Patients Info: Surgical Information: Otosclerosis & Stapedectomy

This transcript provides some background information regarding otosclerosis and the reasons for surgical intervention. This info cannot replace a consultation or advice from your surgeon so please talk to your surgeon! For optimal benefit to you the patient, read this entire transcript carefully.

Please note that there are risks involved in every surgical procedure.

Although patients should be as informed as possible about the surgical treatment, every aspect cannot be covered in this transcript. Therefore, patients are advised to seek a full explanation of their proposed surgery from their surgeon, as every case is different and every personality requires a different approach.

Your surgeon cannot guarantee 100% success or that surgery will meet all your expectations or that surgery has no risks. If you are uncertain, you are encouraged to seek a second opinion from a qualified surgeon. This transcript should only be used in consultation with your surgeon.

Otosclerosis is a hereditary disorder that causes progressive hearing loss. It can already  begin during the early adult years. Patients are often affected in both ears.

A Normal ear structure and function
The human ear is divided into the external (outer), middle and inner ear. Sound waves enter the external ear through the ear canal, causing the eardrum to vibrate. In turn, vibration of the eardrum causes the three small bones in the middle ear to vibrate. These bones are the hammer (or malleus), the anvil (or incus), and the stirrup (or stapes). The footplate of the stapes is the essential bridge between the middle and inner ear. Vibrations of the stapes (stirrup) footplate cause movement of fluid in the inner ear. Tiny hair cells attached to nerve endings in the cochlea pick up the impulses and send them to the brain, where they are interpreted as understandable sounds.

The disease called Otosclerosis occurs when new bone grows over the footplate of the stapes bone. This interferes with the passage of sound to the inner ear and causes a conductive hearing loss, meaning that sound is not conducted from the exterior to the inner ear. This is known as stapedial otosclerosis and can be corrected by surgery (stapedectomy or more accurately the term should be stapedotomy).
This extra growth of bone can spread to the inner ear, causing inner ear deafness. This is known as cochlear otosclerosis and unfortunately this condition is not curable by surgery of the ear bones. Occasionally, otosclerosis can spread beyond the stapes and cause poor balance as well. Obviously it is possible to have both types of otosclerosis at the same time.

Everyone has a right to choose and so there are 3 main treatment options for otosclerosis namely:

  • do nothing at this time
  • a trial with a hearing aid
  • surgery  (stapedectomy).

The Diagnosis of Otosclerosis
A provisional diagnosis of otosclerosis can be made by clinical examination and hearing tests, however the actual diagnosis can only be made at surgery or with a very special CT scan (but the scan can miss some cases). It is possible that having inspected the middle ear, the surgeon may decide that the diagnosis is not otosclerosis and that stapedectomy is not the best form of treatment.

How does this disease present ?

IF OTOCLEROSIS IS PRESENT IN BOTH EARS WHAT CAN YOU EXPECT?
A successful operation on one side can give good hearing provided that cochlear (inner ear) function is good. If the cochlea has deteriorated mildly, a successful operation can restore a fair degree of hearing.

If the cochlea has deteriorated moderately, the patient may, after a successful operation, still need the help of a hearing aid in certain situations.

If the cochlea has deteriorated severely, making it difficult to hear even with a hearing aid, a successful operation could improve the hearing so that a hearing aid might then be of use.

IF OTOSCLEROSIS IS CAUSING HEARING LOSS IN ONE EAR ONLY WHAT CAN YOU EXPECT
A successful operation will give good hearing in that ear provided that cochlear function is good. Overall hearing will be improved in noisy backgrounds, and it will be easier to hear from that side.
Surgery may not be recommended if:

  • the degree of stapedial otosclerosis is minor
  • hearing loss is mainly due to inner ear and nerve involvement.

BEFORE SURGERY

Standard arrangements apply that your surgeon will discuss with you, but in addition:
Surgery may be postponed if you have a cold, sinus infection or ear infection.
Do not take aspirin, anti-inflammatory medications (including ibuprofen), vitamin E, herbal medications or garlic tablets for 3 weeks before surgery. These can increase the risk of excessive bleeding during and after surgery and interfere with the success of the operation.

