1.
TYMPANOPLASTY
OSSICULAR CHAIN RECONSTRUCTION
AND
STAPEDECTOMY
PRESENTERS: Dr Frank Nestory
Dr Sylvia Moshi
FACILITATOR: Dr S. Mawalla

2.
OUTLINE:
• Introduction
• Definition of terms
• Applied anatomy
• Tympanic membrane perforation
• Tympanoplasty
• Ossicular chain reconstruction
• Stapedectomy/Stapedotomy
• Controversies
• References

3.
Introduction
Definition of terms
Tympanoplasty- entails grafting of the tympanic membrane with inspection of ossicular chain
with/without reconstruction of the middle ear hearing mechanism.
Ossiculoplasty- reconstruction of hearing ossicular chain using either autologous graft of
prosthesis.
Meatoplasty- Involves enlargement of the lateral cartilaginous portion of the external
auditory canal. A narrow entrance to the ear canal within the cartilaginous portion of the
canal prevents proper ventilation and self-cleaning of the ear canal, and may compromise
hearing aid fitting.
Canalplasty -is partial or total widening of the bony portion of the external ear canal. In
order to visualize the tympanic annulus, particularly in anterior or subtotal perforations,
canalplasty is essential and may be an integral part of myringoplasty or tympanoplasty.

4.
Applied anatomy
External ear
• Outermost part of the ear
• Separated from middle ear by a
tympanic membrane
• Aural components are used in
harvesting grafts: tragus, concha,
&/or perichondrium
• Multiple flaps are raised from the EAC
during tympanoplasty.

5.
Blood supply of the external ear.

6.
Nerve supply of the external ear

7.
Cont…
• Auriculotemporal nerve- innervates the anterior
superior area of the EAC.
• Arnolds nerve -innervates the Posterior inferior area
of the EAC
• Facial nerve –innervates the skin of the mastoid and
posterior wall of the EAC.

8.
Middle ear
• It contains the tympanic cavity,
mastoid ear cells, ear ossicles and
eustachian tube.
• Pressure balance between the middle
ear and outer ear is essential for
sound transmission(vibratory action
of ossicles and tm)

9.
Tympanic membrane

10.
Cont…
• Eustachian tube Ear ossicles

11.
Chorda tympani

12.
ARTERIAL SUPPLY OF THE MIDDLE EAR
1)Two main arteries
a)Anterior tympanic branch of maxillary artery
b)Stylomastoid branch of posterior auricular
artery
2)Four minor arteries
a)Petrosal branch of middle meningeal artery
b)Superior tympanic branch of middle
meningeal artery
c)Branch of artery of pterygoid canal
d)Tympanic branch of internal carotid
VENOUS DRAINAGE
Pterygoid venous plexus
Superior petrosal sinus

13.
Tympanic membrane perforation

14.
Perforation size calculation
Percentage of perforation=
Perforation/Total area of TM x 100%
Where;
• Group-I (Small)-area in range of 0-8mm2
• Group-II (Medium)- area in range of
8.1-30mm2
• Group-III(large)-area in range ≥30.1 mm2
Percentage of perforation=
Area of perforation/Total area of
perforation x100.
Therefore;
• Small (area involved is ≤25% or one
quadrant)
• Medium (area involved is 25% -50%
or two quadrants)
• Large (area involved is 50%-75% or
more than two quadrants)

15.
TYMPANOPLASTY

16.
History of tympanoplasty
1640- BANZER- first to repair perforated TM using pig’s bladder.
1853-TOYNEBEE- used a rubber disc attached to a silver wire over a
perforated TM and improved hearing.
1878-BERTHOLD-First true tympanoplasty was done using a skin graft.
1950-WULLSTEIN & ZOLLNER- Introduced tympanoplasty using skin
graft by overlay technique, wasn’t successful and other alternative of
grafts were introduced.
1958-PLESTER- Introduced canal skin as free overlay graft.

