Issues In Stapedectomy

Douglas D. Backous, MD
February 6, 1992

The history of stapedectomy is one of near discovery, condemnation, reintroduction and refinement.  Prior to the twentieth century poor lighting and magnification, nonstandardized audiometry, and a lack of understanding of the middle ear conduction mechanism plagued early researchers. Procedures concentrated on either partial or total removal of the tympanic membrane and ossicles. Mobilization of the stapes, described by Miot and later by Blake, would eventually be condemned by the otologic world.  Siebenmann, in 1900, capped the early era of stapes surgery by stating, “Clinical experience teaches that all endeavors at mobilization of the stapes in otosclerosis are not only useless but often harmful.”

Between 1900 and 1952 attempts at fenestration of the horizontal semicircular canal came to the spotlight. Results were reported as excellent but temporary. Microscopy and rotating drills were introduced. In 1929 the American Otologic Society commissioned a committee to compile a resume of  all literature concerning otosclerosis up to 1928. The result included a 700 page, two volume document covering histology of the otic capsule, heredity, audiology, and treatment of otosclerosis.

Successful surgery for hearing restoration truly began with Lempert’s fenestration operation. Rosen, a student of Lempert, serendipitously discovered that footplate mobilization improved hearing immediately in a patient with otosclerosis. He continued to refine his mobilization procedure until Shea, his student,  reopened the era of stapedectomy in 1956. Shea developed the modern technique of footplate mobilization, soft tissue grafting of the oval window, and ossicular replacement.

Shea is also credited with the first stapedotomy, performed on a young girl in 1960. A 6 millimeter stapedotomy with piston insertion and soft tissue packing provides equally improved hearing with less risk for damage to inner ear structures. Higher frequency hearing is preserved better with stapedotomy.
Robinson summed up the stapedectomy/stapedotomy debate best by declaring the “best” procedure is the operation which provides the individual surgeon with a predictable and safe outcome along with improved hearing to levels consistent with current otologic standards.

Depletion of the pool of patients with otosclerosis occurred during the “golden age” of stapes surgery throughout the sixty’s and early seventies. Increased numbers of trained otolaryngologists and improved hearing amplification further contribute to an overall limited exposure in modern practice and residency. Stapedectomy is the second least performed procedure in American residency, as shown by Harris and Osborne in 1990.

The issue of training residents to do successful stapedectomy first appeared in the literature in 1983.  Chandler and Rodriguez-Torro revealed a 62% closure of the air-bone gap to within 10 dB in resident cases, well below the 90-95% standard expected of practicing otologists. Five studies of results from training programs have since revealed results ranging from 64%-82% closure to within 10 Db in training programs. Of interest are the results of Shapira, et al. Their residents, in Israel, did stapedectomy in all four years of training. Results during the first two years of residency compared with American programs. During the second two years, however,results approached and often equaled those of staff. These findings further emphasized the critical importance of adequate numbers of procedures to insure acquisition of competence.

Solutions to the problem of numbers of cases include increased observation of otologic procedures with correlation in the temporal bone laboratory. Residents should display competence in surgery for chronic middle ear disease prior to attempting stapedectomy. Finally, all procedures should be supervised by senior otologic staff and one consistent technique used. For physicians in practice, batching stapedectomies into groups with review of needed skills in the temporal bone lab followed by consecutive case completion and review of results could provide valuable feedback in regard to outcome and maintenance of required skills.

In summary, stapedectomy has a fascinating history. Had Rosen not been open-minded to his first accidental mobilization, more delay in technique development was inevitable. The best procedure is surgeon dependent varying with individual skills and experience. Otosclerosis is now at a steady incidence making increased work in the temporal bone laboratory mandatory for both the acquisition and maintenance of required skills in footplate manipulation.

Case Presentation

A 68-year-old white male presented with a fifteen year history of progressive hearing loss. He had the most difficulty hearing in small group conversations. He denied tinnitus, dizziness, otalgia, or chronic middle ear infections. He did admit to a long history of loud noise exposure. Past surgical and medical histories were unremarkable. Weber exam showed localization to the right. Audiometry revealed normal to moderate sensorineural and severe to moderate conductive loss in the right ear with absence of acoustic reflexes. The left ear had mild to moderate sensorineural loss with normal acoustic immittance measures. Speech intelligibility scores were within the normal range bilaterally. The patient underwent right middle ear exploration, stapedectomy, with perichondrial grafting over the oval window and insertion of a standard well Robinson prosthesis.

Bibliography

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Tympanoplasty (Eardrum Perforation & Reconstruction)

Ear Surgery Information Center
Wonderful site that is very in-depth and helps you to understand the procedure.   Excellent for patients and students.

Grand Rounds Presentation on Tympanoplasty
Very informative website.

