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Treatments

Revision stapes surgery

When the hearing gained by stapes surgery fades, or never came, a second operation is possible. It succeeds less often than the first and carries more risk to the inner ear, so it starts with finding out exactly why the first result failed.

When stapes surgery stops working

Most stapes operations for otosclerosis, whether stapedotomy or stapedectomy, give a lasting result. Over the years, though, about 5–10% of operated ears need a second operation. Sometimes the hearing never improved; sometimes it improved and then faded, months or years later.

Scar has formed and the inner ear has already been opened once, so a revision is less predictable than the first operation and riskier for the inner ear. The first step is to answer one question: why did the first result fail? The general approach is on revision ear surgery.

Symptoms of a failed stapes operation

  • Gradual fading. The gain slips back over months or years. Hearing loss years after stapedectomy that comes on like this usually has a mechanical cause.
  • A sudden drop. Hearing falls over hours or days, sometimes after a blow to the head, a heavy sneeze or a pressure change. A displaced prosthesis or a perilymph fistula is then the usual suspect.
  • Never good. The gap did not close from the start: a prosthesis of the wrong length, a fixed malleus or a wrong first diagnosis becomes more likely.
  • Dizziness set off by loud sound, straining or nose-blowing can mean a prosthesis that is too long, or a fistula.

How urgent? A sudden loss of hearing, or severe or spinning vertigo: same day. Hearing that slips back over a few days: call within a day or two. Gradual fading over months is not an emergency, but an earlier audiogram keeps more options open. See when to contact your surgeon and what is normal after stapedotomy.

The causes

  • Prosthesis displacement. The piston slips out of the opening in the footplate, or its loop slides off the incus. With incus erosion, this is the commonest finding at revision.
  • Incus erosion (necrosis). The tip of the incus, where the loop is attached, wears away, often because its blood supply was compressed; the loop loosens. See stapes prostheses.
  • Oval-window fibrosis or re-fixation. Scar tissue or new otosclerotic bone grows around the piston and tethers it.
  • Malleus fixation. The first hearing bone is itself stiff, which is not always apparent at the first operation.
  • A prosthesis too short or too long. Too short, and it transmits poorly or slips out; too long, and it can cause dizziness.
  • Perilymph fistula. Inner-ear fluid leaks around the prosthesis, typically with fluctuating hearing and dizziness.
  • A wrong first diagnosis. A recognised mimic of otosclerosis is superior canal dehiscence: a missing patch of bone over a balance canal creates a “third window” and an air-bone gap that no stapes operation can close.
  • A change in the inner ear. Sometimes the gap is unchanged and the inner ear has declined. No revision corrects that.

Several causes often coexist. After an older stapedectomy, a tissue graft covers the oval window.

Working out the cause

  1. The story. When did hearing improve, if ever? When and how did it change? What sets off any dizziness?
  2. The audiogram trend. A full audiogram with masked bone conduction and speech scores, compared with the tests before the first operation and in the months after it. Has the air-bone gap reopened, or has the inner ear declined? See understanding your audiogram.
  3. The operation note. What was found, which prosthesis was used and its length, and what was done at the footplate and incus.
  4. A CT scan. High-resolution CT shows where the prosthesis sits, how far it reaches into the inner ear, whether the incus is eroded, and whether there is new bone or a canal dehiscence. It matches surgical findings well for incus erosion, less consistently for a disconnected or wrongly sized prosthesis: a guide, not a verdict.
  5. The other ear. How it hears, and whether it might be the better place to act.
Work-up: technical notes

Stapedial reflexes present before the first operation, supranormal bone conduction or a low-frequency gap raise the question of a third window: obtain VEMPs and reformats in the plane of the superior canal. On CT, look for the piston outside the fenestra or deep in the vestibule, incus long-process erosion, obliterative otosclerosis, soft tissue in the niche and pneumolabyrinth. In one correlation series, surgically confirmed abnormalities included 7 of 7 incus erosions but 3 of 5 prosthesis disconnections and 3 of 6 piston re-sizings.

