OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

INCUS- & MALLEOSTAPEDOTOMY Tashneem Harris & Thomas Linder

Stapedotomy refers to the calibrated fene- surgery, then a malleostapedotomy is per-

stration of a fixed footplate and insertion formed. The rationale behind the endaural
of a prosthesis. Prof Ugo Fisch first intro- approach with an enlarged tympanomeatal
duced the terms incus-stapedotomy where flap and partial anterosuperior canalplasty
the prosthesis is attached to the long pro- as described by Fisch is primarily to im-
cess of the incus, vs. malleostapedotomy prove surgical exposure in order to pro-
where the prosthesis is attached to the mal- perly assess ossicular mobility 7.
leus handle. 1 The surgical steps of both
procedures as described by Prof Fisch will Indication for surgery
be described.
Patients with otosclerosis and a conductive
Otosclerosis is the most common indica- hearing loss with an air-bone gap (ABG)
tion for stapedotomy. Histology of tempo- of >20dB are candidates for surgery.
ral bone specimens show that there may be
a fairly high incidence (up to 30%) of Goals of surgery
additional malleal fixation in otosclerosis.
2
Hyalinisation and ossification of the ante- The aim of surgery is to achieve maximum
rior malleal ligament are related to the hearing gain with minimal damage to the
duration of otosclerosis.2 Fixation of the membranous labyrinth; it may be consider-
malleus head and incus body are usually ed in 3 different categories depending on
found in narrow external ear canals. The the cochlear reserve of the patient:
reported incidence of malleal fixation in • To achieve normal hearing in patients
clinical studies varies significantly for both with normal cochlear reserve (<10dB
primary (0.6 - 6%) 3,4 and revision surgery postoperative air-bone gap)
(3-37%).5,6 In a recent study (unpublished • To achieve serviceable hearing in pa-
data) conducted by the senior author (T.L), tients with minimal reduction in coch-
the incidence was found to be 5% with lear reserve and possibly to eliminate
primary surgery. the need for a hearing aid
• To improve hearing aid satisfaction
The best way to assess mobility of the ossi-
cles and the anterior malleal ligament is by Note that patients with advanced otoscle-
visual assessment of the mobility of the rosis and poor cochlear reserve who no
ossicles on direct palpation. This requires longer benefit from amplification are can-
adequate surgical exposure; it is difficult to didates for cochlear implantation.
assess via a limited transcanal approach.
Partial fixation may be overlooked when Preoperative evaluation
using a limited approach.
Otomicroscopy: A normal stable tympanic
It is the practice of the senior author (T.L) membrane without retraction pockets
to routinely use the endaural approach should be confirmed in otomicroscopy.
and to systematically expose the anterior
malleal ligament as this allows for proper Tuning fork tests: Tuning fork tests are a
assessment and identification of impaired simple means to confirm a conductive hea-
ossicular mobility at the time of the pri- ring loss and can help confirm the validity
mary surgery. If there is even partial of the audiogram. They only assess a sing-
fixity of the malleus or incus at primary
le frequency (commonly 440Hz) at a time Tympanometry: Type A curve
and should be done by the surgeon.
Stapedial reflexes: Absent in otosclerosis
Audiological evaluation
High Resolution CT (HRCT)
• Audiometric testing should be recent
(<3months) It is important to emphasize at this point
• Enables the surgeon to decide which that otosclerosis is a clinical diagnosis
ear requires surgery 8 made on history, audiometric findings and
• It includes pure tone audiometry which confirmed at surgery. However, the role of
typically indicates conductive hearing HRCT in preoperative planning and patient
loss involving the lower frequencies counselling cannot be underplayed.
with a Carhart notch at 2kHz
• The size of the ABG provides an indi- HRCT (0,5mm) is useful (but not manda-
cation of the gain that may be achieved tory) because it can help to confirm the
by surgery 7 presence of otosclerosis 9; it may identify
• A typical audiogram for otosclerosis other middle ear disorders which may mi-
has a larger ABG in the low frequen- mic otosclerosis or be coexistent; it may
cies and good sound transmission at confirm cochlear involvement by the oto-
high frequencies (4kHz). A consistent sclerotic focus; it is useful to assess post-
pancochlear ABG is not typical for operative failures and complications e.g.
otosclerosis! sensorineural hearing loss (SNHL) or
• A Carhart notch is characterised by the disabling vertigo and may identify prob-
apparent elevation of bone conduction lems which need to be managed promptly
threshold of 15dB at 2kHz and is the e.g. too long a prosthesis. 10
hallmark audiologic sign of otosclero-
sis The absence of a Carhart notch suggests
• One can accurately determine the de- another cause for the conductive hearing
gree of secondary cochlear loss by loss. There have also been numerous case
making allowance for the Carhart reports and series of superior semicircular
notch when interpreting bone conduc- canal dehiscence and other pathology
tion thresholds; if the bone conduction which may mimic otosclerosis and are un-
threshold is larger than 15dB at 2kHZ
masked by stapedotomy (stapedial reflex is
it suggests underlying cochlear otoscle-
rosis. This can help the clinician with present in cases of dehiscence only). 11,12,
13,14
preoperative counselling about the anti-
cipated outcome of surgery
• In the absence of a Carhart notch it is It is the practice of the senior author (T.L.)
important to exclude other causes of to do a HRCT scan (0,5mm-1mm) when-
conductive hearing loss which may ever patients have the following features
mimic otosclerosis on pure tone audiogram:
• Speech discrimination is especially • Conductive hearing loss but absent
useful to determine the presence of Carhart notch
cochlear otosclerosis when the ABG is • Equal ABG across all frequencies
>15 dB at 2kHz) • Mixed hearing loss
• All cases of revision stapes surgery