The Learning Center on Tympanoplasty
Looks at the pediatric side of Tympanoplasty.  Very general and easy to understand.

Mayo Clinic on Tympanoplasty
Great break down of the procedure and what exactly happens.

Baylor College on Tympanoplasty
Advanced website with in-depth reading.

Surgery Encyclopedia
Large print article on tympanoplasty that also has questions for patients to ask.  Very useful to really understand the procedure without getting to technical.

Pediatric ENT Associates
The best website that I have seen that shows pictures while explaining the procedure.  Very nice!

MedLine Plus.. Eardrum Repair
Basic information for patients about the procedure.

Michigan Ear Institute
Excellent images of the procedure.

Images of Tympanoplasty … Dr. Sullivan
Very good images if the computer has good graphics.  These are from Dr. Roy Sullivan’s video otoscopy web page.  There are several at this location.

Tinnitus

American Tinnitus Association
Currently under construction, but still has some information about literature and membership.

American Speech-Language-Hearing Association
Very nice site that has answers to a lot of different questions about tinnitus.

T-FAQ
Great website with lots of information. Very useful for patients.

Wikipedia
Great site with lots of information. Much more than most sites. Very interesting.

Doctor, What Causes the Noise in My Ear
This article was from the American Academy of Otolaryngology.    It is consumer oriented and very easy to understand.

Tinnitus Support Message Support
A website that is strictly a message board. Always good to use if you have questions.

Tinnitus Online Community
Excellent concept that has email, online chats, and news groups for people with tinnitus.

RNID Website
Interesting website that actually lets you hear what a person with Tinnitus hears.

Tinnitus … Patient Info
Nice web site that has society, web site, research, and patient information links.

Medline Plus Tutorial
Very Cool Website.  Take a look.

Tinnitus
Basic tinnitus web site that is in outline and paragraph format.

Tinnitus (Ringing in the Ears)
A nice web site that has self-care tips and questions to ask to see if you should have emergency care or call your primary doctor.

Emedicinehealth… Tinnitus
Looks at a variety of topics.

FAQ’s About Tinnitus … The New York Eye & Ear Infirmary
The web site answers the 7 most common questions associated with tinnitus. Brief answers that are easy to understand.

Tinnitus
Tinnitus.org looks at both topics and has some definitions that will be useful.

What Causes Tinnitus
Very nice article that clearly explains what happens in the ear.   It also gives publication information.

Tinnitus Site
This site looked at being careful with some different treatments.

OHSU Tinnitus Sheet
Looked at some different treatments.

Tinnitus … New Hope for a Cure
Synopsis of a book with new scientific information, for both suffers and doctors.

Tinnitus Retraining Therapy,Information for All
Good site that explains how retraining therapy works for patients.   Interesting concept!

Coping with Tinnitus
This web site has articles, computer software, frequently asked questions, and newsgroups.  Good one to visit.

HearNet.com… Hearing Education and Awareness for Rockers
I love this site.  It makes Audiology seem almost cool.

Diagnose-Me.com
I would not use this instead of an Audiologist or ENT, but it looks interesting.

Oregan Tinnitus and Hyperacusis Treatment Clinic
Lots of good information.

American Family Physicians
Great site that is very informative. A little advanced.

Advanced Web Sites

Tinnitus Research Initative
A site that looks at some grants and research for Tinnitus..

Oregon Tinnitus Data Archive
Advanced web site that is intended to serve as a reference source for tinnitus.

Medical Search Engines

HealthAtoZ… The Search Engine for Health and Medicine
An excellent search engine that rates accuracy and content of the sites retrieved by the search engine.

MedHelp International
The largest online consumer health information resource.  Gives basic explanations for a variety audiological and medical conditions.

Medscape….  TheOnline Resource for Better Patient Care
An excellent source for audiological information. You must register to use this site.

The Merck Manual of Medical Information
This search engine uses several Merck manuals in the areas of Audiological information and Geriatrics. It is an excellent resource for consumers and students.

NetWellnessSearch Screen
Uses a variety of resources located in the NetWellness web site.  Most search engine findings are listed in a basic question and answer format.   Very easy to understand

Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences
This site is more advanced and would benefit students in a variety of areas.   Located at the main home page their are topics that would be helpful to patients.

OMNI Quick Search
UK’s gateway to medical resources on the internet. Keywords are defined in each search engine subject. It is very beneficial for basic audiological information.

National Library of Medicine
This site uses a large database from MedLine and other on-line journals.   It is arranged in an abstract type format for quick and easy review.

HealthWorldOnline..  Site Search
Nice site that shows small paraphrase about literature and abstracts that were found.   Allows person to save time by previewing sites.

