Skip to content

Treatments

Stapedectomy or stapedotomy?

Both operations treat a stapes fixed by otosclerosis: a stapedectomy removes all or part of the footplate, a stapedotomy makes a small opening in it. Most surgeons now plan the second, and the two names are often used for the same thing.

Two names, one problem

In otosclerosis the footplate of the stapes, the base of the smallest hearing bone, becomes fixed in the oval window, and sound no longer passes into the inner ear. Stapes surgery bypasses it: a tiny prosthesis, attached to the incus, drives the inner-ear fluid directly.

There are two ways of making room for that prosthesis. A stapedectomy removes the footplate, wholly or partly. A stapedotomy leaves the footplate in place and makes a small round opening in it. The purpose, the approach through the ear canal and the recovery are much the same. The difference lies in less than a millimetre of bone, and in how widely the inner ear is opened.

What each operation removes

In each, the arch of the stapes, the part above the footplate, is normally removed. What happens next differs.

  • Total stapedectomy. The whole footplate is lifted out. The open oval window is covered with a thin graft of the patient’s own tissue, such as vein or fascia, and the prosthesis rests on this graft.
  • Partial stapedectomy. Only part of the footplate is removed, often the back half, and the gap is again covered with tissue.
  • Stapedotomy. The footplate stays. An opening of about 0.4–0.7 mm, the fenestra, is made in it with a laser, a micro-drill or a fine hand perforator, and a slightly narrower piston is placed through it. See stapedotomy for the operation and laser stapedotomy for the choice of instrument.

How the operation evolved

Operations on the stapes were tried in the late nineteenth century, then abandoned for half a century in favour of other approaches.

Mobilisation. In 1953 Samuel Rosen reported that freeing a fixed stapes could restore hearing. The gain was often immediate, but in many ears the footplate fixed again.

Stapedectomy. In 1956 John Shea removed the stapes, covered the oval window with a vein graft and replaced the bone with a Teflon prosthesis. This was the first reliably successful modern stapes operation, and surgeons worldwide took it up. Variations followed: different grafts, wire and piston prostheses, and partial rather than total removal of the footplate.

Small-fenestra stapedotomy. From the 1970s, surgeons increasingly made only a small opening. Smyth, reviewing almost 800 operated ears in 1978, found that a 0.4 mm opening gave similar hearing gains with fewer inner-ear fistulas (leaks of inner-ear fluid) and fewer severe inner-ear losses. Ugo Fisch in Zurich described the 0.4 mm piston stapedotomy as less traumatic to the inner ear. Jean Marquet published his “small hole” technique, and others reported similar experience.

What the comparisons show

There is no large randomised trial. The evidence comes from comparative series, mostly retrospective and often from one surgeon who changed technique over the years, so era, prosthesis and experience differ as well. Even so, the findings are fairly consistent.

  • Overall hearing. In experienced hands both close the air-bone gap well. A House Ear Clinic study of 209 ears, including 42 people with a stapedectomy in one ear and a stapedotomy in the other, found no significant difference in average hearing, speech discrimination or inner-ear loss. Both results were stable over long follow-up.
  • High frequencies. Stapedotomy tends to give better hearing at the higher pitches, around 4 kHz, which carry many consonants. The House study found this, as did a Japanese comparison in which stapedotomy gave larger gains at 1–4 kHz.
  • Low frequencies. Larger openings can give slightly better closure in the low tones. A Geneva series of 604 primary operations found this, without more inner-ear loss after the larger openings.
  • Bone conduction. Inner-ear thresholds are preserved in most ears after either operation. Smyth found less deterioration at 4 kHz three years after small-fenestra operations; the Japanese study found no difference. See bone-conduction preservation.
  • Dizziness. Vertigo after surgery tended to last a shorter time after stapedotomy.
  • Dead ear. Severe or total inner-ear loss is rare with both, about 0.5–1% for first operations overall, too rare for single series to compare reliably. Smyth found fewer severe losses with the small fenestra; the House comparison found no significant difference.
Technical notes on the comparative literature