2
The following pathologies can be excluded CT checklist for revision surgery
with preoperative HRCT scan: • Is the prosthesis in the correct position
• Conductive hearing loss with an absent or is it displaced?
stapedial reflex: • In cases of vertigo, what is the depth of
o Fixation of head of malleus to late- insertion into the vestibule?
ral tympanic wall • Is there evidence of obliterative oto-
o Fixation of incus or erosion of in- sclerosis, particularly of the round win-
cus dow, which may have been missed at
o Congenital ossicular deformity the primary surgery?
o Round window atresia • Is there superior canal dehiscence or
o Tympanosclerosis causing oblitera- any other 3rd window?
tion of footplate • Is there additional fixation of the mal-
• Conductive hearing loss with an intact leus and/or incus?
stapedial reflex:
o A 3rd window: superior or posterior Anaesthesia
semicircular canal dehiscence
o Tympanic facial nerve neuroma • General or local anaesthesia may be
blocking the stapes used
o Gusher syndrome: enlarged internal • Performing the procedure under local
auditory meatus, enlarged endolym- anaesthesia depends on the patient and
phatic aqueduct level of experience and level of com-
o Anomalous facial nerve fort of the surgeon
• Antibiotics are not routinely used
CT scan checklist prior to performing • Antiemetics are administered intraope-
stapedotomy
ratively
• Can one see an otosclerotic focus (fis-
sula ante fenestrum)? Surgical steps
• Is there obliteration of the oval and
round windows? Endaural approach (right ear)
• Is there cochlear otosclerosis? (It is
possible to have fairly extensive coch- • Infiltrate the site of the endaural skin
lear otosclerosis with minimally reduc- incision with local anaesthetic (lido-
ed hearing loss) caine 1% and adrenaline diluted to
• Is there a risk of a CSF gusher (enlar- 1:200 000)
ged aqueduct, enlarged internal audito- • Insert a nasal speculum in the external
ry meatus)? ear canal to improve exposure
• Is there semicircular canal dehiscence? • Infiltrate the skin of the external ear
• What is the position of the tympanic canal anteriorly and posteriorly
segment of the facial nerve? • A helicotragal incision is made using a
• Are there any other ossicular abnor- #15 blade (Figure 1)
malities e.g. fixation of the malleus to • It is vital to achieve adequate haemo-
the lateral wall of the epitympanum? stasis at this point to avoid subsequent
• Is there a stapedial artery? troublesome bleeding