SMOKING
Stop smoking at least 3 weeks before surgery, and do not smoke for several weeks after surgery. Smoking delays healing and can cause Eustachian tube malfunction. Smokers have a much higher risk of a poorer outcome if they continue to smoke. Taste disturbance after the operation is more common in people who smoke.

 

Anaesthesia and pre-surgery communication

Your surgeon needs to know your medical history to plan the best treatment. Fully disclose any health problems you may have had. Some may interfere with surgery, anaesthesia and aftercare. Before surgery, tell your surgeon if you have had:

  • an allergy or bad reaction to antibiotics, anaesthetic drugs or other medicines, surgical tapes or dressings
  • prolonged bleeding or excessive bruising when injured or a family history of excessive bleeding.
  • Previous problems with blood clots in the legs (deep venous thrombosis, DVT) or lungs

 ALL medicines you are taking or have recently taken need to be disclosed to your surgeon. Include medicines prescribed by your family doctor and those bought “over the counter”, without prescription. Include medicines such as insulin, warfarin, the contraceptive pill, or any long term treatments.

THE STAPES OPERATION/ STAPEDECTOMY

A Stapedectomy is performed down the ear canal. To gain a better view of the eardrum, an incision may be made in the roof of the ear canal to widen it slightly. This is sutured with a few stitches at the end of the procedure.
The surgeon uses an operating microscope, lifts the eardrum forward, and the middle ear is opened. The ear canal is usually widened by removing some excess bone to improve visualisation. A laser is used to partially or completely remove the immobile stapes superstructure. A small hole is made in the stapes footplate with this laser and a microdrill, then a prosthesis (artificial stapes) is inserted into the small hole. This is then connected to the incus, and the eardrum is returned to its normal position. The stapes prosthesis allows sound vibrations to pass once more from the eardrum to the inner ear fluids, providing improvement in hearing.
The surgery takes about 60 – 90 minutes.

Second-side stapedectomy: After a successful first side stapedectomy, surgery on the other side may be considered. However, an interval of about 9-12 months is needed to confirm that the first operation has been successful. Improvement in overall hearing from second side stapedectomy is not as dramatic as it is from the first operation. This is because the side with the worst hearing is operated on first and now has improved the overall hearing dramatically already.
Revision stapedectomy: This may be needed if a stapedectomy has initially not improved hearing or hearing has deteriorated after an initially successful surgical result. The revision operation is more demanding than the first operation, and the likelyhood of a complication to the inner ear is increased. Although revision stapedectomy usually produces a good result, the potential for an improvement is reduced compared with the first operation.

 

RECOVERY AND CARE AFTER SURGERY

Most patients stay in hospital overnight. Arrange for someone to drive you home the next day, as there will be some unsteadiness and giddiness for the first few days. Do not try to pop your ears or blow your nose for the first three weeks of the healing period. If you sneeze, try to keep your mouth open. Do not get water in your ear.
Most patients can return to work about two weeks after surgery, though lifting heavy objects should be avoided for three weeks. It is best not to fly for at least one month but discuss this with your surgeon if you are from out of town. Scuba diving after a stapedectomy remains controversial, it is not recommended but patients of mine have done this without problems after the stapedectomy surgery

Hearing Improvement timeline
Improvement may occur at the time of surgery, but hearing usually deteriorates a day later due to swelling and blood in the middle ear. Improvement in hearing may be noticeable within 6 weeks of surgery already but maximum hearing is usually not obtained for a few months after surgery. At first the ear may be hypersensitive to loud sounds and hearing may be distorted, but this usually improves in a few months. In most patients, the ear heals well, and the hearing improves as expected. Sometimes the hearing improvement is only partial or temporary. In some of these cases the ear may be re-operated on with a good chance of success.

Following a stapedectomy (generalised statistics)

  • About 89 patients in 100 have improved hearing
  • About 8 patients in 100 have no noticeable change
  • About 2 patients in 100 have worsened hearing
  • About 1 patient in 100 has total loss of hearing in that ear.
  • After a successful procedure, good hearing is usually sustained for decades. However, cochlear function may decline at a rate slightly faster than normal due to the initial disease invading the cochlear, and in later life, a hearing aid may be needed.

