Downloaded 89 times
Uploaded byMamoon Ameen
Complications of stapes surgry
This document discusses complications of stapes surgery. It begins with an overview of causes of stapes fixation like otosclerosis and tympanosclerosis. It then describes different procedures for stapes surgery like stapedectomy, stapedotomy, and STAMP. Potential intraoperative hazards are outlined such as exostosis, TM perforation, facial nerve dehiscence. Postoperative complications are also summarized, including conductive hearing loss, sensorineural hearing loss, perilymphatic fistula, reparative granuloma, and vertigo. Recommendations are provided for prevention and management of complications.
More Related Content
Similar to Complications of stapes surgry
More from Mamoon Ameen
Complications of stapes surgry
- 1. COMPLICATIONS OF STAPESSURGRY Dr. Mamoon Ameen
- 2.
- 3.
- 4. CAUSES OF STAPESFIXATION • Otosclerosis ≥ 95% of stapes surgery • Congenital stapes fixation Hearing outcomes worse with stapes surgery compared to otosclerosis • Tympanosclerosis can also result in stapes immobility by filling the oval window niche with tympanosclerotic plaques Mobilization through plaque removal –vs- stapedotomy
- 5. OTOSCLEROSIS • Otosclerosis Localized hereditarydisorder affecting enchondral bone of the otic capsule that is characterized by disordered resorption and deposition of bone • Types of Otosclerosis Stapedial Cochlear Mixed
- 6. TYPES OF STAPEDIALOTOSCLEROSIS 1. Anterior focus (commonest): 2 mm anterior to oval window. 2. Posterior focus: 2 mm behind oval window. 3. Circumferential: involves footplate margin only.
- 7. TYPES OF STAPEDIALOTOSCLEROSIS 4. Biscuit type: footplate involved, margin is free. 5. Obliterative: obliterates oval window completely
- 8. STAPES SURGERY Stapedectomy StapedotomySTAMP (STApedotomy Minus Prosthesis) or Stapedioplasty
- 9. STAPEDECTOMY • Results probablyare the best • More traumatic to the inner ear • Increased post-op vestibular symptoms • Higher incidence of postoperative SNHL • The operation is unavoidable in: • Comminuted fracture of the footplate • Revision surgery
- 10. STAPEDOTOMY • Equal orbetter results with less vestibulocochlear side effects
- 11. STAMP • Preservation ofthe stapedius tendon • Reduction in hyperacusis • Reduction in risk for long-term postoperative inner ear injuries • No prosthesis complications • Very difficult technique
- 12. STAPES SURGERY Local anesthesia Patient’s hearing can be tested Patient can report vertigo and dysequilibrium Postoperative nausea is avoided Potential exposure to pressures is avoided
- 13. STAPES SURGERY General anesthesia Generally preferred Complications or difficulties can be managed easily Motionless operative field
- 14. SURGICAL TECHNIQUE • Permeatalapproach: Endaural appraoch:
- 16. • Confirm footplatefixation • Checking for absence of round window reflex
- 17. Assessment • Gentle palpationof stapes suprastructure • Other causes of hearing impairment: tympanosclerosis • Palpation of malleus: fixation of head, anterior ligament and malleoincudal joint • Anatomical anomalies: persistent stapedial artery, overhanging facial nerve
- 20.
- 24.
- 25. Exostosis Small :removed afterelevation of TM flap Large : • Require canaloplasty • stapedotomy done as staged procedure
- 26. TM perforation • Reportedin 2% of cases • usually occurs during elevation of the tympanic membrane from the sulcus in the posteroinferior area • Small tear :reapproximated by advancing the tympanomeatal flap when it is returned to its anatomical position • Large perforation :underlay myringoplasty
- 27. Malleus and IncusFixation • Mobility should be checked in every case • May be responsible for failure to close the air bone gap postoperatively. • Usually associated with stapes fixation but it can be isolated. Abort the surgery and use hearing aid. Remove incus and head of malleus and do ossicular reconstruction.
