Stapedectomy
Encyclopedia
A stapedectomy is a surgical procedure of the middle ear
performed to improve hearing. The world's first stapedectomy is credited to Dr. John J.Shea Jr.
who performed it in May 1956 on a 54-year-old housewife who could no longer hear even with a hearing aid. Significant contributions to modern stapedectomy techniques were then made by the late Dr. Antonio De La Cruz of the House Ear Institute
in Los Angeles
; by the late Professor Henri André Martin of the Hôpital Edouard Herriot in Lyon
, France
, including calibrated platinotomy (stapes footplate rather than whole surgery) and trans-footplate piston surgery that also paved the way for modern stapedotomy; and by the late Dr. Jean-René Causse of the eponymous clinic in Béziers
, France
, who pioneered the use of Teflon piston prostheses (also critical progress for stapedotomy) and, with his late son Dr. Jean-Bernard Causse, the reattachment of the stapedius muscle alongside the use of veinous grafts. In recent decades, Dr. William H. Lippy of the Lippy Group for Ear, Nose & Throat in Warren, Ohio
has also claimed multiple advances of the surgical procedure.
If the stapes footplate is fixed in position, rather than being normally mobile, then a conductive hearing loss
results. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the temporal bone called otosclerosis
. The second is a congenital malformation of the stapes.
In both of these situations, it is possible to improve hearing by removing the stapes bone and replacing it with a micro prosthesis - a stapedectomy, or creating a small hole in the fixed stapes footplace and inserting a tiny, piston-like prosthesis
- a stapedotomy. The results of this surgery are generally most reliable in patients whose stapes has lost mobility because of otosclerosis
. Nine out of ten patients who undergo the procedure will come out with significantly improved hearing while less than 1% will experience worsened hearing ability or deafness. Successful surgery usually provides an increase in hearing ability of about 20 dB. That is as much difference as having your hands over both ears, or not. However, most of the published results of success fall within the speech frequency of 500 Hz, 1000 Hz and 2000 Hz; poorer results are typically obtained in the high frequencies, but these are normally less hampered by otosclerosis in the first place.
When a stapedectomy is done in a middle ear with a congenitally fixed footplate, the results may be excellent but the risk of hearing damage is greater than when the stapes bone is removed and replaced (for otosclerosis). This is primarily due to the risk of additional anomalies being present in the congenitally abnormal ear. If high pressure within the fluid compartment that lies just below the stapes footplate exists, then a perilymphatic gusher may occur when the stapes is removed. Even without immediate complications during surgery, there is always concern of a perilymph fistula
forming postoperatively. In a landmark article by Glasscock et al. the overall complication rate for stapedectomy was found to be 45% with a 10% rate of dead ears.
, and a prosthesis
is placed to touch this area with movement of the tympanic membrane. This procedure can be further improved by the use of a tissue graft seal of the fenestra, which is now common practice.
Laser stapedotomy is a well-established surgical technique for treating conductive hearing loss due to otosclerosis. The procedure creates a tiny opening in the stapes (the smallest bone in the human body) in which to secure a prosthetic. The CO2 laser allows the surgeon to create very small, precisely placed holes without increasing the temperature of the inner ear fluid by more than one degree, making this an extremely safe surgical solution. The hole diameter can be predetermined according to the prosthesis diameter. Treatment can be completed in a single operation visit using anesthesia, normally followed by one or two nights' hospitalization with subsequent at-home recovery time a matter of days or weeks.
, and especially at higher sound frequencies
), and to be less prone to complications. In particular, stapedotomy procedure greatly reduces the chance of a perilymph fistula
(leakage of cochlear fluid).
Stapedotomy, like stapedectomy, can be successful in the presence of sclerotic adhesions
(tissue growths abnormally linking the bones to the tympanic cavity
), provided the adhesions are removed during surgery. However, the adhesions may recur over time. The stapedotomy method is not applicable in those relatively rare cases that involve scleroris of the entire ossicular chain.
Because it is a simpler and safer procedure, stapedotomy is normally preferred to stapedectomy in the absence of predictable complications. However, the success rate of either surgery depends greatly on the skill and the familiarity with the procedure of the surgeon. Furthermore, a major success factor in both surgeries is correctly determining the length of the prosthesis.
Middle ear
The middle ear is the portion of the ear internal to the eardrum, and external to the oval window of the cochlea. The mammalian middle ear contains three ossicles, which couple vibration of the eardrum into waves in the fluid and membranes of the inner ear. The hollow space of the middle ear has...
performed to improve hearing. The world's first stapedectomy is credited to Dr. John J.Shea Jr.
John J. Shea, Jr.
