Stapedectomy - Meaning, Surgery, Failure Symptoms, Recovery

Stapedectomy is an inner ear surgical procedure performed to remove stapes bone from the middle ear and replace it with an implant. 

Anatomy and Physiology of the Ear

The human ear is an organ of hearing it detects and analyses sound by converting sound waves into electrical impulses. The ear has three distinguishable parts: the outer, middle and inner ear.

1. The outer ear comprises:
   1. Pinna or auricle: Pinna or auricle is the outermost part and collects the sound waves.
   2. External auditory canal: It connects the outer ear to the eardrum.
2. The middle ear comprises:
   1. Tympanic membrane: It is also called the eardrum and is made of connective tissue.
   2. Ear bones: It is a chain of three tiny bones malleus, incus and stapes, present in the same order.
      1. Malleus: a hammer-shaped bone attached to the tympanic membrane.
      2. Incus: an anvil-shaped bone present between the malleus and stapes.
      3. Stapes: the smallest bone of the body. It is stirrup-shaped and attached to the oval window of the cochlea.
   3. Eustachian tube: It helps equalize the pressure between the middle ear and the atmosphere.
3. The inner ear comprises:
   1. Labyrinth: It consists of interconnected canals and sacs. It is surrounded by a liquid called perilymph.
   2. Cochlear: cochlear is the coiled portion of the labyrinth, which helps balance.

The sound waves or vibrations are collected by the pinna, which reaches the tympanic membrane through the auditory canal. The collected sound waves vibrate the eardrum and transmit the vibration to three bones in the middle ear. The earbones amplify the sound waves which reach the perilymph through the oval window. Finally, the vibration reaches the cochlear, which converts these vibrations to electrical impulses. These electrical impulses are later sent to the brain, translating into sound.

Generally, stapedectomy is performed to treat otosclerosis. However, this procedure also helps treat the following medical conditions along with otosclerosis:

1. Chronic middle ear infection
2. Excessive fluid buildup (acute otitis media) in the middle ear
3. Hearing problems
4. Ear injuries

Stapedectomy is performed for both children and adults. The candidates who fulfil the following criteria are ideal for undergoing stapedectomy.

1. Overall good health to tolerate anaesthesia
2. Having otosclerosis
3. The presence of an air-bone gap of at least 15 dB confirmed using a tuning-fork test
4. Fair speech recognition

Stapedectomy is generally performed on an outpatient basis. The procedure usually takes about one to two hours to complete, based on the patient’s age, other comorbidities that the patient has and the complexity of the case. The procedure is done under general anaesthesia to keep the patient comfortable. However, in some cases, local anaesthetics can also be used. ENT specialist along with specialised medical staff performs this procedure. The following steps are involved in the procedure:

1. The surgeon will administer general anaesthesia to the patient.
2. They will make a small cut inside the ear canal to access the stapes inside the ear. If the ear canal is too narrow, the surgeon will make a small cut in front of the ear.
3. The surgeon will use a microscope to see the ear bones.
4. Then, the surgeon will lift the eardrum and separate the stapes and incus (another bone in the ear). After this, the surgeon will remove the stapes bone using a micro drill or laser.
5. The surgeon will place a metal or Teflon implant in place of the removed stapes. If a metal implant is used, it will be a bioinert metal (e.g., titanium or gold). The implant will help transmit the sound from the outer ear to the inner ear.
6. The eardrum that was lifted to remove the stapes will be brought back to its original place.
7. Fatty tissue will be removed by making a small cut behind the ear. This fatty tissue is used to seal the surgical site. Sometimes, the surgeon may also use the hand or arm vein to close the surgical site.
8. The patient will then be moved to the hospital ward so that he/she can recover.

Before the stapedectomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Stapedectomy

Before undergoing the stapedectomy procedure, the ENT specialist will:

1. First, review the medical history of the patient and evaluate the signs and symptoms.
2. Perform tests, such as blood tests, to check for overall health and to test hearing before the procedure. 
3. Explain the procedural approach in detail and mentions its potential risks. 
4. Provide precautionary measures that a patient needs to take before the surgery.
5. Prescribe some medicines that the patient needs to take on the day of the surgery. The patient should take these medicines with a sip of water.
6. Advise the patient to stop certain medications, such as blood thinner, that may increase the risk of complications during or after surgery. 
7. Advise not to eat or drink anything from midnight before the day of the procedure.
8. The patient should also inform the doctor about any medication and supplements he/she is taking.