- 28. Dehiscent and overhangingfacial neve • Occurs ~9% of stapes procedures • Consider aborting the procedure • It may rarely herniate down over the oval window • Prosthesis touching facial nerve generally does not create problem • May displace nerve superiorly while performing stapedotomy • The facial nerve canal may also overhang the footplate limiting surgical access
- 29. Persistent Stapedial Arteryand Vascular Anomalies • Rarely, a persistent stapedial artery is encountered running through the arch of the stapes • If small, fine bipolar cautery or laser coagulation may be used to remove the vessel from the field • If larger artery - stop the procedure and prescribe amplification. • less commonly, an aberrant carotid is seen
- 30. FLOATING OR SUBMERGEDFOOTPLATE • During an attempt to fracture the crura the footplate may become • Mobile It is best to terminate the procedure • Totally submerged No effort should be made to retrieve it. Graft should be placed over the oval window • partially submerged May be removed or retrieved using hooks • Suction of the perilymph must be minimized
- 31. Obliterative Otosclerosis 3-11% •Occurs when the footplate, annular ligament, and oval window niche are involved. • Fenestra created with microdrill • Closure of air-bone gap < 10 dB less common. • Refixation commonly occurs
- 32. Perilymph Gusher ( profuseflow of perilymph immediately upon opening vestibule) • Rare – 0.03% incidence • Associated with congenital footplate fixation • Possibly due to: Wide cochlear aqueduct Defect in IAC fundus
- 33. Management • Tissue graftover oval window • Complete procedure if possible • Consider lumbar drain and packing of middle ear if severe • Keep head elevated
- 34. • Intraoperative vertigo Causes •Prosthesis too long • Checking prosthesis mobility Management • Shorter prosthesis (try 0.25mm shorter piston)
- 35.
- 36. Conductive hearing loss 1-displacementof prosthesis • short prosthesis by Valsalva or sneezing • contracture of connective tissue seal over the fenestration (the thicker the oval window sealant, the greater the lateralization of the prosthesis) • Traction from adhesions between the prosthesis and adjacent structures appears capable of displacing a prosthesis
- 39. • 2-incus erosion(causesloosening of the attachment of the prosthesis and a conductive hearing impairment) • 3-bony regrowth over the fenestration (more common in cases that initially demonstrated obliterative otosclerosis)
- 40. Sensorineural hearing loss< 1% • Most devastating complication of stapes surgery • May occur perioperatively or years after surgery • More common in stapedectomies and revision surgeries • Perioperative causes: Extensive drilling associated with obliterative otosclerosis Floating footplate and perilymph aspiration Congenital footplate fixation and CSF gusher
- 41. • Delayed damage: •Barotrauma from air travel or blast injury • Reparative granuloma • Perilymph fistula • Suppurative labyrinthitis
- 42. Perilymphatic Fistula • 0.25-2.5%following stapedectomy • 1.5- 12% following revision surgery Presents with: • fluctuating hearing loss • Vertigo • Tinnitus • sense of fullness in the ear
- 43. Perilymphatic Fistula • Useof gelatin to seal stapedotomy is biggest risk factor • Positive fistula test present in 2-3rd of cases Management • Remove prosthesis carefully → tissue seal the oval window → prosthesis replaced
- 44. Post operative instruction •1. Avoid trauma to the head. • 2. Cough and sneeze with the mouth wide open. • 3. Do not strain against a closed glottis. • 4. Avoid the possibility of barotrauma for at least a month. • 5. Avoid lifting heavy weights. • 6. Report immediately if symptoms like vertigo, tinnitus, or hearing loss manifest themselves.
- 45. Reparative Granuloma • Granulationtissue formation around a stapes prosthesis and the oval window which may extend into the vestibule • Stepedectomy _0.1% Stapedotomy _0.07% • More common when Gelfoam or fat are used Patient presentation • Initial hearing improvement followed by • gradual/sudden deterioration over 1 to 6 weeks • Occasional vertigo • Reddish discoloration in posterosuperior quadrant
- 46. Management • ME exploration •Removal of granulation • Steroids and antibiotic
- 47. Vertigo • More commonwith stapedectomy than stapedotomy Due to serous labyrinthits • Occurs ~5% of cases • Rarely prolonged or severe • Usually lasts a few hours to one week • Supportive management
- 48. If persist • Medializationof the prosthesis into the vestibule • With or without perilymphatic fistula • Reparative granuloma
- 49. Facial nerve palsy •Immediate temporary local anesthesia • Delayed temporary 4 – 10 days result from facial nerve swelling, resulting from the nerve being heated by a drill or laser • Usually incomplete paralysis Management Prednisone- usually complete response • Permanent injury is very rare in stapes surgery
- 50. Discomfort to loudnoise • 35–41 % • It may of course reflect solely the improved hearing in the operated ear
- 51. Alteration in taste •Occurs ~30% of cases due to CT nerve injury (stretching /mobilizing ) • Causes temporary (3-4 months) Metallic taste, taste impairment Dry mouth Tongue soreness • Symptoms less severe with sectioning of nerve
- 52. Cholesteatoma • Cholesteatoma hasbeen reported in the oval window secondary to skin elements implanted during harvesting of a fat graft
- 53. Meningitis • Creation offistula introduces route for potential meningitis • Treated with IV antibiotics • Tympanotomy can be done in any patient with meningitis who has a stapes prosthesis to exclude a fistula.
- 54.