3
 • An endaural raspatory is used to sepa-
rate the skin and soft tissue from the
bone both anteriorly and posteriorly
• The meatal skin flap is elevated using a
Fisch microraspatory and an otosclero-
sis suction with adrenaline gauze to
separate the soft tissue from the bone
as atraumatically as possible. The wor-
king end of the Fisch micro-raspatory
is held at right angles to the bone and
the shoulder of the instrument pushes
Figure 1: Helicotragal incision the adrenaline gauze strip towards the
soft tissue. The suction never touches
• Place two endaural retractors in the the tympanomeatal flap, but sucks on
entrance of the external ear canal. The the gauze
1st retractor is placed vertically; the 2nd
is placed horizontally (Figure 2) Anterosuperior canalplasty

• The exposure may occasionally be lim-

ited by a very prominent tympanosqua-
mous suture which requires removal
with a curette or a diamond drill
• In cases where there is a very promi-
nent anterior bony overhang which pre-
vents adequate exposure of the anterior
tympanic spine, a limited anterior
canalplasty is performed using a 3mm
diamond burr (Figure 3).
Figure 2: Exposing the ear with two
retractors

Meatal skin flap Malleus

Chorda tympani
• Make a posterior incision in the skin of
the ear canal using a #11 blade, starting Incus

at the annulus at 7 o’clock (5 o’clock Stapedius tendon

for left ear) and ascending upwards to
Canalplasty
end at 12 o’clock
• A 2nd incision starts anterior to the lat-
eral process of the malleus at 3 o’clock Figure 3: Anterosuperior canalplasty
(right ear) and passes above the tympa- improves exposure
nosquamous suture to meet the end of
the endaural incision at 12 o’clock • It is very important that all bony work
• It is important that the tympanomeatal is done before raising the tympanic part
flap is made long enough anteriorly of the tympanomeatal flap to avoid
and that the incision stays medial to the contamination of the middle ear with
cartilage plates bone dust

4
Exposure of oval window and rarely, congenital round window
atresia 11
• Elevate the tympanomeatal flap to-
wards the posterior tympanic spine in
order to elevate the annulus from the
sulcus
• The pars flaccida is elevated until the
lateral process of the malleus and the
anterior malleal ligament are visible
• A small curette is used to remove the
posterior tympanic spine taking care to
avoid damage to the underlying chor-
da tympani (Figure 4)
Figure 5: Correct handling of curette

Malleus

Incudomallear joint

Incus

VIIn

Pyramidal process

Figure 4: Small curette used to remove

posterior tympanic spine Figure 6: Final correct exposure

• Remove the rim of bone obscuring the Checking mobility of ossicular chain
inferior portion of the incudomallear
joint with a curette. It is important • Check the mobility of the malleus and
when using the curette, to avoid sub- incus with a 1.5mm, 45° hook (Figure
luxing the incus. The small end of the 7)
curette is used. The index finger of the
non-dominant hand stabilises the curet-
te anteriorly (Figure 5)
• Always preserve chorda tympani. It is
mobilised but kept attached to the
tympanic membrane; this facilitates re-
traction of the chorda away from the
surgical field
• The final correct exposure is obtained
when the pyramidal process, the tym-
panic segment of the facial nerve and
the inferior incudomallear joint are all
visible (Figure 6) Figure 7: Checking mobility of lateral
• Inspecting the round window is impor- ossicular chain
tant to exclude obliterative otosclerosis
reaching the round window membrane
5
• Check the mobility of the stapes • If correctly fractured, the stapes super-
(Figure 8) structure has a long anterior and a short
posterior crus
• Bleeding may occur from the mucosa
when the superstructure is removed, in
which case gelfoam with Ringer’s lac-
tate or diluted adrenaline solution is
placed over the footplate to achieve
haemostasis (wait 2-3 minutes)

