4. otosclerosis

Otosclerosis

Otosclerosis

DR. RS MEHTA, BPKIHS



Stapes becomes immobilized RT growth of bones or deposition of new bone over oval window, causing fixation of the stapesInterferences of the transmission of vibration into the inner ear.Chronic ear diseaseDR. RS MEHTA, BPKIHS

INTRODUCTIONOtosclerosis is a disease of otic capsule in which new vascular spongy bone formation causes ankylosis or fixation of the foot plate of the stapes and progressive conductive deafness.Otosclerosis can result in conductive and/or sensorineural hearing loss. This usually will begin in one ear but will eventually affect both ears with a variable course. DR. RS MEHTA, BPKIHS





ETIOLOGYExact cause not known.Heredity: Family history of deafness is present in 50% of cases.Sex: females are affected twice as often as males. DR. RS MEHTA, BPKIHS

Age of onset: usually occurs between 20-30 years of age and rarely starts before 10 or after 40 years.

Pregnancy: Otosclerosis may be initiated or aggravated by pregnancy but never caused by it.DR. RS MEHTA, BPKIHS

Other factor: Metabolic disorder, endocrinal, vitamin deficiency, focal infection etc.DR. RS MEHTA, BPKIHS

TYPESStapedial Otosclerosis: it causes stapes fixation and conductive deafness is common. Lesion start in fissula ante fenestramCochlear Otosclerosis: it involves region of round window and may cause senso-neural hearing loss due to liberation of toxic materials.Histologic Otosclerosis: remains asymptomatic and cause neither conductive nor senso-neural hearing loss.


PATHOLOGYBony changes vary according to the duration of diseasesFirst: the normal bone is absorbed and replaced by vascular, spongy osteoid tissue and advanced with blood vessels.Later: bone become thicker and less vascularThen: new bone formation takes place at annular ligament of the oval window fixing the stapes and leads to conductive deafness. Spread to footplates of the stapesAlso affect the bony-capsule of the labyrinth, resulting sensory-neural deafness.


SIGNSHearing loss: progressive deafness which is painless and is insidious.TinnitusVertigo: uncommonSpeech: patient has a monotonous, well modulated soft speech.DR. RS MEHTA, BPKIHS

DIAGNOSIS

Tuning fork test revels conductive deafness.Audiometry testH/O hearing lossDR. RS MEHTA, BPKIHS

DIFFERENTIAL DIAGNOSISIt should be differentiated from:Serrous otitis mediaAdhesive otitis mediaTympanosclerosisOtitic fixation of head of malleusOssicular discontinuityDR. RS MEHTA, BPKIHS

Management OptionsMedical AmplificationSurgeryCombinationsDR. RS MEHTA, BPKIHS

TREATMENTMedical: no medical treatment to cure otosclerosis.May use: sodium fluoride in a dose 20 mg BD for 2 years, with calcium , arrests the rapid progress of otosclerosis.DR. RS MEHTA, BPKIHS

MedicalSodium fluorideMechanismFluoride ion replaces hydroxyl group in bone forming fluorapatiteResistant to resorptionIncreases calcification of new boneCauses maturation of active foci of otosclerosisDR. RS MEHTA, BPKIHS

AmplificationExcellent alternative Non-surgical candidatesPatients who do not desire surgeryHearing aids conditions: a. unfit for surgeryb. elderly patientsc. not willing to operationd. after surgery if not improve deafnessDR. RS MEHTA, BPKIHS

StapedectomyStapedectomy: removal of stapes and insertion of prosthesis.

Prosthesis may be a Teflon piston, stainless steel piston, platinum teflon or titanium teflon piston. DR. RS MEHTA, BPKIHS

SURGICAL INTERVENTIONStapedotomyLess trauma to the oval windowLess possibility of damage to the inner earIn addition, revision surgery, if required, is easier due to preserved anatomy


Placement of the ProsthesisProsthesis is chosen and length pickedSome prefer bucket handle to incorporate the lenticular process of the incus


NURSING CAREOperated ear: Upside for 24 hrs after OTVital signCaution in ambulation: as dizziness may occurReassure dizziness is temporaryObserve for S/S of bleeding, drainage, N/VAssess vertigo: quite, rest, sedativeAntibiotic & Analgesic: to control infection & painObserve: Nystagmus or S/S of facial palsy


Medicated ribbon gauze pack removed after 5-7 daysDecongestentant: dilate Eustachian TubeDischarge advice: Avoid water in ear for 2 months, loud noise, blowing nose and mouth open when sneezing Avoid: straining, bending, heavy lifting, and infection.Antibiotic full course and as advised.


Monitor and report complicationsFacial nerve palsyGiddinessVomitingSensory-neural deafnessConductive deafness


CONTRAINDICATIONSThe only hearing earHistory of Menieres diseaseYoung childrenProfessional atheletes, high constructive workers, drivers, frequent air travellers.Pregnancy


SELF CARE AT HOME(POST-OPERATIVE)Take medicine as prescribed.Blow nose gently.Sneeze and cough with mouth open for few weeks after surgery.Avoid heavy lifting, straining and bending.Popping and crackling sensation are normal for 3-5 weeks after surgery.Temporary hearing loss is normal in operative ear.Change cotton ball in the ear as needed.Avoid getting in water for 2 weeks after surgery.DR. RS MEHTA, BPKIHS