17.
Cont...
1959-GLASSCOCK & SHEEHY- Introduced inlay placement of vein graft,
which was successful but later led to re-perforation.
STORRS- Introduce the use of fascia grafts.it solved all problems of skin
grafts.
1964-NET CHALAT- First to perform Tympanoplasty using homograft.
1968 – Success of homograft have been reported worldwide. (loose
areolar tissue, perichondrium, cartilage, fascia)

18.
Why tympanoplasty?
Achieve a dry, self-cleansing ear while preserving or
restoring hearing.
 Restore middle ear function by eradicating infection and
middle ear pathology.
To re-establish a tympanic membrane that resists infection
and epithelial ingrowth.
 To secure a durable connection between the tympanic
membrane and the inner ear.

19.
Types of tympanoplasty
TYPE OF TPLASTY DEFECT POSITION/CONTACT OF GRAFT
TYPE
I(MYRINGOPLASTY)
Tympanic membrane
perforation
TM or malleus
TYPE II Tympanic membrane
perforation with erosion of
malleus
Incus or remnant of
malleus
TYPE III Malleus and incus absent Stapes superstructure
TYPE IV Stapes superstructure Stapes footplate
TYPE V Stapes footplate fixed Fenestra of horizontal
SCC

20.
Indications of tympanoplasty
 Tympanic membrane perforation of more than 20% of its
total size.
 Chronic infections of the ear unresponsive to antibiotic
therapy.
 High ear trauma due to piercing by a sharp object in the ear,
loud explosive noises, head injury etc.
 Ossicular chain dysfunction.

21.
Types of grafts and selection
• Cartilage: Tragal, concha.
• Perichondrium: Tragal/concha
perichondrium.
• Periosteum: Temporalis muscle
periosteum.
• Fascia: Temporalis fascia.
• Fat: Ear lobule fat pad.
• Autologous fascia: AlloDerm
CRITERIA FOR SELECTION OF GRAFTS.
• Type of approach
• Site/location of perforation.
• Surgeons preference
• Eustachian tube function/retraction
pockets
• Revision surgery

22.
Cartilage technique.
Why cartilage use in tympanoplasty
-If ongoing ET dysfunction
-If ossiculoplasty is done-to avoid
extrusion risk and to augment prosthesis-
tissue interface for good hearing results.
-Atelectatic ear
-Second stage ossiculoplasty
-Structural support for posterior superior
retraction pockets
Fascia and perichondrium need a new vascular supply but
cartilage is supplied by diffusion

23.
Cartilage preparation techniques.
• Perichondria cartilage island technique
• Palisade cartilage technique
• Shield technique
• butterfly technique
• Crown cork technique
Perichondria cartilage island technique –concha cartilage

24.
Concha cartilage preferred.
Indications: Subtotal perforation, adhesive processes eg. retraction pockets, tympanosclerosis,
revisions surgeries.
 It is resistant to barometric changes that occur during diving.
 Restores same auditory function as temporalis fascia.

25.
Indications: Total perforations, severely atelectatic tympanic membranes, and
failures of previous tympanoplasty associated with chronic eustachian tube
dysfunction.
Although the graft take of this technique has been reported to be excellent, there
have been concerns regarding hearing results because it replaces the entire
tympanic membrane with cartilage.

26.
Indications: Small and medium sized
perforations with no middle ear disease or
ossicular involvement.
Sapna et al- Endoscopic Cartilage Butterfly Tympanoplasty2020.
The hearing outcomes and successful closure rate are similar to those of other
surgical methods.

