Stapedectomy

A stapedectomy is a microsurgery in the middle ear. The operation is performed with the aim of restoring the physiological mechanism of sound transmission by completely or partially removing the stapes. In the future, stirrup plastic is performed. [1]

The stapedectomy procedure was first performed in 1892, when Frederick L. Jack performed a double stapedectomy on a patient reportedly still having hearing ten years after the procedure. [2] John Shi recognized the importance of this procedure in the early 1950s and proposed the idea of using a prosthesis that mimics the stapes. On May 1, 1956, John J. Shea performed the first stapedectomy with a Teflon stapes prosthesis on a patient with otosclerosis with complete success. [3]

Indications for the procedure

The purpose of any stirrup placement procedure is to restore the vibration of the fluids inside the cochlea; enhancing communication secondary to increasing sound amplification, bringing the audibility level to an acceptable threshold. [4], [5]

When the stirrup becomes motionless, the person loses the ability to hear. This usually happens for two reasons:

• congenital defect;
• an anomaly of the temporal bone associated with excessive mineralization (otosclerosis). [6]

Stapedectomy is especially often indicated for the treatment of patients with otosclerosis. [7]

In general, the indications for stapedectomy may be as follows:

• conductive hearing loss due to immobility of the stirrup;
• the discrepancy between bone and air conduction of sound is more than 40 decibels. [8]

Preparation

Before performing stapedectomy, the patient must go through the necessary stages of diagnosis - to find out the degree of auditory disorder, to exclude contraindications, and also to select the optimal type of surgical intervention. Otolaryngologist give referrals for consultation from other specialists such as a neurologist, endocrinologist, etc. [9]

Before the operation, an external otoscopic examination is required, as well as other types of examination:

• hearing measurement using audiometry;
• tuning fork research;
• tympanometry;
• assessment of spatial auditory function;
• acoustic reflexometry.

If otosclerotic changes are suspected in a patient, then an X-ray and a computed tomogram are additionally performed, thanks to which it is possible to determine the scale and exact localization of the pathological focus.

Immediately before the operation, the patient must provide the results of mandatory examinations:

• fluorographic picture;
• information about belonging to a certain blood group and Rh factor;
• results of general analysis and blood biochemistry;
• the results of the analysis for the quality of blood clotting and glucose content;
• general urine analysis.

Technique stapedectomy

A stapedectomy is performed using general anesthesia.

During the operation, the surgeon inserts a miniature visualizer - a microscope, as well as microsurgical instruments into the auditory canal. Along the border of the tympanic membrane, an incision is made in a circle, the cut tissue flap is lifted. The doctor removes the stirrup and replaces it with a plastic bone implant. After connecting the auditory ossicles, the tissue flap returns to its place, tamponade the auditory canal using antibiotics. [10]

You can perform stapedectomy in another way: the surgeon makes an incision in the area of the patient's earlobe, removes the necessary element of adipose tissue from this area. Subsequently, it is placed in the middle ear to speed up engraftment.

Stapedectomy with stapedoplasty

There are several methods for performing stapedectomy with stapedoplasty, so it is optimal to choose a clinical institution whose specialists use different options for intervention - to select the most suitable one on an individual basis. This operation as a whole is a stirrup prosthetics: first, the implant is placed in relation to the most damaged ear, and after about six months the stapedoplasty is repeated, but on the other side.

The most widespread is the so-called piston stapedoplasty. This operation does not imply significant damage to the vestibule of the inner ear, so there is no risk of damage to nearby tissues.

Before installing the implant, the window is cleaned of mucous membranes and tissues damaged by sclerosis. This is not always necessary, but only when it is difficult for the surgeon to see the operated area.

With the help of a laser device, the doctor makes a hole, inserts an implant into it, strengthening it in its natural seat - this is a long anvil leg. The prognosis of the operation will be better if the surgeon makes the hole as small as possible: in this case, the tissues will tighten faster, and the rehabilitation period will be much easier and shorter.

Most often, stapedectomy and stapedoplasty are performed using a Teflon-cartilage implant. Loop elements are cut from the finished Teflon analogue, after which cartilaginous plates removed from the ear shell are inserted into the holes.

When using a cartilaginous autoprosthesis, engraftment and restoration is faster and cheaper.

