S t a p e d e c t o m y Ver s u s

Stapedotomy
Horace C.S. Cheng, MD, MASc, Sumit K. Agrawal, MD, FRCSC,
Lorne S. Parnes, MD, FRCSC*

KEYWORDS
 Stapes surgery  Stapedectomy  Stapedotomy  Otosclerosis

KEY POINTS
 Stapedectomy and stapedotomy represent the standard surgical procedures to address
conductive hearing loss in otosclerosis.
 Stapedotomy provides better high frequency hearing improvement compared with
stapedectomy.
 Both stapedectomy and stapedotomy have proven long-term stability in conductive hear-
ing improvements.
 Stapedotomy has lower rates of complication compared with stapedectomy.
 Minimally invasive approaches may represent the next major development in stapes sur-
gery in a selected patient population.

Video content accompanies this article at http://www.oto.theclinics.com.

INTRODUCTION

Some of the most illustrious physicians and otologists from the 18th and 19th cen-
turies, including Valsalva, Toynbee, Troltsch, and Politzer, all played key roles in
furthering the understanding of otosclerosis.1,2 Despite some early promise, the
morbidity and even mortality of stapes surgery made it too dangerous, and further at-
tempts were subsequently abandoned. As the understanding of otologic physiology
and medical technology improved, attempts to correct the cause of the conductive
hearing loss were renewed in the 20th century. These efforts were supported by the
introduction of precision surgical tools, better visualization with operating loupes, ad-
vances in the field of anesthesia, and the advent of antibiotics.

Disclosure: The authors have nothing to disclose.

Department of Otolaryngology–Head and Neck Surgery, Schulich School of Medicine and
Dentistry, Western University, London, Ontario, Canada
* Corresponding author. London Health Sciences Centre, University Hospital, B1-333, 339
Windermere Road, London, Ontario N6A 5A5, Canada.
E-mail address: [email protected]

Otolaryngol Clin N Am - (2017) -–-

https://doi.org/10.1016/j.otc.2017.11.008 oto.theclinics.com
0030-6665/17/ª 2017 Elsevier Inc. All rights reserved.
2 Cheng et al

The fenestration operation was the operation of choice in the mid 20th century. This
procedure restored hearing by creating a new route for acoustic energy to propagate
into the inner ear, bypassing the fixed stapes footplate. However, Rosen’s discovery
of hearing improvement from an accidental mobilization of the stapes in 19523 led to
renewed interests in the mobilization procedures. Various new techniques and tools
were introduced to improve the outcomes. However, they failed to address the recur-
rent ankylosis of the stapes footplate, the Achilles heel in the mobilization procedure.
This factor ultimately led to the deterioration of hearing improvement in a significant
proportion of patients.
It was Shea who performed the first stapedectomy in 1956,4 heralding the modern
era of stapes surgery. His first attempts were made with a Teflon replica of the stapes
made by Harry Treace. His subsequent vein graft and polyethylene tube prostheses
have since been modified with other graft materials and more standardized prefash-
ioned prostheses (Fig. 1). Further modifications using micro hand drills, electric micro
drills, and various lasers paved the way for the next innovation in stapes surgery
whereby small openings just large enough to allow the insertion of piston like prosthe-
ses were made in the stapes footplate. Thus stapedotomy, or small fenestra stape-
dectomy as it was known at the time, was born. Marquet was generally considered
to be the pioneer of this technique with his initial attempts in 1963.5 This technique
is illustrated in Fig. 2. Subsequent innovations including different prostheses materials
and designs have further improved surgical outcomes and reduced complications.
The aim of this article is to provide an informed discussion about the differences be-
tween stapedectomy and stapedotomy. Short- and long-term surgical outcomes, and
complications are the key areas for review. Furthermore, interesting aspects of stapes
surgery such as the size of the prosthesis and the anesthetic choice are also dis-
cussed. We provide a brief overview of the modified stapes mobilization procedures
and conclude the article with a “How I Do It” description of our own technique accom-
panied by an edited video of an operation.

Fig. 1. Schematic diagram of total stapedectomy. Note the prosthesis inserted between
the long process of the incus and the tissue graft over the oval window. (ªChristine
Gralapp.)
 Stapedectomy Versus Stapedotomy 3

Fig. 2. Schematic diagram of stapedotomy. The prosthesis is inserted through a small opening
in the stapes footplate to recreate the mobile ossicular chain movement into the labyrinth.
(ªChristine Gralapp.)

INDICATIONS AND CONTRAINDICATIONS

Indications
 Confirmed diagnosis of otosclerosis.
 A 25 dB or greater conductive hearing loss in frequencies 250 Hz to 1 kHz with
negative Rinne at 512 Hz.6,7
 Mixed hearing loss not serviceable by hearing aid unless conductive hearing loss
is reduced8 (far advanced otosclerosis).
Contraindications
 Only hearing ear.
 Active infection of external and/or middle ear.
 Concomitant Meniere’s disease with hearing loss of 45 dB or greater at 500 Hz
and with high-tone loss.9
 Poor overall medical condition.
 Occupational requirement for intact vestibular function.

