Treatment of Otosclerosis by Stapedectomy

Abstract

The surgical treatment of otosclerosis has changed since the open one-stage fenestration was introduced by Lempert (1938). The principal disadvantages of the operation were the creation of a mastoid cavity resulting in chronic otorrhoea in 13% of cases (Hall, 1958), occasionally troublesome post-operative vertigo, and closure of the fenestra in the lateral semicircular canal within the first few months of operation. Indirect mobilization of the fixed stapes as described by Rosen (1953Rosen ( , 1954 (Fowler, 1956), fenestration of the oval window (Rosen, 1957), partial stapedectomy and prosthetic reconstruction (Juers, 1959;Hough, 1960;Bellucci, 1961), and many others. Though results have been better, the major problem remains-re-ankylosis of the stapes footplate. Portmann and Claverie (1959), from Bordeaux, described their " interposition " operation, removing the footplate, vein-grafting the oval window, but still utilizing part of the stapes, with greatly improved results.The more radical total stapedectomy followed by reconstruction of the ossicular chain with a polythene prosthesis was pioneered by Shea (1958Shea ( , 1959Shea ( , 1960 The middle ear is entered postero-superiorly after raising a skin flap from the posterior meatal wall to the tympanic annulus. The chorda tympani is divided if it obscures vision, and enough bone is removed to give access to the long process of the incus, the stapedius tendon, and the stapes. The round window is inspected. (Special Plate, Fig. 1).The incudo-stapedial joint is divided and the stapedius tendon cut. The stapes is then dislocated inferiorly on to the promontory and removed. Both crura normally fracture near the footplate-only once has the stapes come away in toto. Before the footplate is removed haemostasis is secured.The appearance of the footplate and its ease of removal vary greatly, and there is apparently no constant relationship between the degree of deafness and the thickness and ankylosis of the footplate. If thin it is fractured across its centre and first the anterior and then the posterior halves are removed. If moderately thick it is often possible to find an opening into the vestibule at its inferior margin and lever the plate out of the fenestra ovalis. Sometimes the oval-window recess is obliterated by otosclerotic bone, when a micro-drill must be employed to make the fenestra. In this event the superior relationship of the facial nerve and the anteroinferior proximity of the first coil of the cochlea must be remembered. Suction of perilymph is avoided.To prevent perilymph from escaping and to form a new membrane in the oval window a free vein graft is inserted. An assistant removes a 2-cm. length of vein from the dorsum of the hand or foot, opening the lumen and stretching and drying it during the initial stages of the operation. This simplifies the prompt and accurate positioning of the graft, which otherwise is difficult to handle. Unlike Shea and others I always place the less traumatic vein intima facing the vestibule (Special Plate, Fig. 2).T...

A confidential comparative audit of stapedectomies: results of the Royal College of Surgeons of England Comparative Audit of ENT Surgery 1994

“…Further comparison with published rates of immediate sensorineural deafness suggest that our cohort of otolaryngologists seemed to fare no worse than the dedicated otologist. Smyth and Hassard (1978) recorded a rate of 3.5 per cent in 713 operations, Kaplan and Shambaugh (1961) quoted four per cent and Morrison (1962Morrison ( , 1987 in his series of 1000 stapedectomies recorded rates of four per cent for his first 50 cases, two per cent for the next 50, zero per cent for the next 500 and 0.25 per cent for the subsequent 400.…”