27.
Is a technique for the total reconstruction of the tympanic membrane,
Indications: recommended in cases of ear malformation, blunting-phenomena and
total deficiency of the membrane caused by chronic otitis media.
Autologous tragal composite graft is used.
Crowncork technique

28.
Contraindications of tympanoplasty
• Only hearing ear.
• Active vestibulopathy
• Multiple failed previous ear surgery

29.
Pre operative assessment.
• History -otorrhea
• physical examination-Otomicroscopy.
• Audiological assessment (PTA, Tympanometry).
• Assessment of the contralateral ear.
• CT scan of temporal bone.
• Basic investigation.
• ECG,ECHO

30.
Approaches to middle ear
• Postauricular aproach
• Transcanal aproach
• Endoaural

31.
Equipments and uses
• Suction tubes
• Sicke knife
• Round knife
• Surgical blade #15,11
• Mollison mastoid
retractor
• Freer elevator
• Microcrocodile
forceps

32.
Patient preparation
Pre operative counseling
• Change in hearing capability
• Change in taste
• Facial paralysis,Graft failure
• Post aur numbness,vertigo
Review of previous otological
surgeries
.
Anesthesia
• General anaesthesia
• Local anaesthesia (lignocaine
2%+ Adrenaline +Norma saline)
injected at BC junction of EAC
Patient positioning
• Bed turned 180 degrees with
feet toward anesthesia
• Supine with head turned to the
contralateral side

33.
Myringoplasty technique- Underlay
• Simplest and commonly used
• Suitable for anterior quadrant
perforations.
• Graft is placed medial to the
remnant of TM and medial to the
handle of malleus .
• Perforations involving anteroinferior
quadrant, tympanomeatal flap is
divided posteriorly after it has been
elevated.

34.
Cont…
Advantages
• Simple technique and less time
consuming.
• Less blunting / lateralisation.
• High graft take up rate
Disadvantages
• Less suitable for large anterior
perforation.
• Limited visualization of anterior
meatal recess

35.
Overlay technique
• Graft is placed lateral to the fibrous
layer of the TM.
Advantages
I. Good exposure of anterior meatal
recess.
Disadvantages
I. Long healing time required
II. Presence of blunting/Lateralization

36.
Inlay technique
• Graft is placed between inner endothelial
layer and middle fibrous layer of the
tympanic membrane.
• Getting an interplay plane between fibrous
layer and mucosa is easier and faster.
Advantages
No risk of lateralization or medialization
Disadvantages
Time consuming
Requires addition skills used by experienced
surgeons

37.
Surgical steps
POST AURICULAR APROACH
Favors anterior perforations.
Allows one to do a circumferential
canalplasty.
• Cleaning the middle and ear canal.
• Lempet's speculum/Nasal speculum is
used to visualize the BC junction to
inject the 4 quadrants of the skin of the
ear canal.
• Local infiltration of the tissues is done
anteroinferiorly and anterosuperiorly
and post auricular region.

38.
Cont..
• Post auricular incision(1-2cm from
the post auricular sulcus.
• Skin elevation while retracting the
auricle anteriorly to reach the
temporalis fascia.
• Periosteal flap is developed, vertical
incision is made with the superior
incision extended anteriorly along
linear temporalis up to 12 oclock
relative to bony ear canal to harvest
the graft.

39.
Cont..
• Musculoperiosteal (MPF) flap is
elevated 2mm deep to the lateral
edge of bony canal at 12 oclock
exposing the Spine of Henlé.
• The auricle and MPF are retracted
anteriorly using a retractor.

40.
Cont..
• EAC is entered via transverse incision
at 8oclock extending to 12 oclock and
the lumen of the canal comes into
view.
• Further incision is made from 2oclock
to 12 oclock and 5 oclock to meet
2oclock incision.(right ear)

41.
Cont..
• Freshening of margins of a
perforation using a sickle knife.
• Removing the area of
tympanosclerosis.
• Assessment of the ossicular chain.
• Assessment of the Eustachian tube.

42.
Cont…
• Meatal skin flap (Tympanomeatal) is
circumferentially elevated from the bone.
• Meatal skin is transected to 6oclock using a
round knife at 2mm lateral to the annulus and
the flap is elevated.
• Canalplasty can be done.
• Precautions to be taken here.

43.
Cont..
• Gelfom to be placed medial and
lateral to the graft to bolster
it(soaked in ciprofloxacin ear drops)
• In tympanoplasty type one, the graft
in placed in either technique (inlay,
overlay or underlay)
• The graft is connected to the malleus.
• In tympanoplasty type two and above
the ossicular chain is reconstructed.

