1. Otosclerosis
DR. RS MEHTA, BPKIHS

2. DR. RS MEHTA, BPKIHS

3. DR. RS MEHTA, BPKIHS

4.  Stapes
becomes immobilized RT
growth of bones or deposition of
new bone over oval window,
causing fixation of the stapes
 Interferences of the transmission
of vibration into the inner ear.
 Chronic ear disease
DR. RS MEHTA, BPKIHS

5. INTRODUCTION
Otosclerosis is a disease of otic capsule in
which new vascular spongy bone formation
causes ankylosis or fixation of the foot plate of
the stapes and progressive conductive deafness.
 Otosclerosis can result in conductive and/or
sensorineural hearing loss. This usually will
begin in one ear but will eventually affect both
ears with a variable course.

DR. RS MEHTA, BPKIHS

6. DR. RS MEHTA, BPKIHS

7. DR. RS MEHTA, BPKIHS

8. DR. RS MEHTA, BPKIHS

9. DR. RS MEHTA, BPKIHS

10. ETIOLOGY
 Exact
cause not known.
 Heredity: Family history of
deafness is present in 50% of cases.
 Sex: females are affected twice as
often as males.
DR. RS MEHTA, BPKIHS

11.  Age
of onset: usually occurs
between 20-30 years of age and
rarely starts before 10 or after 40
years.
 Pregnancy:
Otosclerosis may be
initiated or aggravated by
pregnancy but never caused by it.
DR. RS MEHTA, BPKIHS

12.  Other
factor: Metabolic
disorder, endocrinal, vitamin
deficiency, focal infection etc.
DR. RS MEHTA, BPKIHS

13. TYPES
Stapedial Otosclerosis: it causes stapes
fixation and conductive deafness is common.
Lesion start in “fissula ante fenestram”
 Cochlear Otosclerosis: it involves region of
round window and may cause senso-neural
hearing loss due to liberation of toxic materials.
 Histologic Otosclerosis: remains
asymptomatic and cause neither conductive nor
senso-neural hearing loss.

DR. RS MEHTA, BPKIHS

14. PATHOLOGY






Bony changes vary according to the duration of
diseases
First: the normal bone is absorbed and replaced by
vascular, spongy osteoid tissue and advanced with
blood vessels.
Later: bone become thicker and less vascular
Then: new bone formation takes place at annular
ligament of the oval window fixing the stapes and
leads to conductive deafness.
Spread to footplates of the stapes
Also affect the bony-capsule of the labyrinth, resulting
sensory-neural deafness.MEHTA, BPKIHS
DR. RS

15. SIGNS
 Hearing
loss: progressive deafness
which is painless and is insidious.
 Tinnitus
 Vertigo: uncommon
 Speech: patient has a monotonous,
well modulated soft speech.
DR. RS MEHTA, BPKIHS

16. DIAGNOSIS
 Tuning
fork test revels conductive
deafness.
 Audiometry test
 H/O hearing loss
DR. RS MEHTA, BPKIHS

17. DIFFERENTIAL DIAGNOSIS
It should be differentiated from:
 Serrous otitis media
 Adhesive otitis media
 Tympanosclerosis
 Otitic fixation of head of malleus
 Ossicular discontinuity
DR. RS MEHTA, BPKIHS

18. Management Options
Medical
Amplification
Surgery
Combinations
DR. RS MEHTA, BPKIHS

19. TREATMENT
 Medical:
1.
no medical treatment to cure
otosclerosis.
May use: sodium fluoride in a dose
20 mg BD for 2 years, with calcium ,
arrests the rapid progress of
otosclerosis.
DR. RS MEHTA, BPKIHS

20. Medical
 Sodium
fluoride
 Mechanism
Fluoride
ion replaces hydroxyl group in
bone forming fluorapatite
Resistant to resorption
Increases calcification of new bone
Causes maturation of active foci of
otosclerosis
DR. RS MEHTA, BPKIHS

21. Amplification

Excellent alternative
 Non-surgical
candidates
 Patients who do not desire surgery
Hearing aids conditions:
a. unfit for surgery
b. elderly patients
c. not willing to operation
d. after surgery if not improve deafness
DR. RS MEHTA, BPKIHS

22. Stapedectomy
 Stapedectomy: removal of stapes and
insertion of prosthesis.
 Prosthesis may be a Teflon piston, stainless
steel piston, platinum teflon or titanium
teflon piston.
DR. RS MEHTA, BPKIHS