NewEngland Journal of Medicine …  Search Engine
Advanced medical journal that could benefit students.

Yahoo.. HealthSearch Engine
General search engine that uses a narrowing down process to help locate medical information.

CliniWeb… Oregon Health Sciences University
An excellent medical search engine. Very easy to use due to the organization of the search engine.

MetaFindMulti-Engine Search
Nice search engine, but need to be very specific with keywords so amount of information retrieved can be beneficial.

HealthTouchOnline
You will find drug information, a health resource directory, and health information at this site.

HealingWell.Com
Nice website with information on many different medical pathologies.

24DR.com
Information about specific medical conditions or symptoms can be found here, as can useful anatomical diagrams to help you understand the conditions

MedlinePlus Health Information
A service of the National Library of Medicine & National Institutes of Health.

Research and Reference Material

The Visible Human Project
Great website for information and X-rays of the human body.   It is an outgrowth of The National Library of Medicine.

Washington University
Looks like some interesting articles.

Virtual Tour of the Ear
Great website!!!

Purdue University Libraries
Really great website with a wealth of information for a variety of subjects.

Journal of Speech, Language, and Hearing Research
This Journal is for Audiologists and Speech pathologists.   Very Technical.

American Journal of Audiology
This link allows you to browse their journals. If you are an ASHA member you can get the article for free online.

Massachusetts Eye and Ear Infirmary…Research Dept.
Excellent site that has information about the latest research projects that are being done at Harvard in the area of Audiology.

Research Papers Publication List…. Cochlear Fluids
Excellent site to get publication information on Dr. Alex Salt’s research material.   There is a large number of written material on the subject.   You can also visit his site at Cochlear Fluids Lab .

Miami Ear Institute
Large website in different areas of Audiology and Otolaryngology.

Dizziness/Vertigo Technical Papers
The pages that are listed are more technical in nature than other things on this site.  The pages listed would be of interest to healthcare providers who are studying audiology.

Audiology Resources
This is a great website geared mainly toward Audiologists and students.

Pediatric Audiology

Pediatric Audiology Internet Resources
Nice site that has resources for a variety of areas.  Seems really good for parents looking for information and support (has some dead links).

List of Pediatric Audiologist
Nice list that was compiled to show some of the Audiologists in the US that have the equipment to test and fit children birth to 6 months.

AAA Newborn Hearing Screening
Excellent article on hearing screenings for infant.

American Society for Deaf Children
A good source for information and resources for parents who have children with a hearing loss, as well as for students.

HiPMag Online
This is a great consumer and patient oriented online resource for deaf and hearing impaired kids and their parents. It takes a hip approach to hearing loss.

Parent Pals.Com
This is nice site for parents to visit that have a child with a hearing loss.

Is My Baby’s Hearing Normal… Midwest Ear Institute
This site gives information on when a child should have their hearing tested, indicators for a possible hearing loss, and what you should do if you believe your child may have a hearing loss.

KidsHealth.com
Really good web site for Parents, kids, and teens looking for information.   Just type in hearing in search box under parents and you will get a potpourri of topics.

General Pediatrics
Nice site for all kinds of Pediatric info.

Deafness:  Disney Encyclopedia of Children’s Health
Nice article on Deafness in children.   Good site for additional information on other topics with kids.

VOICE for Hearing Impaired Children
Very nice link for parents to visit!   It is an organization that is dedicated to ensuring that hearing impaired children have services available to them to aid in developing communication skills.

Advanced Web Sites

Congenital Sensorineural Hearing Loss
At first glance this site does not look very beneficial, but there are several links to use to find valuable information. This is an intermediate level site.

Considerations In the Evaluation of the Hearing Impaired Child
A nice article about the different syndromes and conditions that may accompany a child with a hearing loss. It had a nice bibliography, for possible reference material.

ASHA Readings in Pediatric Audiology
Nice list of reference material

Congenital Inner Ear Malformations
Advanced site that gives a lot of good information.

Otosclerosis & Stapedectomy

Otosclerosis

Otosclerosis… Ear Surgery Information Center
Excellent site that has a computer generated slide show of the actual procedure. It takes a few reviews of the slides to understand what everything actually represents.

FAQs about Otosclerosis …  New York Eye and Ear Infirmary
Nice site that answers common questions people have about the pathology.

Otosclerosis … Department of Otolaryngology
Learn the types of otosclerosis, surgical procedures and possible complications in surgery.

Otosclerosis… Hereditary Hearing Impairment Resource Registry
Good site that has really good information and also looks at the genetic background of the pathology.

National Institute on Deafness and Other Communication Disorders
Very nice explanation of Otosclerosis and the different treatments.  Check this web site out for a good overview.