Dr. John J. Shea, Jr. is an American medical doctor, professor and surgeon.He attended Christian Brothers High School, Memphis, Tennessee, the University of Notre Dame and Harvard Medical School. He performed the first successful reconstructive stapedectomy in May, 1956...
who performed it in May 1956 on a 54-year-old housewife who could no longer hear even with a hearing aid. Significant contributions to modern stapedectomy techniques were then made by the late Dr. Antonio De La Cruz of the House Ear Institute
House Ear Institute
The House Ear Institute is a non-profit 501 organization, based in Los Angeles, and dedicated to advancing hearing science through research and education to improve quality of life. Established in 1946 by Howard P...
in Los Angeles
Los Ángeles
Los Ángeles is the capital of the province of Biobío, in the commune of the same name, in Region VIII , in the center-south of Chile. It is located between the Laja and Biobío rivers. The population is 123,445 inhabitants...
; by the late Professor Henri André Martin of the Hôpital Edouard Herriot in Lyon
Lyon
Lyon , is a city in east-central France in the Rhône-Alpes region, situated between Paris and Marseille. Lyon is located at from Paris, from Marseille, from Geneva, from Turin, and from Barcelona. The residents of the city are called Lyonnais....
, France
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...
, including calibrated platinotomy (stapes footplate rather than whole surgery) and trans-footplate piston surgery that also paved the way for modern stapedotomy; and by the late Dr. Jean-René Causse of the eponymous clinic in Béziers
Béziers
Béziers is a town in Languedoc in southern France. It is a sub-prefecture of the Hérault department. Béziers hosts the famous Feria de Béziers, centred around bullfighting, every August. A million visitors are attracted to the five-day event...
, France
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...
, who pioneered the use of Teflon piston prostheses (also critical progress for stapedotomy) and, with his late son Dr. Jean-Bernard Causse, the reattachment of the stapedius muscle alongside the use of veinous grafts. In recent decades, Dr. William H. Lippy of the Lippy Group for Ear, Nose & Throat in Warren, Ohio
Warren, Ohio
As of the census of 2000, there were 46,832 people, 19,288 households and 12,035 families residing in the city. The population density was 2,912.4 people per square mile . There were 21,279 housing units at an average density of 1,322.9 per square mile...
has also claimed multiple advances of the surgical procedure.
If the stapes footplate is fixed in position, rather than being normally mobile, then a conductive hearing loss
Conductive hearing loss
Conductive hearing loss occurs when there is a problem conducting sound waves anywhere along the route through the outer ear, tympanic membrane , or middle ear ....
results. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the temporal bone called otosclerosis
Otosclerosis
Otosclerosis is an abnormal growth of bone near the middle ear. It can result in hearing loss.-Clinical description:Otosclerosis can result in conductive and/or sensorineural hearing loss...
. The second is a congenital malformation of the stapes.
In both of these situations, it is possible to improve hearing by removing the stapes bone and replacing it with a micro prosthesis - a stapedectomy, or creating a small hole in the fixed stapes footplace and inserting a tiny, piston-like prosthesis
Prosthesis
In medicine, a prosthesis, prosthetic, or prosthetic limb is an artificial device extension that replaces a missing body part. It is part of the field of biomechatronics, the science of using mechanical devices with human muscle, skeleton, and nervous systems to assist or enhance motor control...
- a stapedotomy. The results of this surgery are generally most reliable in patients whose stapes has lost mobility because of otosclerosis
Otosclerosis
Otosclerosis is an abnormal growth of bone near the middle ear. It can result in hearing loss.-Clinical description:Otosclerosis can result in conductive and/or sensorineural hearing loss...
. Nine out of ten patients who undergo the procedure will come out with significantly improved hearing while less than 1% will experience worsened hearing ability or deafness. Successful surgery usually provides an increase in hearing ability of about 20 dB. That is as much difference as having your hands over both ears, or not. However, most of the published results of success fall within the speech frequency of 500 Hz, 1000 Hz and 2000 Hz; poorer results are typically obtained in the high frequencies, but these are normally less hampered by otosclerosis in the first place.
Indications
Indications of stapedectomy:- Conductive hearing loss (due to fixation of stapes).
- Air bone gap of at least 30 dB.
- Presence of Carhart's notch in the audiogram of a patient with conductive hearing loss (relative)
- Good cochlear reserve as assessed by the presence of good speech discrimination.
Contraindications
Contraindications for stapedectomy:- Poor general condition of the patient.
- Only hearing ear.
- Poor cochlear reserve as shown by poor speech discrimination scores
- Patient with tinnitus and vertigo
- Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign.