23. SURGICAL INTERVENTION

Stapedotomy
Less trauma to the oval
window
 Less possibility of
damage to the inner
ear
 In addition, revision
surgery, if required, is
easier due to preserved
anatomy

DR. RS MEHTA, BPKIHS

24. Placement of the Prosthesis
Prosthesis is chosen
and length picked
 Some prefer bucket
handle to
incorporate the
lenticular process of
the incus

DR. RS MEHTA, BPKIHS

25. NURSING CARE








Operated ear: Upside for 24 hrs after OT
Vital sign
Caution in ambulation: as dizziness may occur
Reassure dizziness is temporary
Observe for S/S of bleeding, drainage, N/V
Assess vertigo: quite, rest, sedative
Antibiotic & Analgesic: to control infection &
pain
Observe: Nystagmus or S/S of facial palsy
DR. RS MEHTA, BPKIHS

26. 





Medicated ribbon gauze pack removed after
5-7 days
Decongestentant: dilate Eustachian Tube
Discharge advice:
Avoid water in ear for 2 months, loud noise,
blowing nose and mouth open when
sneezing
Avoid: straining, bending, heavy lifting, and
infection.
Antibiotic full course and as advised.
DR. RS MEHTA, BPKIHS

27. Monitor and report complications
 Facial
nerve palsy
 Giddiness
 Vomiting
 Sensory-neural deafness
 Conductive deafness
DR. RS MEHTA, BPKIHS

28. CONTRAINDICATIONS





The only hearing ear
History of Meniere’s disease
Young children
Professional atheletes, high
constructive workers,
drivers, frequent air
travellers.
Pregnancy
DR. RS MEHTA, BPKIHS

29. SELF CARE AT HOME(POSTOPERATIVE)








Take medicine as prescribed.
Blow nose gently.
Sneeze and cough with mouth open for few weeks
after surgery.
Avoid heavy lifting, straining and bending.
Popping and crackling sensation are normal for 3-5
weeks after surgery.
Temporary hearing loss is normal in operative ear.
Change cotton ball in the ear as needed.
Avoid getting in water for 2 weeks after surgery.
DR. RS MEHTA, BPKIHS

30. THANK YOU
DR. RS MEHTA, BPKIHS

31. Surgical Steps

Subtleties of technique and style
Local vs. general anesthesia
 Stapedectomy vs. partial stapedectomy vs.
stapedotomy
 Laser vs. drill vs. cold instrumentation
 Oval window seals
 Prosthesis

DR. RS MEHTA, BPKIHS

32. Total Stapedectomy

Uses
Extensive fixation of the footplate
 Floating footplate


Disadvantages
Increased post-op vestibular symptoms
 More technically difficult
 Increased potential for prosthesis migration

DR. RS MEHTA, BPKIHS

33. Stapedotomy/Small Fenestra
Less trauma to the vestibule
 Less incidence of prosthesis migration
 Less fixation of prosthesis by scar tissue

DR. RS MEHTA, BPKIHS

34. Drill Fenestration

0.7mm diamond burr



Motion of the burr
removes bone dust
Avoids smoke production
Avoids surrounding heat
production
DR. RS MEHTA, BPKIHS

35. Laser Fenestration

Laser


Avoids manipulation of the footplate
Argon and Potassium titanyl phosphate (KTP/532)





Wave length 500 nm
Visible light
Absorbed by hemoglobin
Surgical and aiming beam
Carbon dioxide (CO2)



10,000 nm
Not in visible light range
Surgical beam only


Requires separate laser for an aiming beam (red helium-neon)
Ill defined fuzzy beam
DR. RS MEHTA, BPKIHS

36. Placement of the Prosthesis


Prosthesis is chosen and
length picked
Some prefer bucket
handle to incorporate the
lenticular process of the
incus
DR. RS MEHTA, BPKIHS

37. COMPLICATIONS OF
SURGERY





Overhanging facial
nerve
Floating footplate
Diffuse obliterative
otosclorosis
Perilymphatics
Guscher
SNHL




Round window
closure
Recurrent CHL
Regenerative
granuloma
Vertigo
DR. RS MEHTA, BPKIHS

38. Oval window seal






Tragal perichondrium
Vein (hand or wrist)
Temporalis fascia
Blood
Fat
Gelfoam (now discouraged)
DR. RS MEHTA, BPKIHS

