<=
/a>TITLE: Complications of
Stapes Surgery
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: November 21, 2007
RESIDENT PHYSICIAN: Garrett Hauptman, MD
FACULTY PHYSICIAN:
SERIES EDITORS: Francis B. Quinn, Jr., MD
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties, eit=
her
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
INTRODUCTION
= Otosclerosis is a bone disease only seen in the otic capsule. It causes hearing loss whi= ch may be conductive, mixed, or sensorineural hearing loss. Toynbee first described the condition in 1860= as causing a hearing loss by fixation of the stapes. In 1894, Politzer referred to the fixation of the stapes as otosclerosis. Siebenmann revealed on microscopic examination that the lesion seemed to begin as spongification of the bone and termed the process otospongiosis.
= Otosclerosis clinically presents with progressive hearing loss. If the otospongiotic cha= nge primarily involves the stapes, then the hearing loss is conductive. The fis= sula ante fenestram is the most common area for stapedial fixation. The process = may progress to involve the entire footplate or may continue anteriorly toward = the cochlea, causing a sensorineural hearing loss.
= Otosclerosis is an autosomal-dominant hereditary disease. It has varialble penetrance and expression. Women are effecte= d by otosclerosis 2:1. Hearing loss usually begins in the late teens or early twenties, but may occur later. The prevalence of otosclerosis vari= es with race and its expression. The disease is found between 7-10% of cadevaric temporal bones in Caucasians. <= span style=3D'mso-spacerun:yes'> Clinical otosclerosis is rare in bl= acks, Asians, and Native Americans.
HISTOPATHOLOGY
= Early lesions tend to begin near the fissula ante fenestram. They begin as connective tissue replacing bone, which in turn is remodeled by osteocytes resulting in disorganized bone with enlarged marrow spaces. When this process involves= the mobility of the stapes, a conductive hearing loss results. Occasionally, the lesion c= an involve only the cochlea, causing an isolated sensorineural hearing loss.
EVALUATION
=
History
= Patient history is one of the most important aspects of the evaluation of the otosc= lerosis patient. Hearing loss usually gradual in onset and slowly progressive over several years. Approximately 70% of otosclerosis cases are bilateral. Typically, hearing loss becomes ap= parent in the late teens or twenties, but may not become apparent to the patient u= ntil age 30 or 40 years. As is typical with conductive hearing loss, patients wi= ll report difficulty hearing conversation while chewing and may hear better in noisy rooms because people speak louder in noisy surroundings. Unilateral h= earing loss is less noticeable to the patient and results in difficulty with direc= tion of sound and in noisy rooms. = Family history is usually positive for hearing loss often with surgical correction= .
=
Physical Examination
Physical examination includes the following:
1. Otoscopy (often with the operating microscope)- look for Schwartze sign which is a r= ed blush over the promontory or the area anterior to the oval window
2. Pneumo-otoscopy- evaluates for middle ear effusion or small perforation
3. Tuning fork exam- may confirm or dispute the finding of a conductive hearing loss = on audiometry
The standard audiometric evaluation includes air conduction, bone conduction, a= nd speech audiometry. Additionally, the immittance audio= metry battery consists of tympanometry, static compliance, and acoustic reflex testing. The middle ear pressure is not affected by otosclerosis, and, therefore, the tympanogram is normal with a distinct peak that occurs with = the normal range. The peak may be lower (As) than normal in the presence of a healthy appearing tympanic membrane, thus alerting the examiner to the poss= ible diagnosis. Acoustic reflexes are a sensitive = measure of the movement of the stapes, which in the presence of advanced otoscleros= is, the reflex will be absent.
As with all surgery, surgical options for treatment of otosclerosis involves risk. Total sensorineural hea= ring loss occurs in about 0.2% of cases, but the patient is told that there is a less than 2% chance of further hearing loss and a less than 1% chance of lo= sing all hearing in the operated ear. Dizziness may occur postoperatively also.<= span style=3D'mso-spacerun:yes'> Dizziness is usually transient and= brief. However, it may persist for a short period of time and rarely could be permanent. The possibility of facial pal= sy should be mentioned as well.
Surgical techniques include stapedotomy or stapedectomy performed with either a lase= r or microdrill. Please refer to o= tology texts for further description of surgical techniques.
