Underlying cause - Otosclerosis

Most stapedotomies are performed for fenestral otosclerosis, where abnormal bone remodelling occurs around the oval window and stapes footplate. This abnormal bone gradually fixes the stapes, preventing it from vibrating. Sound waves can still reach the eardrum, but they are no longer efficiently transmitted into the fluid of the inner ear, producing a progressive conductive hearing loss often starting in early to middle adulthood.

Otosclerosis is thought to result from a combination of genetic predisposition, hormonal influences and possibly viral triggers, although the exact cause is still not fully understood. It often runs in families and can be bilateral. Women are affected slightly more often than men, and symptoms may worsen during pregnancy due to hormonal changes that influence bone metabolism.

Why a patient may be offered stapedotomy

Stapedotomy is usually considered when:

1. There is a conductive or mixed hearing loss with a significant air-bone gap on audiometry, consistent with stapes fixation.

2. The patient's hearing loss has progressed to the point that hearing aids alone are no longer satisfactory or desired.

3. The inner ear (sensorineural) function is sufficiently healthy to expect improvement—i.e. bone-conduction thresholds are not too poor.

4. The eardrum and middle ear are otherwise healthy, with no chronic infection or major Eustachian tube dysfunction.

Some patients with superior semicircular canal dehiscence (SSCD) or other “third window” conditions may show a pseudo-conductive hearing loss mimicking otosclerosis. In such cases, detailed imaging is used before deciding on stapes surgery. Recent work suggests that, in carefully selected patients with both otosclerosis and radiographic SSCD, stapedotomy can still give good hearing improvement, but persistent conductive loss is more common, so counselling is important.

Risk factors and contraindications

Patients are more likely to need stapedotomy if they:

1. Have a family history of otosclerosis or early-onset progressive hearing loss.

2. Are in mid-adult life when otosclerosis commonly becomes symptomatic.

3. Have bilateral conductive hearing loss with characteristic audiogram changes (e.g. Carhart notch).

Relative contraindications to stapedotomy include:

1. Very poor inner-ear (sensorineural) reserve - surgery may offer limited benefit.

2. Active middle-ear infection or chronic eustachian tube dysfunction.

3. Uncontrolled vertigo or inner-ear disorders, where surgery could aggravate symptoms.

4. Severe medical comorbidities that make anaesthesia risky, although stapes surgery can often be done under local anaesthesia in suitable patients.

Patients who eventually undergo stapedotomy usually have symptoms of otosclerosis, not of the surgery itself.

Before surgery - symptoms of otosclerosis

Typical complaints include:

1. Gradual hearing loss - often starting in one ear and then affecting both; patients may notice they turn up the TV, struggle in meetings or have trouble hearing in noisy environments.

2. Better hearing in noisy places (paracusis of Willis) - some patients feel they hear comparatively better in noisy settings than in quiet ones, which is characteristic of conductive hearing loss.

3. Tinnitus - a ringing or buzzing in the affected ear is common.

4. Rarely, dizziness or imbalance - otosclerosis mainly affects the stapes, but in some cases it can involve the inner ear and cause mild vestibular symptoms.

On examination, the eardrum typically looks normal, because the problem is in the ossicles, not the drum. Tuning fork tests reveal a conductive pattern: sound heard better by bone conduction than by air in the affected ear. Audiometry shows a conductive or mixed hearing loss, often with a classic dip in bone-conduction thresholds around 2 kHz (Carhart notch).

After surgery - early postoperative sensations

Immediately after stapedotomy, patients may experience:

1. Blocked or full feeling in the operated ear due to packing and swelling; hearing in that ear is usually not immediately better and may even feel worse until packing is removed and healing progresses.

2. Dizziness or unsteadiness, which is common for a few hours or days and usually improves with rest and medication. Rarely, mild dizziness can last longer.

3. Metallic or altered taste on the front two-thirds of the tongue on the operated side due to stretching or disturbance of the chorda tympani nerve; this is often temporary but can persist for weeks or months before improving.

4. Mild pain around or in front of the ear, especially when chewing or yawning, which usually settles within days.

Patients are asked to report severe vertigo, sudden complete hearing loss, intense pain or fluid leakage from the ear, as these may signal complications needing urgent review.

Clinical evaluation

Diagnosis and surgical planning start with:

1. A detailed history of hearing loss (onset, progression, family history), tinnitus, dizziness, noise exposure and prior ear problems.

2. Otoscopy to inspect the ear canal and eardrum and rule out other causes of conductive loss such as wax, chronic otitis media or ossicular chain discontinuity.

