Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Causes of Failure and Complication in Surgery for Otosclerosis The pertinent anatomy includes the tympanic membrane, the anterior and posterior crus of the stapes, the capitulum, the long process of the incus, the tendon and stapedius muscle, the footplate of the stapes, the tympanic segment of the facial nerve, the cochlea, and the labyrinth. The earliest surgical attempts to improve hearing loss associated with stapes fixation was by Kessler in 1876. In this procedure, he incised the posterior portion of the tympanic membrane, separated the incus stapedial joint, removed the bony canal wall when necessary and attempted to mobilize the stapes by applying pressure to the capitulum in various directions. If the stapes could not be mobilized, it was removed. The interest in stapes surgery abruptly stopped in 1900 when at the International Congress, Politzer and Sutton and other prominent otologists declared these operations were useless and dangerous. It is surmised that this statement was prompted by large numbers of complications that had gone unreported. Next, the area of surgical fistulization began with the work of Barany and Holmgren. They fistulized the superior semicircular canal in otosclerotic ears, allowing the dura to rest against the membranous labyrinth. Hearing improvement was fruitfully noted with this procedure. Sordell studied with Holmgren and devised a three-stage operation in which the skin-covered horizontal canal fistula was used to improve hearing. In 1938, Lempert simplified this to a one-stage operation. After being modified in 1945, this operation became the standard for the next seven years. The next major advancement occurred in 1952 when Rosen accidentally mobilized the stapes during palpation on the ossicular chain in a fenestration operation. The patient noticed remarkable, immediate hearing improvement, which lasted for years. One year later, when mobilization had become the standard of care, Rosen reported hearing improvement to at least the 30 decibel level in 22% of 211 operations he performed. In 1954, Shambaugh applied the operating microscope to stapes mobilization. This paved the way for Shea to revive the stapedectomy with the modifications of an intact ossicular chain in a covered oval window. To date, multiple modifications of this procedure have been performed using various types of prostheses and grafts. Otosclerosis is the primary focal spongiform disease of the labyrinthine capsule. Valsalva first described this pathologic process underlying otosclerosis in 1735, from the autopsy of a deaf patient. Today, there is still some controversy regarding the etiology and pathogenesis of otosclerosis. Briefly, otosclerosis, otherwise known as otospongiosis, is thought to be a familial autosomal dominant disorder with a variable penetrance of 25% to 40%. The mechanism has recently been suggested to be an autoimmune reaction to cartilaginous remnants and collagen fiber type II. This is thought to stimulate an inflammatory reaction in lysosomal proteases in and around the otospongiotic foci. For a successful surgical outcome, one must begin planning treatment with the initial physical examination. This begins with an overall observation of the patient. The age of the patient alone should not be a contraindication to performing surgery. In patients less than 16 years of age, there is a greater chance that the conductive impairment is secondary to congenital anomalies rather than otosclerosis. Likewise, very active diffuse obliterative otosclerosis may be found in a young patient, predisposing to a higher incidence of complications. Yet surgery should be considered in the young because hearing acuity is essential during the formative years of development. Patients older than 75 years are still surgical candidates if they are in good health. Hearing acuity becomes more important as other senses decline with age. In order to prepare for surgery and to prevent failures and complications, infections and anatomic variations must also be considered. The otologic evaluation may reveal dermatological conditions of the external ear canal that will predispose to postoperative infections. These include chronic external otitis, trauma from hearing aides or self-inflicted injury with cotton-tipped swabs. Likewise, one may see a small, crooked stenotic ear canal that, until corrected, will restrict surgical movement. Small exostosis usually does not impair access to the mesotympanum and may be left untouched. Even larger exostosis, which is limited to the anterior canal wall, usually does not interfere with the surgical approach. When the removal of the large posterior exostosis is necessary, it may be impossible to preserve a satisfactory tympanomeatal skin flap. In such cases, it is best to remove the exostosis first and delay the stapedectomy. Brahe Pedersen and Felding have postulated a connection between the influenza viral infection and unexplained sensorineural hearing loss immediately after stapes surgery. Although without evidence, this cannot be proven, it would seem prudent to avoid operation when respiratory viral infections are prevalent, especially