Multiple problems can be encountered during stap= es procedures. These are listed = below:
- Exposed, Overhanging Fac=
ial
Nerve
An exposed facial nerve occurs in approximately 9% of stapes procedures. It may block access to the footplat= e, making the completion of the procedure impossible. Gentle retraction of the= nerve superiorly with a small suction while the drill or laser is used to create = the fenestra is possible. If the prosthesis is touching the f= acial nerve it generally does not create a problem for postoperative hearing or facial function.
=
-Fixed Malleus
A fixed malleus is a rare problem, but it should be checked for in every procedure. When this occurs, the sound conducti= on can be reestablished with an incus replacement prosthesis or a total ossicular replacement prosthesis and tragal cartilage.
=
-Solid or Obliterated
Footplate
A solid or obliterated footplate can be managed with a microdrill to create a fenestra. It was a greater problem in the past when a total stapedectomy was performed.
=
-Floating Footplate
A floating footplate rarely occurs when using the laser or microdrill, especi= ally when the crura are left in place until after the prosthesis is placed. Management includes carefully drilling a small hole in the promontory at the inferior edge of the footplate followed by using a small hook to gently ele= vate the footplate out of the oval window.
=
Perilymph Gusher
A perilymph "gusher" is the profuse flow of cerebrospinal fluid (CS= F) immediately on opening the vestibule. It is rare with a reported incidenc= e of 0.03% and is most often associated with congenital footplate fixation in the pediatric population. The eti= ology of this CSF leak is thought to be due to either a widened cochlear aqueduct= or a defect in the fundus of the internal auditory canal. Management involves placement of a tissue graft over the oval window and completion of the procedure, if possible, rather than packing the ear and terminating the surgery. Placement of a lumbar drain can also be used to reduce CSF pressur= e.
=
Tympanic Membrane Perfor=
ation
A tympanic membrane perforation may occur during elevation of the tympanomeatal flap. = Perforation does not preclude compl= etion of the operation. Repair invo= lves myringoplasty with either synthetic material or autologous tissue.
=
Chorda Tympani Nerve Dam=
age
Damage to the chorda tympani nerve may occur in up to 30% of cases secondary to st= retching and mobilization of the nerve during removal of the posterosuperior bony ca= nal wall. Sequelae include compla= ints of temporary dry mouth, tongue soreness, or a metallic taste that usually subsides in 3 to 4 months. Symptoms are less severe with complete sectionin= g of the nerve rather than stretching or partial tearing.
=
Intraoperative Vertigo<=
span
class=3Dtext>
When the prosthesis is too long, vertigo may result. Vertigo also may be induced when checking the mobility of the prosthesis. In this situation, a shorter prost= hesis generally corrects this problem. If the vertigo does not resolve, the prosthesis can be removed and replaced with a 0.25-mm shorter piston.
=
Sensorineural Hearing Lo=
ss
The most devastating complication of stapes surg= ery is sensorineural hearing loss which occurs in less than 1% of cases. Sensorineural hearing loss may be m= ild or isolated to high frequencies. When sensorineural hearing loss is suspected, prednisone is started immediately and tapered.
Serous labyrinthitis is common after stapedectomy due to inner ear inflammation. P= atients may exhibit mild unsteadiness, positional vertigo, and/or a slight decrease= in high-frequency hearing. The above symptoms typically resolve within several days to weeks, correlating with the resolution of the serous labyrinthitis.=
Postoperative reparative granuloma is rare and has previously been recognized as a cause = of sensorineural hearing loss after stapedectomy. Patients present with initial improvement in hearing followed by a gradual or sudden deterioration 1 to 6 weeks postoperatively. Vertigo can also occur and clinical examination often reveals a reddish discoloration in the posterosuperior quadrant of the tympanic membrane. Treatment consists of prompt recog= nition and removal of the granuloma from around the oval window.
Vertigo
Mild vertigo or dizziness is fairly common and occurs in about 5% of cases. It is rarely prolonged or severe and usually lasts for a few hours, subsiding rapidly. Management is usually not necessary or may be supportive only.
=
Facial Paralysis
Rarely, delayed onset of facial palsy occurs postoperatively usually occurring in t= he 5 day post-operative setting. It typically lasts for a few weeks. It is usually incomplete and responds quic= kly and completely to prednisone.