3. Bedside tests (Rinne, Weber) to distinguish conductive from sensorineural hearing loss.

Audiological assessment

1. Pure-tone audiometry - shows the size of the air-bone gap and bone-conduction thresholds. This is key for deciding whether surgery or hearing aids are appropriate and for counselling about expected results.

2. Speech audiometry - evaluates how well the patient understands speech at different loudness levels, helping to set realistic expectations.

3. Immittance testing (tympanometry and acoustic reflexes) - tympanograms are often normal or show reduced compliance; acoustic reflexes are usually absent because the stapes is fixed.

Imaging

Imaging is not always mandatory for straightforward, classic otosclerosis, but CT scanning of the temporal bones is increasingly used to:

1. Confirm fenestral otosclerosis and assess the thickness and shape of the stapes footplate.

2. Rule out alternative causes of conductive loss such as ossicular anomalies, congenital malformations, or superior semicircular canal dehiscence.

3. Evaluate the inner ear and facial nerve course before surgery.

Preoperative assessment

Before scheduling stapedotomy, the surgeon and anaesthetist also:

1. Assess general health, blood pressure, diabetes control and other comorbidities.

2. Discuss anaesthesia options (local vs general) and perioperative instructions.

3. Counsel the patient about expected hearing improvement, the small but real risk of permanent sensorineural hearing loss (“dead ear”), possible dizziness, taste changes and need for revision surgery in future.

Non-surgical options

Not every patient with otosclerosis needs surgery. Treatment choices include:

1. Observation - suitable if hearing loss is mild and not significantly affecting daily life.

2. Hearing aids - can effectively amplify sound in conductive hearing loss and are often the first option; some patients prefer continuing with aids rather than undergoing surgery.

Surgical options

When hearing loss is moderate to severe, and the patient desires more natural hearing:

1. Stapedotomy (preferred)

   1. A small opening is created in the fixed stapes footplate (using a micro-drill or laser), and a piston prosthesis is attached to the long process of the incus and inserted into the fenestration.

   2. Only a tiny portion of the footplate is disrupted, which helps maintain inner-ear integrity.

   3. Numerous studies show excellent closure of the air-bone gap, with high rates of patient satisfaction and relatively low complication rates.

2. Stapedectomy (less common today)

   1. Partial or total removal of the stapes footplate, with placement of a graft and prosthesis.

   2. Similarly effective in restoring hearing but carries a somewhat higher risk of sensorineural hearing loss and other complications in many series, so it is often reserved for specific situations or when a stapedotomy must be converted intraoperatively.

3. Endoscopic vs microscopic approach

   1. Microscopic stapedotomy is the traditional standard, providing magnified binocular vision through the ear canal or a small incision.

   2. Endoscopic stapedotomy uses a rigid endoscope inserted through the ear canal, providing wide-angle views of the middle ear, often with less canal drilling. Recent work suggests similar hearing outcomes, with reduced postoperative pain and taste disturbance in some endoscopic series.

4. Anaesthesia choice

   1. Stapes surgery can be performed under either local anaesthesia with sedation or general anaesthesia. Choice depends on surgeon preference, patient anxiety, medical status and local practice. Studies show both options are safe and effective when properly selected.

Can otosclerosis be prevented?

There is currently no proven method to prevent otosclerosis since it is largely genetic and related to abnormal bone metabolism in the otic capsule. Early diagnosis and appropriate treatment, however, can prevent long-term disability from hearing loss.

Preventing surgical complications

Although not all risks can be eliminated, careful planning and meticulous technique reduce complications:

1. Accurate diagnosis and exclusion of other causes of conductive loss (e.g. ossicular discontinuity, SSCD).

2. Choosing an experienced otologist who regularly performs stapes surgery.

3. Selecting appropriate prosthesis type and diameter; modern materials like titanium and nitinol are designed for reliable coupling and long-term stability.

4. Using intraoperative techniques that minimise trauma to the footplate and inner ear (e.g. fine micro-drilling, low-energy lasers, gentle handling of the ossicles).

Postoperative management

Good postoperative care is essential for safe healing and optimal hearing:

1. Ear protection - avoiding nose blowing, heavy lifting, flying, swimming and sudden pressure changes until cleared by the surgeon.

2. Medication - using prescribed pain relief, anti-nausea agents, and sometimes short courses of antibiotics or steroids.

3. Follow-up - typically within 1-2 weeks to remove packing and check wound healing, and again after several weeks for audiometry to assess hearing improvement.