Contraindications to the procedure

Stapedectomy will not be performed if the patient has certain contraindications:

• states of decompensation, severe illness of the patient;
• hearing problem in only one ear;
• small functional snail reserve;
• sensation of ringing and noise in the ears, dizziness;
• active otosclerotic zones. 
• if the patient has ongoing balance problems, such as concomitant Meniere's disease with a hearing loss of 45 dB or more at 500 Hz and loss of high pitch. [11]

Consequences after the procedure

Stapedectomy can effectively treat significant conductive hearing loss associated with otosclerosis by reconstructing the sound-conducting mechanism of the middle ear. [12] Success rates for these procedures are usually assessed by observing the patient's air gap closure (ABG) rate on audiometric evaluation.

For several days after the stapedectomy operation, the patient may complain of slight discomfort and pain. This condition will continue until the tissues are relatively healed: to make you feel better, the doctor may prescribe pain relievers.

A slight noise in the ear is considered normal. It may appear already during stapedectomy and is present before the implant engraftment, but most often disappears within about 1-2 weeks. If there is a strong growing noise, then it is recommended to consult a doctor: most likely, you will have to repeat stapedectomy. [13], [14]

Among other short-term effects, the patient may note:

• slight nausea;
• slight dizziness;
• slight pain in the ear when swallowing.

Complications are rare, in less than 10% of cases, and appear about a month after stapedectomy. As a rule, the occurrence of complications indicates the need for reoperation or drug therapy.

Complications after the procedure

Most often, stapedectomy takes place without any difficulties, but in some cases, exceptions to the rules are possible. Among the relatively frequent complications, the most famous are:

• perforation of the membrane due to a sharp jump in pressure in the middle ear cavity;
• fistula formation in the oval window when the implant moves away from the middle ear bone;
• necrosis of tissues (possible when using an artificial implant with synthetic components);
• unilateral facial paralysis on the affected side, associated with damage to the branches of the facial nerve;
• postoperative dizziness;
• displacement of the implant (sometimes it happens when installing Teflon elements);
• nausea, up to vomiting;
• the outflow of cerebrospinal fluid from the ear canal;
• mechanical damage to the labyrinth;
• inflammation of the labyrinth.

With the development of severe complications, when inflammation spreads to the tissues of the brain and spinal cord, meningitis may develop. The patient is admitted to a hospital where emergency antibiotic therapy is performed. [15]

Care after the procedure

After stapedectomy, the patient continues to be in the hospital under the supervision of doctors for four or five days.

Perhaps the introduction of antibacterial agents, analgesics, non-steroidal anti-inflammatory drugs.

Do not blow your nose or inhale sharply through your nose. This is due to the following factors:

• the openings of the Eustachian tubes go to the posterior surface of the nasopharynx;
• these tubes connect the nasopharyngeal cavity and the middle ear and promote even pressure between these structures;
• Sharp fluctuations in the air in the nasopharynx lead to an increase in pressure and motor activity of the membrane, which can cause displacement of the tissue flap and impair the healing process.

Approximately ten days after discharge, the patient should visit the attending physician for a follow-up examination. Measurements of auditory function demonstrate the effectiveness of stapedectomy. In many patients, there is a reduction in the bone-air run, and the threshold of sound perception decreases.

It is recommended to measure the auditory function immediately before the patient is discharged from the hospital, then after four, twelve weeks, six months and one year after the stapedectomy operation.

Additional safety measures that should be followed by the operated patient after stapedectomy:

• do not wear headphones to listen to music;
• avoid physical overload, sudden movements;
• avoid carrying heavy objects;
• do not smoke, do not drink alcohol;
• do not allow water to enter the affected ear;
• do not swim, do not take a bath or go to the bathhouse for 6 weeks after stapedectomy;
• do not dive (for most patients, this restriction remains for life);
• women who have operated on are not advised to become pregnant within 1-2 months after the procedure.

Reviews about the operation

Surgical intervention in the form of stapedectomy in 90% of cases is completed successfully, no complications arise. Surgeons warn that the most favorable and rapid healing is observed when the autoimplant is installed. Artificial implants sometimes do not take root well, which causes rejection and necrosis.

The quality of restoration of auditory function varies, and it depends on a whole host of different factors:

• individual characteristics of patients;
• quality of the implant;
• operating doctor qualification;
• the presence of conditions necessary for healing.

In the vast majority of operated patients, hearing function improves within the first 3-4 weeks. Significant recovery is observed within three or four months after the intervention.

If all the doctor's recommendations are followed, for the majority of patients, stapedectomy ends favorably, the quality of hearing increases.