 

SPECIFIC RISKS AND COMPLICATIONS OF STAPEDECTOMY SURGERY

Increased deafness
Hearing may be worse after surgery in 2 out of 100 patients. This is due to the development of scar tissue, infection, blood vessel spasm, irritation of the inner ear, or a leak of inner ear fluid.
One patient in 100 has a total loss of hearing in the operated ear to the point where a hearing aid is of no use.
If hearing loss occurs in the operated ear, ringing of the ear (tinnitus) may be pronounced, and giddiness and unsteadiness may be prolonged.

Dizziness
Dizziness is normal for few hours following stapedectomy and may be accompanied by nausea and vomiting. Some unsteadiness is common during the first week after surgery. Dizziness  after sudden head movement may persist for several weeks. On rare occasions dizziness is prolonged and severe.

 

Taste disturbance/Mouth dryness
Loss of taste on the same side on the front of the tongue and mouth dryness are not uncommon for a few weeks after surgery. In 5 patients in 100 this disturbance is prolonged and can be permanent. This is because the nerve for taste sensation to that side of the front of the tongue may need to be cut during the operation; the nerve passes through the middle ear.
Most patients adjust to this loss of taste as remaining taste buds take over. This complication should especially be discussed with your surgeon if you are having the second ear operated on following a successful first stapedectomy or if your job demands an excellent sense of taste.

Perilymph Fistula Formation
A fistula is a small hole through which fluid from the inner ear leaks into the middle ear. This rare complication may develop when the hole made in the stapes footplate fails to heal. Air bubbles find their way into the inner ear causing increased deafness and giddiness. Normally the hole is sealed by a mucous membrane that grows around the prosthesis within several days of the operation. Further surgery may be needed to plug a fistula in the first week or two after stapedectomy if this complication occurs.
A fistula may also develop months or years after the operation. Again, surgery may be required to plug the fistula as infection can spread through it from the middle ear to the inner ear. Deeper spread of infection from the inner ear can cause meningitis.

Reparative Granuloma
Raised tissue may grow at the base of the stapes and prosthesis in less than 1 patient in 100, causing further hearing loss. Although this can be removed surgically, hearing may not be improved.

Eardrum Perforation
A perforation (hole) in the eardrum is an unusual complication occurring in less than one patient in 100. This is often associated with infection. The eardrum may heal by itself, or surgery may be needed to repair the hole.

Facial Paralysis
The facial nerve can be damaged during a stapedectomy as it lies less than 1mm from operation site . Though this is less than 1 in a 1000 (very rare), this can cause facial paralysis, resulting in permanent disfigurement and an inability to smile or close the eye and mouth completely on one side of the face. Also rare is weakness of the face resulting from swelling of the facial nerve. Such weakness is usually temporary.

Diving or Flying
Discuss this with your surgeon regarding the risks of scuba diving, parachuting, snorkelling or flying, especially in an unpressurised aircraft. Risks vary from negligible to severe, depending on Eustachian tube function and the ease with which you can “pop” your ears. Modifications to stapedectomy have helped overcome some earlier problems associated with the procedure. Previously, severe inner ear deafness could be caused by rapid changes in pressure after stapedectomy, due to modifications in the current surgical technique there is now little risk.

Loud noise exposure risks
After stapedectomy, patients in noisy work places or other places of loud noise may be slightly more at risk of developing noise-induced hearing loss. After stapedectomy patients should wear noise protection in noisy workplaces as a preventative measure.

 Ringing of the ears (Tinnitus)
If hearing is improved by surgery, tinnitus (ringing of the ears) often improves as well, but in very rare cases this may be worse after the procedure. If hearing is worse after surgery, tinnitus is usually also more pronounced.

Contacting your surgeon after the procedure

Tell your surgeon at once if you develop any of the following:

    • Temperature higher than 38 degrees Celsius or chills.
    • Severe ear pain
    • Nausea or vomiting over and above what is to be expected
    • Severe dizziness
    • Any troublesome ear symptoms
    • Any concerns you have regarding your surgery
    • No hearing even when the ear dressing (bandage) is scratched