44.
TRANSCANAL APROACH
• Indicated in traumatic perforations or in cases where there is a wide ear canal
with a posterior perforation.
• Done microscopically or endoscopically .
• The ear canal must be wide enough, and one should be able to visualize the
entire margins of the perforation.
• The anterior margin of an anterior perforation may be obscured by an
overhanging canal wall

45.
ENDOAURAL APPROACH
• Better for posterior perforation.
• An incision between the tragus and
helix; the entrance to the ear canal is
then stretched open with end aural
retractors.
• Infiltration of local anesthesia in four
quadrants.

46.
• A skin incision from 12 o’clock position, spiraling upwards
between the cartilages of the helix of the pinna and tragus.
The incision is 1,5cm in length and extends down to the
bone.
• Another skin incision is made in the posterior aspect of the
bony EAC parallel to the annulus, starting at 8 o’clock and
ascending in a spiral fashion to meet the endaural incision at
12 o’clock.
• Skin and soft tissue is then reflected laterally and away from
the edges of the tympanomeatal flap.

47.
Cont…
•An incision is made anteriorly in the bony canal skin, parallel to
the annulus and remaining medial to the cartilage of the ear
canal. It starts at 2 o’clock and meets the endaural skin incision
at 12 o’clock
•Retractors will then be placed in the canal to improve
exposure
•Before tympanomeatal flap elevation Edges of perforations are
freshened using sickled knife

48.
Cont…
• The tympanomeatal flap is returned to its original
position and gelfoam pledgets are placed over the
graft to secure it over the posterior tympanic sulcus
followed by the closure of endaural skin incision.

49.
Cont..
• In case of tympanoplasty 2 and above,
Ossicular chain reconstruction is done.
• Austins classification of ossiculoplasty
• Based of the status of malleus and
stapes.
Materials used; Cartilage, teeth,
autograft or homograft and cortical
bone.
TYPE STATUS OF OSSICLE
A M+,S+
B M-,S+
C M+,S-
D M-,S-
E OSSICULAR HEAD FIXATION
F STAPES FIXATION

50.
Ossiculoplasty
TYPES OF OSSICULOPLASTY
• Primary- ossiculoplasty done with
mastoidectomy at the same sitting.
• Secondary- staged
ossiculoplasty.mastoidectomy first, 6-
12month after, ossiculoplasty can be
done.
TECHNIQUE OF OSSICULOLASTY
1.Partial OCR (POCR)- When malleus
and stapes are mobile, stapes mobile
but malleus fixed(aims to connect
TM/Handle of malleus to stapes.
2.Total OCR (TOCR)-Total ossicular
replacement prosthesis connected to
the stapes or open vestibule.

51.
Cont..
PROSTHESIS FOR OSSICULOPLASTY
• Bone cement
• Titanium
• Perichondrium

52.
Cont…

53.
Cont…
PLACEMENT OF PROSTHESIS
•Prosthesis should be in minimal/slight tension and at a
favorable angle.
•The prosthesis should fit perfectly without tension before
cartilage.
•Middle ear filled with packs before placement of prosthesis

54.
Complications of tympanoplasty
• Worsening of hearing loss
• Vertigo
• Loss of taste
• Graft failure/re-perforation.
• Cholesteatoma formation
• TM lateralization

55.
CONTROVERSIES
• Partial vs Full thickness cartilage-perichondrium.
• Post operative mastoid pressure dressing vs post
auricular simple dressing.
• Tympanoplasty in total dry ear vs wet ear in term of
failure rate.

56.
STAPES SURGERY

57.
History of stapes surgery
1704- Valsava’s first description of hearing loss due to stapes fixation
1878- Kissel, founder of stapes surgery –mobilization of stapes then
removed stapes footplate
1888- Boucheron reported 60 mobilizations with best-early ankylosis
1890- Miot- 200 mobilizations with improved bone conduction
1892- Blake coined “stapedectomy”
1893- Jack reported series of cases of extraction of stapes
Early attempts at stapes mobilization were fraught with complications,
including fatal labyrinthitis, and provided hearing gain for only days.