- Conductive deafness due to Ehlers-Danlos Syndrome (EDS)
Complications
Complications of stapedectomy:- Facial palsy
- Vertigo in the immediate post op period
- Vomiting
- Perilymph gush
- Floating foot plate
- Tympanic membrane tear
- Dead labyrinth
- Perilymph fistula
- Labyrinthitis
- Granuloma (Reparative)
- Tinnitus
When a stapedectomy is done in a middle ear with a congenitally fixed footplate, the results may be excellent but the risk of hearing damage is greater than when the stapes bone is removed and replaced (for otosclerosis). This is primarily due to the risk of additional anomalies being present in the congenitally abnormal ear. If high pressure within the fluid compartment that lies just below the stapes footplate exists, then a perilymphatic gusher may occur when the stapes is removed. Even without immediate complications during surgery, there is always concern of a perilymph fistula
Perilymph fistula
A labyrinthine fistula is an abnormal opening in the bony capsule of the inner ear, resulting in leakage of the perilymph from the semicircular canals into the middle ear . This includes specifically a perilymph fistula , an abnormal connection between the fluid of the inner ear and the air-filled...
forming postoperatively. In a landmark article by Glasscock et al. the overall complication rate for stapedectomy was found to be 45% with a 10% rate of dead ears.
Stapedotomy
A modified stapes operation, called a stapedotomy, is thought by many otologic surgeons to be safer and reduce the chances of postoperative complications. In stapedotomy, instead of removing the whole stapes footplace, a tiny hole is made in the footplate - either with a microdrill or with a laserLaser
A laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. The term "laser" originated as an acronym for Light Amplification by Stimulated Emission of Radiation...
, and a prosthesis
Prosthesis
In medicine, a prosthesis, prosthetic, or prosthetic limb is an artificial device extension that replaces a missing body part. It is part of the field of biomechatronics, the science of using mechanical devices with human muscle, skeleton, and nervous systems to assist or enhance motor control...
is placed to touch this area with movement of the tympanic membrane. This procedure can be further improved by the use of a tissue graft seal of the fenestra, which is now common practice.
Laser stapedotomy is a well-established surgical technique for treating conductive hearing loss due to otosclerosis. The procedure creates a tiny opening in the stapes (the smallest bone in the human body) in which to secure a prosthetic. The CO2 laser allows the surgeon to create very small, precisely placed holes without increasing the temperature of the inner ear fluid by more than one degree, making this an extremely safe surgical solution. The hole diameter can be predetermined according to the prosthesis diameter. Treatment can be completed in a single operation visit using anesthesia, normally followed by one or two nights' hospitalization with subsequent at-home recovery time a matter of days or weeks.
Stapedectomy vs. stapedotomy
Comparisons have shown stapedotomy to yield either as good or better results than stapedectomy (measured by hearing improvement and reduction in the air-bone hearing gapPure tone audiometry
Pure tone audiometry is the key hearing test used to identify hearing threshold levels of an individual, enabling determination of the degree, type and configuration of a hearing loss. Thus, providing the basis for diagnosis and management. PTA is a subjective, behavioural measurement of hearing...
, and especially at higher sound frequencies
Audio frequency
An audio frequency or audible frequency is characterized as a periodic vibration whose frequency is audible to the average human...
), and to be less prone to complications. In particular, stapedotomy procedure greatly reduces the chance of a perilymph fistula
Perilymph fistula
A labyrinthine fistula is an abnormal opening in the bony capsule of the inner ear, resulting in leakage of the perilymph from the semicircular canals into the middle ear . This includes specifically a perilymph fistula , an abnormal connection between the fluid of the inner ear and the air-filled...
(leakage of cochlear fluid).
Stapedotomy, like stapedectomy, can be successful in the presence of sclerotic adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
(tissue growths abnormally linking the bones to the tympanic cavity
Tympanic cavity
The tympanic cavity is a small cavity surrounding the bones of the middle ear.It is formed from the tubotympanic recess, an expansion of the first pharyngeal pouch....
), provided the adhesions are removed during surgery. However, the adhesions may recur over time. The stapedotomy method is not applicable in those relatively rare cases that involve scleroris of the entire ossicular chain.
Because it is a simpler and safer procedure, stapedotomy is normally preferred to stapedectomy in the absence of predictable complications. However, the success rate of either surgery depends greatly on the skill and the familiarity with the procedure of the surgeon. Furthermore, a major success factor in both surgeries is correctly determining the length of the prosthesis.
External links
- The LION Foundation's Live International Otolaryngology Network offers annual symposia geared for continuing education of practicing surgeons, and subsequently available via streaming internet.http://www.lion-web.org/index.html
- Dr. Lippy and his partner, Dr. Leonard Berenholz, have an online library of their collective 60 peer review papers and 6 book chapters, and videos about their surgical experience and related hearing loss topics.http://www.TheLippyLibrary.com
- Overview of Otosclerosis and Stapedectomy http://www.scribd.com/doc/7698474/Otosclerosis-and-Stapedectomy-the-Expected-Complications - details of the procedure with pictures
- Amanda Jenner, Lynne Shields PhD ccc-slp "Speech and Language Issues" http://www.ehlersdanlos.ca/MSHA.htm
- M. Hawthorne, FRCS-ENT Surgeon. "Hearing Impairment and EDS" http://www.ehlersdanlos.ca
- S.O. "blood in the water" McM- "Stapedectomy- complications and pitfalls"