What revision can achieve

After a first stapedotomy, the air-bone gap closes to within 10 dB in about 80–90%. After revision:

  • a meta-analysis of 19 studies (2,602 patients) found closure to within 10 dB in about 57% and to within 20 dB in 79%; the odds of closure to within 10 dB were about a third of those after first operations;
  • in 78 revision stapedotomies the gap closed to within 10 dB in 54%;
  • in the Swedish national quality register (156 revisions), 75% of patients reported better or much better hearing a year later.

Prosthesis or ossicular problems, such as displacement or incus erosion, generally do better than scar or new bone at the oval window, and a first revision does better than a second or third.

The inner ear. The risk is higher than after a first operation, for which severe or total inner-ear loss is about 0.5–1%. In the meta-analysis about 1 in 100 revised ears lost all hearing; in the Swedish register about 4 in 100 had hearing at least 20 dB worse a year later; and in one large comparison, inner-ear hearing fell by more than 10 dB about twice as often after revision as after first operations.

The options

A new prosthesis on the incus. If enough incus remains, the old prosthesis is freed or removed and a new one fitted, sometimes higher up the incus or secured with bone cement.

Malleostapedotomy. When the incus is eroded, fixed or unusable, a longer prosthesis runs from the malleus to the footplate. A systematic review of 632 ears, mostly revisions, reported closure to within 10 dB in 44.8% and to within 20 dB in 84.9%.

A hearing aid. When the inner ear is in good condition, as it usually is in otosclerosis, a hearing aid works well and carries no surgical risk. A bone-conduction or middle-ear implant is occasionally considered. See hearing aid or surgery.

Doing nothing. If the gap is small, the other ear hears well and daily life is manageable, waiting with repeat audiograms is legitimate. A slowly fading result without dizziness is not dangerous in itself.

When not to revise

Think twice about revision when:

  • the gap is small. The Swedish register authors recommended revision mainly for a large air-bone gap with moderate to severe hearing loss.
  • the inner ear is the problem. If bone conduction or speech scores have fallen, closing the gap will not restore clear hearing; see far-advanced otosclerosis.
  • it is an only-hearing ear, or the other ear hears poorly. The small risk of a dead ear becomes unacceptable.
  • a third window is the cause. Stapes revision does not close a gap caused by canal dehiscence, and can harm the inner ear.
  • there have been several revisions. Second and later revisions do clearly worse and fade sooner; a hearing device is often the better choice.
  • no likely correctable cause has been found and the gap is modest.

None of this rules out surgery, but the decision deserves more care than the first time.

Findings and outcomes: technical notes

The 2025 meta-analysis (19 studies) reported closure to <10 dB in 57.2% (95% CI 52.8–61.4%), dead ears in 1.2% (0.7–2.1%), OR 0.36 against primary surgery, and no significant difference between revision incudostapedotomy and malleovestibulopexy. In 78 revisions, sensorineural loss occurred in 6%. In 809 operations including 170 revisions, bone-conduction PTA worsened by >10 dB in 13.1% of revisions versus 7.1% of primaries. The author's Utrecht group published an internally validated prognostic model (705 revisions; closure to ≤10 dB in 57.7%): previous technique, primary cause of failure and prosthesis type at revision were predictive, with moderate discrimination (AUC 0.69 after bootstrapping). Practice varies on removing or leaving a piston bound in fibrous tissue at the oval window, the highest-risk step.

Recovery after revision

Recovery is broadly similar to that after a first operation (stapedotomy recovery). Many centres send people home the same day or after one night. At the Clinique Causse in Colombiers, where the author practises, the hospital stay is up to a week; the usual advice there is one week off work, sometimes more, and no flying and no sport for two months if recovery is uncomplicated, adjusted after a complication. Elsewhere, advice on flying ranges from two weeks to two months. Follow the advice given for your own operation; see flying after ear surgery.

The ear feels blocked for one to two weeks, and the result is judged at three to six months. A sudden loss of hearing or severe spinning vertigo needs same-day review.