58.
Cont..
1899 – The 6th International Otology Congress declared stapes surgery
useless, dangerous, and unethical thus ending further work on stapes
mobilization procedures.
1920- Holmgren “father of fenestration”
accidental fenestration in the lateral scc
1930 - Soudrile –modification with 3 stage fenestration operation
1938- Lempert – popularized single stage procedure.

59.
Cont…
1950 – current era of stapedectomy when he created the first stapes
prosthesis from Teflon
 1980-81- Rob perkins- first laser stapedotomy

60.
Stapedectomy
Definition: Restoration of the impedance transfer of the ossicular chain
and the acoustic impedance of the annular ligament of the stapes
footplate in order to achieve normal physiologic vibration of the inner
ear fluid.
Goals:
• Open the oval window for sound transmission
• Reconstruct sound conducting mechanism without complication

61.
Biophysics of stapes surgery
• Middle ear acts as impedance transformer
It converts the incoming vibrations from
large low impedance T.M to much small, high impedance
oval window.
This allows 60% of sound energy to dissipate in
inner ear

62.
Cont..
The most important factor in the middle ear’s impedance matching are:
• Area of tympanic membrane relative to oval window.
• The lever action of the middle ear ossicles.
• The shape the tympanic membrane
The combined effects of the area ratio and
the lever ratio give the middle ear output
a 28-dB gain.

63.
Cont…
Acoustic impedance of annular ligament
Resistance
Mass
Rigidity and elasticity

64.
Indications for stapedectomy/stapedotomy
• Conductive hearing loss due to stapes fixation with an air–bone gap
greater than 30 dB & good speech discrimination (SDS 60% or more)
• Stapes malformations (monolateral stable conductive hearing loss
associated with a suggestive CT scan for a stapes malformation).
The ear with poorer hearing, based on the patient’s report rather than
audiography, should undergo the operation first.
In bilateral cases, the second ear can be operated on 6 months later,
assuming this is now the poorer-hearing ear.

65.
Contraindications
• Poor general condition of the patient.
General medical illness
Extreme of age(70 yrs) :sd score becoming worse in 40%of cases , risk of fistula is more
Pregnancy- delayed untill 12 months post delivery
• Physical strain –sports men risk of perilymph fistula is high.
• Otitis externa/tm perforation
• Unilateral otosclerosis
• The affected ear being the only hearing ear.
• Poor cochlear reserve as shown by poor speech discrimination scores
• The patient having untreatable tinnitus and vertigo.
• Presence of active otosclerotic foci (otospongiosis) as evidenced by a
positive flamingo sign(shwartze sign)
• Conductive deafness from other causes other than stapes fixation eg due
to Ehlers–Danlos syndrome, otosclerosis.

66.
Preoperative evaluation
• Good history and physical examination.
• Otoscopy
• Preoperative binocular microscopy should be performed and with
inspection of the tympanic membrane to rule out evidence of
atelectasis or cholesteatoma/myringosclerosis can point towards
fixation of any of the ossicles.
• Tuning fork testing

67.
• Audiometry. Pure tone thresholds and speech audiometry.
A Carhart notch, decreased bone conduction threshold at 2000 Hz, is typical and
is indicative of otosclerosis
• Tympanometry. A subtype S.

68.
Stapedial reflex
• Two distinct patterns of abnormal stapedial
reflexes are seen in otosclerosis.
• If footplate mobility has decreased but it is not
yet completely fixed, nearly all patients will
show a biphasic response the so called “on –
off effect”
• If stapes is firmly fixed no reflexes can be
elicited from the affected ear.