OUTCOME COMPARISON

Numerous studies have been conducted to assess the outcome of stapedectomy and
stapedotomy procedures. Among them are studies that directly compared the 2
approaches. The focus of this section is to summarize the short- and long-term
outcome data from such comparison studies. In addition, complications reported
from these studies are also discussed.
Short-Term Results
A summary of key studies that compared short-term outcomes of stapedectomy and
stapedotomy is provided in Table 1.
 4
Cheng et al
Table 1
Short-term outcome differences for STE and STO

Pure Tone Audio (Technique Air–Bone Gap (Technique Speech

with Better Outcome at with Better Outcome at Discrimination Incidence of
Number STE/STO Listed Frequencies) Listed Frequencies) Results SNHL STE/STO (%)
House et al,10 2002 134/75 NS STO; 4 kHz NS 9.8/5.9b (NS)
11
Fisch, 1982 170/170 — STO; 4 kHz — 0.6/0 (NS)
Colletti & Fiorino,12 1994 428/1030 STO; 8 kHz NS STO —
Somers et al,13 1994 165/1429 STO; 4 and 8 kHz — — Total STE: 2.56
Partial STE: 0.71
STO: 0.68
Bailey et al,14 1981 50/50 STO; 2, 4, and 8 kHz STO: 4 kHz STE: 81% 6/2
STO: 96%
McGee,15 1981 141/139 — STO; 0.5–2 kHz STE: 83.7% —
STO: 92.8%
Moon & Hahn,16 1984 106/264 STO; 2, 4, and 8 kHz STO; 1–4 kHz and 4 kHz STE: 83% 0/0.3
STO: 95%
Persson et al,17 1997 275/162 STE; 0.25, 0.5, 1, 2, and 4 kHz STE; 0.25, 0.5, 1, and 2 kHz — Total STE: 6.2a
Partial STE: 3.8a
STO: 5.4a
Kos et al,18 2001 51/553 — NS — 5.9/3.1
Sedwick et al,19 1997 227/323 NS STE; 250 and 500 Hz NS 11.9/6.9b
Cremers et al,20 1991 150/161 NS — — 2.1/0.6
Quaranta et al,21 2005 72/79 NS STO; 4 kHz — 1.4/1.3
Spandow et al,22 2000 60/55 — — — 5/0
Levy et al,23 1990 50/50 — STO NS 0/0
Vasama et al,24 2006 47/47 NS NS — 0/0
Pedersen & Elbrønd,25 1983 30/30 STO; 4 and 8 kHz NS — 0/0

Abbreviations: NS, no statistical difference; SNHL, sensorineural hearing loss; STE, stapedectomy; STO, stapedotomy.
a
A 15 dB BC decrease.
b
A 10 dB BC decrease.
 Stapedectomy Versus Stapedotomy 5

House and colleagues10 performed an in-depth study of the surgical outcomes of their
patients who had undergone stapedectomy and stapedotomy procedures. Stapedec-
tomy was defined as removal of 25% or more of the footplate. One hundred thirty-four
stapedectomy cases were compared against 75 stapedotomy cases. At early
follow-up between 3 and 12 months, the improvement in pure tone average (PTA) of
the air–bone gap was 16.9 dB for stapedectomy and 16.4 dB for stapedotomy. No dif-
ferences were found in PTA and speech discrimination score between the groups.
The percentage of patients with an air–bone gap closure to within 10 dB per frequency
showed no significant difference except at 4 kHz, where the stapedotomy group demon-
strated a higher closure rate. A unique aspect of this study was the subgroup comparison
of 42 patients who had both procedures performed, stapedectomy in 1 ear and stape-
dotomy in the other, for bilateral otosclerosis. Thus, each patient acted as self-control,
although stapedectomy was performed as the first surgery in all cases, so there may
have been learning bias favoring the stapedotomy. Similar findings with no significant
difference in PTA were found for all paired cases. Improvement of air–bone gap at
4 kHz was once again noted for stapedotomy group reaching statistical significance.
Fisch11 conducted a similar study with 340 cases equally divided among 2 groups.
Both total and partial stapedectomy were included under the stapedectomy group.
Stapedotomy was performed using the 0.6-mm diameter prosthesis. Air–bone gap
measurements at 0.5 to 2 kHz and 4 kHz were calculated. The percentage of patients
achieving air–bone gap closure to within 10 dB at 1 year was 54% for stapedectomy
and 58% for stapedotomy. There was no significant difference for the 0.5 to 2 kHz
range at 3 weeks to 3 years. However, the stapedotomy group performed significantly
better at 4 kHz at 1 year follow-up. This study also included further discussion and
analysis of stapedotomy using a 0.4-mm diameter prosthesis. The impact of pros-
thesis diameter on hearing outcome is discussed elsewhere in this article.
Colletti and Fiorino12 published a large surgical series comparing stapedectomy and
stapedotomy, with additional analysis performed on stapedius tendon preservation
within the stapedotomy group. They reviewed 1459 cases consisting of 428 stapedec-
tomies, 561 stapedotomies with stapedius tendon section, and 470 stapedotomies in
which they preserved the incudostapedial joint and stapes head and neck, keeping the
tendon attached. Audiometric results at 0.5 to 2 kHz, 4 kHz, and 8 kHz were analyzed
6 months after surgery. The result showed stapedectomy achieving a slightly higher
rate of air–bone gap closure at 0.5 to 2 kHz, although this difference did not attain sta-
tistical significance. The converse is true with a stapedotomy air–bone gap closure
performing better at 4 kHz, although this difference was not statistically significant.
Air conduction at 8 kHz was found to be significantly better for the stapedotomy
group. Thirty subjects in each group were chosen randomly to undergo speech audi-
ometry 1 to 2 years after surgery. With ipsilateral masking, there was a statistically sig-
nificant decrease in speech discrimination scores in the stapedectomy group
compared with the stapedotomy group. A subgroup analysis of the stapedotomy
cohort showed that those with stapedius tendon preservation performed better still.
Somers and colleagues13 published an in-depth statistical analysis of otosclerosis
surgery performed by Jean Marquet, who pioneered the stapedotomy procedure. A
total of 1681 surgical procedures were included in the analysis. Total stapedectomy,
partial stapedectomy, and stapedotomy accounted for 4.1%, 5.8%, and 85% of the
cases, respectively. At the follow-up period of 6 to 12 months, the stapedotomy group
demonstrated better postoperative air conduction with statistical significance
compared with both the partial and total stapedectomy groups at 4 kHz, and over
the total stapedectomy group at 8 kHz. Clearly, however, with the vast majority being
stapedotomy cases, practice bias must be considered in the results.
6 Cheng et al

