Stapedectomy: surgery for otosclerosis, recovery

Stapedectomy is a surgical procedure on the stapes in the middle ear designed to restore sound conduction when it is blocked due to otosclerosis. The procedure involves removing the block at the base of the stapes and restoring the transmission of vibrations to the fluid of the inner ear using a prosthesis. The goal is to reduce conductive hearing loss, improve speech intelligibility, and reduce the need for a hearing aid. [1]

Otosclerosis is a focal pathological remodeling of the bony capsule of the labyrinth, which most often leads to fixation of the stapes and typical conductive hearing loss; in some patients, a sensorineural component develops over time. The disease affects both ears in a significant proportion of patients, but the degree of damage can vary, so surgery usually begins with the weaker ear. [2]

There are two main approaches: classic stapedectomy and stapedotomy. Stapedotomy involves creating a small opening at the base of the stapes and inserting a thin prosthesis; this method has become preferred in recent decades due to its consistent hearing results and lower morbidity, but the term "stapedectomy" is widely used as an umbrella term for the entire spectrum of stapes surgeries.[3]

The surgery is a functional intervention: it doesn't treat the underlying cause of otosclerosis, but it does address its key consequence—the block at the stapes level. With proper patient selection, most achieve clinically significant hearing improvement within the first few months after surgery. [4]

When is surgery indicated and what is the alternative?

The primary indication is clinically significant conductive hearing loss due to stapes fixation with intact cochlear function. Audiometry, tympanometry, and otomicroscopy are required for confirmation; in questionable cases, a CT scan of the temporal bones is prescribed. If the neurosensory component is pronounced, the expected benefit of surgery is lower, and hearing aids are more appropriate. [5]

Hearing aids remain a viable alternative: they improve hearing without the risks of surgery and can be used as a temporary or permanent strategy. The choice between aids and surgery is a collaborative decision that takes into account risk tolerance, lifestyle, professional requirements, and examination results. [6]

In bilateral cases, the weaker ear is operated on first; the decision on the other side is considered after the result on the first side has stabilized, usually after several months. In certain situations, with extremely advanced cases and poor speech intelligibility, cochlear implantation is considered. [7]

It's important to remember that even without surgery, otosclerosis can progress slowly over years. This doesn't mean intervention is urgent for all patients, but it does highlight the value of regular hearing monitoring and timely discussion of options. [8]

Table 1. Who is the operation primarily suitable for?

Situation	Why is this an argument for surgery?
Conducted hearing loss with preserved cochlear function	High probability of auditory win
Persistent need for high gain	The operation may reduce dependence on the device.
Professional requirements for sound localization	Return of binaural perception in a bilateral process
Gain intolerance due to sound distortion	Surgery removes the mechanical block, rather than amplifying the sound.
Summary of patient recommendations and reviews. [9]

How is the diagnosis confirmed and readiness for surgery assessed?

The diagnostic standard includes otomicroscopy, pure tone and speech audiometry, and tympanometry; the audiogram typically reveals a gap between bone and air conduction, i.e., an increased air-bone interval. Computed tomography of the temporal bones is used to clarify the anatomy, rule out alternative pathologies, and plan the technique. [10]

Preoperatively, realistic expectations are discussed: improved air conduction and a reduction in the air-bone gap are likely, but absolutely "normal" hearing is not guaranteed. Risks are also discussed in detail, including rare but potentially irreversible hearing loss in the operated ear. [11]

In a bilateral procedure, prioritization is important: the worse-hearing ear is treated first. This approach minimizes potential harm in the event of rare adverse outcomes and allows for better expectations before a possible second surgery. [12]

Preparation for the day of the procedure is standard for short-term general anesthesia: contraindications are clarified, tolerance is assessed, and active ear infections and sudden hearing changes the day before are ruled out. In most centers, the surgery is performed as a day hospital procedure. [13]

Table 2. Diagnostic framework before surgery

Stage	What does it give?	Why is it needed?
Otomicroscopy	Evaluation of the eardrum and auditory ossicles	Exclusion of other causes of conductive hearing loss
Audiometry	Measuring auditory thresholds and pathway gaps	Quantification of the purpose of the operation
Tympanometry	Assessment of pressure and mobility in the middle ear	Exclusion of effusion and tubal dysfunction
Computed tomography	Picture of otosclerosis foci and anatomy	Planning tactics and eliminating anomalies
Collection of patient records and reference books. [14]

Interventional techniques: stapedotomy and stapedectomy

Today, stapedotomy is more often preferred: a small opening is created at the base of the stapes and a piston-like prosthesis of the appropriate diameter is inserted. This reduces trauma, facilitates sealing of the oval window, and is associated with a sustained reduction in the air-bone gap. Recent reviews confirm comparable or superior results compared to classical stapedectomy, especially at high frequencies. [15]