Determining length of prosthesis

• Accurate measurement of the length of

the prosthesis is crucial
• A piston that is too long can contact or
even pierce the underlying membra-
Figure 8: Checking mobility of stapes
nous labyrinth
• A piston that is too short will be dis-
• If malleus and/or incus are fixed, then
placed easily when the patient sneezes
proceed to malleostapedotomy
or performs a Valsalva manoeuvre
• If the malleus and incus are mobile and
• A malleable measuring rod is used to
the stapes is fixed then, using the
determine the distance between the
1.5mm 45° hook, elevate the malleus
footplate and the lateral surface of the
handle to determine where the incudo-
long process of the incus (Figure 9)
stapedial joint is
• Add 0,5 mm to the measured distance
• Use a joint knife to separate the incu-
to account for the protrusion of the
dostapedial joint
prosthesis into the vestibule
• Check mobility of the stapes again

Removal of stapes arch

• Cut the stapes tendon with fine Belluc-

ci scissors
• Cut the posterior crus of the stapes
with (left or right) crurotomy scissors
• Exposure of the pyramidal process is
essential to provide sufficient space for
the crurotomy scissors
• Fracture the anterior crus at the level of Figure 9: Measuring rod used to
the footplate, using a 2.5mm, 45° hook determine length of prosthesis
• To fracture the anterior crus, insert the
2.5mm, 45° hook between the incus Trimming prosthesis
and the malleus neck, close to the foot-
plate. The tip of the hook is close to the • The Storz titanium stapes piston is
level of the footplate, even if the entire placed on a special cutting block which
anterior crus is not visible holds the prosthesis (Figures 10, 11)
• The hook is rotated towards the pro-
montory

6
 Figure 10: Teflon-wire prosthesis VIIn

Stapedotomy

Stapedius tendon
(remnant)
Round window

Figure 12: Initial small stapedotomy

• For a 0.4mm prosthesis the ideal diam-

eter is a stapedotomy of 0.5mm (Fig-
ure 13)

Figure 11: Cutting block

• The trimmed prosthesis is handled with

watchmaker’s forceps and placed up-
right in the 4mm hole of the cutting
block while proceeding to stapedotomy
• The Storz titanium stapes piston is hy-
groscopic and is therefore easier to
work with when wet. Therefore, the
cutting block is moistened with a few
drops of water before placing the Figure 13: Making the final 0.5mm
piston on it stapedotomy

Perforating the footplate • The tip of the perforator is gently

applied to the footplate without using
• A set of four manual perforators are any force at all
(0.3-0.6mm) are used to make the • The perforator is held vertically to the
stapedotomy stapes footplate and is gently rotated
• Start with the smallest perforator between the thumb and index finger of
(0.3mm) and ensure that there is no the right hand while the left hand
evidence of a CSF gusher before en- stabilises it (Figure 14)
larging the stapedotomy with the larger • The tip of the perforator only partially
perforators (Figure 12) enters the vestibule as the stapedotomy
• The safest place to make the stapedo- opening is created by the shoulder of
tomy opening is in the posterior two- the perforator
thirds of the stapes footplate (see
below)

7
 Choice of instrument for stapedotomy

• In the senior author’s (T.L.) experien-

ce, the type of footplate is important
when selecting a perforator
• An alternative to manual perforators is
laser or a Skeeter drill. Lasers that have
been used for stapes surgery include
CO2, KTP, Argon, Diode and
Erbium:YAG lasers
• When one encounters a biscuit (thick)
footplate, or a thick footplate which is
only partially fixed, then there is a risk
of causing a floating footplate
Figure 14: The perforator is gently ro- • If the footplate is too thick, then it is
tated between the thumb and index preferable to use a drill
finger of the right hand while the left
hand stabilises it Footplate fracture during stapedotomy

Additional important points and clinical • If only small bony fragments surround
scenarios the stapedotomy opening and the open-
ing is of the desired size, then one can
Safest position for stapedotomy carefully elevate the fragments with a
0.2mm footplate elevator to avoid the
• The risk of stapedotomy is damage to fragments from entering the vestibule
the membranous utricle and saccule and causing vertigo postoperatively
which lie in close proximity to the (Figure 15)
stapes footplate
• Surgeons should know the safety mar-
gins required to perform the proce-ure
without damaging the underlying vesti-
bule
• The minimum distances to the utricle
are at the posterior (0.58mm) and supe-
rior (0.62mm) borders of the footplate;
therefore placing a prosthesis to a
depth of 0.5mm in this region of the
footplate will place the utricle at risk of
injury 15 Figure 15: Carefully elevate bony frag-
• The minimum distance to the saccule is ments with 0.2mm footplate elevator
at the anterior border of the footplate
(0.76 -1mm) 14 • If the footplate has been fractured but
• All other measurements from the foot- the stapedotomy is still too small and it
plate to the underlying membranous is not possible to enlarge the opening
utricle and saccule are >1mm without displacing the bony fragments,
• The safest area for manipulation is then the fractured segments can be re-
therefore the central third in the moved with either a 0.2mm footplate
inferior segment of the footplate elevator or a 0.5mm, 45° hook, such