4. Prompt reporting of worrying symptoms such as severe vertigo, sudden profound hearing loss, persistent watery discharge from the ear, intense pain or facial weakness.

Stapes surgery is generally very successful, but both minor and major complications can occur. Overall, serious complications are infrequent, especially in experienced hands.

Intraoperative complications

1. Tympanic membrane (eardrum) tear when elevating the tympanomeatal flap; usually repaired immediately with fascia or gel-foam.

2. Chorda tympani nerve injury leading to taste disturbance or dry mouth; this can happen if the nerve is stretched, cauterised or divided to gain access.

3. Ossicular chain disruption, such as incus dislocation, which may require reconstruction.

4. Floating or fractured footplate, or perilymph gush if the inner ear fluid space is widely opened; these events demand careful sealing of the oval window and may increase the risk of postoperative sensorineural hearing loss.

5. Rare facial nerve injury if the nerve lies in an unusual position or if the bony canal is dehiscent.

Early postoperative complications

1. Transient vertigo and nausea, common for a few days; rarely can persist longer.

2. Taste disturbance and dry mouth, often quite frequent initially (reported in many series, though most cases improve within months).

3. Wound infection or otitis media, uncommon with proper sterile technique and care.

4. Hyperacusis - sounds may seem temporarily too loud or sharp as the brain adjusts to new hearing levels.

Late complications

1. Persistent or recurrent conductive hearing loss due to prosthesis displacement, fibrosis around the oval window, incus erosion or progression of otosclerosis elsewhere in the ossicular chain.

2. Sensorineural hearing loss (SNHL) - the most feared major complication, sometimes called a “dead ear” when profound; fortunately rare (around 1% or less in many modern series), but must be discussed during consent.

3. Reparative granuloma or perilymph fistula, causing delayed vertigo and hearing deterioration, which may require revision surgery.

When problems occur, many can be addressed with revision stapes surgery, though the risks and expected benefits of repeat operations must be weighed carefully.

Hearing outcomes and quality of life

For appropriately selected patients, stapedotomy offers excellent chances of hearing improvement:

1. A large proportion achieve closure of the air-bone gap to within about 10 dB, meaning hearing approaches near-normal levels for everyday communication.

2. Many experience improved sound clarity, better localisation, and less dependence on hearing aids; some may still use aids but at much lower volume, particularly if there is residual sensorineural component.

Patients often report that they can participate more fully in conversations, social events and work meetings, and feel less isolated and fatigued from constantly straining to hear.

Daily life after recovery

Once healing is complete and the ear is cleared:

1. Most individuals can resume normal activities, including work, travel and exercise, with a few common-sense precautions (e.g. protecting the ears from very loud noise, avoiding direct trauma to the ear).

2. For some time, patients may be asked to avoid activities that cause rapid pressure changes (deep diving, forceful nose blowing) to protect the inner ear and prosthesis.

3. Regular audiological check-ups help document hearing stability and detect any deterioration early.

Long-term follow-up and future options

Otosclerosis can progress, and other parts of the ear may change with age, so:

1. Long-term follow-up with an ENT/otologist and audiologist is recommended, especially if hearing changes again.

2. If hearing deteriorates significantly due to prosthesis problems or further otosclerosis, revision stapedotomy/stapedectomy or updated hearing aids can be considered.

3. In very advanced combined hearing loss, some patients may eventually be candidates for implantable hearing devices or cochlear implantation, depending on inner-ear function and overall health.

Emotional and practical aspects

Living with hearing loss, surgery and follow-up can be emotionally demanding. Clear education about what stapedotomy can and cannot achieve, realistic expectations about hearing, and early discussion of alternatives (hearing aids, future revisions, implants) help patients feel informed and in control. Many find that after the initial healing period, the combination of better hearing and reduced dependence on devices significantly improves self-confidence, social interaction and overall quality of life.

1. What is Stapedotomy, and why is it performed?

Stapedotomy is a highly specialized ear surgery performed to treat otosclerosis, a condition in which the stapes bone (one of the tiny bones in the middle ear) becomes fixed and unable to vibrate. This fixation prevents sound waves from transmitting properly to the inner ear, resulting in conductive hearing loss. During a stapedotomy, the surgeon removes a portion of the immobile stapes bone and replaces it with a tiny prosthesis that restores the natural movement of sound vibrations. The goal of the surgery is to improve hearing, reduce symptoms like tinnitus, and enhance the patient's overall communication ability and quality of life.