THANK YOU


Surgical StepsSubtleties of technique and styleLocal vs. general anesthesiaStapedectomy vs. partial stapedectomy vs. stapedotomyLaser vs. drill vs. cold instrumentationOval window sealsProsthesisDR. RS MEHTA, BPKIHS

Total StapedectomyUsesExtensive fixation of the footplateFloating footplateDisadvantagesIncreased post-op vestibular symptomsMore technically difficultIncreased potential for prosthesis migrationDR. RS MEHTA, BPKIHS

Stapedotomy/Small Fenestra

Less trauma to the vestibuleLess incidence of prosthesis migrationLess fixation of prosthesis by scar tissue


Drill Fenestration0.7mm diamond burrMotion of the burr removes bone dustAvoids smoke productionAvoids surrounding heat production


Laser FenestrationLaserAvoids manipulation of the footplateArgon and Potassium titanyl phosphate (KTP/532)Wave length 500 nmVisible lightAbsorbed by hemoglobin Surgical and aiming beamCarbon dioxide (CO2)10,000 nmNot in visible light rangeSurgical beam onlyRequires separate laser for an aiming beam (red helium-neon)Ill defined fuzzy beamDR. RS MEHTA, BPKIHS

Placement of the ProsthesisProsthesis is chosen and length pickedSome prefer bucket handle to incorporate the lenticular process of the incus


COMPLICATIONS OF SURGERYOverhanging facial nerve Floating footplateDiffuse obliterative otosclorosisPerilymphatics GuscherSNHLRound window closureRecurrent CHLRegenerative granulomaVertigoDR. RS MEHTA, BPKIHS

Oval window sealTragal perichondriumVein (hand or wrist)Temporalis fasciaBloodFatGelfoam (now discouraged)DR. RS MEHTA, BPKIHS

Reconstructing the annular ligament


Special Considerations and Complications in Stapes SurgeryDR. RS MEHTA, BPKIHS

Overhanging Facial NerveUsually dehiscentConsider aborting the procedureFacial nerve displacement (Perkins, 2001)Facial nerve is compressed superiorly with No. 24 suction (5 second periods)10-15 sec delay between compressionsPerkins describes laser stapedotomy while nerve is compressedWire piston usedAdd 0.5 to 0.75 mm to accommodate curve around the nerveDR. RS MEHTA, BPKIHS

Floating FootplateFootplate dislodges from the surrounding OW nicheIncidental findingMore commonly iatrogenicPreventionLaserFootplate control holeManagementAbortH. House favors promontory fenestration and total stapedectomyPerkins favors laser fenestration


Diffuse Obliterative OtosclerosisOccurs when the footplate, annular ligament, and oval window niche are involved Closure of air-bone gap < 10 dB less common.Refixation commonly occurs


Perilymphatic GusherAssociated with patent cochlear aqueductMore common on the leftIncreased incidence with congenital stapes fixationIncreases risk of SNHLManagementRough up the footplateRapid placement of the OW seal then the prosthesisHOB elevated, stool softeners, bed rest, avoid Valsalva, +/- lumbar drain


Round Window Closure20%-50% of cases1% completely closed

No effect on hearing unless 100% closed

Opening has a high rate of SNHL


SNHL1%-3% incidence of profound permanent SNHLSurgeon experienceExtent of diseaseCochlearPrior stapes surgeryTemporarySerous labyrinthitisReparative granulomaPermanentSuppurative labyrinthitisExtensive drillingBasilar membrane breaksVascular compromiseSudden drop in perilymph pressure


Reparative GranulomaGranuloma formation around the prosthesis and incus2 -3 weeks postopInitial good hearing results followed by an increase in the high frequency bone line thresholdsAssociated tinnitus and vertigoExam reddish discoloration of the posterior TMTreatmentME explorationRemoval of granulomaPrognosis return of hearing with early excisionAssociated with use of GelfoamDR. RS MEHTA, BPKIHS

VertigoMost commonly short lived (2-3 days)More prolonged after stapedectomy compared to stapedotomyDue to serous labyrinthitisMedialization of the prosthesis into the vestibuleWith or without perilymphatic fistulaReparative granulomaDR. RS MEHTA, BPKIHS

Recurrent Conductive Hearing LossSlippage or displacement of the prosthesisMost common cause of failureImmediateTechniqueTrauma DelayedSlippage from incus narrowing or erosionAdherence to edge of OW nicheStapes re-fixationProgression of disease with re-obliteration of OWMalleus or incus ankylosisDR. RS MEHTA, BPKIHS

AmplificationExcellent alternative Non-surgical candidatesPatients who do not desire surgery

Patient satisfaction rate lower than that of successful surgeryCanal occlusion effectAmplification not used at nightDR. RS MEHTA, BPKIHS

MedicalBisphosphonatesClass of medications that inhibits bone resorption by inhibiting osteoclastic activityDosing not standardOften supplement with Vitamin D and CalciumStudies conducted on otosclerosis patients with neurotologic symptoms report the majority of patients with subjective improvement or resolution.Future application of this treatment unclear, especially with new reports of bisphosphonate related osteonecrosis.DR. RS MEHTA, BPKIHS

PostoperativeWater precautionsNo valsalvaPostop audio


Rare complicationsFacial paralysisAcute otitis mediaCholesteatomaDR. RS MEHTA, BPKIHS

Monitor and report complicationsFacial nerve palsyGiddinessVomitingSensory-neural deafnessConductive deafnessDR. RS MEHTA, BPKIHS


STAPEDOTOMY


Thank-YouDR. RS MEHTA, BPKIHS

Health & Medicine

4. otosclerosis