Stapedectomy: Surgery for Otosclerosis & Hearing Loss

What Is Otosclerosis and How Does It Affect Hearing?

Otosclerosis is a condition where abnormal bone growth in the middle ear causes the stapes bone (stirrup) to become fixed and unable to vibrate properly. This prevents sound waves from being transmitted effectively to the inner ear, resulting in progressive conductive hearing loss that typically develops between ages 20-40.

The human ear relies on a delicate chain of three tiny bones in the middle ear - the malleus (hammer), incus (anvil), and stapes (stirrup) - to transmit sound vibrations from the eardrum to the inner ear. The stapes is the smallest bone in the human body, measuring only about 3 millimeters in height. In a healthy ear, the stapes moves freely, acting like a piston that transfers sound energy into the fluid-filled cochlea of the inner ear.

In otosclerosis, abnormal bone remodeling causes spongy bone tissue to form around the stapes, particularly at the point where it connects to the oval window of the inner ear. As this abnormal bone hardens over time, it gradually restricts the movement of the stapes, reducing its ability to transmit sound. This process typically progresses slowly over years, leading to gradually worsening hearing loss.

Otosclerosis affects approximately 0.3-0.4% of the general population, making it one of the most common causes of hearing loss in young adults. The condition has a strong genetic component, with about 50-60% of patients having a family history of otosclerosis. It is more prevalent in Caucasian populations and affects women approximately twice as often as men. Hormonal factors appear to play a role, as many women first notice hearing changes during pregnancy.

Understanding the Types of Otosclerosis

Otosclerosis can be classified based on which structures in the ear are affected. Stapedial otosclerosis, the most common form, primarily affects the stapes bone and causes conductive hearing loss that can be effectively treated with surgery. Cochlear otosclerosis involves the inner ear itself and can cause sensorineural hearing loss, which is more difficult to treat surgically. Some patients may have both types simultaneously, which is known as mixed otosclerosis.

The progression of otosclerosis varies considerably between individuals. Some people experience rapid deterioration of hearing over just a few years, while others may have a slow, gradual decline spanning decades. Environmental factors, hormonal changes, and possibly viral infections may influence the rate of progression, though the exact triggers remain under investigation.

Common Symptoms of Otosclerosis

The hallmark symptom of otosclerosis is progressive hearing loss that typically begins in one ear but often eventually affects both ears. Patients frequently describe difficulty understanding speech, especially in noisy environments. Interestingly, some people with otosclerosis experience a phenomenon called paracusis of Willis - they actually hear better in noisy surroundings because others speak louder to overcome the background noise.

Many patients also experience tinnitus (ringing, buzzing, or humming sounds in the ear), which can range from mildly annoying to significantly distressing. Low-frequency sounds are typically affected first, meaning patients may notice difficulty hearing bass tones or deep voices before higher-pitched sounds become problematic. Balance disturbances and dizziness, while less common, can occur in some cases of advanced otosclerosis.

When Is Stapedectomy Surgery Recommended?

Stapedectomy is recommended when otosclerosis causes significant hearing loss that cannot be adequately managed with hearing aids, or when patients prefer a surgical solution over long-term hearing aid use. The decision depends on hearing test results showing sufficient air-bone gap, good inner ear function, and the patient's overall health and preferences.

The decision to undergo stapedectomy involves careful consideration of multiple factors. Not every patient with otosclerosis requires surgery - many people successfully manage their condition with hearing aids, especially in the early stages when hearing loss is mild to moderate. However, as the condition progresses and hearing aids become less effective, surgery often becomes the preferred treatment option.

Audiological evaluation plays a crucial role in determining surgical candidacy. Hearing tests measure both air conduction (sound traveling through the ear canal and middle ear) and bone conduction (sound transmitted directly through the skull to the inner ear). The difference between these measurements, called the air-bone gap, indicates how much of the hearing loss is due to middle ear problems versus inner ear damage. A significant air-bone gap (typically 15-20 decibels or more) suggests that surgery could substantially improve hearing.

The condition of the inner ear is equally important. If the cochlea is healthy and functioning well (as indicated by good bone conduction scores), stapedectomy has an excellent chance of restoring hearing. However, if significant sensorineural hearing loss is present, the benefits of surgery may be limited, and the patient might not achieve normal hearing even with a successful procedure.