69.
Preoperative imaging
• Temporal bone CT scan.
Preoperative analysis of oval window width and facial promontory
angle to predict operative difficulty.
Identifying anatomical variants (ie, dysplasia of the IAC or cochlea
consistent with X linked gusher) that could pose problems during
surgery or for possible factors that could explain surgical failure in
revision operations.

70.
Equipments.
• Necessary equipment for stapedectomy includes a full set of middle-ear
instruments with multiple sizes of otologic specula.
• Various blades, eg sickle knife and round knife.
• Microscope vs endoscope use=Similar hearing outcomes
Ianella et al 2016-Endoscopic Versus Microscopic Approach in Stapes Surgery
Huner et al –outcome of endoscopic stapes surgery.
Challenges in endoscopic surgery include instrument limitation, single-
handed work, lack of stereoscopic view, and a potentially high surgeon
learning curve.

71.
Cont..
• Creating the fenestration in the stapes footplate
Skeeter drill or microdrill vs use of laser = no difference in drop of bone
conduction thresholds.
 Cuda et al 2009- Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative study.
Somers et al 2006- Stapedotomy with microdrill or carbon dioxide laser: influence on inner
ear function.
Laser- Advantage: Drop in bone conduction thresholds from sensorineural hearing
loss at high frequencies due to acoustic trauma at the basal turn.
KTP and argon laser vs co2 laser = CO2 laser.
Due to its high reflectance off of the perilymph, versus the KTP and argon laser,
which have lower wavelengths allowing greater penetration into the perilymph and
potentially greater energy absorption by the pigmented tissues of the membranous
labyrinth in the line of laser fire at the base of the vestibule(saccule).

72.
Cont..
• Facial nerve monitoring
If general anesthesia is used.
Use of the facial nerve monitor does not
eliminate the risk of facial nerve injury
during stapedectomy.
The monitor can provide the surgeon with feedback while
microdissection in the area of the facial nerve is performed, allowing
the surgeon to modify technique to minimize risk of injury to the
nerve.

73.
Cont…
• Types of prostheses
Categorized as either hooked or handled prostheses.
Materials evolved from Teflon, metal, to plastic, and most recently to gold
and titanium.
Initially the diameter of the pistons used was 0.8 and 0.6 mm, recently
smaller dm are used in order to ease the procedure and reduce the risk of
inner ear damage.
Improvement in the way the prosthesis is fixed to the long incus process,
resulting in different solutions like Teflon memory effect, platinum and gold
band, titanium-gold clip prostheses or nickel-titanium alloy.

74.
Patient Preparation
• Anesthesia
Either local monitored anesthesia care (MAC) or general anesthesia.
Long-acting paralytics are not recommended owing to the inability to
monitor facial nerve function.
Local anesthetic of choice is used in incisions to be made depending
on approach eg planned posterior canal skin incision area,
anterior to the helical crus area .

75.
• Positioning
The patient is placed in the supine position on the operating table with
the head turned to the opposite side from the operative ear, to about
30–45°.

76.
Patient preparation.
• Preparation and draping of patient.
• Povidone-iodine solution irrigated out of the ear canal using warm saline.
• Examination of TM
-Perforations
-Sclerosis

77.
Stapedectomy vs Stapedotomy
• Stapedectomy
Complete removal of the posterior and
anterior portions of the footplate leaving
the membrane below the footplate intact.
This is accomplished with various
instruments angled appropriately to
allow removal of the bone with
preservation of the underlying
membrane.
Recently reserved only for select cases.
• Stapedotomy
Creation of fenestration in the
footplate using laser once the stapes
superstructure has been removed.

78.
Approaches to middle ear
• Endomeatal (Transcanal or
Transmeatal) Approach
Rosen incision (Endomeatal approach)
• Endaural Approach (Lempert or
Heerman incision)

79.
Flap elevation
ct, chorda tympani; in, incus; an, anulus; eac, external ear canal.

80.
Displacement of the chorda tympani
ct-chorda tympani; in, incus; ma, malleus; s, stapes; dr, eardrum; rw, round window.