Sources

  • Tomasoni M, Borsetto D, et al. Indications, surgical strategies and hearing outcomes of revision stapes surgery for otosclerosis: a systematic review and meta-analysis on 2602 patients. Otolaryngol Head Neck Surg. 2025;172(1):50-62. PubMed
  • Babighian GG, Albu S. Failures in stapedotomy for otosclerosis. Otolaryngol Head Neck Surg. 2009;141(3):395-400. PubMed
  • Schwam ZG, Schettino A, et al. Outcomes in revision stapes surgery. Otolaryngol Head Neck Surg. 2021;165(5):705-709. PubMed
  • Pauli N, Finizia C, et al. Are there differences in revision stapes surgery outcomes between university and county clinics? A study from the quality register for otosclerosis surgery in Sweden. Eur Arch Otorhinolaryngol. 2023;280(5):2247-2255. PubMed
  • Wegner I, Vincent R, et al. An internally validated prognostic model for success in revision stapes surgery for otosclerosis. Laryngoscope. 2018;128(10):2390-2396. PubMed
  • Whetstone J, Nguyen A, et al. Surgical and clinical confirmation of temporal bone CT findings in patients with otosclerosis with failed stapes surgery. AJNR Am J Neuroradiol. 2014;35(6):1195-1201. PubMed
  • Alicandri-Ciufelli M, D’Alessandro E, et al. Malleostapedotomy in patients with stapes fixation: a systematic review. Laryngoscope. 2026;136(4):1601-1613. PubMed
  • Benedict PA, Zhou L, et al. The malleus to oval window revision stapedotomy: efficacy and longitudinal study outcome. Laryngoscope. 2018;128(2):461-467. PubMed

Common questions

What are the symptoms of a failed stapedectomy?

Usually the hearing gain fades: the ear sounds muffled again, conversation becomes harder, or a hearing aid that had been put away is needed once more. This can happen gradually over months or years, or suddenly, sometimes after a blow to the head, a heavy sneeze or a pressure change. Some people notice dizziness set off by loud sounds or straining. A sudden loss of hearing or severe spinning vertigo needs same-day review; a slow decline needs an audiogram, not an emergency visit.

Why has my hearing got worse years after stapedectomy?

The commonest reasons are mechanical: the tip of the incus has worn away where the prosthesis is attached, the prosthesis has shifted, or scar tissue or new bone has formed around it. Sometimes the operation is still working and the inner ear itself has declined, with age or with otosclerosis. An audiogram with bone conduction, compared with your earlier tests, tells these apart, and a CT scan shows where the prosthesis sits.

How successful is revision stapedectomy?

Less predictable than the first operation. In pooled data from 19 studies, revision closed the air-bone gap to within 10 dB in about 57% of ears and to within 20 dB in about 79%, compared with roughly 80–90% within 10 dB after a first stapedotomy. Results tend to be better when the cause is a displaced prosthesis or an eroded incus than when it is scar or new bone at the oval window, and better after a first revision than after later ones.

Is revision stapes surgery riskier than the first operation?

Yes. Scar, a prosthesis stuck in place and a changed oval window make the operation more delicate, and the inner ear has already been opened once. In pooled data about 1 in 100 revised ears lost all hearing, and smaller inner-ear losses occur more often than after a first operation. This is why a revision is weighed carefully, especially in an only-hearing ear or when the other ear hears poorly.

Can a stapes prosthesis move or come loose?

It can, although in most people it stays in place for life. The piston can slip out of the opening in the footplate, or its loop can loosen on the incus, particularly if the tip of the incus erodes. A sudden drop in hearing, sometimes after a blow to the head or a heavy sneeze, is the typical sign. Prosthesis displacement is one of the commonest findings at revision, and one of the causes that does comparatively well when corrected.

Should I have a revision or a hearing aid?

Both are reasonable. Revision is most worthwhile when the air-bone gap is large, the inner ear is healthy, the cause looks mechanical and the operated ear is not your only good one. A hearing aid works well in an ear with a conductive loss and carries no surgical risk. Choosing an aid now does not rule out surgery later; the decision can be revisited if your hearing or your priorities change.

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.