---

2. What conditions lead to the need for Stapedotomy?

Stapedotomy is most commonly performed for otosclerosis, an abnormal bone growth around the stapes bone. Other conditions that may require this surgery include:

1. Anomalies or malformations of the stapes

2. Previous trauma affecting middle ear bones

3. Fixation of the stapes due to chronic conditions

4. Failed earlier ear surgeries (rare)
   When the stapes bone loses mobility, it prevents sound from reaching the inner ear efficiently, making surgery the most effective long-term solution.

---

3. How is the Stapedotomy procedure performed?

Stapedotomy is usually performed under local anesthesia with sedation or sometimes under general anesthesia. The steps include:

1. Ear canal access: The surgeon works through the ear canal without external incisions.

2. Lifting the eardrum: The eardrum is gently lifted to expose the middle ear bones.

3. Removing part of the stapes bone: A small hole is created in the footplate of the fixed stapes using a laser or microdrill.

4. Inserting a prosthesis: A tiny prosthetic piston is attached to the incus (another middle ear bone) and inserted into the hole created in the stapes footplate.

5. Eardrum repositioning: The eardrum is placed back into position, and the ear canal is packed for healing.

The entire surgery typically takes 45-90 minutes and is usually done on an outpatient basis.

---

4. Is Stapedotomy safe? What are the risks?

Stapedotomy is generally safe and highly successful, but, like all surgeries, it carries some risks. Potential complications include:

1. Taste disturbances due to nerve proximity

2. Dizziness or vertigo, often temporary

3. Tinnitus (ringing in the ears), which may improve or persist

4. Infection in the middle ear

5. Hearing loss, including rare cases of sensorineural hearing loss

6. Failure of the prosthesis or need for revision surgery

7. Perforation of the eardrum
   However, with modern techniques and experienced surgeons, the risk of serious complications is low.

---

5. What is the recovery process like after Stapedotomy?

Recovery is usually smooth, and most patients go home the same day. During the first few days, it is normal to experience:

1. Mild dizziness or imbalance

2. Slight ear fullness or pressure

3. Temporary changes in hearing

4. Mild discomfort in the ear
   Patients should avoid blowing the nose forcefully, heavy lifting, bending, or flying for a few weeks. The ear canal packing is removed within 1-2 weeks, and hearing improvement often begins once healing progresses. Full recovery usually takes 4-6 weeks, although hearing may continue improving over several months.

---

6. How effective is Stapedotomy in improving hearing?

Stapedotomy has a very high success rate, with 80-95% of patients experiencing significant improvement in hearing. Many patients regain near-normal hearing levels, and others experience a meaningful reduction in hearing loss. Improvements are often noticeable early in recovery and continue to refine as the ear heals. In many cases, surgery also reduces symptoms such as tinnitus and enhances sound clarity and communication ability.

---

7. Can the hearing loss return after Stapedotomy?

While Stapedotomy provides long-lasting results, hearing loss can recur in some cases. Possible reasons include:

1. Progressive otosclerosis affecting other areas of the ear

2. Movement or loosening of the prosthesis

3. Age-related hearing loss (presbycusis)

4. Middle ear infections or fluid buildup
   If hearing worsens again, revision stapes surgery or hearing aids may be recommended.

---

8. Are there any activity restrictions after Stapedotomy?

Yes. To protect the healing ear and ensure the prosthesis remains stable, patients should avoid:

1. Strenuous exercise and heavy lifting for several weeks

2. Blowing the nose forcefully

3. Swimming or allowing water into the ear

4. Air travel for 2-4 weeks

5. Exposure to loud noises

6. Sleeping on the operated side initially
   Patients should follow the surgeon's post-operative instructions closely to ensure the best outcomes.

---

9. Will I feel pain during or after the surgery?

Most patients feel little to no pain during surgery because anesthesia keeps them comfortable. After surgery, mild discomfort or pressure in the ear is expected. This is usually managed easily with over-the-counter pain relievers or medication prescribed by the surgeon. Dizziness may occur temporarily but typically resolves within a few days.

---

10. What results can I realistically expect after Stapedotomy?

Most individuals experience outstanding results, including:

1. Improved hearing levels

2. Better sound clarity

3. Reduced dependence on hearing aids

4. Improved speech understanding

5. Higher quality of life and confidence in communication
   However, it is important to understand that results vary depending on the severity of the disease, inner ear health, and overall medical condition. A small percentage of patients may require revision surgery if the prosthesis becomes displaced or if otosclerosis continues to progress.