What is ostosclerosis? What are the complication of Stapedectomy surgery and describe brief how you will manage them. What is neo-stapedotomy?

• Otosclerosis is a localized hereditary disorder affecting endochronal bone of the otic capsule that is characterized by disordered resorption and deposition of bone.
• Clinical otosclerosis refers to a lesion that involves the stapes bone or stapedio-vestibular joint and consequently is clinical manifested by conductive hearing impairment.
• Histological otosclerosis refers to a lesion that does not involve the stapes bone, stapediovestibular joint or cochlear endosteum, is consequently asymptomatic, and can be diagnosed only by post-mortem examination of the temporal bone.
• Cochlear otosclerosis is a term generally reserved for the occurrence of pure sensory hearing impairment due to otosclerosis in an ear without any conductive component to the hearing impairment.
• Capsular otosclerosis is usually associated with stapedial fixation and results in a mixed hearing loss which is invariably progressive in nature.

The complications of Stapedectomy surgery can be divided into:

PERIOPERATIVE HAZARDS

1. Surgical approach:
   • narrow EAC → correction before stapedectomy
   • TM perforation: underlay myringoplasty
2. Injury to chorda tympani nerve
3. Dehiscent, overhanging facial nerve: gentle retraction
4. Aberrant internal carotid artery or persistent stapedial artery: careful division and coagulation
5. Narrow oval window niche: drilling on promontory with skeeter drill.
6. Ossicular problems:
   • Fixed malleus: TORP or malleostapedomy
   • Incus may be displaced during curettage or fixed
7. Other diagnosis:
   • Congenital abnormality
   • Fracture
   • Post-inflammatory fixation
   • Tympanosclerotic fixation
   • Erosion of ossicles
   • Dead  ears
   • Osteogenesis imperfecta
8. Stapes footplate
   1. Solid or obliterated footplate:
      • “thick rice grain” footplate
      • Use microdrill
   2. Floating footplate:
      • Carefully drill  a small hole in promontory at the inferior edge of footplate
      • Use small hook to elevate footplate out of oval window
      • Place slightly short wire or piston from the incus to floating footplate
      • Use laser or microdrill
      • Leave the crura in place until the prosthesis is placed
9. Perilymph gusher:
   • Profuse flow of CSF
   • 0.03%
   • Most commonly associated with congenital footplate fixation in paediatric patients.
   • Place a tissue graft over oval window
   • Lumbar drain can be used to reduce CSF pressure.
10. Intraoperative vertigo: long prosthesis→ use 0.25 mm shorter piston if this doesn’t improve.

POSTOPERATIVE COMPLICATIONS

1. Conductive hearing impairment may persist due to
   • Prosthesis displacement
   • Incus erosion
   • Bony regrowth over the fenestration
   • Fibrous adhesion
   • Footplate re fixation
2. Sensory neural hearing loss:
   • <1%
   • Start prednisolone immediately and taper over 10 days(60mg/day X 5 days and 40 mg for 1 day followed by 10 mg/day until 10th day)
   • Serous labyrinthitis: resolve within several days to weeks
   • Perioperative SNHL : surgical trauma, floating footplate and perilymph gusher
   • Delayed SNHL: barotraumas, suppurative labyrinthitis
3. Facial nerve injury:
   • Delayed onset occurs about 5 days post-operatively
   • Usually incomplete
   • Responds quickly to prednisolone
   • Full recovery over days to weeks
4. Vertigo:
   • Usually last for few hours and subside rapidly
   • Rarely severe or prolonged
   • Usually only supportive management
   • Serous labyrinthitis
   • BPPV
   • fistula
5. Perilymphatic fistula:
   • Primary: at the end of surgery
   • Secondary: months or year later
   • Persistent fluctuant hearing loss, vertigo, sense of fullness
   • D/D : endolymphatic hydrops
   • Prompt treatment
   • Replace new prosthesis if displaced
   • Graft the defect
6. Reparative granuloma:
   • Common with gel foam or fat graft
   • Rare with perichondrium, fascia or vein
   • Presents 1-2 weeks after surgery
   • Suspect if symptoms of serous labyrinthitis fail to settle or progressive sudden SNHL or mixed
   • Dull red TM in postero superior quadrant
   • Steroids and antibiotics
   • Surgical intervention if no improvement within two weeks
7. Discomfort to loud noise:
   • Damage to stapedius tendon or
   • Improved hearing in operated ear
8. Alteration of taste:
   • Stretching of chorda tympani results more symptoms than sectioning
   • Symptoms severe if bilateral damage
   • Metallic taste, impairment or dry mouth or soreness of the tongue
   • Most resolve within 3-4 months
9. Cholesteatoma:
   • Implantation of skin element while harvesting fat graft
10. Meningitis
    • Due to fistula formation: exploratory tympanotomy
11. Tinnitus: preexisting which improves as ear heals, reassurance.

Neostapedotomy is a method of preserving the stapedius tendon for preserving the blood supply to the long process of incus and reducing discomfort at high sound pressure levels and of improving speech intelligibility. Tendon preservation may lead to a higher noise discomfort threshold (98 dB with tendon preservation ans 124.1 dB without)

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