This document discusses complications of stapes surgery. It begins with an overview of causes of stapes fixation like otosclerosis and tympanosclerosis. It then describes different procedures for stapes surgery like stapedectomy, stapedotomy, and STAMP. Potential intraoperative hazards are outlined such as exostosis, TM perforation, facial nerve dehiscence. Postoperative complications are also summarized, including conductive hearing loss, sensorineural hearing loss, perilymphatic fistula, reparative granuloma, and vertigo. Recommendations are provided for prevention and management of complications.

1. COMPLICATIONS OF STAPES SURGRY
Dr. Mamoon Ameen

2. ANATOMY

3. ANATOMY

4. CAUSES OF STAPES FIXATION
• Otosclerosis
≥ 95% of stapes surgery
• Congenital stapes fixation
Hearing outcomes worse with stapes surgery compared to otosclerosis
• Tympanosclerosis
can also result in stapes immobility by filling the oval window niche with
tympanosclerotic plaques
Mobilization through plaque removal –vs- stapedotomy

5. OTOSCLEROSIS
• Otosclerosis
Localized hereditary disorder affecting enchondral bone of
the otic capsule that is characterized by disordered
resorption and deposition of bone
• Types of Otosclerosis
Stapedial
Cochlear
Mixed

6. TYPES OF STAPEDIAL OTOSCLEROSIS
1. Anterior focus (commonest): 2 mm anterior to oval window.
2. Posterior focus: 2 mm behind oval window.
3. Circumferential: involves footplate margin only.

7. TYPES OF STAPEDIAL OTOSCLEROSIS
4. Biscuit type: footplate involved, margin is free.
5. Obliterative: obliterates oval window completely

8. STAPES SURGERY
Stapedectomy Stapedotomy STAMP (STApedotomy Minus
Prosthesis) or Stapedioplasty

9. STAPEDECTOMY
• Results probably are the best
• More traumatic to the inner ear
• Increased post-op vestibular symptoms
• Higher incidence of postoperative
SNHL
• The operation is unavoidable in:
• Comminuted fracture of the footplate
• Revision surgery

10. STAPEDOTOMY
• Equal or better results with less vestibulocochlear side effects

11. STAMP
• Preservation of the stapedius tendon
• Reduction in hyperacusis
• Reduction in risk for long-term postoperative inner ear
injuries
• No prosthesis complications
• Very difficult technique

12. STAPES SURGERY
Local anesthesia
 Patient’s hearing can be tested
 Patient can report vertigo and dysequilibrium
 Postoperative nausea is avoided
 Potential exposure to pressures is avoided

13. STAPES SURGERY
General anesthesia
 Generally preferred
 Complications or difficulties can be managed easily
 Motionless operative field

14. SURGICAL TECHNIQUE
• Permeatal approach: Endaural appraoch:

16. • Confirm footplate fixation
• Checking for absence of
round window reflex

17. Assessment
• Gentle palpation of stapes suprastructure
• Other causes of hearing impairment: tympanosclerosis
• Palpation of malleus: fixation of head, anterior ligament and malleoincudal joint
• Anatomical anomalies: persistent stapedial artery, overhanging facial nerve

20. Prosthesis placed over graft

24. PERIOPERATIVE HAZARDS

25. Exostosis
Small :removed after elevation of TM
flap
Large :
• Require canaloplasty
• stapedotomy done as staged procedure

26. TM perforation
• Reported in 2% of cases
• usually occurs during elevation of the tympanic membrane from the sulcus in the
posteroinferior area
• Small tear :reapproximated by advancing the tympanomeatal flap
when it is returned to its anatomical position
• Large perforation :underlay myringoplasty

27. Malleus and Incus Fixation
• Mobility should be checked in every case
• May be responsible for failure to close the air bone gap postoperatively.
• Usually associated with stapes fixation but it can be isolated.
Abort the surgery and use hearing aid.
Remove incus and head of malleus and do ossicular reconstruction.

28. Dehiscent and overhanging facial neve
• Occurs ~9% of stapes procedures
• Consider aborting the procedure
• It may rarely herniate down over the oval window
• Prosthesis touching facial nerve generally does not
create problem
• May displace nerve superiorly while performing
stapedotomy
• The facial nerve canal may also overhang the
footplate limiting surgical access

29. Persistent Stapedial Artery and Vascular
Anomalies
• Rarely, a persistent stapedial artery is encountered
running through the arch of the stapes
• If small, fine bipolar cautery or laser coagulation may be
used to remove the vessel from the field
• If larger artery - stop the procedure and prescribe
amplification.
• less commonly, an aberrant carotid is seen

30. FLOATING OR SUBMERGED FOOTPLATE
• During an attempt to fracture the crura the footplate may become
• Mobile
It is best to terminate the procedure
• Totally submerged
No effort should be made to retrieve it.
Graft should be placed over the oval window
• partially submerged
May be removed or retrieved using hooks
• Suction of the perilymph must be minimized

