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Surgical mx of otosclerosis

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Surgical mx of otosclerosis

  1. 1. Dr. SANJAY MAHARJAN PG, ENT – HNS MCOMS, Pokhara. SURGICAL TREATMENT OF OTOSCLEROSIS
  2. 2. History : • Surgery for otosclerosis has developed through three distinct eras: 1) The mobilization era 2) The fenestration era 3) The stapedectomy era
  3. 3. • THE MOBILIZATION ERA: In 1842, Prosper Meneire first reported mobilization of stapes In late 1800s, Kessel attempted stapes mobilization without ossicular reconstruction In 1891, Jack left oval window open after removing stapes Several french otolaryngologists performed mobilization of stapes, including Boucheron And Miot Adam Politzer, Siebenmann And Moure, declared that stapes surgery was useless, dangerous and unethical at 6th international Otology Congress in London
  4. 4. • THE FENESTRATION ERA : In 1897, Passov suggested promontory fenestration In 1899, Floderus suggested opening of vestibular labyrinth In 1913, Jenkins in London described this as fenestration of lateral semicircular canal In 1920s, Nylen in Sweden was first to use microscope for ear surgery In 1923, With advent of operating microscope, fenestration era began
  5. 5. Gunnar Holmgren (Father of fenestration surgery); created fistula in lateral semicircular canal and sealed it immediately with periosteum Popularized during 1930’s by Sourdille in France (developed three stage technique) Julius Lempert in New York developed One-stage technique for horizontal semicircular canal fenestration
  6. 6. • THE STAPEDECTOMY ERA: Started prior to end of fenestration era In 1952, Samuel Rosen from New York, tested mobility of stapes using transcanal approach before semicircular canal fenestration On 1st May 1956 John Shea Jr., in collaboration with Treace, an engineer, created stapes prosthesis made of Teflon & used it for first time In 1960s, Plester suggested technique of partial stapedectomy in which only posterior third of foot plate was removed
  7. 7. In 1961, the piston concept was introduced in which a cup or piston prosthesis was used with connective tissue graft of vein to seal oval window In 1962, Shea et al and Marquet and Martin made small opening in middle of footplate into which prosthesis piston fitted exactly This initiated era of “stapedotomy” which has continued till present time Reverse Stapedotomy was popularized by Fisch and involved insertion of a prosthesis before removal of suprastructure of stapes
  8. 8. INDICATIONS : • An air-bone gap of 25 dB or more at frequencies of 250 Hz to 1 kHz and a negative Rinne at 512 Hz are considered to be good indicators • In cases of bilateral involvement, worse hearing ear is usually operated first
  9. 9. CONTRAINDICATIONS: • ABSOLUTE CONTRAINDICATIONS: 1. Only hearing ear 2. Active middle ear or external ear infections 3. When otosclerotic patient presents with symptoms of hydrops and has vertigo and tinnitus 4. Severe middle ear atelectasis
  10. 10. • RELATIVE CONTRAINDICATIONS: 1. Unfit for GA 2. When patient presents positive Schwartz sign 3. Pregnancy 4. Whose professional activities put them at risk, such as boxers, professional wrestlers, and those who indulge in severe physical strain
  11. 11. PREOPERATIVE COUNSELING : • Should be informed about amplification as alternative mode for improved hearing • Informed consent must include description of procedure and discussion of all potential risks:
  12. 12. a) Failure of procedure to correct conductive component of hearing loss b) Partial or complete SNHL (occurs in approximately 1% ) c) Vestibular disturbances d) Perforation of tympanic membrane e) Facial nerve injury f) Development of Perilymphatic fistula (PLF) g) Delayed failure after initial good result h) Disturbance of taste
  13. 13. OPERATIVE NOTE : • The operative note must include: 1. Shape and mobility of incus and malleus 2. Presence of otosclerosis, fixation of stapes, patency of round window 3. Location of and bone covering facial nerve 4. Status of chorda tympani at end of procedure 5. Unusual perilymphatic flow 6. Type and size of prosthesis
  14. 14. ANESTHESIA : • Choice of anesthesia depends on patient's and surgeon's preferences and nature of surgery planned A. Local anesthesia; saves time • Intraoperative patient reports of vestibular stimulation may be used as safety measure to prevent excessive inner ear irritation B. General anesthesia; • provides assurance against pain and head movement
  15. 15. SURGICAL TECHNIQUE: • POSITIONING: Head turned towards contralateral shoulder and tilted downward 10 to 15 degrees
  16. 16. • EXPOSURE AND EXPLORATION:
  17. 17. • Transcanal approach • Dotted line represents canal incision of tympanomeatal flap • Flap is longer superiorly to cover scutectomy defect • For flap to properly fold on itself exposing posterior superior quadrant it is best to carry incision slightly beyond malleus
  18. 18. • Using twisting motion incision is created with circular knife • Tunnel is created under the “vascular strip,”
  19. 19. • Flap is raised to the level of tympanic annulus • To avoid disturbance to ossicles middle ear is first entered inferiorly • Bony prominence is often encountered slightly lateral to tympanic membrane level
  20. 20. • Continuous pressure with knife against bony canal should be maintained • Tympanic mucosa is lysed with a curved needle
  21. 21. • Using back of annulus elevator, flap pushed against anterior canal wall where surface tension will adhere it
