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Treatments

Stapedotomy

A small opening in a fixed stapes footplate and a prosthesis a few millimetres long. In most suitable ears this restores sound transmission; the decision to have it done deserves as much care as the operation itself.

Audiogram Pure-tone audiogram showing air conduction thresholds around 40 to 50 decibels and bone conduction thresholds around 10 to 25 decibels. The shaded area between them is the air-bone gap. 0 20 40 60 80 100 120 250 500 1k 2k 4k 8k Frequency (Hz) Hearing level (dB HL) <<<<< air-bone gap
Air conduction <Bone conduction Air-bone gap

Purpose

Stapedotomy is the operation for otosclerosis when the stapes footplate is fixed. Its single purpose is mechanical: to let sound vibration reach the inner ear again. It does nothing for the inner ear itself, and it is not a treatment for tinnitus or dizziness, although both may improve when hearing improves.

Anatomy in one paragraph

The stapes is a stirrup two to three millimetres tall. Its footplate sits in the oval window, a membrane-sealed opening into the fluid of the cochlea. Normally the footplate rocks in and out with every vibration passed to it by the incus. In otosclerosis, new bone around the window locks the footplate. The eardrum and the other two ossicles still move, but the vibration stops at the fixed plate.

The operation

The operation is performed entirely through the ear canal — no incision behind the ear, no visible scar — under general anaesthesia in most centres, or under local anaesthesia with sedation in some. The eardrum is lifted to expose the middle ear. The surgeon confirms that the stapes is fixed and the other ossicles are mobile — this confirmation is the first real diagnostic step, and occasionally shows a different problem. The stapes superstructure is removed, leaving the footplate in place. A small opening — the fenestra, about 0.4–0.7 mm — is made in the footplate with a laser, a micro-drill or a fine hand perforator. A piston-shaped prosthesis is placed through the opening and attached to the long process of the incus. The eardrum is replaced. The procedure takes under an hour.

Small fenestra is the key concept. Earlier stapedectomy removed the whole footplate; the small opening disturbs the inner ear far less and has largely replaced it.

Technical notes

Fenestration method (CO2 or diode laser, skeeter micro-drill, manual perforator) has not been shown in randomised trials to alter air-bone gap closure in a clinically important way; surgeon familiarity matters more. Prosthesis diameter of 0.4–0.6 mm is standard; several series suggest a modest low-frequency advantage for larger diameters, of uncertain clinical relevance. Length is measured from the incus to the footplate and typically 4.25–4.75 mm; over-length prostheses are a recognised cause of postoperative vertigo. Self-crimping nitinol pistons reduce incus trauma from manual crimping. Sealing the fenestra with blood or connective tissue reduces perilymph leak. Intraoperative findings that change the plan include an obliterated footplate, a floating footplate, an overhanging or dehiscent facial nerve, persistent stapedial artery and a fixed malleus. Laser choice is not neutral: temporal-bone measurements of thermal, mechanical and acoustic effects of surgical lasers in the middle ear, published by the author's Utrecht group (2013–2017), led it to advise against the thulium laser after clinical complications — see the research page.

Hearing objectives and how they are measured

The target is closure of the air-bone gap: air conduction within 10 dB of bone conduction. The audiogram at three to six months is the usual yardstick. A second measure is bone-conduction preservation — the inner-ear thresholds should be unchanged, and at 2 kHz often improve. A third is word recognition. And the fourth, which the audiogram cannot give, is what the person reports: whether they still use a hearing aid, and how hearing is in the places that matter to them.

Limitations

  • Surgery closes the gap; it does not repair a damaged inner ear. In mixed loss, expect a partial result.
  • Results can change over years. Most stay good; a minority deteriorate and some need revision.
  • Not every fixed stapes can be safely operated: an obliterated footplate, an abnormal facial nerve, or a very narrow oval window may lead the surgeon to stop.
  • An only-hearing ear is rarely a good candidate, because the small risk becomes an unacceptable one.

Risks

Stated plainly, from most to least common: a temporary change of taste on one side of the tongue (the chorda tympani, the taste nerve, runs across the field; it is identified and preserved, but can be stretched — published series report a change in a substantial minority, usually recovering within weeks to months), brief dizziness and unsteadiness, a small high-frequency inner-ear loss that may pass unnoticed, worse tinnitus, persistent vertigo, and severe or total inner-ear hearing loss in about 0.5–1%. Facial nerve injury is very rare. Perforation of the eardrum during exposure is uncommon and usually heals.

The first operation is the one that counts

The operative field is a few millimetres across and the margin between a good result and damage to the inner ear is small. Results are related to how often a surgeon performs the procedure, and a revision after a poor first result has a lower chance of success and a higher risk to the inner ear. There is no hurry — otosclerosis is slow — so it is reasonable to wait to be operated by someone who does this regularly, and to ask for that surgeon’s own figures rather than the literature’s: how many stapedotomies a year, in what proportion of their patients the air-bone gap closes, and how often permanent inner-ear loss has occurred in their hands. An experienced surgeon answers these without difficulty.