Bailey and colleagues14 compared the results of stapedectomy and stapedotomy in

100 patients randomized into the 2 surgical arms. The short-term results from 1 to
12 months demonstrated significant improvement in the stapedotomy group in terms
of postoperative air conduction at 2, 4, and 8 kHz. The percentage of air–bone gap
closure was also superior in the stapedotomy group at 4 kHz. The mean speech
discrimination score was increased by 11.8% in the stapedotomy group, whereas a
slight decrease of 0.4% was observed in the stapedectomy group.
McGee15 reviewed his surgical series consisting of 280 total cases of stapedec-
tomy and stapedotomy. At 6 months of follow-up, the percentages of air–bone
gap closures to within 10 dB over the 0.5 to 2.0 kHz frequency range were 85.8%
for the stapedectomy group and 96.4% for the stapedotomy group. Additionally,
only 83.7% of stapedectomy patients achieved a speech discrimination score within
10% or better of preoperative score, compared with 92.8% of patients in stapedot-
omy patients. The differences in the air–bone gap and speech audiometry were sta-
tistically significant.
Moon and Hahn16 performed a similar study with 106 cases of stapedectomy and
264 cases of stapedotomy. In this study, stapedectomy was defined as greater than
50% of footplate removal. At the 6-month follow-up, the gain in air conduction in
the stapedotomy group demonstrated significant improvement over its counterpart
at 2, 4, and 8 kHz. The percentage of air–bone gap closure in the stapedotomy group
was also significantly higher than the stapedectomy group at 1 to 4 kHz range, and at
4 kHz. The percentage of patients with better or same speech discrimination scores
was 83% for stapedectomy, compared with 95% for stapedotomy.
Persson and colleagues17 published a detailed analysis comparing total stapedec-
tomy (n 5 205), partial stapedectomy (n 5 70), and stapedotomy (n 5 162). A stainless
steel wire prosthesis (House wire) and fascia to cover the oval window was used for
stapedectomy, whereas a 0.4-mm Teflon-platinum piston (Fisch piston) without a graft
was used for stapedotomy. At the 1-year follow-up, the gain in PTA was greater in both
the total and partial stapedectomy cohorts compared with the stapedotomy proced-
ure. The air–bone gap showed better performance of stapedectomy, except at 4 kHz.
The overall rates of air–bone gap closure to within 10 dB were 94.0% with total stape-
dectomy, 83.9% with partial stapedectomy, and 82.8% with stapedotomy. The au-
thors also observed a statistically significant improvement of postoperative bone
conduction in favor of the stapedectomy groups at frequencies lower than 4 kHz.
Kos and colleagues18 analyzed a series of 51 cases of stapedectomy with 553
cases of stapedotomy. The surgical series included operations by 19 surgeons
including residents. At 6 weeks of follow-up, the percentages of patients achieving
air–bone gap closure within 10 dB was comparable between the groups.
Sedwick and colleagues19 compared a series of 227 stapedectomy and 323 stape-
dotomy procedures from the House ear clinic. At 4 months of follow-up, the percent-
ages of air–bone gap closure over 0.5 to 2.0 kHz were similar with 78.7% for
stapedectomy and 77.8% for stapedotomy. However, the rate of air–bone gap closure
was statistically higher at 250 and 500 Hz for the stapedectomy group.
Cremers and colleagues20 analyzed a series of 311 primary operations for otoscle-
rosis consisting of 48 total stapedectomy, 102 partial stapedectomy, and 161 stape-
dotomy procedures. In addition, a subgroup of 114 cases, 38 from each of the
operative techniques, were carefully matched for patient characteristics, clinical
type of otosclerosis, and prosthesis design and selected for further analysis. No sig-
nificant difference was noted in the overall patient groups in terms of PTA at the 6- to
12-month follow-up. However, the matched subgroup analysis showed the total sta-
pedectomy group was outperformed by both of the 2 other groups with a statistically
 Stapedectomy Versus Stapedotomy 7

significant difference of 7.4 dB in mean hearing gain. No significant difference in