Key parameters influencing hearing outcomes are the size of the stapes base opening and the diameter of the prosthesis. According to a recent review, improvements in air conduction of 20–30 dB and a reduction in the gap to 10 dB or less are achieved in a significant proportion of patients, although the exact percentages vary between series and depend on the technique. [16]

The surgery can be performed using an operating microscope or endoscope. An endoscope provides a wide field of view with minimal bone resection, which in some cases simplifies access and reduces trauma. The choice of optics is determined by the team's experience and anatomy. [17]

The use of a microdrill or laser is a matter of instrumental nuances, not fundamentally different procedures. Studies show similar hearing results when safety precautions are followed; the determining factors remain precision, sealing of the oval window, and correct prosthesis selection. [18]

Table 3. Stapedotomy and stapedectomy: what is fundamentally important

Criterion	Stapedotomy	Stapedectomy
Opening volume at the base of the stapes	Small spot window	Wider window with part of the base removed
Typical auditory effect	Sustainable correction of the gap	Comparable correction with greater tissue trauma
Risks	Potentially less trauma	There is a higher risk of the gap reopening in the long term
Practice	Often the method of choice	It is used according to indications and in a number of schools
Results of modern reviews and abstracts. [19]

How the operation is performed and what determines its quality

Access is achieved through the ear canal. The tympanic membrane flap is dissected, the incus and stapedial manubrium are mobilized, a window is created at the base of the stapes, the prosthesis is inserted, and it is secured to the long process of the incus. Finally, the flap is replaced, the oval window is sealed, and a soft packing is placed in the ear canal. The procedure typically takes approximately 1 hour. [20]

Key quality elements include accurate measurement and selection of prosthesis length, gentle handling of the chorda tympani, stable sealing of the oval window, and meticulous hemostasis. These details are directly related to the risk of dizziness, taste disturbances, and future rupture recurrence. [21]

In most centers, the surgery is performed as a day hospital procedure. The patient goes home the same day or the following day, provided they are feeling stable and without significant dizziness or nausea. The dressing and packing are removed at a follow-up appointment in 1-3 weeks. [22]

Once in the operating room, the surgeon checks the prosthesis for mobility and the absence of perilymph leaks. Early audiometry is performed after healing, with a final assessment performed after 1-3 months, once hearing has stabilized. [23]

Table 4. Quality control at key stages

Stage	What do they check?	For what
Window formation	Size and smooth edges	Reduced trauma and improved sealing
Selection of a prosthesis	Length and diameter correspond to anatomy	Optimal transmission of vibrations
Sealing of the oval window	Reliability of fabric laying	Preventing dizziness and leaks
Final test	Free mobility of the system	Early detection of kinks and displacements
Surgical guidelines and routing for day surgery. [24]

Efficiency and long-term results

In modern series, the proportion of patients achieving an air-bone gap reduction of 10 dB or less often exceeds 50-60%, and overall satisfactory results of reduction to 20 dB or less are achieved in the vast majority. The average improvement in air conduction is approximately 20-30 dB. The exact figures depend on the technique, prosthesis diameter, and the initial gap. [25]

Patient leaflets and reviews indicate an overall "good outcome" rate of over 80% for experienced surgeons. This means that air conduction thresholds are practically brought closer to the level dictated by the cochlear condition, although absolute normality is not guaranteed. [26]

Long-term hearing dynamics are possible, related to the natural course of otosclerosis and age-related changes. Moreover, long-term studies note the stability of the functional effect of the surgery and the preservation of the gain in conductivity over a period of years, although in a small proportion of patients the gap may widen again. [27]

After an unsuccessful primary operation, revision surgery can significantly reduce the air-bone gap and improve hearing, although the outcomes are somewhat more modest than with primary intervention. The causes of failure are varied: prosthesis displacement, length discrepancy, regeneration of otosclerotic foci, granulation, and changes in the incus. [28]

Table 5. How to interpret the audiogram after surgery

Indicator	What is considered a good outcome?	Comment
Air conduction	Improvement by 20-30 dB	Average review score
Air-bone rupture	Reduction to 10 dB or less	Target indicator for series with modern technology
Speech intelligibility	Improved at quiet and medium levels	Depends on the condition of the snail
Dynamics per year	Minor fluctuations in the norm	Take into account the natural aging of hearing
Summarized from major series and reviews. [29]

Risks and Complications: An Honest Conversation Before Consent

Brief dizziness and unsteadiness are expected in the first few days. Sometimes symptoms last longer, but persistent dizziness is rare. This is due to interference with the oval window and the transmission of vibrations to the inner ear. [30]

Taste disturbance on the affected side of the tongue is explained by tension or transection of the chorda tympani. Recent data show that taste complaints occur in approximately 40% of patients early on, in 20% after several months, and persist in 9% after a year; according to patient reports, persistent taste disturbances are noted in approximately 10%. [31]