  22. 22. • Elevation of annulus superiorly done with curved needle • chorda tympani nerve identified and dissected free • Elevation needs to be carried superiorly until flap is free from notch of Rivinus
  23. 23. • Scutum has to be removed to provide full access to oval window • Done with either a curette or microdrill or combination
  24. 24. • Curette is firmly braced against speculum to create a fulcrum effect • Motion is rotational and outward, inward leads to incus dislocation • Considerable force is needed to fracture pieces of bone
  25. 25. • Curetting is complete when facial nerve is in full view superiorly and junction of stapes tendon and pyramid are visible posteriorly
  26. 26. • It is important to have sufficient room to bring instruments into action from superior, posterior, and inferior directions
  27. 27. • Palpation of the stapes superstructure to confirm fixation
  28. 28. • For sizing of prosthesis, measuring done from lateral aspect of incus to footplate • To achieve proper angle, instrument shaft has to lean on anterior wall of speculum • Correct measurement is between center and posterior third of footplate • 4.5 mm in majority of cases
  29. 29. • Slight outward pressure on incus with incudostapedial joint knife demonstrates thin gray line of joint • Joint is cut with gentle “worming” motion in anterior direction • gentle outward lifting of incus is best while strictly avoiding downward pressure on stapes capitulum
  30. 30. • Stapedial muscle tendon divided using microscissors
  31. 31. • Removal of stapes superstructure through down fracture toward promontory • Should always be conducted away from facial nerve • Curved needle should contact both crura, but preferentially apply force to anterior crus • Excessive pressure on posterior crus will potentially lead to transverse footplate fracture
  32. 32. • Creation of small fenestra stapedotomy with diamond burr • Slightly larger than intended prosthesis (eg: 0.7 mm for 0.6- mm piston) • Quick, subtle inward drilling motion with goal of having burr penetrate to its meridian (ie: widest point) and not beyond
  33. 33. • Optimal position of fenestra is in posterior central region of footplate as vestibule is deepest in this region • Contact with footplate should be brief • This procedure is delicate and potentially dangerous, a mere extra 1 mm of penetration can kill the ear
  34. 34. • Using smooth alligator prosthesis is seated in position • It is important to have both shepherd’s crook engage incus as well as the piston the fenestra • If wire misses incus, piston can penetrate vestibule too deeply
  35. 35. • Crimper must be stabilized on the wall of speculum • Must be aligned perfectly with the wire
  36. 36. • Once prosthesis is seated and crimped, its mobility is tested both by gently moving either incus or malleus handle • Shallowly placed prosthesis will pop out when subjected to stress • If this occurs, prosthesis is replaced with one 0.25 mm longer
  37. 37. TOTAL STAPEDECTOMY: • In certain situations, stapedotomy is not possible and stapedectomy is performed Floating footplate Comminuted fracture of footplate Footplate inadvertently removed during suprastructure dislocation through anterior crus attachment Some revision surgeries When instruments required to create small fenestra are lacking
  38. 38. • Gap between prosthesis and oval window opening to vestibule must be sealed with tissue graft, such as fat
  39. 39. STAPEDECTOMY VS STAPEDOTOMY :
  40. 40. LASERS IN OTOSCLEROSIS : Offer precision Avoids use of manual mechanical force Offer excellent hemostasis • These qualities are desirable for: 1. Fenestrating thin footplate with reduced risk of resultant floating footplate 2. Having the ability to fenestrate mobile footplate 3. Creating fenestra with minimal movement of footplate or perilymph
  41. 41. • TYPES OF LASERS: • Visible green light lasers (argon or potassium titanyl phosphate [ktp-532]) • Invisible or infrared light lasers (Carbon Dioxide, CO2)
  42. 42. • ADVANTAGES OF VISIBLE LASERS: 1. Convenience of handheld probe for use of lasers during surgery 2. Spot size can be chosen accurately • DISADVANTAGES: 1. The visible light lasers depend on char formation 2. Char absorbs laser energy and creates heat 3. The laser energy can pass through either directly or by scatter and injure neural tissue of utricle or saccule
  43. 43. • ADVANTAGE OF CARBON DIOXIDE LASERS: • Not absorbed in perilymph, thus potentially reducing risk to structures within vestibule • DISADVANTAGES: • Need for separate aiming beam • Requirement of microscope-attached delivery system Recently, special flexible cable developed by OmniGuide allows CO2 laser beam to be precisely delivered through handheld probe
  44. 44. • COMPLICATIONS OF LASERS:
  45. 45. TYPES OF PROSTHESIS : 1. Robinson prosthesis: • Metal stem prosthesis designed to fit under lenticular process of incus • Advantage  does not require crimping, relatively easy to insert • Self-centering • A narrow stem prosthesis is also available that can be used for posterior half footplate removal
  46. 46. 2. Causse prosthesis: • Made of teflon and is designed to attach to long process of incus. • Teflon ring is spread open and prosthesis is snapped onto incus • Teflon has a long memory and does not require crimping • Can be adjusted easily • Can be used in small fenestra stapedectomy
  47. 47. 3. Fisch/McGee-type piston prosthesis: • Consists of malleable ribbon-like crook connected to metal or teflon stem • Crook is attached to long process of incus and must be crimped into position. • Distal end of prosthesis is scored  checking exact length of prosthesis that is required easy • Can be used in small fenestra stapedectomy.