in the patient, the patient's family or the surgeon. The diagnosis of otosclerosis should be confirmed only after other reasons for progressive hearing loss have been ruled out. The most common differential diagnoses of conductive losses are malleus fixation, serous otitis media, ankylosis of the malleus incus joint, Waardenburg's syndrome, Paget's disease, tympanosclerosis and progressive lysis to the long process of the incus. Tympanometry provides the most useful method to exclude most of these cases, particularly serous otitis media and ossicular fixation. Clinical history is of special value to rule out systemic disease such as Paget's disease, osteogenesis imperfecta or ankylosing rheumatoid arthritis. Many of the common anatomic variations, congenital anomalies and pathologic conditions are not known until seen during surgery. The surgeon must be well trained and experienced, first in recognizing these malformations, and second, in skillfully correcting them. A systematic examination of the unusual should be done. A superiorly located jugular bulb may come into juxtaposition with a tympanic annulus and in this position is vulnerable to injury during elevation of the tympanic meatal flap. For this reason, the elevation of the tympanic annulus inferiorly should not be performed with both strobes of the elevator. Tears of the jugular bulb, of course, result in profuse bleeding and constitute an alarming, although not serious, complication. Elevating the head of the operating room table and packing the area with Gelfoam may control the bleeding. If the bleeding is readily controlled, the operation may be completed. If the tear is large and the bleeding is difficult to control, the procedure should be terminated. The location of the facial nerve should be determined before proceeding with removal of the stapes. Usually, the facial nerve lies superior to the oval window, which permits the surgeon to acquire a complete view of the footplate. In this position, the lateral surface of the nerve is usually covered by bone, although the inferior surface may be partially dehiscent. When the nerve overhangs the footplate, there is frequently a lateral as well as an inferior dehiscence to the fallopian aqueduct. Dehiscence of the facial nerve is not uncommon, and in about 0.5% of middle ears there is a sizable dehiscence, so that the nerve bulges down and obscures the arch and footplate. Even in these cases, for the experienced surgeon, it is often possible to remove the footplate, although somewhat blindly, and the prosthesis can be contoured so as to adapt to the overhanging facial nerve. Otosclerosis of the round window niche is of no significance unless the round window opened is completely closed. When obliteration of the niche is severe, only a dimple may mark its location. From a retrospective study of 30,567 stapedectomies, this has been shown to occur in 300 patients or 1% of cases. In this situation, the mucosa should be elevated in an attempt to determine that the closure is complete. When it is not possible to determine with certainly whether the window is blocked, the stapedectomy should be performed. Patients with round window closure tend to have an early onset of hearing loss, frequently beginning in childhood or in adolescence, similar to the hearing losses associated with obliterative otosclerosis. However, these patients develop a more severe mixed hearing loss than those patients with disease limited to the oval window. A family history can be obtained from 50% of the patients with otosclerosis. Shea's series showed 78% of patients who developed round window closure had a strong family history consistent with otosclerosis. The stapedial artery, which is present in the early stage of embryonic life and persists in many lower animals, is usually absent in the human ear. A pulsating vessel nearly filling the crural arch will identify a persistent stapedial artery. In some cases, the stapes can be removed and the prosthesis introduced, but in 0.2% of the operations it is not feasible to proceed with the surgery. Rupture of the vessel could result in profuse hemorrhage and is to be meticulously avoided. A small artery on the footplate is a consistent finding and is not to be confused with the persistent stapedial artery. Until the advent of stapedectomy surgery, the high incidence of malleus ankylosis had not been recognized. Malleus ankylosis occurs with a disease entity unrelated to, but sometimes associated with, otosclerosis of the oval window. A bridge of lamellar bone extending from the anterior part of the head of the malleus to the anterior epitympanic wall fixes the head of the malleus. Presumably, this bridge of bone results from failure of the malleus to completely separate from the epitympanic wall during embryonic development. The otologic history, often secured in retrospect, usually reveals hearing loss in childhood that becomes worse in adult life. Such cases represent malleus ankylosis with subsequent development of otosclerosis. When there is a history of hearing loss since early childhood without progression, the case may represent pure malleus fixation without oval window otosclerosis. If