=
Tinnitus
Preexisting tinnitus will usually resolve in patients after stapes surgery. However, some patients will complai= n of new-onset tinnitus. As discussed previously,tinnitus is possibly related to serous labyrinthitis and may improve as the ear continues to heal. When tinnitus persists, patients are treated with reassurance and routine tinnit= us measures.
=
Taste Disturbance
Taste disturbance occurs in approximately 9% of patients. Stretching of the chorda tympani is usually the cause of this rather than nerve sectioning. Therefor= e, if the nerve has been stretched or otherwise injured, it is preferable to section it. Usually taste disturbance resolves in 3 to 4 months.
=
Tympanic Membrane Perfor=
ation
A small marginal perforation may be repaired by freshening the edges and appl= ying a paper patch. If the perforation has not healed, the process is repeated.<= span style=3D'mso-spacerun:yes'> If this still fails, a myringoplas= ty can be performed.
=
Perilymph Fistula
Perilymph fistula is a rare complication after stapes surgery with an incidence rangi= ng from 3 to 10%. With the use of a small fenestra technique, fistula is rarely seen as a cause of failure in stapes surgery. The patient presents with a m= ixed conductive sensorineural hearing loss with some vague unsteadiness and, rar= ely, vertigo. In order to repair this, the prosthesis is carefully removed, a ti= ssue seal is placed over the open oval window, and the prosthesis is replaced. A laser is helpful to remove granulation and scar tissue.
=
Ménière's
Disease
Endolymphatic hydrops may occur due to otosclerosis or as two separate disease entities. Stapedectomy in the presence of uncontrolled Ménière's disease can potentially result in a dead ear and should be avoided. A review of patients with otosclerosis and Ménière's disease at the House= Ear Clinic revealed that stapedectomy does not increase the risk of sensorineur= al hearing loss for patients with bone conduction thresholds of 35 dB or bette= r at 500 Hz and no high-tone hearing loss. Stapedectomy is contraindicated for patients with levels of 45 dB or greater at 500 Hz and with high-tone loss.= In this later group of patients, postmortem histopathologic analysis revealed contact of the saccular membrane or Reissner's membrane with the stapes footplate, which increased the risk of significant postoperative sensorineu= ral hearing loss.
Bibli=
ography
Albera = R et al. Delayed vertigo after stapes surgery. Laryngoscope 2004; 114: 860-2.
Cummings CW. Otolaryngology: Head and Neck Surgery 4 Gros A et al. Success rate in revision stapes surgery =
for
otosclerosis. Otol Neurotol 2005; 26: 1143-8. Lesinski SG. Causes of conductive hearing loss after
stapedectomy or stapedotomy: a prospective study of 279 consecutive surgical
revisions. Otol Neurotol 2002; 23: 281-8. Mangham CA. Platinum ribbon-Teflon piston reduces devi=
ce
failure after stapes surgery. Otolaryngol Head Neck Surg 2000; 123: 108-13.=
Massey BL et al. Stapedectomy in congenital stapes fix=
ation:
are hearing outcomes poorer? Otolaryngol Head Neck Surg 2006; 134: 816-8.
Matthews SB et al. Stapes surgery in a residency train=
ing
program. Laryngoscope 1999; 109: 52-3. Mevio E et al. Stapes surgery and psychiatric complica=
tions.
Auris Nasus Larynx 2000; 27: 275-6. Nielsen TR et al. Meningitis following stapedotomy: a =
rare
and early complication. J Laryngol Otol 2000; 114: 781-3. Salvinelli F et al. Delayed peripheral facial palsy in=
the
stapes surgery. Am J Otolaryngol 2004; 25: 105-8. Shea JJ et al. Delayed facial palsy after stapedectomy=
. Otol Neurotol 2001; 22: 465-70. Szymans=
ki M et
al. The influence of the sequence of surgical step on complication r=
ates
in stapedotomy. Otol Neurotol 2007; 28: 152-6. Vincent R et al. Surgical findings and long-term heari=
ng
results in 3.050 stapedotomies for primary otosclerosis: a prospective study
with the otology-neurotology database. Otol Neurotol 2006; 27: S25-47.