31. Obliterative Otosclerosis 3-11%
• Occurs when the footplate, annular ligament, and
oval window niche are involved.
• Fenestra created with microdrill
• Closure of air-bone gap < 10 dB less common.
• Refixation commonly occurs

32. Perilymph Gusher
( profuse flow of perilymph immediately upon opening
vestibule)
• Rare – 0.03% incidence
• Associated with congenital footplate fixation
• Possibly due to:
Wide cochlear aqueduct
Defect in IAC fundus

33. Management
• Tissue graft over oval window
• Complete procedure if possible
• Consider lumbar drain and packing of middle
ear if severe
• Keep head elevated

34. • Intraoperative vertigo
Causes
• Prosthesis too long
• Checking prosthesis mobility
Management
• Shorter prosthesis (try 0.25mm shorter
piston)

35. POSTOPERATIVE COMPLICATIONS

36. Conductive hearing loss
1-displacement of prosthesis
• short prosthesis by Valsalva or sneezing
• contracture of connective tissue seal over the fenestration (the thicker the
oval window sealant, the greater the lateralization of the prosthesis)
• Traction from adhesions between the prosthesis and adjacent structures
appears capable of displacing a prosthesis

39. • 2-incus erosion(causes loosening of the attachment of the prosthesis and a conductive
hearing impairment)
• 3-bony regrowth over the fenestration (more common in cases that initially
demonstrated obliterative otosclerosis)

40. Sensorineural hearing loss < 1%
• Most devastating complication of stapes surgery
• May occur perioperatively or years after surgery
• More common in stapedectomies and revision surgeries
• Perioperative causes:
 Extensive drilling associated with obliterative otosclerosis
 Floating footplate and perilymph aspiration
 Congenital footplate fixation and CSF gusher

41. • Delayed damage:
• Barotrauma from air travel or blast injury
• Reparative granuloma
• Perilymph fistula
• Suppurative labyrinthitis

42. Perilymphatic Fistula
• 0.25-2.5% following stapedectomy
• 1.5- 12% following revision surgery
Presents with:
• fluctuating hearing loss
• Vertigo
• Tinnitus
• sense of fullness in the ear

43. Perilymphatic Fistula
• Use of gelatin to seal stapedotomy is biggest risk factor
• Positive fistula test present in 2-3rd of cases
Management
• Remove prosthesis carefully → tissue seal the oval
window → prosthesis replaced

44. Post operative instruction
• 1. Avoid trauma to the head.
• 2. Cough and sneeze with the mouth wide open.
• 3. Do not strain against a closed glottis.
• 4. Avoid the possibility of barotrauma for at least a month.
• 5. Avoid lifting heavy weights.
• 6. Report immediately if symptoms like vertigo, tinnitus, or hearing loss manifest
themselves.

45. Reparative Granuloma
• Granulation tissue formation around a stapes prosthesis and the oval window which may extend
into the vestibule
• Stepedectomy _0.1% Stapedotomy _0.07%
• More common when Gelfoam or fat are used
Patient presentation
• Initial hearing improvement followed by
• gradual/sudden deterioration over 1 to 6 weeks
• Occasional vertigo
• Reddish discoloration in posterosuperior quadrant

46. Management
• ME exploration
• Removal of granulation
• Steroids and antibiotic

47. Vertigo
• More common with stapedectomy than stapedotomy
Due to serous labyrinthits
• Occurs ~5% of cases
• Rarely prolonged or severe
• Usually lasts a few hours to one week
• Supportive management

48. If persist
• Medialization of the prosthesis into the
vestibule
• With or without perilymphatic fistula
• Reparative granuloma

49. Facial nerve palsy
• Immediate temporary local anesthesia
• Delayed temporary 4 – 10 days
result from facial nerve swelling, resulting from the nerve being heated by a drill or laser
• Usually incomplete paralysis
Management
Prednisone- usually complete response
• Permanent injury is very rare in stapes surgery

50. Discomfort to loud noise
• 35–41 %
• It may of course reflect solely the improved hearing in
the operated ear

51. Alteration in taste
• Occurs ~30% of cases due to CT nerve injury (stretching /mobilizing )
• Causes temporary (3-4 months)
Metallic taste, taste impairment
Dry mouth
Tongue soreness
• Symptoms less severe with sectioning of nerve

52. Cholesteatoma
• Cholesteatoma has been reported in the oval window secondary to
skin elements implanted during harvesting of a fat graft

53. Meningitis
• Creation of fistula introduces route for potential meningitis
• Treated with IV antibiotics
• Tympanotomy can be done in any patient with meningitis who has a
stapes prosthesis to exclude a fistula.

54. THANK YOU