hearing gain was observed between the stapedotomy and partial stapedectomy
groups.
The following are the key findings from several smaller studies. Quaranta and col-
leagues21 compared the results of 72 partial stapedectomy with 79 stapedotomy pro-
cedures. At the 6-week follow-up, the percentage of air–bone gap closure did not
reveal any statistical difference. However, the proportion of air–bone gap closure
achieved statistical significance at 4 kHz with superior result for the stapedotomy
group. The change in air–bone gap was also compared, and it showed statistically sig-
nificant superior results in the stapedotomy group at 2, 3, and 4 kHz. In addition, the
mean postoperative change in bone conduction over 1, 2, and 4 kHz was significant,
showing an improvement of bone conduction for the stapedotomy group. Spandow
and colleagues22 compared 60 stapedectomy with 55 stapedotomy procedures.
The results of air conduction and residual air–bone gap pointed to superior perfor-
mance of the stapedotomy group, especially in the high-frequency range. Levy and
colleagues23 reported the results from 100 procedures with 50 cases from each pro-
cedure randomly selected from their case archive. At the 8-week follow-up, the per-
centage of patients with air–bone gap closure to within 10 dB was 92% for
stapedotomy and 68% for stapedectomy. This difference was statistically significant.
No statistical difference was noted in speech discrimination. Vasama and col-
leagues24 conducted a study with 47 stapedectomies and 47 stapedotomies. There
were no statistically significant differences in terms of PTA for air conduction, PTA
for bone conduction, or percentage of patients with an air–bone gap closure between
groups. Pedersen and Elbrønd25 compared the outcome of 60 procedures, 30 of
which were done using a stapedectomy technique with the House prosthesis and
30 using a stapedotomy using the Fisch prosthesis. By analyzing the data at 3 weeks
and 3 months, a statistically significant improvement of postoperative hearing was
noted at 4 and 8 kHz in the stapedotomy group compared with the stapedectomy
cohort. Moreover, improvement in the air–bone gap was noted to be superior in the
stapedotomy group at 4 kHz, although the P value was not reported. Esquivel and col-
leagues26 analyzed a series of 17 stapedectomy and 18 stapedotomy procedures. At
the initial 6- to 12-month follow-up of this long-term study, the PTA of air conduction
was compared between groups and no statistical significance was detected.
The body of literature suggests that both stapedectomy and stapedotomy provide
excellent outcomes in addressing conductive hearing loss owing to otosclerosis. In
most studies, stapedotomy using a 0.6-mm diameter prosthesis provides superior
audiometric responses and air–bone gap closures in the higher frequencies. The
restoration of high-frequency hearing is thought to have a direct impact on improved
speech discrimination.14,15 However, these findings are all based on case series ana-
lyses. There are currently no studies with a high level of evidence to support these ob-
servations in an unequivocal manner.

Long-Term Results
Shea,27 the pioneer of the stapedectomy procedure, published his long-term results
comparing stapedectomy versus stapedotomy in 200 patients, 100 from each cohort.
Patients, were randomly selected for long-term audiometric analysis. The percentages
of air–bone gap closure and further cochlear loss were found to be stable over the
period of 5 to 15 years in stapedectomy, and from 5 to 20 years in stapedotomy.
Key findings about the stability of both stapedectomy and stapedotomy from other
relevant long-term studies are summarized in Table 2. There remain disagreements in
terms of which of the 2 procedures provides better long-term outcome. However, the
 8
Cheng et al
Table 2
Long-term outcome differences for STE and STO

Pure Tone Audio

(Technique with Better Air–Bone Gap (Technique with
Follow-up Period Outcome at Listed Better Outcome at Listed Speech Discrimination
Number STE/STO STE/STO (y) Frequencies) Frequencies) Results
Colletti & Fiorino,12 1984 188/191 10/10 — STO; 4 kHz —
McGee,15 1981 22/18 at 4 y 7/7 — STO (years 4–6) STO (years 4–7)
22/20 at 5 y NS (year 7)
26/24 at 6 y
5/11 at 7 y
Spandow et al,22 2000 60/55 5/5 STO; 4 and 6 kHz STO; 0.5–3 kHz —
Kürsten et al,28 1994 22/35 9.3/6.2 STO; 4 kHz — —
House et al,10 2002 134/75 11.5/6.0 NS; 0.5–2 kHz NS NS
STO; 4 kHz
House et al,10 2002 42/42a 10.4/6.8 NS NS —
26
Esquivel et al, 2002 17/18 7.6/7 NS NS —
Kos et al,18 2001 41/400 7/7 — NS —

Abbreviations: NS, no statistical difference; STE, stapedectomy; STO, stapedotomy.

a
Patients with stapedectomy in 1 ear and stapedotomy in the other ear.
 Stapedectomy Versus Stapedotomy 9

long-term stability of the 2 approaches has been unambiguously demonstrated in the

studies included in Table 2.

Stapedotomy Long-Term Superiority

Colletti and Fiorino12 reviewed their surgical series with a follow-up period of 10 years.
The percentage of patients with air–bone gap closure to within 10 dB remains equiv-
alent between the groups in the 0.5 to 2.0 kHz range. However, a statistically signifi-
cant difference at 4 kHz was noted with a better air–bone gap closure rate in the
stapedotomy group. The difference was approximately 20%. This result is consistent
with the series by the same group at a 5-year follow-up interval,29 demonstrating a sta-
ble trajectory over the long term.
McGee15 reported his series of 280 patients with long-term data of 7 years.
Comparing the percentage of patients with air–bone gap closure to within 10 dB,
the group of patients undergoing stapedotomy performed better (P<.05) compared
with the group that had undergone stapedectomy at years 4 to 6. The stapedotomy
group also performed better in speech discrimination between years 4 and 7. Similar
results showing the improvement of air conduction in stapedotomy over stapedec-
tomy was demonstrated by Spandow and colleagues.22 In their series of 115 patients
over a period of 5 to 10 years of long-term follow-up, improved audiometric outcomes
in the stapedotomy group was noted in the high frequencies. Kürsten and col-
leagues28 drew similar conclusions with their study of 57 patients. The mean
follow-up duration was 6.2 years for stapedotomy and 9.3 years for stapedectomy.
The 2 surgical groups had similar long-term results in 0.5 to 2.0 kHz, but an improved
outcome at 4 kHz in the stapedotomy group. Consistent in all the studies mentioned
was the stability of the long-term outcomes for both stapedectomy and stapedotomy.