there is a history of hearing loss dating from childhood or if the hearing loss is unilateral, the preoperative evaluation could certainly include tests for malleus mobility. Should examination with the pneumatic otoscope be inconclusive, mobility should be determined with direct instrumental manipulation with the aid of magnification. If there is fixation, it is necessary to perform an atticotomy and widely expose the head of the malleus and the body of the incus. Proper treatment will consist of amputation of the head of the malleus followed by ossicular reconstruction. Congenital anomalies of the stapes and incus are usually suspected because of a history of hearing problems from early childhood. The anomalies may range from simple fixation of the footplate due to incomplete resolution of the mesenchymal tissue during embryologic development, to the absence of the stapes in infancy. The stapes may be small and articulate with a short, underdeveloped long process of the incus. The crural arch may contain bone or may be replaced by a single bony strut. The floor of the oval window niche may consist of a solid layer of bone without evidence of a footplate or the oval window niche may be completely missing. The correction of simple congenital stapes fixation may be the same as for fixation due to otosclerosis. Corrective surgery for anomalies is attended with a higher incidence of injury to the inner ear because of frequent associations of anomalies to the membranous labyrinth. For example, the utriculosaccular deck may be located in the oval window area and may be vulnerable to injury. These patients should be counseled regarding the greater risk of sensorineural hearing loss. In very rare cases, the otosclerotic foci may not only obliterate the oval window niche, but may also extend into the vestibule. This has been shown to occur in 7%-11% of the cases in which stapedectomies failed. When removing the bone, the surgeon will find that the growth extends into the vestibule beyond the footplate level. This is best managed using a slow rotation per minute microdrill to create a 0.8-mm diameter cylinder. In this situation, laser creates a potential risk to the patient because of heat transfer to the perilymph of the vestibule and subsequently to the utriculosaccular. The gusher is a dramatic complication to stapes surgery. The smallest control hole in the footplate can produce a perilymph leak so profuse that it fills the middle ear and internal auditory canal within seconds. The existence of this abnormality is suggested by an upward sloping air conduction audiogram with best responses at 2 kilohertz. This complication is more common in ears with congenital fixation of the footplate. Management of the stapes gusher is the same as management for a CSF leak. Once the surgeon notes the onset of fluid leaking from the aperture in the stapes footplate, leakage may be controlled with a small piece of Surgicel. A graft should be placed over the leaking footplate with the completion of the stapedectomy. A lumbar drain will now effect a diversion of the CSF thereby decreasing the pressure of the purulence. The head of the patient's bed is elevated and daily fluid intake is restricted. The flow of CSF may last for several days and a sensorineural hearing loss is likely to occur. Clearly, if such ears can be identified, the operation is contraindicated. Next, we will move on to surgical trauma. Tears of the tympanic meatal flap that may occur in the following locations. First, a linear tear or buttonhole perforation may occur in the skin flap. Usually, these tears require no repair. However, when replacing a flap at the completion of the procedure, care must be taken to avoid enfolding the margins of the tear. The skin flap may separate from the tympanic annulus as well. This usually occurs in an inferior location and is due to failure to elevate the tympanic annulus from the sulcus. Another cause of a tear of this type is failure to achieve total elevation of skin flap from incision-to-incision. Usually no repair is required if separation occurs inferiorly. However, if it occurs superiorly, grafting may be necessary. Subluxation and luxation of the incus consists of a tear in the capsule of the incudomalleolar joint, but with a sufficiently intact capsule to maintain the incus in its normal anatomical position. Although the long process of the incus will be excessively mobile, the operation may be completed and functional results may be satisfactory. Luxation of the incus is due to a complete disruption of the incudomalleolar joint and demands that the removal of the incus and the use of a malleus over-window prosthesis. Attempts to replace and maintain the incus in its original position are usually not successful. The incus may be accidentally dislocating during curetting of the bony annulus and during manipulations of the oval window. The long process of the incus may be accidentally displaced when withdrawing the instrument from the oval window niche. Fractures of the long process of the incus are an unusual complication, but may happen during the wire tightening procedure. If the fracture appears near the tip of the long