39. Reconstructing the annular ligament
DR. RS MEHTA, BPKIHS

40. Special Considerations
and Complications in
Stapes Surgery
DR. RS MEHTA, BPKIHS

41. Overhanging Facial Nerve



Usually dehiscent
Consider aborting the procedure
Facial nerve displacement (Perkins, 2001)




Facial nerve is compressed superiorly with No. 24 suction (5
second periods)
10-15 sec delay between compressions
Perkins describes laser stapedotomy while nerve is
compressed
Wire piston used

Add 0.5 to 0.75 mm to accommodate curve around the nerve
DR. RS MEHTA, BPKIHS

42. Floating Footplate

Footplate dislodges from the surrounding
OW niche



Prevention



Incidental finding
More commonly iatrogenic
Laser
Footplate control hole
Management



Abort
H. House favors promontory fenestration and total
stapedectomy
Perkins favors laser fenestration
DR. RS MEHTA, BPKIHS

43. Diffuse Obliterative Otosclerosis



Occurs when the
footplate, annular
ligament, and oval
window niche are
involved
Closure of air-bone gap
< 10 dB less common.
Refixation commonly
occurs
DR. RS MEHTA, BPKIHS

44. Perilymphatic Gusher





Associated with patent cochlear aqueduct
More common on the left
Increased incidence with congenital stapes fixation
Increases risk of SNHL
Management



Rough up the footplate
Rapid placement of the OW seal then the prosthesis
HOB elevated, stool softeners, bed rest, avoid Valsalva, +/lumbar drain
DR. RS MEHTA, BPKIHS

45. Round Window Closure


20%-50% of cases
1% completely
closed

No effect on
hearing unless
100% closed

Opening has a high
rate of SNHL
DR. RS MEHTA, BPKIHS

46. SNHL

1%-3% incidence of profound permanent SNHL


Surgeon experience
Extent of disease



Prior stapes surgery
Temporary



Cochlear
Serous labyrinthitis
Reparative granuloma
Permanent





Suppurative labyrinthitis
Extensive drilling
Basilar membrane breaks
Vascular compromise
Sudden drop in perilymph pressure
DR. RS MEHTA, BPKIHS

47. Reparative Granuloma






Granuloma formation around the prosthesis and incus
2 -3 weeks postop
Initial good hearing results followed by an increase in
the high frequency bone line thresholds
Associated tinnitus and vertigo
Exam – reddish discoloration of the posterior TM
Treatment




ME exploration
Removal of granuloma
Prognosis – return of hearing with early excision
Associated with use of Gelfoam
DR. RS MEHTA, BPKIHS

48. Vertigo


Most commonly short lived (2-3 days)
More prolonged after stapedectomy compared
to stapedotomy


Medialization of the prosthesis into the vestibule


Due to serous labyrinthitis
With or without perilymphatic fistula
Reparative granuloma
DR. RS MEHTA, BPKIHS

49. Recurrent Conductive Hearing Loss

Slippage or displacement of the prosthesis


Most common cause of failure
Immediate



Technique
Trauma
Delayed





Slippage from incus narrowing or erosion
Adherence to edge of OW niche
Stapes re-fixation
Progression of disease with re-obliteration of OW
Malleus or incus ankylosis
DR. RS MEHTA, BPKIHS

50. Amplification

Excellent alternative
Non-surgical candidates
 Patients who do not desire surgery


Patient satisfaction rate lower than that of
successful surgery
Canal occlusion effect
 Amplification not used at night

DR. RS MEHTA, BPKIHS

51. Medical

Bisphosphonates





Class of medications that inhibits bone resorption by
inhibiting osteoclastic activity
Dosing not standard
Often supplement with Vitamin D and Calcium
Studies conducted on otosclerosis patients with neurotologic
symptoms report the majority of patients with subjective
improvement or resolution.
Future application of this treatment unclear, especially with
new reports of bisphosphonate related osteonecrosis.
DR. RS MEHTA, BPKIHS

52. Postoperative
Water
precautions
No valsalva
Postop audio
DR. RS MEHTA, BPKIHS

53. Rare complications



Facial paralysis
Acute otitis media
Cholesteatoma
DR. RS MEHTA, BPKIHS

54. Monitor and report complications
 Facial
nerve palsy
 Giddiness
 Vomiting
 Sensory-neural deafness
 Conductive deafness
DR. RS MEHTA, BPKIHS

55. DR. RS MEHTA, BPKIHS

56. STAPEDOTOMY
DR. RS MEHTA, BPKIHS

57. Thank-You
DR. RS MEHTA, BPKIHS