No Difference Between Stapedectomy and Stapedotomy

House and colleagues10 noted no statistical differences in PTA at the 0.5 to 2 kHz, air–
bone gap, and speech discrimination in their long-term surgical series of 209 patients.
The only result with statistically significant difference was for air conduction at 4 kHz,
with a superior performance of the stapedotomy group. However, this observation
might be influenced by the difference in late follow-up period of 11.5 years in the sta-
pedectomy compared with only 6 years in the stapedotomy group. A further subgroup
analysis of 42 patients who had received stapedectomy in one ear and stapedotomy in
the other ear again failed to demonstrate any significant difference in PTA, air–bone
gap, and speech discrimination in the long term. Esquivel and colleagues26 conducted
a long-term study with 34 patients. The mean follow-up duration was 7.6 years for sta-
pedectomy and 7 years for stapedotomy. The stability of the hearing results from both
groups was maintained over the study duration, and no statistical difference in hearing
deterioration rate between the 2 groups was found. Kos and colleagues18 analyzed the
long-term results from their series consisting of 41 stapedectomy and 400 stapedot-
omy procedures. The follow-up duration ranged between 1 and 21 years with a mean
of 7 years. They found no difference between groups in terms of percentage air–bone
gap closure at 0.5 to 2.0 kHz.
In summary, all the studies reviewed consistently demonstrate stable long-term
hearing results for both stapedectomy and stapedotomy, although overall stapedot-
omy provided better long-term audiometric results, especially in the high-frequency
range. It should always be kept in mind that, over the long term, bone conduction
thresholds, and in turn air conduction thresholds will deteriorate in most otosclerotic
ears with or without stapes surgery compared with normal ears because of the dis-
ease’s effect on the cochlea.
10 Cheng et al

SENSORINEURAL HEARING LOSS

Although the majority of patients with otosclerosis achieve a good outcome after stape-
dectomy and stapedotomy, some unfortunately suffer early and/or late complications. A
detailed account on the complications of otosclerosis surgery is beyond the scope of this
article; a limited review of sensorineural hearing loss based on the studies included is
provided instead. Most authors defined sensorineural hearing loss as a more than
20-dB decrease in postoperative bone conduction, although other definitions have
also been used. The rates of sensorineural hearing loss for the studies reviewed are sum-
marized in Table 1. Sensorineural hearing loss of 20 dB or more occurred in approxi-
mately 6% of the stapedectomy procedures in the series by Bailey and coworkers14
and Kos and associates.18 The rate of sensorineural hearing loss was lower for stapedot-
omy at 2.0% and 3.1%, respectively. Results by Fisch,11 Somers and associates,13
Cremers and colleagues,20 and Spandow and coworkers22 also demonstrated the
higher rate of sensorineural hearing loss with stapedectomy. Results from House and
colleagues10 and Sedwick and associates19 provided additional information about the
rate of sensorineural hearing loss with 10 dB or more. Based on these 2 studies, the
rate of sensorineural hearing loss with a 10-dB or greater decrease occurred in 9.8%
to 11.9% for stapedectomy, and 5.9% to 6.9% for stapedotomy. Overall, higher rates
of sensorineural hearing loss are observed in stapedectomy compared with stapedot-
omy. One potential explanation of this phenomenon is the greater mechanical trauma
on the inner ear structures during footplate manipulation and removal.
Mann and colleagues30 performed a careful review of their surgical series involving
1229 cases, including 691 stapedectomies, 234 stapedotomies, and 304 revision pro-
cedures. Twenty cases of moderate to severe sensorineural hearing loss with a greater
than 40-dB decrease in bone conduction were identified and underwent to careful
analysis. Some of the factors identified as potential causes of hearing deterioration
including revision status, increased intraoperative bleeding, and obliterative otoscle-
rosis requiring significant drilling were deemed unmodifiable. However, postoperative
acute otitis media was identified as a potentially modifiable cause of sensorineural
hearing loss. The authors have, therefore, advocated for routine perioperative anti-
biotic prophylaxis in stapes surgery.

ASPECTS OF STAPES SURGERY

Prosthesis Size
A key consideration in stapedotomy is the size of prosthesis. The diameter of the pros-
thesis is thought to have an integral role in the outcome. The overall size could also
influence surgical approach. For instance, Fisch11 proposed a technique consisting
of reversal of the classic steps of stapedectomy made possible by the smaller
0.4-mm piston. Throughout the evolution of stapes surgery, different surgeons had
proposed different-sized prosthesis as being the optimal design. Those who favored
the larger diameter piston pointed to larger surface area of contact and theoretic
benefit in the transmission of mechanical energy. However, those who advocate for
a smaller diameter claimed that a smaller prosthesis induces less trauma to the inner
ear,31 and that the smaller size may allow modification of surgical approach to improve
stability and improved safety.11 Numerous experimental studies have been performed
to model the biomechanics of stapes surgery. An excellent summary of this body of
literature was captured in a review article by Hüttenbrink.32
Despite all the elegant models proposed by the scientists, the restoration of hearing
remains the gold standard for surgical success. Using this as the metric, Laske and
colleagues33 conducted a metaanalysis on the outcome of stapedotomy procedures
 Stapedectomy Versus Stapedotomy 11

based on prosthesis diameter. Five controlled studies11,34–37 consisting of 590 cases