Otosclerosis and Stapedectomy
Good pictures and images to explain this topic

Stapendectomy

Issues in Stapedectomy… Grand Rounds
The article at this web site is mainly about the history of the Stapendectomy. It is interesting to read.

Cornell University … Stapes Surgery
Nice website about the actual surgery.

Otitis Media (Middle Ear Infection)

Earaches & Otitis Media
Very nice website that has a lot of useful information for parents or someone with concerns about an ear infection.

Fluid in Your Ears … Cochlear Fluids Lab
Excellent pictures!!!  Good site to visit to help people understand the difference between middle ear and inner ear fluid.

Acute Otitis Media
Excellent site that has a large amount of information that is very beneficial for a parent, patient, or student to know.  It has several pages of great easy to understand text.

McKinley Health Center
An excellent web site that has information on the definition,  alternative names, causes, prevention, signs, treatments, and several other topics.

Middle Ear Infection: Information for Parents and Patients
Excellent easy to understand text with very nice pictures. Good site to visit!

Frequently Asked Questions About Otitis Media
Good site that answers common questions people have about earaches.

Medline: Otitis Media
Good site that shows illustrations with a nice volume of information for patients and parents.

Health WorldOnline
Article by David Parry, MD and Peter S Roland, MD which looks at medical treatments as well as alternative medicines. I found it interesting to read.

National Institute on Deafness and Other Communication Disorders
Informative website on a variety of topics dealing with ear infections.

KidsHealth.org
Very Nice web site dedicated to informing parents about health issues.  It also has tabs for related articles. Kudos!!!

Advanced Web Sites

American Academy of Otolaryngology
Nice descriptive article on the symptoms and treatment of Otitis Media.

Chronic Otitis Media …  The Merck Manual
Very nice website that has advanced information and was published in 1992.   It may be out of date, but has some interesting information about perforations of the tympanic membrane.

National Library of Medicine….  Health Services / Technology Assessment Text
Typing in Otitis Media into the search engine will produce a large amount of advanced material on this subject.

Otitis Externa (Outer ear infection, Swimmer’s Ear)

Swimmer’s Ear and More
Very nice page that lists the causes, symptoms, and how to prevent getting Swimmer’s Ear.   It also mentions why ears itch and what to do if you get a bug or foreign object in the ear canal.

Mayo Clinic Outer Ear Infection (Swimmer’s Ear)
General information is given about the description of an outer ear infection, prevention, possible complications, and treatment.

Swimmer’s Ear…. Pool Solutions
Very nice site that lists general information and has several links that may be of interest on the subject.

Otitis… External and Internal
Nice site that lists the definition, causes, prevention, symptoms, treatment,  prognosis, and several other areas of interest.

Otitis Media and Externa
Gives basic information about both types of infection.   Has a nice picture to help in the understanding the information and where the differences are.

Otitis Externa… Baylor Collegeof Medicine
Advanced information that is intended for health care professionals.  It has a large bibliography at the end of the article.

American Family Physician
Very advanced web site by Robert Sander, M.D.  Very interesting and detailed.

Noise Exposure & Hearing Conservation

Hear-It.org
Really good web site that is dedicated to hearing conservation and noise exposure and how it effects people. .

Occupational Safety Health Administration…. Noise and Hearing Conservation Index
Excellent website to find out OSHA’s standards on a number of areas dealing with noise in the work place.

Occupational Hearing Conservation Home Page
This is an excellent site that has OSHA documents, downloadable software for Macintosh computers, government programs and positional statements, consumer information, and organizations.  University of Wisconsin-Whitewater

HearNet
HearNet is a site that is dedicated to hearing education for musicians.  It is a very unique site that is fun to visit. It has a lot of useful info.

House Ear Institute
This is a fact sheet that can give you a lot of information. If you do a search on this site you can come up with even more info. Used to have a hearing conservation program called HIP (Hearing is Priceless), but could not find it.

Sound Partners
New Hearing Conservation Program through House Ear Institute.

Noise Exposure…. Midwest Ear Institute
This is a good web site that is set up in an easy to understand format. It answers frequently asked questions by the general public about noise exposure.

SHHHH! Just Quietly, You Could be Going Deaf
Excellent site with pictures to help patients understand about noise exposure and hearing loss.

Department of Labor and Industries Hearing Conservation Guidelines
This is a great site that looks at hearing conservation programs, hearing protection, training, noise level computation, and an online sample of an actual hearing conservation training program.

Military Audiology Association… Research into the Treatment and Prevention of Noise-Induced Hearing Loss
Interesting web site that looks at the latest research and treatment for sensorineural hearing loss. It talks about delivering medication to the cochlear fluids.

Noise, Ears, & Hearing Protection
An easy to understand web site that looks at common questions people often ask about or wonder about in the area of noise exposure.