Revision ear surgery

Why results disappoint

Ear operations fail, or fade, for a limited set of reasons. Knowing which one applies changes everything about what to do next.

• Residual conductive loss. The gap was never fully closed: a prosthesis too short, a fixed malleus that was not recognised, a partially mobile chain.
• Prosthesis problems. Displacement from the fenestra or off the incus; erosion of the incus long process at the attachment; a prosthesis that is too long, causing dizziness.
• Scar tissue and adhesions tethering the reconstruction or the drum.
• Persistent perforation after tympanoplasty, from infection, poor ventilation or graft failure.
• Recurrent disease — cholesteatoma, retraction, new otosclerotic fixation of the footplate margins.
• Inner-ear hearing changes. Bone conduction that has fallen since the first operation: the gap may be unchanged but the ear now hears worse for a reason no revision can fix.
• Incorrect assumptions about the original cause. The stapes was fixed, but so was the malleus; or the gap was due to a third-window lesion, which no stapes surgery closes.
• Other pathology — a middle-ear mass, a perilymph fistula, a reparative granuloma.

Reassessment before re-intervention

The temptation after a poor result is to “have another look”. The better first step is to re-examine the evidence as if the ear had never been operated.

1. The history. When did hearing improve, if ever? When did it decline — suddenly (displacement, fistula) or gradually (erosion, re-fixation)? Is there vertigo, and what provokes it?
2. The audiogram. A full audiogram with careful masking, speech scores, tympanometry and reflexes. Compare with the pre-operative and early post-operative records. Has bone conduction changed?
3. The previous operation. Obtain the operative report. What was found, what prosthesis, what length, what was done to the footplate and the incus.
4. Imaging. High-resolution CT shows prosthesis position, incus erosion, a floating or migrated piston, obliterative disease, malleus fixation, and — crucially — a canal dehiscence or a large vestibular aqueduct.
5. The other ear. A good result may be more likely on the unoperated side.

Only after this does a plan make sense: revision, a device, or leaving well alone.

Hearing preservation in revision

The inner ear has already been opened once. Scar, an adherent prosthesis and a distorted oval window make revision more hazardous than the first operation, and the risk of a worse inner ear is higher. In an ear whose bone conduction has already deteriorated, or in an only-hearing ear, the argument for a device rather than another operation is often strong. This is not a counsel of despair: a well-fitted hearing aid in a closed, dry ear can be an excellent result.

When a second opinion helps

A disappointing result after surgery is one of the most common reasons for seeking a second opinion. The review consists of exactly the reassessment above, with a written summary of what is known, what is not, and the reasonable options — including the option of no further surgery.

This page provides general educational information. It cannot replace an individual assessment, which depends on a full history, examination, audiometry and, where relevant, imaging. If you have sudden hearing loss, severe pain, facial weakness, severe dizziness or discharge with fever, seek medical care promptly.