On the day of the Stapedectomy

1. The patient should reach the hospital before the scheduled time.
2. The patient must leave all the valuables, wearables, and piercings at home before leaving for the hospital.
3. The patient will be asked to sign the consent form before the surgery.
4. The staff will take the patient to the pre-operative area. There, the patient will be given a surgical gown to change into.
5. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
6. The vitals of the patient will also be monitored.
7. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone stapedectomy can expect the following after the surgery:

The recovery process at the hospital

1. The healthcare staff will move the patient from the operating room to a recovery room to monitor the recovery process.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. The doctor may prescribe some medications:
   1. Painkillers such as paracetamol or ibuprofen relieve pain.
   2. Ear drops or Antibiotics to prevent bacterial infection.
   3. Avoid blood-thinning medications (e.g., aspirin) unless recommended.
4. The patient would need to stay in the hospital for at least three to four hours. In case the procedure was conducted in the evening, the surgeon would recommend the patient to stay overnight in the hospital.
5. The patient may get discharged on the same as depending on his/her recovery post surgery.
6. In some instances (e.g., if the patient is at a higher risk for post-operative vertigo), the surgeon will recommend staying in hospital for four to five days.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. The hearing will return immediately after surgery, but the patient will notice the changes one week after the surgery when the pack placed in the ear is removed.
3. The patient may also feel a cracking or popping sound while chewing or yawning.
4. To protect your eardrums, the ENT specialist will suggest the following:
5. Keep the area in and around the ears dry.
6. Hair wash:
   1. The patient can wash hair three days after surgery, but he/she must place cotton coated with Vaseline in the ear opening. This will keep the ears dry.
   2. If possible, the patient must wait for seven to ten days before getting the hair washed.
7. If the patient wants to sneeze, he/she must keep mouth open. The patient must avoid blowing the nose for four weeks after the surgery.
8. The patient must also avoid lifting an object, squatting, or getting constipated, as that can increase the internal ear pressure and increase the possibility of fluid leak from the inner ear. If the patient has constipation after surgery, he/she must use stool softeners.
9. The patient can perform light exercises like walking or using a stationary bicycle one week after surgery. The patient can return to his/her routine workouts one month after the surgery.
10. Avoid going to the office for a week after surgery. The patient should follow this so that he/she can reduce the chances of catching a cold.
11. The patient must avoid going on an aeroplane for four to five weeks post-surgery.
12. The patient should start eating the regular diet depending on how the body responds to the food.

First follow-up appointment

1. The ENT specialist will schedule a follow-up one or two weeks after the stapedectomy.
2. During this appointment, they will remove the sponge tampon/pack placed in the ear.
3. The ENT specialist will also check the patient’s hearing during this follow-up.
4. The patient may also be recommended a hearing test and can return to work and do regular activities from the next day.
5. The ENT specialist might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.

Stapedotomy is an effective surgical procedure for the treatment of otosclerosis which leads to improvement in patients' quality of life. Below mentioned are some of the benefits of stapedectomy.

1. Improved hearing
2. Minimal surgical trauma
3. Less pain

Like any surgical procedure, stapedectomy also has some risks and complications. These include:

1. Perforation of the eardrum (a hole in the tissue that separates your ear canal from the middle ear), which again can lead to hearing loss.
2. Hearing loss can also occur if the implant gets displaced when precautions are not taken. You might require revision surgery in such a case.
3. There is a rare chance of complete hearing loss (a two per cent chance), which can be a risk for up to six weeks and might require revision surgery.

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she experiences:

1. Discharge coming out of your ears
2. Ear bleeding
3. Pain that does not go after taking painkillers
4. High body temperature
5. Dizziness

Delaying a stapedectomy procedure can increase the severity of the pain and discomfort in the ear, leading to reduced quality of life. Below mentioned are some of the common risks of delayed stapedectomy:

1. Delays in learning, speech, and developing social skills. 
2. Impairment in psychological development.
3. Developing tinnitus, or ringing in your ear.

The cost of stapedectomy ranges from ₹20,000 to ₹2,00,000. The cost varies based on the following factors:

1. Age of the patient
2. The type of procedure done
3. The technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.