process, the wire may still be placed on the stump. If this is not possible, the procedure must be altered. Injury to the facial nerve during stapedectomy is uncommon, but there may be a direct injury to the nerve in the facial canal by careless use of the instruments, touching with the drill or heating by a drill if the tip is not cool. An interesting remark made by Schuknecht states that direct instrumental injury to the facial nerve is extremely rare and has only occurred once during his numerous stapedectomies. Since the risk to the facial nerve injury is almost nil, Schuknecht considered that the possibility of its occurrence need not be mentioned to the patient before operation. During a stapedectomy operation, it is frequently necessary to displace the chorda tympani nerve to gain adequate exposure. There is controversy concerning the advisability of stretching the nerve or cutting it. Approximately one-fourth of patients complain of ageusia in the postoperative period. Chorda tympani nerve dysfunction is usually transient and fewer than 5% of patients experience permanent deficits. It should be appreciated that if the nerve is cut, it will produce permanent loss of sensation of taste on the anterior two-thirds of the tongue on the same side. No reinnervation of the taste buds can take place, either from the chorda tympani nerve on the opposite side or the posterior third of the tongue supplied by the glossopharyngeal nerve. Permanent loss of the chorda tympani innervation results in atrophy of the taste receptors. The dorsum of the tongue becomes smooth and pale. The patient may not complain of the loss of taste if one nerve is cut, as long as the tongue retains sensation for 66% of the surface. If the nerve is stretched during operation, a persistent abnormal sensation in the tongue may occur, described by the patient as salty or metallic. Bilateral loss of the chorda tympani nerve produces marked symptoms in the majority of patients. In addition to the loss of taste, there is loss of secretum motor supply to the submandibular and sublingual glands that produces an uncomfortably dry mouth. Deficits include a diminution of taste sensation or a dry mouth. Revision causes cases to deserve special attention. Sensorineural hearing loss is perhaps the most disappointing and devastating complication for both the surgeon and patient. Complete sensorineural hearing loss can occur even in the most meticulously and appropriately performed stapes procedure. Most commonly, however, are complications due to surgical trauma. Intraoperative studies performed in stapedectomy indicate that acoustic trauma in drilling, excessive movement of the stapes producing a hydraulic effect, rupture of the membranous inner ear, rapid loss in perilymph that may lead to damage at the membranous structures in the vestibule, footplate fragments or bone death in the vestibule, and the floating footplate are the great offenders for vestibular and presumably cochlear damage. The reported incidence of dead ears after operation varies from 0.5% to 4%. It is important to appreciate that these are figures from a series of operations performed by expert surgeons with a special interest in stapedectomy. Results achieved by the occasional operator are not reported and it is likely that the incidence of cochlear damage is much higher. Mawson has shown that in a series of 1000 operations, there was a hearing loss at 4% in the first 50 operations, 2% hearing loss after the next 50 operations, no loss in the next 500 and 0.25% of the remaining 400 operations. An attempt at removal of the floating footplate may result in a dead ear and if this complication is encountered it must be dealt with correctly. If the footplate is visible, it may be possible to remove it by manipulation and extraction with a fine hook, or a small drill hole may be made at the margin of the oval window and a fine hook used to remove it. If the footplate cannot be removed without excessive manipulation, it should be left in place and a soft tissue graft placed over the oval window and the operation abandoned. The depressed footplate may result from incorrect attempts to remove a floating footplate or may occur during attempts to carry out a total stapedectomy. Causse documented this at an incidence of 0.16%. No attempt should be made to retrieve the submerged footplate by instrument as this may cause severe cochlear damage. Roche et al have described a method of dealing with this complication that is not damaging to the contents of the vestibule. Drops of blood are poured laterally into the vestibule and when the vestibule is full of blood and a clot is formed, the clot is removed by a lateral application of the sucker and the footplate coated with the clot is usually removed from the oval window. It is of paramount importance for the surgeon to understand the relationship of the stapes footplate to the vestibular contents. Almost all patients have a minimal safe distance of approximately 1-mm between the medial surface of the footplate and the utricle and saccule. Penetration of the vestibule by more than 1 mm with the footplate instruments or prosthesis may perforate the utricle and saccule