were selected for the metaanalysis comparing the surgical outcomes between
0.4-mm and 0.6-mm diameter prosthesis. In these studies, success was defined
as closure of air–bone gap to less than 10 dB. The success rate was 67% for a
0.6-mm diameter prosthesis versus 58% for a 0.4-mm diameter prosthesis, achieving
statistical significance of P 5 .05. Further analysis of the odds ratio was performed
with events defined as surgical success and exposure defined as a 0.4-mm diameter
prosthesis usage. The overall odds ratio of the metaanalysis was 0.68 (95% confi-
dence interval, 0.46–1.00), indicating that exposure to a 0.4-mm diameter prosthesis
is associated with lower odds of surgical success. The results show that a 0.6-mm
diameter prostheses are associated with a higher success rate.
Laske and colleagues33 also performed a pooled data analysis consisting of 62
studies with 9536 cases. The analysis revealed that a 0.6-mm prosthesis was used
in 58.8% and a 0.4-mm prosthesis in 34.4% of cases. In contrast, the combined num-
ber of 0.3-mm, 0.5-mm, and 0.8-mm prostheses accounted for only 6.9% of the total
cases. The small number of 0.3-mm, 0.5-mm, and 0.8-mm diameter prosthesis groups
were too small to reach statistical significance in subsequent analyses. The 0.6-mm
diameter prosthesis group once again demonstrated significantly higher success
rate of 81.1% compared with 75.1% in the 0.4-mm diameter prosthesis group. Further
analysis of air–bone gap per frequencies shows statistical significance at 0.5, 1, and
2 kHz between groups. No statistical difference was observed at 0.25 and 4 kHz. A
potential selection bias within studies could influence study outcomes. For instance,
a 0.4-mm diameter prosthesis might have been selected preferentially in cases with
difficult anatomy.
Based on the results from this metaanalysis and the pooled data analysis, the use of
a 0.6-mm diameter prosthesis was associated with a higher rate of surgical success.
However, this conclusion must be interpreted with the view that no randomized
controlled trial on this topic has been conducted to date.

General Versus Local Anesthesia

The anesthetic used for stapes surgery is another factor to be considered. Both mo-
dalities offer unique benefits and drawbacks.38 Stapes surgery is suitable for condi-
tions provided by local anesthetic mainly owing to the limited surgical field. The
most commonly used agent is 1% to 2% lidocaine with 1:100,000 epinephrine injec-
tion. Most patients are able to tolerate the procedure with local anesthesia alone, but
some surgeons prefer additional intravenous sedation to achieve greater patient com-
fort. The main advantage of performing the surgery under local anesthesia is the
immediacy of feedback from patients during prosthesis placement. Improvements
in hearing can be with from patient feedback. Tuning fork examination can also be
done to confirm improvement of conductive hearing loss. Patient report of vestibular
symptoms can also alert surgeons during the footplate manipulation39 or prosthesis
insertion. Corrective maneuvers such as reducing further footplate manipulation or
reducing the length of the prosthesis can be attempted to minimize the risks. In addi-
tion, local anesthetic also reduces the theoretic risk of prosthesis displacement during
emergence from general anesthesia.
One major drawback of performing local anesthetic is the limited duration of action
by the anesthetic agent. Lidocaine with epinephrine mixture has a duration of 2 to
6 hours depending on the volume and concentration infused, the location of adminis-
tration, and tissue pH.40 This finding was further characterized in a study by Collins
and colleagues,41 whereby the onset and duration of local anesthetic agents were
tested intradermally. The duration of 1% lidocaine with 1:100,000 epinephrine was
12 Cheng et al

found to have a range of 3.22 to 10.32 hours with a mean of 6.63 hours. The surgeon
must be able to finish the entire surgery within this time frame, which could be stressful
in difficult cases. Patients under local anesthesia need to cooperate throughout the
entire case by laying still. They might become physically or emotionally distressed
from the experience despite the surgeon’s and anesthesiologist’s best efforts.
General anesthesia is superior in terms of control over the depth and duration of
anesthesia. Stillness of the surgical field can be achieved with use of paralytic agents.
The senior author had a case under local anesthesia in which the patient sat up during
the crucial footplate drilling. The drill entered the inner ear leading to a profound
sensorineural hearing loss. Postoperative amnesia and patient comfort are also key
considerations. However, the surgeon loses direct feedback from patient under gen-
eral anesthesia. There are also increased overall risks of general anesthesia, although
these risks are very low compared with the early years of stapes surgery because of
safer anesthetic agents and techniques for securing airways.
In a systematic review by Wegner and colleagues,42 3 studies with a total of 417 pro-
cedures were selected to compare the effect of anesthesia on surgical outcomes. The
pooled analysis did not demonstrate any statistically significant differences in postop-
erative air–bone gap, rate of sensorineural hearing loss, or vertigo between the 2 anes-
thetic approaches. One of the 3 studies found a statistically significant difference in the
incidence of postoperative dead ear with 1.87% in the general anesthesia group
compared with 0% in the local anesthesia group.39
Overall, it seems that there is no significant surgical outcome difference attributable
to the anesthetic administered. From a practical logistic perspective, it seems
self-evident that cases done under local anesthesia will be faster, with quicker turn-
overs between cases. However, cases done under local anesthesia may be more
stressful not just for the patient, but also the surgeon, depending on the degree and
type of associated conscious sedation. In many institutions, anesthesiologists admin-
ister the sedation, and their protocols can vary widely. Surgeons should work together
with the anesthesiologists in determining the optimal approach specific to their expe-
riences and skill sets to achieve the best possible surgical outcomes.