8
 that a partial or total stapedectomy is • The prosthesis is placed onto the foot-
performed. A graft is then placed over plate with the loop over the incus
the (partial) stapedectomy before inser- • One can estimate at this point whether
ting the prosthesis (Figure 16) the prosthesis is too long and needs to
be shortened, or too short and needs to
be replaced
• Using a 1mm, 45° hook, move the loop
of the prosthesis along the long process
of the incus to guide the shaft of the
piston towards the stapedotomy open-
ing (Figure 17)

Figure 16: Partial stapedectomy sealed

with a graft before inserting prosthesis

Floating footplate
Figure 17: The loop is hooked over
The footplate may become completely incus with the piston resting on the
mobile before the stapedotomy has been footplate
made. Management options in this situa-
tion are: • Once the piston is positioned within the
• Proceed with the stapedotomy using a stapedotomy opening, the loop of the
laser prosthesis is crimped with a large
• Proceed with a total stapedectomy and smooth crocodile forceps to achieve a
seal the oval window a graft (peri- more stable coupling of the prosthesis
chondrium / vein / fascia) before plac- to the incus; this is repeated with
ing the piston prosthesis smaller smooth crocodile forceps
• Postpone the surgery for one year if the (Figure 18)
stapes superstructure is still intact; the • Using a 1.5mm 45° hook, check the
annular ligament will progressively be- mobility of the ossicular chain with the
come refixed due to otosclerosis prosthesis in place
• There should be no free movement of
Inserting and crimping the prosthesis the prosthesis on the incus when the
incus is moved
• The prosthesis is picked up with a large
crocodile forceps from its hole in the Crimping technique
cutting block by its wire loop
• For first-time correct placement of the • To achieve good results correct crimp-
loop over the long process of the incus ing is absolutely essential
it is essential to pick up the prosthesis • Loose coupling of the prosthesis to the
at the correct angle incus will result in reduced sound
9
 Figure 20: Crimping is performed from the
most superior part of the loop
Figure 18: Crimped prosthesis with
• Correct angulation of the piston rela-
piston in stapedotomy; note position of
tive to the footplate is crucial to ach-
facial nerve immediately adjacent to
ieve good acoustic results. The piston
the prosthesis
must be at right angles to the footplate
to avoid contact of the piston with the
transmission and inferior acoustic
bony edges of the stapedotomy which
results 16
will result in attenuation of vibration
• To crimp the loop of the prosthesis, the
and reduced sound transmission 17
crocodile forceps is held with the right
(Figure 21)
hand and stabilised with the left hand
• Kwok, Fisch et al reported that crimp-
using the thumb and the index finger
ing results depend on the instrument
(Figure 19)
used for crimping and the material of
• It may be necessary to remove the hori-
the stapes prosthesis, but not on the
zontal retractor in order to gain more
surgeon. The straight crocodile forceps
space to crimp the prosthesis correctly
was shown in their study to produce
• Crimping is performed from the most better crimping results than the McGee
superior part loop, so that the prosthe- crimper 17
sis loop makes even contact with the
incus (Figure 20)