  48. 48. 4. House wire prosthesis: • One end is shepherd crook-like arrangement • At other end is a loop • Crook is attached and crimped to long process of the incus • Technically more difficult to attach than other prostheses • Used in total stapedectomy
  49. 49. POSTOPERATIVE CARE : • Patients are instructed to keep their ears dry to avoid strenuous physical activities (eg, heavy lifting, Valsalva maneuvers) to avoid nose blowing, and to sneeze with an open mouth Air travel is permissible a couple of days after operation Oral antibiotics are continued for a week Audiometric evaluation is performed after 6 to 8 weeks
  50. 50. INTRAOPERATIVE COMPLICATIONS: A. TEARS IN TYMPANOMEATAL FLAP: • Elevation of flap in limited segment • Elevating TM without annulus.
  51. 51. • Repaired by placement of tragal perichondrium or fascia graft • Underlay technique • Small tears in vicinity of annulus  closed with piece of Gelfoam • Small linear tears in canal skin flap  typically need no repair
  52. 52. B: SUBLUXATION OF THE INCUS: • During curettage of bony annulus • Separation of incudo-stapedial joint • Manipulation around oval window • Crimping • If disarticulation or complete disruption of joint  best to remove incus and use malleus attachment prosthesis
  53. 53. C: OVERHANGING FACIAL NERVE: • Can be dehiscent of its covering bone, but usually does not extend significantly out of fallopian canal • If prolapsed nerve abuts the promontory inferior to oval window, surgery should not be completed • Drilling small fenestra that includes the inferior aspect of the annular ligament • Prosthesis must be longer than usual to accommodate bending inferiorly to avoid the nerve
  54. 54. D. OBLITERATIVE OTOSCLEROSIS:
  55. 55. • Fenestration made by saucerizing the obliterated niche and thinning the obstructing bone • After blue lining the vestibule, with a 0.7-mm diamond burr
  56. 56. E. PERSISTENT STAPEDIAL ARTERY: • Incidence  1 of 5000 to 10,000 ears
  57. 57. • It cannot be safely coagulated with bipolar cautery or laser • Often occupies only anterior half of footplate and fenestration can be completed in the posterior half
  58. 58. F. PERILYMPH GUSHERS AND OOZERS: • Incidence  0.03% • Flow of cerebrospinal fluid • Oozers  steady trickle of fluid, associated with persistent cochlear aqueduct • Gusher  strong and forceful flow originating from defect in cribrose area of fundus of internal auditory canal • Rapid drainage of inner ears fluids can threaten sensorineural hearing
  59. 59. • Fenestra is packed with tissue graft or a cotton pledget • Placing lumbar drain can be useful
  60. 60. G. FLOATING OR DEPRESSED FOOTPLATE: • Footplate that is irretrievably depressed into vestibule will almost certainly cause vertigo • Fenestration by laser reduces chances of footplate disarticulation • Assessing movement of footplate before completing fracturing and disengaging suprastructure
  61. 61. H. OTOSCLEROSIS INVOLVING THE ROUND WINDOW: • Attempts at removing this obstruction have resulted in SNHL • Hence contraindicated
  62. 62. POSTOPERATIVE COMPLICATIONS: 1. PERILYMPH FISTULA: PLF • Most common single complication of stapedectomy • Potentially dangerous d/to risk of meningitis • May give rise to dysequilibrium and hearing loss • Types: • Primary or early PLF • Secondary or aquired PLF
  63. 63. A. PRIMARY OR EARLY PLF : • Occurs when fistula created at time of surgery persists and fails to seal off vestibule • Use of gelatin sponge (gelfoam) as a seal for oval window fenestra is associated with high incidence (1) It may be resorbed before neomembrane has formed (2) Gelatin sponge will get softened by perilymph and prosthesis will penetrate through it (3) Neomembrane that forms with gelatin sponge is very thin • Vein graft shows less incidence
  64. 64. • SIGNS AND SYMPTOMS: Vary with size of leak Large fistulas  rapid hearing loss, tinnitus, and vertigo In early PLF when leak is small  hearing loss may initially appear as CdHL and then has sensorineural component and then progresses to total SnHL Minute fistula  failure of good closure of an air–bone gap, mild fluctuation in hearing, and small decrease in speech discrimination scores