Sensorineural hearing loss after surgery is possible, but uncommon. Systematic reviews report a low incidence of significant, persistent hearing loss, and the risk of complete hearing loss in the operated ear, based on patient records from experienced surgeons, is estimated at approximately one in 100. This is why the worse-hearing ear is operated on first. [32]

Rare complications include facial nerve paralysis, eardrum perforation, prolonged tinnitus, problems with oval window sealing, and the need for early revision. Most of these are extremely rare and can be prevented with careful technique and proper postoperative care. [33]

Table 6. Complications and estimated frequencies

Complication	How does it manifest itself?	Frequency estimate based on modern data
Temporary dizziness	Nausea, unsteadiness in the first days	Often, usually short-term
Taste disturbance	Bitterness, "metal", numbness of half the tongue	Up to 40% early, about 10% remains by the year
Persistent sensorineural hearing loss	Deterioration of thresholds after healing	Small percentage, units of percent
Complete hearing loss in the operated ear	Deaf Ear	Around 1% for experienced teams
Facial nerve paralysis	Facial asymmetry	Extremely rare
Summary of leaflets and reviews. [34]

Recovery: What to do week by week

On the day of surgery, the patient is observed until complete stabilization and typically goes home. Rest, ear protection from water, a soft ear canal packing, and limiting sudden bending and heavy lifting are recommended for the first few weeks. Mild nagging pain and ear congestion are normal until the packing is removed. [35]

An initial follow-up is performed after 1-3 weeks for examination, tamponade removal, and healing assessment. Basic audiometry is scheduled after stabilization—usually after 1-3 months. Flights and dives are undertaken with caution and only after surgeon approval. [36]

If severe dizziness, rapid hearing loss, severe pain, or purulent discharge from the ear suddenly develops, this is a reason to immediately seek an unscheduled examination. Such scenarios are rare, but require prompt correction. [37]

Most patients return to daily activities within 1-2 weeks, and gradually return to full-time work, depending on how they feel. Practical hearing results are assessed by audiometry, not by subjective sensations in the first few days. [38]

Table 7. Recovery by stages

Period	Expected sensations	Mode
0-3 day	Fatigue, mild nausea, congestion	Rest, protect your ear from water, do not strain
1-3 weeks	Gradual improvement in well-being	Check-up with a doctor, removal of the tamponade
1-3 months	Hearing stabilization	Control audiometry
Further	Second party's plan for testimony	Joint decision with the surgeon
Summary of day surgery routes and patient information sheets. [39]

Private clinical situations

Endoscopic techniques can be useful in cases of narrow ear canals and anatomical variations, allowing for better visualization of the working field and reducing the amount of bone removal. According to series of studies, the hearing gain is comparable to that of microscopic techniques, provided safety principles are observed. [40]

The parameters of the stapes base opening and the diameter of the prosthesis influence hearing outcomes; studies show that proper sizing helps achieve air conduction thresholds closer to desired values. These decisions are the surgeon's responsibility and are tailored to the specific anatomy. [41]

If the outcome of sensorineural intelligibility in one ear is unfavorable, but a good conducted effect remains possible in the other, the area with the highest expected benefit is treated first. In extremely advanced cases with low speech intelligibility, cochlear implantation is considered, as it provides a more stable increase in speech understanding. [42]

Revision surgeries after failure can provide clinically significant improvement, but the likelihood of achieving ideal rupture reduction is lower than with primary surgery. Before revision, it is important to document the cause of failure: prosthesis displacement, incus necrosis, granulation, or focal regeneration. [43]

Table 8. When to consider non-operative and alternative solutions

Situation	Preferred tactics	Justification
Mild hearing loss without complaints	Observation	No surgical need
Mixed hearing loss with low intelligibility	Hearing aid or implantation	The forecast for speech understanding is higher.
Recurrence of rupture after primary surgery	Revision surgery according to indications	Chance of clinically significant improvement
A two-way process	First surgery on the weaker ear	Rare Risk Management
Summary of clinical series and reviews. [44]

Frequently Asked Questions

How long does the result last?
Long-term observations show a consistent functional effect, but in some patients, the gap may widen over time due to the natural progression of the disease. Regular audiometry allows for early detection of changes. [45]

Is it true that stapedotomy is better than stapedectomy?
Stapedotomy is currently the preferred method due to its lower invasiveness and comparable or better hearing results in some series, but the surgeon's experience and correct technique remain decisive. [46]

What is the chance of hearing loss?
According to patient reports and reviews, the likelihood of significant, persistent hearing loss is low, and the risk of complete hearing loss in the operated ear is estimated at approximately one in a hundred in experienced hands. This is why the worse-hearing ear is operated on first. [47]

Is it possible to operate on the second ear?
Yes, usually after the results on the first side have stabilized. The timing is determined individually during follow-up. [48]