Fisch (1982, 392 ears) found that a 0.4 mm wire-Teflon piston stapedotomy did not increase postoperative fistula compared with stapedectomy under a tissue graft; low-frequency results were poorer at three weeks but equal to a 0.6 mm stapedotomy by three months. Kos and colleagues aimed for a 0.8 mm stapedotomy but performed a larger opening or a stapedectomy in 22% of 604 primary cases for surgical or anatomical reasons; the larger openings improved low-frequency closure without more sensorineural loss. A Swedish series found partial and total stapedectomy ahead at most frequencies at one year but losing ground faster over the next two. A 2018 review concluded that stapedotomy gives better high-frequency gain and fewer complications.

Why most surgeons now aim for a small opening

  • Less of the inner ear is opened. The balance organs lie just beneath the footplate. A pinhole lets less fluid escape and admits less blood or bone dust.
  • The piston stays where it is put. The footplate rim holds it centred, and its length can be set precisely. A prosthesis resting on a graft over an open window can shift as the tissue heals and contracts.
  • The balance of results. Better high-frequency hearing and shorter early dizziness weigh more for most people than a small low-frequency gain.

None of this makes the stapedectomy a bad operation; long-term series show that many done decades ago still work well.

When a stapedectomy is still the right step

The plan is usually a stapedotomy, but the footplate decides.

  • A floating footplate. Occasionally the whole footplate comes loose while the arch is removed or the opening is made, and floats on the inner-ear fluid. Drilling a hole in it is then unsafe, and surgeons differ in what they do. Some remove it gently and cover the window with tissue, which is a stapedectomy; others cover the loose footplate with a graft and rest the prosthesis on it, or stop and finish months later. In one long series using the graft method, thin footplates did well; thick ones needed revision in about 30% of ears, mostly because they had fixed again.
  • A thick or obliterated footplate. When otosclerotic bone fills the oval-window niche, it has to be drilled down before any opening can be made. Some surgeons then make a small opening in the thinned bone; others remove more. The operation is technically more demanding and the inner-ear risk is higher: in one large stapedotomy series the air-bone gap still closed to within 10 dB in 95% of such ears, but a significant inner-ear loss occurred in 4.8%, against 0.5% overall.
  • Revision. At a second operation the original opening may be covered by scar or new bone, or footplate remnants may hold the prosthesis. Clearing them can turn the procedure into a partial stapedectomy. A fixed malleus may need a different reconstruction (see ossicular disorders and revision ear surgery).

Why the names are used loosely

For its first twenty years “stapedectomy” was simply the name of the operation. When small openings came in, many surgeons called them “small-fenestra stapedectomy”, and some still do. To many patients, and some doctors, stapedectomy therefore means stapes surgery in general; stapedoplasty and stapesplasty are used the same way. In French the footplate is the platine: platinotomie is a stapedotomy, platinectomie a stapedectomy.

Hospital and insurance codes often group the two operations together, so a code on an insurance form may not tell you which operation was done. The operation note does.

Reading your operation note

Four things in the description matter more than the title.

  • The footplate. Words such as “calibrated fenestra” or “platinotomy” with a size in millimetres, “partial” or “total” platinectomy or stapedectomy, “drill-out” or “floating footplate” tell you which operation was actually done.
  • The seal or graft. Vein, fascia, perichondrium (the lining of cartilage), fat or blood.
  • The prosthesis. Type, material, diameter and length, which you may need before an MRI scan (see stapes prosthesis and MRI) and for any later operation.
  • The findings. Obliterative disease, a floating footplate, a fixed malleus or an exposed facial nerve can explain an unusual recovery or result.

Keep a copy: if the result changes years later, it is one of the first documents a surgeon will ask for. If a term is unclear, ask the surgeon who operated what was done to the footplate.

In the end the result counts, not the label: the air-bone gap at three to six months, bone conduction unchanged or better, and how you hear in daily life (see measuring hearing outcomes).