inducing sensorineural hearing loss, vertigo or both. In patients with endolymphatic hydrops the saccule may extend to contact the medial surface of the footplate, thereby placing these patients at a higher risk for complications from this procedure. Prosthesis loosening due to erosion or notching of the incus and prosthesis displacement due to necrosis of the incus also occurs. With removal of the stapes arch, the blood supply to the long process of the incus is divided as it courses over the incudostapedial joint. Collateral vessels exist from the body of the incus and maintain the viability of the remaining bone. Circumferential overtightening of the prosthesis can remove the blood supply to the tip of the incus. The signs and symptoms of perilymphatic fistula were first described by Lewis in 1961, and this complication, which at one time was thought be unusual, is now accepted as being one of the more common complications of stapedectomy. The surgeon creates a fistula at every stapedectomy operation and relies on the natural process of healing or in some techniques a graft of soft tissue, to seal the opening that has been made. In most operations, there is enough surgical trauma to the oval window mucoperiosteum to lead to the production of an inflammatory repair envelope around the prosthesis, sealing the opening into the oval window. With symptoms of a perilymphatic fistula or fluctuating hearing loss, tinnitus, a feeling of fullness in the ear and vertigo, there is no doubt that a small fistula remained after many stapedectomy operations with incomplete closure of air bone gap, but the hearing result may be acceptable to the patient. Although a perilymph fistula usually leads to sensorineural hearing loss, this is not always the case and a persistent conductive loss after an operation should warn the surgeon that there might be a fistula. A revision operation to close it would be the best line of treatment. The fistula may be primary, dating from the time of operation when there is a failure of the oval window to seal, or it may be secondary, where it can appear many months or even years after the original operation. Hearing tests carried out soon after the onset of fistula will show findings similar to those seen in labyrinthine hydrops. For example, puretone sensorineural hearing loss and low frequency initially, followed by a flat loss that fluctuates. There may be recruitment as well. Vestibular tests such as the Hallpike caloric test, EMG, and fistula test with a pneumatic otoscope may all be helpful, but have been found to be negative in 20% of the cases. Welder described a newer technique, diagnosis by radioactive Indian-111 that is injected into the lumbar subarachnoid space. The demonstration of an increased radioactivity in the nasopharyngeal secretions strongly supports the diagnosis of a fistula. The treatment of a perilymphatic fistula is a tympanotomy at the earliest possible moment with an attempt to close the fistula. When the leak is detected, the fistulous track is excised and the prosthesis removed with great care. The opening of the vestibule is covered with a soft tissue graft that is held in place by another prosthesis. Unless early treatment is instituted, the chances of restoration or improvement of hearing are small. In some cases troublesome dysequilibrium may remain. It is imperative that the surgeon is fully aware of these complications and realizes that some techniques are safer than others. The use of Gelfoam to seal the oval window in stapedectomy produces a very thin membrane and has caused the highest incidence of fistula formation. The perilymphatic fistula is the only complication of stapedectomy that is dangerous, and although the risk of meningitis is small, death from meningitis after this operation has been reported. As with the perilymphatic fistula, postoperative granulomas can also be a cause of dysequilibrium, vertigo or progressive sensorineural hearing loss. Granuloma formation is seen in approximately 1:100 cases of revision stapedectomy. Foreign body reaction is a suspected etiology of postoperative granuloma formation. Glove, starch and Teflon have all been implicated. For this reason, direct pullout prosthesis contact should be avoided. It may also be prudent to rinse the prosthesis prior to its insertion. The condition usually manifests between the 5th and 15th postoperative day and is characterized symptomatically by hearing loss after an initial hearing gain or a sensation of unsteadiness. Associated with the hearing loss are loss of speech discrimination and a sensation of fullness in the ear. Examination reveals an edematous, thickened and hypervascular skin flap as well as dullness and reddening at the posterior part of the tympanic membrane. Audiometric studies show a combined sensorineural and conductive hearing loss that is worse in the higher frequency that is also associated with decreased speech discrimination. High-dose steroids may decrease the inflammatory response and its effects on the inner ear. Emergency surgical intervention is imperative. Surgical exploration reveals a granulomatous mass extending from the oval window niche to completely envelop