Factors Favoring Surgical Treatment

Several circumstances make stapedectomy particularly advantageous. Patients who find hearing aids uncomfortable, inconvenient, or socially unacceptable often prefer the possibility of restored natural hearing. Those with occupations requiring acute hearing - musicians, healthcare workers, or professionals in communication-intensive fields - may benefit greatly from surgery. Young patients facing decades of progressive hearing loss often choose surgery to avoid long-term dependence on hearing aids.

The presence of bilateral otosclerosis (affecting both ears) presents additional considerations. Surgeons typically operate on one ear at a time, starting with the ear that has worse hearing. This approach minimizes risk - if an unexpected complication occurs, the patient still retains hearing in the unoperated ear. The second ear can be addressed in a separate procedure, usually at least six months later.

When Surgery May Not Be Appropriate

Certain conditions may make stapedectomy inadvisable or require careful consideration. Patients with only one functioning ear face higher stakes, as any surgical complication could result in total deafness. Those with active ear infections must wait until the infection resolves before surgery can be performed. Certain medical conditions affecting blood clotting or healing may increase surgical risks.

Patients with cochlear otosclerosis or significant sensorineural hearing loss may achieve limited benefit from stapedectomy. In such cases, hearing aids or cochlear implants might be more appropriate options. The surgeon will discuss these considerations thoroughly during the consultation process, ensuring patients have realistic expectations about potential outcomes.

How Should You Prepare for Stapedectomy Surgery?

Preparation for stapedectomy includes stopping blood-thinning medications one week before surgery, fasting from midnight the night before, arranging transportation home, and informing your surgeon about all medications and health conditions. Proper preparation ensures the safest possible procedure and optimal healing.

Thorough preparation is essential for a successful stapedectomy. The process begins with comprehensive pre-operative consultations where your surgeon reviews your medical history, conducts physical examinations, and orders necessary tests. This evaluation helps identify any factors that could affect the surgery or anesthesia and allows the medical team to plan accordingly.

Your surgeon will provide specific instructions regarding medications. Blood-thinning medications, including aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDs), should typically be stopped one week before surgery. These medications can increase bleeding risk during and after the procedure. If you take prescription blood thinners like warfarin or newer anticoagulants, your surgeon will coordinate with your prescribing physician to determine the safest approach.

If you need pain relief in the week before surgery, acetaminophen (paracetamol) is generally safe to use as it does not affect blood clotting. However, always confirm with your surgical team before taking any medications. You should also inform your surgeon about all supplements and herbal products you take, as some (like vitamin E, fish oil, and ginkgo) can also affect bleeding.

Fasting and Anesthesia Requirements

Stapedectomy is typically performed under general anesthesia, which requires fasting beforehand. You will be instructed to have nothing to eat or drink after midnight the night before surgery. This includes water, coffee, gum, and mints. The empty stomach is crucial for safe anesthesia - if stomach contents are present during anesthesia, there is a risk of aspiration into the lungs, which can cause serious complications.

In some cases, local anesthesia with sedation may be used instead of general anesthesia. This approach allows patients to remain conscious but relaxed and pain-free during the procedure. Your anesthesiologist will discuss the options and help determine which approach is best for your situation based on your health status and preferences.

Practical Arrangements

Since you will be under anesthesia and may experience some dizziness afterward, you cannot drive yourself home. Arrange for a responsible adult to accompany you to the hospital, wait during the procedure, and drive you home afterward. This person should also be available to stay with you for the first night after surgery in case you need assistance.

Prepare your home for recovery before the surgery. Stock up on easy-to-prepare meals, ensure you have any prescribed medications filled, and set up a comfortable resting area. You may want to have entertainment options like books, podcasts, or streaming services ready, as you should avoid activities requiring concentration in the first few days.

How Is Stapedectomy Surgery Performed?

During stapedectomy, the surgeon makes small incisions to access the middle ear, removes the fixed stapes bone, and inserts a tiny titanium prosthesis to restore sound transmission. The procedure typically takes 1-2 hours, is performed under general anesthesia, and most patients go home the same day.

