STAPEDECTOMY Atypical Surgical Situations

© Bruce Black MD

1. Congenital deformity, right ear. The horizontal facial nerve lies inferior to the stapes, occluding access to the

oval window. Case abandoned. © Bruce Black MD

Detail of image 1.

© Bruce Black MD

1. Congenital deformity, left ear. The horizontal facial nerve overlies much of the oval window. The incus is intact but

the crura of the stapes superstructure are absent. © Bruce Black MD

2. Detail of prevous image. the stapedius tendon lies lateral to the nerve. The edge of the oval widow is just evident

superiorly. © Bruce Black MD

3. A very limited stapedotomy has been created manually, just above the VII, and a Teflon-platinum piston inserted,

avoiding pressure on the nerve. © Bruce Black MD

4. Malleus-oval window reconstruction, when the stapes is fixed and the incus absent. The key is to create a large

pocket along the malleus handle, to permit piston fixation. © Bruce Black MD

An absent or insufficient incus (congenital or past disease)requires alternative reconstruction methods.

© Bruce Black MD

Illustration by courtesy Robt Jackler MD

Malleus-oval window technique, partial stapedectomy. The handle periosteum is incised along the posterior aspect

(Kley knife, Storz Gmb). © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Elevation of the drum and periosteum off the handle, from the lateral process to the umbo, where the drum is firmly

attached. Creation of a large pocket is an essential. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Insertion of a (Sheehy IRP) wire prosthesis into the pocket, facilitated by the larger pocket size. With direct angulation,

a 5-5.5 mm Teflon-platinum piston serves well. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Attaching a wire loop tho the handle. Wire has “memory” and may skid off instruments. A platinum loop minimises

these difficulties and is easier to crimp into position. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Greater angulation requires an indirect strut. Angling wire in situ is challenging, and often best performed before

insertion, after careful assessment of the angle. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Common angulation difficulties. With the often direct angulation (Rt), a direct piston serves well, but requires

simultaneous insertion into both pocket and stapedotomy. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Malleus-oval window wire in situ. With a partial stapedectomy, a fine tissue sheet is desirable to seal the

window and avoid fistulae. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Fibro-fat or cement, used to prevent bio-reactions between wire and drum. Tissue may resorb, and cement may

impede wire removal. A fine cartilage sliver is preferred. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

1. Congenital deformity, right ear. The long process of an undersized incus is absent (left), as is the stapes. A tiny

oval widow is seen to the right of the horizontal facial nerve. © Bruce Black MD

2. A small micro-drill stapedotomy has been created at the window site.

© Bruce Black MD

3. Creation of an ample malleolar pocket, from the lateral process to the umbo. The drum is firmly attached at the

latter. © Bruce Black MD

4. A 5.0 mm Richards Teflon-platinum piston has been sited on the malleus. These are more easily crimped than the Teflon- wire models, but require fairly direct angulation. © Bruce Black MD

A Schuknecht Teflon-wire malleus-oval window piston, used in a case of greater malleus-oval window angulation.

A necrosed incus is seen to the left. © Bruce Black MD

Post Teflon-wire reconstruction, seen crimped on the mid malleus handle. Cartilage cover is preferred, to avoid

biomaterial reactions. © Bruce Black MD

Post Teflon-platinum malleus-oval window repair. A sliver of cartilage under the membrane overlies the platinum loop,

preventing extrusion. © Bruce Black MD

A Teflon-titanium malleus-oval window strut. Left side . Revision stapedectomy case, good oval window membrane. Necrosed long process of the incus. © Bruce Black MD

Footplate drill-out for obliterative otosclerosis. A 1.mm diamond burr is preferred for the drill-out, continued until a liberal area of oval window is “blued” by thinning the bone. © Bruce Black MD

Gross otosclerosis, left ear. The grey bulges are bosses of immature bone with the chorda and stapedius tendon seen

between, superficial to the stapes arch. © Bruce Black MD

Grossly obliterative bulges of otosclerosis, overhanging the right footplate.