Recovery

Most people go home the same day or after one night, depending on the centre. Expect a blocked, muffled feeling for one to two weeks while packing and blood clear; hearing usually opens up over the following weeks. Avoid nose-blowing, straining, heavy lifting and water in the ear until told otherwise. See recovery after ear surgery and flying after ear surgery.

Alternatives

A hearing aid is the main alternative and is a good treatment for otosclerosis. Observation is reasonable when the loss is mild. The choice is set out on hearing aid or stapedotomy?.

On the other sites

How the operation is organised in the Colombiers practice — anaesthesia, hospital stay, follow-up, coming from a distance — is described on grolman-orl.fr. Patient information in Dutch and English, including a printable question list for your ENT surgeon, is on otosclerose.nl.

The surgical decision

Seven questions every recommendation should answer

  1. Problem

    What is wrong?

    Conductive hearing loss from fixation of the stapes footplate by otosclerosis, confirmed by an air-bone gap with a normal eardrum, absent stapedial reflexes and a compatible history.

  2. Objective

    What are we trying to achieve?

    Restore sound transmission into the inner ear so that the air-bone gap closes and, in many cases, a hearing aid is no longer needed for that ear.

  3. Expected benefit

    What may improve?

    Air-bone gap closure to within 10 dB in roughly 80–90% of first operations; speech understanding at conversational level without amplification in most of these.

  4. Alternatives

    What other options exist?

    Observation with periodic audiometry; a hearing aid, which treats otosclerosis well because the inner ear is usually healthy; occasionally a bone-conduction or middle-ear implant.

  5. Preservation

    What existing hearing must be protected?

    Bone-conduction thresholds and speech discrimination — the inner-ear hearing that a hearing aid would rely on if the operation did not succeed. The opposite ear is never operated until the first result is stable.

  6. Risk

    What are the relevant trade-offs?

    Severe inner-ear hearing loss in about 0.5–1%; temporary dizziness common, persistent rarely; taste disturbance often temporary; tinnitus usually improves but can worsen; late deterioration and need for revision in a minority over decades.

  7. Personal priorities

    What matters to this individual?

    Freedom from a device, the demands of work and music, tolerance of a small irreversible risk, time for recovery, and how much the person values a natural rather than amplified sound.

Hearing preservation

What can we improve — and what must we protect?

  1. Hearing before treatment

    Air conduction typically 40–60 dB; bone conduction near normal apart from a Carhart notch at 2 kHz; excellent word recognition when amplified.

  2. Function we want to improve

    Air-conduction thresholds and the air-bone gap; hearing without a device; often binaural hearing when the other ear is normal or aided.

  3. Function we want to preserve

    Cochlear function (bone conduction and speech discrimination), the vestibular system, taste, and the facial nerve — and, in an only-hearing ear, everything.

  4. Possible trade-offs

    A small risk of a worse inner ear in exchange for a durable device-free result; possible dizziness in the first days; the chance that the result changes over years.

  6. How outcome will be measured

    Pure-tone air and bone conduction and the air-bone gap at 3–6 months; word recognition; whether a hearing aid is still used; and the person's own account of hearing in daily life.

Common questions

How much hearing improvement may occur?

In a typical case the air conduction improves to within 10 dB of the bone conduction — often a gain of 25 to 35 dB. If bone conduction is normal, hearing may return to normal or near-normal levels. If the inner ear is also affected (mixed loss), the gain is limited to closing the gap and some loss remains.

Can a hearing aid become unnecessary?

For most people with a purely conductive loss, yes. For those with a mixed loss, a hearing aid may still be needed but will work better with the gap closed.

Can tinnitus change?

Tinnitus improves or disappears in a majority of people whose hearing improves. It stays the same in some, and in a small minority it becomes louder, particularly if inner-ear hearing worsens. It should be discussed before surgery rather than assumed.

Why can dizziness occur?

The prosthesis sits in an opening to the inner-ear fluid, and the vestibular system shares that fluid. Brief unsteadiness in the first days is common and settles. Persistent vertigo is uncommon and may indicate a prosthesis that is too long, a perilymph leak, or reparative granuloma, and needs review.

Can hearing become worse?

Yes. A severe or total inner-ear hearing loss occurs in roughly 0.5–1% of first operations and somewhat more often in revisions. A smaller high-frequency loss occurs more often and may not be noticed. This irreversible risk is the main reason the decision should not be rushed.

When may flying be possible?

Most surgeons advise waiting two to four weeks, until the ear has healed and any dizziness has settled. Follow the advice given for your own operation; see the page on flying after ear surgery.

Why might revision become necessary?

A result that was never good, or that fades after months or years, can be caused by prosthesis displacement, erosion of the incus where the prosthesis attaches, scar tissue, re-fixation, or a second problem such as malleus fixation that was not apparent at the first operation. Revision starts with working out which.

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.