Sources

  • Vincent R, Sperling NM, Oates J, Jindal M. Surgical findings and long-term hearing results in 3,050 stapedotomies for primary otosclerosis: a prospective study with the otology-neurotology database. Otol Neurotol. 2006;27(8 Suppl 2):S25-47. PubMed
  • Häusler R. General history of stapedectomy. Adv Otorhinolaryngol. 2007;65:1-5. PubMed
  • Smyth GD, Hassard TH. Eighteen years experience in stapedectomy. The case for the small fenestra operation. Ann Otol Rhinol Laryngol Suppl. 1978;87(3 Pt 2 Suppl 49):3-36. PubMed
  • Fisch U. Stapedotomy versus stapedectomy. Am J Otol. 1982;4(2):112-117. PubMed
  • Kos MI, Montandon PB, Guyot JP. Short- and long-term results of stapedotomy and stapedectomy with a Teflon-wire piston prosthesis. Ann Otol Rhinol Laryngol. 2001;110(10):907-911. PubMed
  • House HP, Hansen MR, Al Dakhail AA, House JW. Stapedectomy versus stapedotomy: comparison of results with long-term follow-up. Laryngoscope. 2002;112(11):2046-2050. PubMed
  • Sakamoto T, Kikuta S, Kikkawa YS, et al. Differences in postoperative hearing outcomes and vertigo in patients with otosclerosis treated with laser-assisted stapedotomy versus stapedectomy. ORL J Otorhinolaryngol Relat Spec. 2015;77(5):287-293. PubMed
  • Lippy WH, Fucci MJ, Schuring AG, Rizer FM. Prosthesis on a mobilized stapes footplate. Am J Otol. 1996;17(5):713-716. PubMed
  • Cheng HCS, Agrawal SK, Parnes LS. Stapedectomy versus stapedotomy. Otolaryngol Clin North Am. 2018;51(2):375-392. PubMed

Common questions

Is a stapedectomy the same as a stapedotomy?

Not quite. Both restore sound transmission past a stapes fixed by otosclerosis, using a tiny prosthesis attached to the incus. A stapedectomy removes all or part of the footplate, the base of the stapes. A stapedotomy keeps the footplate and makes a small opening, about half a millimetre across, for a piston. In everyday speech, and on many forms and codes, 'stapedectomy' is still used for both.

Which is better, stapedectomy or stapedotomy?

In experienced hands both close the air-bone gap well, and overall hearing results are similar. Comparative series favour stapedotomy for high-pitched hearing and for shorter dizziness after surgery, which is why most surgeons now plan a stapedotomy. Larger openings sometimes give slightly better low-pitched hearing. No large randomised trial has compared the two, and the surgeon's experience matters more than the name of the technique.

My operation note says stapedectomy. Did something go wrong?

Not necessarily. Many surgeons, hospitals and coding systems use 'stapedectomy' for any stapes operation, including a small-opening stapedotomy. And when the footplate comes loose or is thick with otosclerotic bone, removing part or all of it can be the right step rather than a complication. What the note says was done to the footplate, and your audiogram at three to six months, tell you more than the title.

Is the risk of losing hearing different between the two operations?

Severe or total inner-ear hearing loss is rare with both, in the order of 0.5–1% for first operations. Because it is so rare, single studies are too small to compare the techniques reliably: some large series found fewer severe losses with the small opening, others found no significant difference. Smaller losses of high-pitched inner-ear hearing were more frequent after larger openings in several series, but not in all.

Is recovery different after a stapedectomy?

Mostly not. Both are done through the ear canal, and the precautions are the same: no nose-blowing or straining, a dry ear, and no flying for several weeks (two months in the author's practice). Dizziness in the first days tends to be shorter after a stapedotomy. Follow the advice given for your own operation. Severe spinning vertigo with vomiting, or a sudden drop or complete loss of hearing in the operated ear, needs care the same day.

Can a stapedectomy or stapedotomy be redone if the hearing fades?

Often, yes, but revision starts by working out why the result faded: a prosthesis that has shifted, erosion of the incus where it is attached, scar tissue, new bone, or a second problem such as a fixed malleus. After an old stapedectomy the window is covered by a tissue membrane, which the surgeon has to work through. Revision results are less predictable than a first operation, and the inner-ear risk is higher.

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.