MODIFIED STAPES MOBILIZATION PROCEDURES

Since the original discovery of hearing restoration from stapes mobilization by Rosen,3
attempts at mobilization of the stapes have been made with varying degrees of suc-
cess. The theoretic advantage of restoring the body’s native ossicular chain and
avoiding the use of prostheses is intrinsically appealing. However, the long-term pres-
ervation of hearing gain in the era of stapes mobilization was limited by recurrent anky-
losis of the stapes footplate. It was discovered that patients with otosclerotic foci
limited to the anterior aspects of the footplate along with a fracture of the footplate
outside of the foci had longer lasting hearing improvement.43 Several novel proced-
ures were devised to achieve this result. These procedures all involved resection of
the anterior crus and isolation of the otosclerotic focus. The isolation was achieved
by intentional fracturing of the footplate by some, and partial stapedectomy by others.
Although some investigators simply mobilized the posterior segment, others elected
to remove the entire footplate and interposed a piece of tragal perichondrium between
the posterior crus and the oval window. These procedures were technically chal-
lenging owing to the limited exposure with poor optics at the time and challenges
discerning the diseased structures from those that were to be intentionally left intact.
After the invention of stapedectomy by Shea, its simplicity, superior results, and
long-term stability soon made stapes mobilization obsolete.
 Stapedectomy Versus Stapedotomy 13

In the last 2 decades, some surgeons have returned to the concept of stapes mobi-
lization. Key technological breakthroughs that enabled these attempts include use of
the laser in stapes surgery, fiberoptic delivery of laser energy, and the high-resolution
otoendoscope. Using these technologies, stapes mobilization can be performed as a
minimally invasive procedure. Silverstein and coworkers36 described the laser stape-
dotomy minus prosthesis (laser STAMP) operation and its preliminary outcomes in
1998. Poe43 published the result of his investigative work and prospective study of
laser stapedioplasty in 2000. The basic concept and goals of the 2 surgical
approaches were similar: to mobilize and isolate the posterior crus and posterior
segment of the footplate using precise surgical techniques and instrumentations.
Patient selection was paramount in ensuring surgical success. The otosclerotic foci
must be limited to the anterior footplate. A thin blue footplate with proper visualization
must be present for separation of the posterior footplate from its anterior otosclerotic
foci. In laser STAMP, an Argon laser was used to vaporize the anterior crus via an
endoprobe. Visualization was provided by either microscopy or otoendoscopy. The
laser was also used to divide the anterior and posterior segments of the footplate,
leaving a 0.5-mm gap. In laser stapedioplasty, a prototype Argon laser endoscope
was used to provide visualization as well as instrumentation in the small surgical field.
Because the suitability for a minimally invasive procedure was determined intraoper-
atively, all patients were counseled for possible stapedotomy. In the prospective study
by Poe, 11 of the 34 patients were deemed suitable for laser stapedioplasty, whereas
the remaining 68% of patients underwent conventional stapedotomy.
The initial results from these 2 procedures were promising. In the laser stapedio-
plasty study, the postoperative results of laser stapedioplasty and stapedotomy in
the control arms showed no statistically significant differences. Both groups achieved
a mean air–bone gap closure to less than 10 dB at 6 weeks after surgery.43 From the
first 12 patients who had undergone the laser STAMP procedure, the postoperative
mean air–bone gap improved significantly by 17.4 dB.44 None of the patients who
had undergone the laser STAMP procedure developed hyperacusis. This was thought
to be due to the preservation of the stapedius tendon and hence the acoustic reflex.
Additionally, the laser STAMP procedure demonstrated statistically significant
improvement in the 6 to 8 kHz range compared with laser stapedotomy.45
The rate of refixation was also investigated by Silverstein and colleagues.46 Over a
follow-up interval of 5 to 53 months (mean, 25.6 months), only 1 of the 46 patients who
had undergone the laser STAMP procedure developed worsening of conductive hear-
ing consistent with refixation.46 A subsequent long-term study47 of 43 patients
showed that only 3 patients developed refixation over a 12- to 140-month follow-up
(median, 33 months). All 3 patients were successfully revised with stapedotomy
with 1 revision performed 12 years after the laser STAMP procedure.
The development of modified mobilization prosthesis-free procedures may repre-
sent yet another breakthrough in the surgical management of otosclerosis. These
novel approaches have been shown to provide good hearing outcome in a selected
group of patients. It was estimated that these approaches could be used in 45% to
50% of all cases of otosclerosis cases requiring surgery.44 Further studies to address
preoperative patient selection as well as to confirm the long-term stability would
further advance this exciting area of innovation.

“HOW I DO IT”

Stapes surgery is a technically challenging operation with little margin for error. It has
undergone a fascinating evolution since its inception by Dr John Shea in 1956. Major
14 Cheng et al