  65. 65. B. SECONDARY OR AQUIRED FISTULA : • Usually due to barotrauma, (flying, mountaineering, lifting heavy objects, coughing, sneezing, and head injury) which breaks fragile seal • Characteristics symptom  change of hearing after successful operation; as/w fullness, tinnitus and dysequilibrium • Can occur anytime after surgery
  66. 66. • MANAGEMENT OF A PERILYMPH FISTULA: Surgical closure of fistula is treatment of choice Fistulous track is excised and prosthesis removed with great care Mucosa over footplate is elevated completely Fresh soft tissue seal is placed over adequately created fenestra New adequate prosthesis is placed over seal Patient is advised total rest in bed for 48 hours
  67. 67. 2. CHORDA TYMPANI DYSFUNCTION: • Injury to nerve may result in a. Hypogeusia and dysgeusia b. Atrophy of fungiform papillae in denervated area c. Temporary symptoms, which will improve in course of 3 to 6 months
  68. 68. 3. FACIAL PALSY: • Immediate facial paralysis is related to local anesthesia or intraoperative trauma to the nerve • Can be damaged by a. Bone curette or drill during removal of bony annulus b. By fracturing stapes toward nerve rather than toward promontory c. By injuring anomalous nerve
  69. 69. 4. VERTIGO: • Vertigo may appear during surgery, immediately following it, or in a delayed manner • During surgery  insult to membranous labyrinth or may be result of air entering vestibule • Pneumolabyrinth generally resolves in 24 to 48 h • Blood causes chemical irritation and resolves in days • Vertigo extending beyond that time suggests more serious insult to inner ear and is often associated with SNHL • Delayed vertigo can be result of BPPV or PLF
  70. 70. 5. REPARATIVE GRANULOMA: • Mass of exuberant granulation tissue developing in reaction to surgery, foreign body or to perilymph • Manifests in 5th to 15th POD • Symptoms and signs of labyrinthitis appear after an early period of hearing gain • Otoscopy reveals edema, thickening, and hyperemia of skin flaps and tympanic membrane • Immediate reexploration; granulation tissue and prosthesis are removed, and fenestra is sealed with tissue graft • Steroids may be useful
  71. 71. 6. SENSORINEURAL HEARING LOSS: • Slight transient SnHL immediately  common occurrence and d/to mild serous labyrinthitis • Permanent SNHL can occur immediately following surgery or appear weeks or months after • Early loss, especially at high tones  surgical trauma • Delayed SNHL  PLF • Delayed fluctuating low-frequency loss  post-traumatic hydrops • Up to 1% of patients suffer partial or even complete SNHL
  72. 72. 7. CONDUCTIVE HEARING LOSS: • Can appear immediately or more commonly delayed after initial good result • Common reasons for immediate conductive loss: (1) Malfunctioning prosthesis, eg: one that is too short (2) Unrecognized malleus fixation (3) Unrecognized round window obliteration (4) Middle ear effusion, and (5) Presence of unrecognized SSCD
  73. 73. • CdHL after good initial closure or reduction of airbone gap 1. Erosion of incus at site of prosthesis attachment (64%) 2. Malpositioned prosthesis (41%) 3. Bony (14%) or fibrous regrowth at oval window area 4. Round window obliteration (23 %)
  74. 74. SUMMARY: • Surgery for otosclerosis requires specific acquired skills • Most common procedure to correct stapedial fixation is small fenestra stapedotomy with incus attachment prosthesis • Successful surgery reduces air-bone gaps to less than 10 db and is achieved in 90% of patients • Noteworthy complications include SNHL(1%), chorda tympani nerve dysfunction, and vestibular injury • Revision surgery associated with lower success rates and slightly higher complication rates
  75. 75. REFERENCES: • Shambaugh - Ear surgery 6th edn • Scott – Browns otolaryngology 6th edn • De Souza – Otosclerosis • Evolution of Stapes Surgery, P Karthikeyan, D Thomas

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