the prosthesis and the long process of the incus. In about half of the cases the granuloma extends into the vestibule. The granuloma, including the portion within the vestibule, must be removed in its entirety along with the prosthesis. They may also be vaporized with laser after the prosthesis has been removed. Cholesteatoma following stapedectomy is a rare complication. Mawson reported only one post-stapedectomy cholesteatoma in a review of nearly 2000 cases. Only five other cases have been previously reported in the literature. Proposed mechanisms for formation include prosthesis extrusion, the presence of a squamous epithelium in the fascial graft, inversion of the tympanomeatal flap and a marginal perforation associated with a disruptive annulus. Diplacusis occurs in approximately one-third of the patients. There may be a variation of distortion of sound, especially music and the human voice, of which patients frequently complain. For the first few weeks after the operation most people complain of pure tones appearing higher in pitch when compared with the unoperated side. It is seldom problematic and usually fades by six weeks postoperatively. Almost all patients have some degree of phonophobia postoperatively as well. Reassurance is adequate treatment. A subset of this has been documented as an abnormal, emotional response. In a 1993 article in Laryngoscope, Lloyd Stores describes such a case: "This is the most curious and unexpected phenomena that I have ever encountered. They brought this girl in that I had performed the stapedectomy a few days prior. Honestly, her mouth was open and fixed and she had a glassy stare. From the history, it turns out that her symptoms developed almost immediately after I took the first packing out of her ear canal. The mother-in-law was a talker and she continued to talk about how useless her daughter-in-law was. The daughter-in-law, my patient, had not been hearing all of this for years and she went into a catatonic trance that was unbelievable. She really freaked." In conclusion, we have come a long way from the original attempts at mobilization of the stapes by Kessel, as resurrected by Rosen, which led to the modern day stapedectomy performed by Shea. A survey of articles in the last 30 years concerning the complications of stapedectomy indicates that although there are some differences over the relative importance attributed to a certain problem, there is general agreement about the direction in which new research should be directed. The situation is well summarized by Dr. Shea in his 40-year report on over 14,449 stapedectomies, where he makes the observation that although the original objections to stapedectomy have all but disappeared, it is now increasingly necessarily to concentrate on the problems arising from the operation itself. Case Report I.K. is a 36-year-old Indian male who presents to the BTGH clinic with a several year history of progressively worsening hearing loss in his left ear. The patient has previously undergone an unknown middle ear procedure on the right ear, performed in another state for hearing loss. Of note is that the patient's mother and father also have had some degree of hearing loss. An audiogram obtained on March 23, 1999 revealed a 40-50 decibel conductive hearing loss in the left ear with a pure tone average of 67 decibels. On physical exam, the patient had an unremarkable head and neck examination except for his conductive hearing loss. The patient was taken to the operating room on April 13, 1999. Upon elevation of the patient's tympanomeatal flap, there was a narrowed oval window niche. The facial nerve was in the fallopian canal without dehiscence. The stapes was fixed with diffuse otosclerosis of the footplate. A 0.8 mm diamond drill was then used to thin the thickened footplate. The footplate was then perforated and a 4.0 mm Fisch stapes piston was placed. Postoperatively, the patient did well, and during the first 15 days, he stated that his hearing was markedly improved. On post operative day 16, the patient experienced a sudden decrease of hearing in that ear. There were no associated symptoms of vertigo, otorrhea or ear pain. A repeat audiogram was performed which revealed similar results as the preoperative test. The patient was thus taken to the operating room again on June 17, 1999, for a middle ear exploration, where it was noticed that the oval window was once again obliterated. It was demonstrated that the prosthesis was no longer sitting in the oval window, but was surrounded and riding on top of a thickened and obliterated footplate. A re-drill out of the oval window was performed, and the vestibule was entered carefully with a sharp pick. A longer 4.5mm Fisch prosthesis was then used. Postoperatively, the patient was started on sodium fluoride. Unfortunately, the patient never returned for a postoperative visit. Bibliography Backous DD, Coker NJ, Jenkins HA. Prospective study of resident-performed stapedectomy. Am J Otol 1993;14:451-454. Beales PH. Otosclerosis. Triangle West, Bristol: John Wright & Sons; 1981. pp 85-185. Belal A Jr, Ylikoski J. Poststapedectomy dizziness. 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