Otosclerosis - School of Medicine

Microdrill Fenestra

Laser Fenestra

Prosthesis placement

Cummings Ch. 144

Types of Prostheses

 Autologous homograft - skill
 House wire loop fat graft – extrusion
 Polyethylene piston – delayed fistula
 Gelfoam piston - granuloma
 Smart Piston
 Nitinol piston
 Robinson bucket handle

 …not really

 Shapes – wire loop, bucket handle, and piston

 Teflon, steel, platinum gold, nickel titanium alloy
(nitinol).

 Self crimping nitinol may have less risk of incus
necrosis

 No difference in hearing outcomes when comparing
smart piston to non-smart (nitinol) pistons

Intraoperative Decisions

 Facial nerve malposition
 Persistent stapedial artery

Overhanging facial nerve

 Dehiscent in 55%
 Partial vs full obstruction of oval window

Complete Obstruction of oval window

Nerve inferior to oval window

Biphid nerve – note atrophic stapes

What to do

 Options

 Abort
 Gentle retraction 5 second durations, 10 second breaks
 Facial nerve decompression and displacement
 Cochleotomy – at edge of oval window and cochlea

 “No surgeon should be criticized for judging a malformation
unrepairable and certainly for the inexperienced or
infrequent stapes surgeon, withdrawal is the most
appropriate option.” - Jahrsdoerfer

Persistent Stapedial Artery

What to do?

 Reconstruct with teflon piston – smooth and wont
cause vascular injury

Tympanic Membrane Perforation

 Occurs in 1.9% of cases (Causse and Causse)
 Does not preclude completion of the procedure

 Options

 Do nothing 9%
 Underlay 60%
 Paper patch repair 13%

Chorda Tympani Injury

 Present in 30% of cases

 Will cause dry mouth, soreness of tongue, and a metalic
taste

 Resolves in 3-4 months
 Options

 Cut it – better results than leaving a tattered nerve

 36% respondents will section it

 Leave it

 64% prefer to leave it alone

Malleus Fixation

 Present in 1% of stapedectomy cases
 Ossification of the superior and anterior suspensory

ligaments which leads to attachment of the head to
the anterior wall of the epitympanum
 Rarely have air bone gap >30 dB
 Options for management

 Open epitympanum and mobilize by tapping on malleus
 Incus replacement procedure to bypass the malleus

 Remove incus and head of malleus, place prosthesis between
TM and umbo

 TORP

Obliterated footplate

 Drill vs laser slowly down to level of oval window
 If recurs

 On reoperation

 May reposition prosthesis
 Do not attempt to re open otosclerotic focus if present

CSF Gusher

 Rush of clear fluid fills the EAC upon entering
vestibule

 Associated with congenital cases with sensorineural
loss present

 Due to widened IAC

 May be noticed by an abnormally anterior
positioned posterior crura or avascular middle ear

CSF Gusher Management

 Elevate head of bed
 Small fenestra
 Tissue graft then prosthesis
 Possible lumbar drain

Postoperatively

 You’ve completed the case and the patient has
discharged home the same day.

Patient calls clinic….

 5 days later
 Decreased hearing, +tinnitus, and vertigo

 What to do?

 Audiogram – decreased bone conduction across all
frequencies

 Vertiginous in clinic

Diagnosis and Management

 Serous labrynthitis

 Delayed (3-7 days) onset of SNHL, vertigo, tinnitus

 Diagnose with audiogram
 Steroids x 14 days
 Antibiotics x 10 days

Patient comes to clinic…

 Hearing initially improved after surgery

 Then gradually declined 2-3 weeks later

 Audiogram

 Decreased bone conduction
 Decreased discrimination scores

 Physical Examination

 TM has reddish discoloration in posterosuperior quadrant

Diagnosis and Management

 Reparative Granuloma

 Immediate operative removal
 Consider an associated serous labrynthitis due to the

inflammatory mediators associated with granulomas
 Quick intervention can return the hearing and

discrimination scores

Patient comes to clinic…

 Hearing initially improved after surgery

 Then suddenly declined 6 weeks later

 Audiogram

 Decreased air conduction

Diagnosis and Management

 Prosthesis displacement
 If symptoms persist then may revise surgery 2-6

months after the initial operation

Perilymph Fistula

 Fluctuating hearing loss and imbalance after
surgery