Figure 21: Prosthesis must be at right

angles to footplate for optimal hearing
results
Figure 19: Crocodile forceps is held with
right hand and stabilised with left hand
using thumb and index finger
10
Sealing stapedotomy opening • The endaural incision is closed with
4/0 nylon sutures. One subcutaneous
Connective tissue placed around the piston stitch may help in readapting the
serves as a seal to prevent perilymph leak- wound edges
age. Once the seal has matured it also pre- • An outer strip of gauze which has been
vents displacement of the piston. The con- impregnated with antibiotic ointment
nective tissue seal also increases the sound (Terracortril) is placed in the lateral
transmitting area, so that a 4mm piston is part of the external ear canal
equivalent to the surface area of a 6mm
piston, therefore improving sound trans- Postoperative care
mission and achieving better acoustic re-
sults. If one performs tympanometry at 2 • Outer gauze dressing is removed after
weeks and no vertigo is induced, then the one week together with the Ivalon® ear
seal is adequate and it is safe for patients to wick
fly. • Postoperative audiograms are done at
1-2 months, 1 year and 5 years
• Connective tissue from the endaural
incision is used to seal the stapedotomy Reversal of stapedotomy
opening
• Use a 1.5mm, 45° hook to place pieces Fisch described reversing the steps of the
of connective tissue around the stape- stapedotomy procedure in order to reduce
dotomy complications relating both to the incus
• Venous blood taken from the patient at (luxations/subluxations) and footplate
the beginning of the procedure is stored (subluxations/fractures/floating footplate).
at 3-4°C to prevent the blood from The point of departure for the following
clotting until it is needed; this blood is description of the surgery is exposure of
now used to seal the stapedotomy the oval window as previously described.
opening
• Check ossicular chain mobility and
Repositioning tympanomeatal flap confirm stapes fixation
• Determine prosthesis length and trim
• The tympanomeatal flap is repositioned the prosthesis accordingly
• If any small tears in the tympanomeatal • Stapedotomy is performed
flap are noticed, then temporalis fascia • Introduce the prosthesis and crimp it to
is harvested and underlay grafting is the incus with the stapes arch still
done intact
• Cut the stapedius tendon and remove
Packing and wound closure the arch of the stapes (Figure 22)
• Check the mobility of the ossicular
• Gelfoam pledgets are placed in the chain with the prosthesis in place
bony canal to secure the meatal part of • Seal the stapedotomy opening as
the flap previously described
• Do not place gelfoam pledgets over the
tympanic membrane as they could Malleostapedotomy
swell and displace the prosthesis in-
wards causing vertigo This is a technique whereby both the incus
• Two pieces of Ivalon® are placed in and stapes are replaced by a single
the external ear canal prosthesis in order to establish a direct

11
 mal part of the handle of the malleus
(just 1mm distal to the lateral malleal
process) (Figure 23)

Figure 22: Stapedius tendon and posterior

crus being cut with stapes prosthesis
already in final position and crimped to
incus
Figure 23: Elevating Shrapnell’s mem-
connection between the malleus and the brane from proximal part of handle of
vestibule. It is indicated for stapes fixation malleus
with pathology of the incus and/or malleus
head that rules out an incus-stapedotomy • The final exposure for malleostapedo-
tomy includes the pyramidal process,
Surgical exposure oval window niche, tympanic segment
of facial nerve, inferior part of the
The initial surgical steps relating to end- incudomallear joint and anterior mal-
aural approach, elevation of a tympano- leal process and ligament (Figure 24)
meatal flap, and exposure are identical to
that we have already described in this
chapter for incus-stapedotomy. The point
of departure of the description of the sur-
gery that follows is exposure of ossicular Malleus handle
chain and oval window.
Malleoincudal joint

• Elevate the annulus, starting at the pos- Chorda tympani

terior tympanic spine Incus
• The chorda tympani is left attached to
VIIn
the tympanic membrane
• The tympanic membrane is reflected Pyramid

until the anterior malleal process and

ligament are exposed
• Assess the mobility of the malleus
using a 1.5mm 45° hook Figure 24: Final view of middle ear
• Use a joint knife to separate the incu- structures before proceeding to remove
dostapedial joint incus
• Mobility of the malleus and incus is
reassessed
• Use a 2.5mm 45° hook to elevate
Shrapnell’s membrane from the proxy-

12
Removal of incus and malleal head malleus so that malleus head may be
removed
• Laterally rotate and mobilise the incus
with a 1.5mm 45° hook, and remove it • The malleus head is then removed
with crocodile forceps (Figure 25)
Removal of arch of stapes