© Bruce Black MD

7. Partial removal and hollowing of the overlying bosses has been followed by a routine Teflon-platinum

reconstruction. © Bruce Black MD

Congenital absence of stapes superstructure, fixed footplate.

© Bruce Black MD

Teflon-platinum piston sited through a small micro-drill stapedotomy.

© Bruce Black MD

Persistent stapedial artery. Abandon and aid substantial cases. Shrink vestigial vessels with an adrenaline pledget

and undertake a routine procedure. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Narrow oval window niche, widen by a limited promontory drill-back.

© Bruce Black MD

Illustration by courtesy Robt Jackler MD

Overhanging facial nerve. Minor degrees of prolapse can be accommodated by routing the wire around the nerve

using the double bend technique. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Double bend piston technique, used for overhanging facial nerve. This requires an extra 1mm piston length. Two

bends are created using fine alligators. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Congenital stapes fixation. An atypical curved lenticular process is fixed to a frozen stapes. No incudo-stapedial

joint. © Bruce Black MD

Prior case. Removal of the stapes superstructure shows a grossly overhanging facial nerve, occluding access to the

oval window. Double bent piston technique required. © Bruce Black MD

Stapes “gusher” due to an enlarged vestibular aqueduct or other situations. Head elevation may permit a successful

stapedectomy using an underlying fine tissue sheet. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Otosclerosis in endolymphatic hydrops (R). The swollen inner ear components risk trauma, that contra-indicates

surgery, which may also cause Tullio noise-induced vertigo. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Tympanosclerosis: a warning of possible stapes or attic fixation from prior middle ear disease.

© Bruce Black MD

Illustration by courtesy Robt Jackler MD

Focal tympanosclerotic fixation. Clearance of minor foci offers a good chance of permanent stapes mobilisation, but

is less effective in more advanced or active disease. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Extensive, circumferential tympanosclerotic stapes fixation. Stapes surgery may not be effective with such extensive

disease. © Bruce Black MD

Illustration by courtesy Robt Jackler MD

Gross tympanosclerosis, left ear. Stapedectomy was partially successful, a 20db air-bone gap persisting.

© Bruce Black MD

Marked drum tympanosclerosis. Beware non-stapedial ossicular fixation if a large air-bone gap is present.

© Bruce Black MD

Conductive deafness with a normal drum, but due to necrosis of the long process of the incus, ? congenital,

? past infection. Stapes mobile. © Bruce Black MD

Management with a Spanner strut.