advancements have included the development of micro drills, the use of various la-
sers, variations in prostheses materials and styles, and, perhaps most important,
much improved visualization with brighter, clearer microscopes and most recently
with rigid endoscopes.
Back in its heyday in the 1960s through the 1980s there was such a huge backlog of
patients, the surgery went under the purview of most community otolaryngologists.
Now that the procedure is much less commonly performed, for the younger generation
of surgeons it has almost become an otologic subspecialty procedure. Our informal
survey of fellowship-trained otologists in Canada suggests that an annual of volume
of at least 10 cases is required to maintain skills, maximize results, and minimize
complications.
There are many variations of the technique, instruments, and prostheses. Each can
be very effective in different hands depending on the experience of the surgeon. The
following is a synopsis of how this author (LSP) performs a stapedotomy with pros-
thesis. Patients must meet audiological criteria and have no general or regional anes-
thetic contraindications. I perform primary stapes surgery under general anesthesia.
For most revision cases, and in some special circumstances, I operate using local
anesthesia with conscious sedation.
Almost all my cases are done as day surgery. I work in a teaching hospital and have
residents partake in my cases. Each case is scheduled for 1.5 hours, including turn-
around time. Patients are typically discharged home 2 to 3 hours after the procedure.
I do not routinely use perioperative antibiotics or corticosteroids. Patients are posi-
tioned supine on the operating table with the head turned away from the operative
ear. The head is placed in a ring headrest in a laterally flexed position to angle the
ear canal away from the shoulder.
The description of the surgery that follows is accompanied by a video (Video 1). I use
povidone-iodine 7.5% to prep the pinna and periauricular skin, but do not take any ex-
tra measures to prep the deeper ear canal or tympanic membrane. I inject the ear ca-
nal skin inferiorly, posteriorly, and anteriorly with 1% lidocaine in 1:40,000 adrenaline
with a 26-G 1.5-inch needle on a 1-mL tuberculin syringe. Injections require no more
than a total of 1.0 to 1.5 mL of local anesthesia. Slow, gentle injections are crucial to
prevent blebs in the canal skin and to ensure medial diffusion for hemostasis along the
entire incisions.
I always work through a speculum. I freehand the speculum for the first part of the
case, but then secure it in a speculum holder once I have maximized the exposure. It is
always best to fit in the largest diameter speculum to maintain its stability and maxi-
mize exposure. The minimum working diameter speculum is 5 mm, but 8 mm is ideal.
I make the superior and inferior canal incisions with a sagittal roller knife and join
them horizontally with a triangle knife, making the flap about 6 mm in length. I elevate
the meatal flap evenly throughout its width with a McCabe flap knife elevator so that
the flap falls forward onto the tympanic membrane before I enter the middle ear.
Before elevating the annulus, I enter the middle ear superiorly near the notch of Rivinus
to identify the chorda tympani. I divide the mucosa and find the top of the annulus, and
then bluntly elevate it inferiorly out of its sulcus with the flap knife down to the bottom
end of the incision.
Not uncommonly, ear canal tortuosity can obscure the inferior exposure so that
some of the flap elevation has to be done blindly. This highlights the importance of
elevating in the proper plane under the annulus so as to not tear the flap or tympanic
membrane. After its elevation, the tympanomeatal flap is folded forward at the malleus
attachment to expose the entire posterior one-half of the middle ear. The incus and
stapes are identified and palpated with a Rosen needle or equivalent before curetting
 Stapedectomy Versus Stapedotomy 15

the bone. A fixed stapes with a mobile lateral chain confirms the diagnosis, as does the
observation of white otosclerotic bone anterior to the footplate at the fissula ante
fenestrum.
In most cases, posterior/superior ear canal bone needs to be excavated to improve
exposure. Although some use a drill for this part, I always use a small sharp bone
curette. The curetting action should be away from the chorda tympani and ossicles.
All attempts should be made to preserve the chorda and not stretch it, which means
working around the chorda without retracting it. Required exposure includes the pyra-
midal process and stapedius tendon posteriorly, the facial nerve canal superiorly, and
the anterior footplate anteriorly.
After maximizing the exposure, I secure the speculum in the speculum holder.
I separate the incudostapedial joint using a 45 pick with great care to not rock the sta-
pes so as to not mobilize the footplate. I cut the stapedius tendon with small Bellucci
scissors. I do not use a laser in my practice and I do not create a control hole in the
footplate. Thus, my next step is to down fracture the superstructure toward the prom-
ontory with a 45 pick. So as to not avulse the chorda, the pick is inserted inferior to the
chorda and then up under the stapes neck. The suprastructure is flicked off the foot-
plate, as opposed to pushed off the footplate, to minimize the chances of footplate
mobilization.
I use a prosthesis with a 0.6-mm piston diameter. Thus, I create a stapedotomy with
a 0.8-mm diameter stapedotomy with a diamond drill bit on the Skeeter drill. The wider
opening accommodates a piston angle that is not orthogonal to the footplate. Ideally,
the opening is centered in the footplate, although sometimes its location must be
altered by limitations in the overall exposure or local factors like a facial nerve canal
overhang. For a typical thin footplate, very little drilling is required to create the
fenestra. Visual and tactile feedback determines the right amount of pressure. Once
the vestibule is open, great care must be taken to not aspirate perilymph. This occur-
rence is best prevented by using a 24-G suction with thumb off the thumb plate hole
when removing the fluid from around or over the stapedotomy.
I do not routinely measure the distance from footplate to incus. In the majority of
cases I use a 4.5-mm long piston prosthesis. I use a De La Cruz style piston because
it has the shortest piston segment at 1.27 mm, making it easy to determine how
much of the piston is lateral and medial to the footplate. I prefer the Eclipse pros-
thesis (Grace Medical, Memphis, TN) made with a Teflon piston and nitinol wire
that can be hand or heat crimped. The crimped wire should be secure enough to
not fall off the incus but not be constrictively tight. After crimping, the incus should
be gently balloted to ensure free movement of the piston in the stapedotomy. I do
not routinely place tissue under or around the prosthesis unless the stapedotomy
is inadvertently made too large. In these latter instances, I typically use a blood patch
acquired by venopuncture by the anesthesiologist, which I instill with a 26-G needle
on the tuberculin syringe.
I carefully reposition the tympanomeatal flap and pack the canal by injecting a paste
made from Gelfoam powder, saline, and antibiotic ointment through a 16-G blunt nee-
dle loaded onto a 3-mL syringe. Patients are seen about 9 or 10 days postoperatively
for follow-up to remove the packing and then about 2 to 3 months later for follow-up
audiometric testing.

SUMMARY

Stapedectomy and stapedotomy represent the state-of-the-art surgical procedures in

addressing the conductive hearing loss caused by otosclerosis. Their high rates of
16 Cheng et al

success and long-term stability have been demonstrated repeatedly in many studies.
In comparing the short- and long-term results of the 2 procedures, it is evident that
stapedotomy confers better hearing gain at the high frequencies as well as lower
complication rates. Over time, many innovations by otologists have further improved
the surgical outcomes and led to dramatic improvements in patent’s quality of life.
Modified stapes mobilization approaches may represent the next major development
in stapes surgery in a select patient population.

SUPPLEMENTARY DATA

Supplementary data related to this article can be found online at https://doi.org/10.

1016/j.otc.2017.11.008.

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