Crurotomy scissors are used to cut the an-

terior and posterior crura close to the foot-
plate. Note in Figure 27 that the anterior
and posterior crura are equal length; in
incus-stapedotomy the posterior crus
would be shorter than the anterior crus

Figure 25: Removing incus with croco-

dile forceps

• If the incus is bulky then the long

process of the incus is cut with a
malleus nipper so as not to injure Figure 27: Anterior and posterior crura
chorda tympani have been cut close to footplate
• If the ligament of the malleus is ossi-
fied, then a 0.8mm diamond burr is Preparation of prosthesis
used to excise the neck and anterior
process; separate the chorda tympani • A 0.4mm diameter titanium piston with
from the under surface of the neck of a total length of 8.5mm is used
malleus with a 2.5mm, 45° hook before • The distance between the stapes foot-
drilling (Figure 26) plate and the lateral surface of the mal-
leus handle (just below the lateral
process) is measured with a malleable
measuring rod; 0.5mm is added to this
measurement
• Using the technique described for
incus-stapedotomy the desired length is
achieved by cutting the prosthesis on a
special cutting block
• To confirm the correct length, the pros-
thesis is introduced into the middle ear
with a large crocodile forceps, so that it
extends between the malleus handle
and stapes footplate (Figure 28)
Figure 26: Diamond burr being used to
excise neck and anterior process of
13
 Figure 28: Prosthesis placed in middle Figure 29: Initial small stapedotomy
ear to check its length
• The prosthesis is picked up by its loop
• If the prosthesis extends above the mal- with a large alligator forceps at the re-
leus handle by 0.5mm, then the length quired angle and placed on the foot-
is correct. A prosthesis that is too long plate
may need to be cut shorter. If is too • The loop of the prosthesis is placed
short then it needs to be replaced. over the malleus just distal to the
• To accommodate the slightly off-centre lateral malleal process
position of the malleus relative to the • The loop is crimped to the malleus by
stapes footplate, the shaft of the piston applying the alligator forceps perpendi-
must be adapted so that it will lie per- cularly to the handle of the malleus. A
pendicular to the stapes footplate McGee Crimper/Wire Closure Forceps
• The loop of the prosthesis it must be may be helpful to deal with the angle
enlarged in order to fit over the malleus between the stapedotomy and malleus
handle by stretching it open by moving • If correctly crimped, the loop of the
it along 1.5mm, 45° hook with a prosthesis should be perpendicular to
watchmaker’s forceps the inclination of the malleus handle
• The loop may need to be adapted so and the shaft should be perpendicular
that it is oriented at 90° to the malleus to the stapes footplate (Figure 30)
handle

Performing the stapedotomy

• A perforation is made between the

middle and inferior 1/3 of the footplate
with a manual perforator or laser as for
incus-stapedotomy (Figure 29)