© Bruce Black MD

STAPEDECTOMY�Atypical Surgical Situations1. Congenital deformity, right ear. The horizontal facial nerve lies inferior to the stapes, occluding access to the oval window. Case abandoned.Detail of image 1.1. Congenital deformity, left ear. The horizontal facial nerve overlies much of the oval window. The incus is intact but the crura of the stapes superstructure are absent.2. Detail of prevous image. the stapedius tendon lies lateral to the nerve. The edge of the oval widow is just evident superiorly.3. A very limited stapedotomy has been created manually, just above the VII, and a Teflon-platinum piston inserted, avoiding pressure on the nerve. 4. Malleus-oval window reconstruction, when the stapes is fixed and the incus absent. The key is to create a large pocket along the malleus handle, to permit piston fixation.An absent or insufficient incus (congenital or past disease)requires alternative reconstruction methods.�Malleus-oval window technique, partial stapedectomy. The handle periosteum is incised along the posterior aspect (Kley knife, Storz Gmb).Elevation of the drum and periosteum off the handle, from the lateral process to the umbo, where the drum is firmly attached. Creation of a large pocket is an essential.Insertion of a (Sheehy IRP) wire prosthesis into the pocket, facilitated by the larger pocket size. With direct angulation, a 5-5.5 mm Teflon-platinum piston serves well.Attaching a wire loop tho the handle. Wire has “memory” and may skid off instruments. A platinum loop minimises these difficulties and is easier to crimp into position.Greater angulation requires an indirect strut. Angling wire in situ is challenging, and often best performed before insertion, after careful assessment of the angle.Common angulation difficulties. With the often direct angulation (Rt), a direct piston serves well, but requires simultaneous insertion into both pocket and stapedotomy.Malleus-oval window wire in situ. With a partial stapedectomy, a fine tissue sheet is desirable to seal the window and avoid fistulae.Fibro-fat or cement, used to prevent bio-reactions between wire and drum. Tissue may resorb, and cement may impede wire removal. A fine cartilage sliver is preferred.1. Congenital deformity, right ear. The long process of an undersized incus is absent (left), as is the stapes. A tiny oval widow is seen to the right of the horizontal facial nerve.2. A small micro-drill stapedotomy has been created at the window site. 3. Creation of an ample malleolar pocket, from the lateral process to the umbo. The drum is firmly attached at the latter.4. A 5.0 mm Richards Teflon-platinum piston has been sited on the malleus. These are more easily crimped than the Teflon- wire models, but require fairly direct angulation. A Schuknecht Teflon-wire malleus-oval window piston, used in a case of greater malleus-oval window angulation. A necrosed incus is seen to the left.Post Teflon-wire reconstruction, seen crimped on the mid malleus handle. Cartilage cover is preferred, to avoid biomaterial reactions.Post Teflon-platinum malleus-oval window repair. A sliver of cartilage under the membrane overlies the platinum loop, preventing extrusion. A Teflon-titanium malleus-oval window strut. Left side . Revision stapedectomy case, good oval window membrane. Necrosed long process of the incus.Footplate drill-out for obliterative otosclerosis. A 1.mm diamond burr is preferred for the drill-out, continued until a liberal area of oval window is “blued” by thinning the bone. Gross otosclerosis, left ear. The grey bulges are bosses of immature bone with the chorda and stapedius tendon seen between, superficial to the stapes arch. Grossly obliterative bulges of otosclerosis, overhanging the right footplate.7. Partial removal and hollowing of the overlying bosses has been followed by a routine Teflon-platinum reconstruction. Congenital absence of stapes superstructure, fixed footplate. Teflon-platinum piston sited through a small micro-drill stapedotomy.Persistent stapedial artery. Abandon and aid substantial cases. Shrink vestigial vessels with an adrenaline pledget and undertake a routine procedure.Narrow oval window niche, widen by a limited promontory drill-back.Overhanging facial nerve. Minor degrees of prolapse can be accommodated by routing the wire around the nerve using the double bend technique. �Double bend piston technique, used for overhanging facial nerve. This requires an extra 1mm piston length. Two bends are created using fine alligators. �Congenital stapes fixation. An atypical curved lenticular process is fixed to a frozen stapes. No incudo-stapedial joint.Prior case. Removal of the stapes superstructure shows a grossly overhanging facial nerve, occluding access to the oval window. Double bent piston technique required.Stapes “gusher” due to an enlarged vestibular aqueduct or other situations. Head elevation may permit a successful stapedectomy using an underlying fine tissue sheet.Otosclerosis in endolymphatic hydrops (R). The swollen inner ear components risk trauma, that contra-indicates surgery, which may also cause Tullio noise-induced vertigo.Tympanosclerosis: a warning of possible stapes or attic fixation from prior middle ear disease.Focal tympanosclerotic fixation. Clearance of minor foci offers a good chance of permanent stapes mobilisation, but is less effective in more advanced or active disease.Extensive, circumferential tympanosclerotic stapes fixation. Stapes surgery may not be effective with such extensive disease.�Gross tympanosclerosis, left ear. Stapedectomy was partially successful, a 20db air-bone gap persisting.Marked drum tympanosclerosis. Beware non-stapedial ossicular fixation if a large air-bone gap is present.Conductive deafness with a normal drum, but due to necrosis of the long process of the incus, ? congenital, �? past infection. Stapes mobile.Management with a Spanner strut.