of 10 dB or less were accomplished in 69% of cases in which a visible wavelength laser was used, whereas only 51% of patients on whom standard techniques were used had the same results.89

The risk of SNHL is greater with revision surgery. Rates seem to be higher when revision of stapedectomy is undertaken compared with cases with stapedotomy as the primary technique. Oval window drill-out is associated with an unacceptably high rate of inner ear injury and hearing loss and should be avoided.72 Reported rates of SNHL with revision surgery vary from 0 to 7.6%.44,72,86,90 We currently quote patients a rate of SNHL twice that of primary surgery.

CONCLUSION

Successful performance of surgery for otosclerosis includes thorough mental and physical preparation. A solid knowledge base of potential complications and their management is vital to patient counseling, treatment, and outcome. Although complications are unavoidable, and certain ones can be rectified, avoidance with proper surgical technique and planning is preferable for the patient and the surgeon.

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