Introducing and crimping the prosthesis

• Accurate crimping is crucial to obtain

good results; the larger exposure
afforded by the approach described
facilitates accurate crimping Figure 30: The loop is perpendicular
to malleus handle and shaft is perpen-
dicular to footplate
14
Sealing the stapedotomy otosclerosis. Otol. Neurotol. 2001;22:
776-85
The stapedotomy opening is sealed with 7. Linder TE, Fisch U. A checklist for
connective tissue from the endaural surgical exposure in stapes surgery:
incision and blood taken from the patient how to avoid misapprehension. Adv
as described for incus stapedotomy. Otorhinolaryngol. 2007;65:158-63
8. Probst R. Audiological evaluation of
Repositioning the tympanomeatal flap patients with otosclerosis. In Oto-
and wound closure: As for incus- sclerosis and stapes surgery. Arnold W,
stapedotomy Häusler R (eds): otosclerosis and
stapes surgery. Adv Otorhinolaryngol.
Postoperative care Basel Karger, 2007, vol 65, pp 119-26
9. Ayacha D. Lejeune D, Williams.
• As for incus-stapedotomy Imaging of postoperative complica-
• Patients can fly after 2weeks (as for tions of stapes surgery. In Otosclerosis
incus-stapedotomy) and Stapes Surgery. Arnold W, Häusler
• Patients who have undergone malleo- R (eds): Otosclerosis and Stapes
stapedotomy are not permitted to scuba Surgery. Adv Otorhinolaryngol. Basel
dive Karger, 2007, vol 65, 308-13
10. Linder TE, Ma F, Huber A. Round
References window atresia and ist effect on sound
transmission. Otol Neurotol. 2003;
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toidectomy and Stapes Surgery. New 11. Van Rompaey V, Offeciers E, De Foer
York: Thieme; 1994. B, Somers T. Jugular bulb diverticulum
2. Nandapalan V, Pollak A, Langner A, dehiscence towards the vestibular aq-
Fisch U. The anterior and superior mal- ueduct in a patient with otosclerosis. J
leal ligaments in otosclerosis. Otol Laryngol Otol. 2012 Mar;126(3):313-5
Neurotol. 2002;23(6):854-61 12. Neyt P, Govaere F, Forton GE.
3. Vincent R, Sperling NM, Oates J, Simultaneous true stapes fixation and
Jindal M. Surgical findings and long- bilateral bony dehiscence between the
term hearing results in 3,050 stapedo- internal carotid artery and the apex of
tomies for primary otosclerosis: a the cochlea: the ultimate pitfall. Otol
prospective study with the otology- Neurotol. 2011.32(6):909-13
neurotology database. Otol Neurotol. 13. Merchant SN, Rosowski JJ, McKenna
2006;27(8 Suppl 2):S25-47 MJ. Superior semicircular canal dehis-
4. Vincent R, Lopez A, Sperling NM. cence mimicking otosclerotic hearing
Malleus Ankylosis: A Clinical, Audio- loss in Otosclerosis and stapes surgery.
metric, Histologic, and Surgical Study Adv Otorhinolaryngol. Basel Karger,
of 123 Cases. Am J Otol. 1999; 20:717- 2007, vol 65, 137-45
25 14. Pauw BK, Pollak AM, Fisch U.
5. Dalchow CV, Dünne AA, Sesterhenn Utricle, saccule, and cochlear duct in
A, Teymoortash A, Werner JA. relation to stapedotomy. A histologic
Malleostapedotomy: The Marburg human temporal bone study. Ann Otol
experience. Adv Otorhinolaryngol. Rhinol Laryngol.1991;100(12):966-70
2007;65:215-21 15. Huber AM, MA F, Felix H, Linder T.
6. Fisch U, Acar GO, Huber AM. Malleo- Stapes prosthesis attachment: the effect
stapedotomy in revision surgery for of crimping on sound transfer in

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 otosclerosis surgery. Laryngoscope. Editor
2003;113(5):853-8
16. Hüttenbrink KB. Biomechanics of Johan Fagan MBChB, FCS(ORL), MMed
stapesplasty: A review. Otol Neurotol. Professor and Chairman
2003;24:548-59 Division of Otolaryngology
17. Kwok P, Fisch U, Strutz J, May J: University of Cape Town
Stapes surgery: how precisely do Cape Town, South Africa
different prosthesis attach to the long johannes.fagan@uct.ac.za
process of the incus with different
instruments and different surgeons?
Otol Neurotol 2002;23:289-95 THE OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY, HEAD &
Acknowledgements
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
This guide is based on the text by
Professor Fisch (Tympanoplasty, Mastoid-
ectomy, and Stapes Surgery) and personal
experience of Professor Linder, as well as
course materials for the advanced temporal The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
bone course conducted annually by johannes.fagan@uct.ac.za is licensed under a Creative
Professors Fisch and Linder at the Commons Attribution - Non-Commercial 3.0 Unported
License
Department of Anatomy, University of
Zurich, Switzerland

Author

Tashneem Harris MBChB, FCORL,

MMed (Otol), Fisch Instrument
Microsurgical Fellow
ENT Specialist
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
harristasneem@yahoo.com

Senior Author

Thomas Linder, M.D.

Professor, Chairman and Head of
Department of Otorhinolaryngology,
Head, Neck and Facial Plastic Surgery
Lucerne Canton Hospital, Switzerland
thomas.linder@ksl.ch

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