Stapedectomy is a microsurgical procedure requiring exceptional precision due to the tiny structures involved. The stapes bone measures only about 3 millimeters, and the surgical field is accessed through the narrow ear canal. Surgeons use specialized microscopes providing high magnification and intense illumination to visualize these delicate structures.

The procedure begins with the administration of anesthesia. Once you are comfortably sedated or fully asleep, the surgical team positions your head to provide optimal access to the ear. The surgeon then makes a small incision in front of the ear (at the junction where the ear meets the scalp) and another inside the ear canal. These incisions allow the surgeon to lift the eardrum carefully and access the middle ear space.

With the middle ear exposed, the surgeon examines the ossicular chain (the three hearing bones) and confirms the diagnosis of otosclerosis by assessing the mobility of the stapes. In otosclerosis, the stapes will be visibly fixed rather than moving freely. The surgeon then carefully disconnects the stapes from the incus (the bone it connects to above) and removes part or all of the stapes bone.

Prosthesis Placement

After removing the diseased stapes, the surgeon creates a small opening in the stapes footplate (the flat portion that rests against the oval window) if one does not already exist. A tiny prosthesis, typically made of titanium or other biocompatible materials, is then inserted. One end of the prosthesis hooks onto the incus bone, while the other end extends through the opening into the inner ear.

The prosthesis acts as a replacement stapes, transmitting vibrations from the incus to the inner ear fluids. Modern prostheses are remarkably small and lightweight, measuring only a few millimeters in length. They are designed to mimic the natural movement of the stapes as closely as possible, restoring the mechanical connection necessary for normal hearing.

Stapedectomy vs. Stapedotomy

There are two main surgical approaches: stapedectomy and stapedotomy. In traditional stapedectomy, the entire stapes footplate is removed. In stapedotomy, which is more commonly performed today, only a small hole is made in the footplate using a laser or microdrill, and a piston-type prosthesis is inserted through this opening. Both techniques have excellent success rates, with stapedotomy generally associated with slightly lower risk of complications.

After the prosthesis is in place, the surgeon replaces the eardrum to its normal position and packs the ear canal with a small dressing or tampon. This packing supports the healing tissues and is typically removed at the follow-up appointment one week after surgery. Small sutures close the incision in front of the ear, and a bandage covers the ear for protection.

What to Expect During Recovery and Aftercare?

Recovery from stapedectomy involves mild ear pain for a few days, possible dizziness, and activity restrictions for 4-6 weeks. Most patients return home the same day, can resume light activities within a week, and experience improved hearing within 6-8 weeks as swelling subsides and tissues heal.

The immediate post-operative period requires careful attention to promote optimal healing. After awakening from anesthesia, you will be monitored in a recovery area until the medical team confirms you are stable and alert. Most patients experience some grogginess from the anesthesia, mild ear discomfort, and possibly slight dizziness. These effects typically resolve within hours, and most patients are discharged home the same day as surgery.

Ear pain after stapedectomy is usually mild to moderate and well-controlled with over-the-counter pain relievers like acetaminophen. The discomfort typically peaks within the first day or two and then gradually improves, with most patients reporting minimal pain by one week post-surgery. If you experience severe pain, especially accompanied by fever or discharge from the ear, contact your surgeon immediately as these could indicate infection.

Dizziness and imbalance are common in the first few days following surgery due to the proximity of the inner ear's balance organs. The inner ear's vestibular system may be temporarily affected by the surgical manipulation, causing a sensation of unsteadiness or vertigo. These symptoms usually improve significantly within the first week, though some patients may notice mild imbalance for several weeks.

Activity Restrictions

Protecting the operated ear during healing requires following specific activity restrictions. For approximately four weeks after surgery, you should avoid:

• Strenuous exercise or heavy lifting - Activities that increase pressure in the head can stress the healing tissues
• Air travel - Pressure changes during flight can damage the healing surgical site
• Swimming or submerging the ear in water - Water entering the ear can cause infection
• Exposure to loud noises - The ear is more sensitive during healing
• Blowing your nose forcefully - This creates pressure that can affect the middle ear

During showers, protect your ear from water using a cotton ball covered with petroleum jelly or a specially designed ear cover. Light walking and gentle daily activities are generally safe and even encouraged to promote circulation and healing. However, avoid any activity that causes straining or could impact your head.

