Stapedectomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Stapedectomy is an ENT microsurgical procedure to treat otosclerosis — an abnormal bone remodelling disorder of the middle ear in which the stapes (stirrup bone, the smallest bone in the human body) becomes progressively fixed in the oval window due to pathological new bone growth around its footplate. This fixation prevents the normal transmission of sound vibrations from the tympanic membrane through the ossicular chain (malleus, incus, stapes) to the cochlear fluid, resulting in progressive conductive hearing loss that typically begins in the second or third decade of life.

The procedure removes the fixed stapes footplate (or creates a hole in it — stapedotomy) and replaces the stapes with a prosthetic piston, typically 0.4–0.6 mm in diameter, made of titanium, platinum-fluoroplastic, or nitinol memory metal. The piston is crimped to the incus long process and inserted through the oval window, directly transmitting sound vibrations to the perilymph of the inner ear, restoring near-normal hearing in the majority of patients.

Stapedectomy (complete footplate removal) and stapedotomy (small fenestra technique, creating a 0.6–0.8 mm hole) are the two main variants; stapedotomy is now preferred by most surgeons for its lower risk of inner ear trauma and equivalent hearing outcomes. The procedure is performed entirely through the ear canal using an operating microscope or endoscope, with no external incisions.

Stapedectomy is indicated for patients with confirmed otosclerosis causing progressive conductive hearing loss with a minimum air-bone gap (ABG) of 25–30 dB on pure tone audiometry. The audiometric hallmarks of otosclerosis include a type As (low compliance, low peak) tympanogram with absent stapedial reflexes, and a characteristic Carhart notch (dip in bone conduction at 2 kHz) that reverses after successful surgery.

Surgery is offered unilaterally first, on the worse-hearing ear, with the second ear operated at least 6–12 months later to confirm safety before bilateral surgery. Bilateral simultaneous stapedectomy is generally avoided to protect the patient's hearing in both ears simultaneously.

Alternative management includes hearing aids, which provide effective amplification but do not halt disease progression or address the underlying pathology. Medical management with sodium fluoride (thought to stabilise the otosclerotic process) is used in some centres, particularly in patients with coexisting cochlear otosclerosis causing sensorineural loss, though evidence for its efficacy remains limited.

Contraindications include: only-hearing ear (relative — surgery carries risk of total deafness); active middle ear disease (otitis media); uncontrolled systemic disease; occupational or recreational activities with significant pressure change (diving, aviation) incompatible with a middle ear prosthesis; and patient refusal after counselling about the risks.

Stapedectomy is performed under general anaesthesia or local anaesthesia with sedation. The patient lies supine with the head turned away from the operated ear. The ear canal is infiltrated with lignocaine and adrenaline for vasoconstriction and anaesthesia.

A transcanal approach is used — the surgeon operates entirely through the ear canal with no external incision. A tympanomeatal flap (skin flap from the posterior ear canal wall) is elevated and reflected forward to expose the posterior middle ear space and the ossicular chain. The chorda tympani nerve (taste nerve, a branch of the facial nerve running across the middle ear) is carefully identified and gently retracted or, if necessary, divided.

The fixity of the stapes is confirmed by palpating the ossicular chain. The incudostapedial joint is divided. The stapes superstructure (arch) is fractured and removed. In stapedotomy (small fenestra technique), a 0.6–0.8 mm hole is drilled or lasered (CO2 or KTP laser preferred — the laser beam creates a precise, bloodless fenestra without mechanical trauma) through the stapes footplate into the vestibule.

A tissue seal (vein graft from the back of the hand or ear canal, or perichondrium) is placed over the footplate to seal the inner ear. The prosthesis (piston) is inserted through the fenestra, its hook crimped to the long process of the incus, and the piston length and position confirmed to ensure it projects approximately 0.5 mm into the vestibule without touching the utricle. The tympanomeatal flap is replaced. No sutures are required. Total operative time: 45–75 minutes.

Patients are typically discharged on the same day as surgery or after one overnight stay. Dizziness and unsteadiness for 24–72 hours are expected — the inner ear requires time to adapt to the new prosthesis in the oval window. Patients are advised to rest at home for 1–2 weeks. Hearing improvement may be apparent immediately, though the ear is often packed with absorbing dressing material which temporarily muffles sound; clear improvement becomes noticeable as the ear canal packing dissolves over 2–4 weeks.

Specific restrictions are important to protect the new prosthesis: avoid nose-blowing and forceful Valsalva manoeuvre for 3–4 weeks to prevent prosthesis displacement; avoid swimming and water entry into the ear for 6 weeks; avoid air travel for 4–6 weeks; avoid strenuous exercise for 2–4 weeks; avoid loud noise exposure during healing. Heavy lifting is avoided for 2–3 weeks.

Audiometric assessment at 6–8 weeks post-operatively documents the air-bone gap closure. A further formal audiogram at 3–6 months confirms the final hearing result. Taste disturbance from chorda tympani manipulation is common (20–30%) and usually resolves within 3–6 months. Most patients return to normal daily activities within 2 weeks and to work within 1–2 weeks for sedentary roles.

Total sensorineural hearing loss in the operated ear (dead ear) is the most feared complication, occurring in approximately 1–2% of cases even with experienced surgeons. This risk arises from inner ear trauma (direct damage to the utricle or saccule, perilymph fistula, or acoustic trauma from the drill), which is reduced but not eliminated by using laser fenestration and a small fenestra technique. Patients must be counselled that deafness is a rare but definitive risk before consenting.

Tinnitus can worsen or appear de novo in approximately 5–10% of patients. Facial nerve injury from the nerve's proximity to the oval window is rare (less than 0.5%) with an experienced surgeon who identifies the nerve at the start of the procedure. Taste disturbance (metallic taste, loss of taste on one side of the tongue) from chorda tympani manipulation occurs in 20–30% of patients and typically resolves within 3–6 months.

Prosthesis displacement or extrusion may cause deterioration of hearing and require revision surgery. Perilymph fistula (leak of inner ear fluid) causes vertigo and sensorineural loss. Middle ear infection (suppurative otitis media) early post-operatively can lead to prosthesis infection and severe complications. Late revision surgery is required in approximately 5–10% of cases for prosthesis displacement, adhesions, or recurrence.

Stapedectomy achieves hearing improvement — closure of the air-bone gap to within 10 dB of normal — in 85–90% of patients at 12 months, with the majority achieving near-normal hearing. In experienced hands (surgeons performing more than 50 stapedectomies per year), closure to within 10 dB is achieved in over 90% of cases. The procedure provides permanent hearing restoration without the daily burden of hearing aid use.

Hearing gain from stapedectomy is typically 20–35 dB (the average pre-operative air-bone gap), restoring speech comprehension without the need for amplification in quiet environments. Many patients describe the restoration of hearing as transformative, enabling normal social interaction, telephone use, and professional communication.

Unlike hearing aids, which amplify all sounds including background noise, the prosthesis restores near-normal sound processing through the natural middle ear and cochlea, providing superior speech clarity in noise — a significant quality advantage. Hearing preservation is maintained at 10-year follow-up in over 80% of successfully operated ears without progression of the otosclerotic process (though cochlear otosclerosis may still progress independently). The procedure is cost-effective when compared to the lifetime cost of binaural hearing aids.