81.
Exposure of incudostapedial joint
a-b: Curettage of the external
auditory canal with a bone
curette.
.
c–d: Exploration of the tympanic
cleft
ct, chorda tympani; in, incus; ma, malleus; s, stapes; dr, eardrum; pe, pyramidal eminence; cp, cochleariform process.

82.
Establishment of anatomical landmarks.
ct, chorda tympani; in, incus; ma, malleus; s, stapes; rw, round window; pe, pyramidal eminence; cp, cochleariform process;

83.
Types of surgical procedure.
• Traditional stapedotomy/stapedectomy without preservation of the
stapedial tendon
• Stapedotomy with preservation of stapedial tendon.
When the anatomical conditions are favorable (wide and not too deep oval
window niche, wide space between the facial nerve and the crura of the stapes)
In order to respect the vascular supply of the long process of the incus.

84.
..without preservation of stapedial joint
• The stapedial tendon is divided with small curved scissors. The stapes
superstructure is down fractured with delicate force (or with a small drill or a
laser) and removed, leaving the footplate.

85.
Stapes removal
a Disarticulation of the
stapes.
b Removal of the stapes.
c Drilling of the footplate.
d The footplate
visualized after drilling

86.
• Drilling fenestration techniques.
• Fisch technique
• Marquets’ microhook technique

87.
Prosthesis placement
Piston placement.
a Endoscopic view of the oval
window after stapedotomy.
b–d Placement of the piston is
carried out with a hook.

88.
Cont..
a-b Placement of the
piston on the incus.
c, d The piston is secured
by tightening the
platinum hook

89.
Tympanomeatal flap replacement
The tympanomeatal flap is repositioned and sealed with antibiotic ointment or Gelfoam
treated with antibiotic solution.

90.
Stapedectomy vs stapedotomy

91.
Cont …

92.
Precautions.
• Excessive heat dissipation, since endoscopes tend to transfer heat from the
light source.
• Suctioning of perilymphatic fluid is avoided to minimize postoperative
vertigo and cochlear damage.
• Tip of the endoscope can potentially be very hot.
• Accidental movement of the endoscope and secondary direct trauma from
the tip of the instrument particularly to the EAC, to avoid causing
unnecessary bleeding or damage to the ossicular chain, eardrum, and facial
nerve.

93.
Surgical challenges
• Narrow ear canal
• Fixed incus/malleus
• Dehiscent/prolapsed facial nerve (0.5%)
• Floating footplate
• Obliterative otospongiosis
• Biscuit footplate
• Perlymph gusher (0.03-0.3%)
• Persistent stapedal artery
• Adhesions in oval window niche

94.
Post op care and follow up
• Analgesics
• Antipyretics
• Antiemetics
• Avoid straining

95.
Complications
• Complications during TM flap elevation
Ear drum perforation
Facial nerve palsy
Chorda tympani injury
Incus laxation (anterior/posterior/lateral)
• Complications during removal of stapes
Snhl
Floating footplate

96.
Cont…
• Complications after stapedectomy
Reparative granuloma
Perilymph fistula
Delayed snhl
Delayed fn palsy
Cholesteatoma
Labyrinthitis / meningitis

97.
Cont..
• Conductive hearing loss after stapedotomy
Mechanism:
Erosion of incus causing looseningof wire loop
Collagen tissue seal contracts
Prosthesis lifts out of stapedotomy/migrates to the fixed stapes footplate

98.
• Surgical technique of stapedectomy
• 1. total stapedectomy
• Partial stapedectomy

99.
• https://reference.medscape.com/viewpublication/11498
• Outcomes Following Endoscopic Stapes Surgery. Otolaryngol Clin
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• Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative
study. Otol Neurotol. 2009; 30(8):1111-5 (ISSN: 1537-4505)
Cuda D; Murri A; Mochi P; Solenghi T; Tinelli N
Stapedotomy with microdrill or carbon dioxide laser: influence on inner
ear function.Ann Otol Rhinol Laryngol. 2006; 115(12):880-5; discussion
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