Timeline for Hearing Improvement

Patients are often eager to assess their hearing after surgery, but it's important to understand that improvement takes time. In the first weeks after surgery, hearing may actually seem worse than before due to the packing in the ear canal and post-operative swelling. Once the packing is removed at your one-week follow-up appointment, you may notice some improvement.

Significant hearing improvement typically becomes apparent six to eight weeks after surgery as internal swelling resolves and the tissues fully heal. Some patients report that sounds seem unusually loud or have a different quality initially - this is normal and usually adjusts as your brain adapts to the improved hearing. The final outcome is typically stable by three months, though subtle improvements may continue for up to a year.

What Happens at Follow-Up Appointments?

Follow-up appointments occur at approximately one week (to remove packing and sutures), 2-3 months (for hearing assessment), and one year after surgery. These visits monitor healing, evaluate hearing improvement, and ensure the prosthesis is functioning properly.

Regular follow-up appointments are essential for monitoring your recovery and ensuring optimal outcomes. Your surgical team will schedule these visits before you leave the hospital, and it's important to attend all appointments even if you feel you are recovering well.

The first follow-up appointment typically occurs about one week after surgery. At this visit, the surgeon removes the packing from your ear canal and any external sutures. This is usually a quick and relatively painless procedure. The surgeon will examine the ear canal and eardrum to assess initial healing. You may receive a prescription for antibiotic ear drops to use for the following weeks to help prevent infection and promote healing.

Your surgeon will provide instructions on how to use the ear drops properly. This typically involves tilting your head to allow the drops to flow into the ear canal, then remaining in that position for a few minutes to allow the medication to penetrate. Proper technique ensures the medication reaches all areas of the healing surgical site.

Hearing Evaluation

The second follow-up, usually scheduled for 2-3 months after surgery, includes a comprehensive hearing test (audiogram). This evaluation compares your post-operative hearing to your pre-operative baseline and quantifies the improvement achieved. The audiologist will test both air conduction and bone conduction, calculating whether the air-bone gap has been successfully closed.

Most patients show significant improvement at this point, with many achieving hearing within the normal range or close to it. The audiogram results help your surgeon assess the success of the procedure and identify any issues that might require attention. If hearing improvement is less than expected, additional evaluation may be needed to determine the cause.

A one-year follow-up appointment provides a long-term assessment of your surgical outcome. By this point, healing is complete, and the hearing results represent the stable, final outcome. This visit also allows the surgeon to monitor for any late complications and address any ongoing concerns. Many surgeons recommend periodic hearing tests in subsequent years to track hearing stability over time.

What Are the Potential Risks and Complications?

While stapedectomy is generally safe, potential risks include temporary taste changes (most common), dizziness, tinnitus, and in rare cases (less than 1%), severe hearing loss. Most complications are minor and resolve within weeks, and serious complications are uncommon in experienced hands.

Like any surgical procedure, stapedectomy carries certain risks. Understanding these potential complications helps you make an informed decision about surgery and recognize warning signs during recovery. Fortunately, serious complications are rare, especially when the procedure is performed by experienced otologic surgeons.

Taste disturbance is one of the most common side effects, occurring in a significant percentage of patients. The chorda tympani nerve, which carries taste sensation from the front two-thirds of the tongue, passes through the middle ear and may be stretched or damaged during surgery. Patients may notice altered taste on one side of the tongue, often described as a metallic taste or reduced ability to taste certain flavors. In most cases, this resolves within weeks to months as the nerve recovers.

Temporary dizziness and vertigo affect many patients in the immediate post-operative period. The inner ear's balance organs are located adjacent to the surgical site, and some disturbance is expected. Most patients experience improvement within days, though mild imbalance may persist for several weeks. True prolonged vertigo is uncommon and should be reported to your surgeon.

Hearing-Related Complications

Tinnitus (ringing or buzzing in the ear) may develop or worsen after surgery. In most cases, this is temporary and resolves as healing progresses. However, some patients may experience persistent tinnitus, which can range from barely noticeable to bothersome. Pre-existing tinnitus does not necessarily worsen after surgery and may even improve.

Incomplete hearing improvement occurs when the surgery successfully places the prosthesis, but hearing does not improve as much as hoped. This may happen if there is underlying sensorineural hearing loss, prosthesis displacement, or excessive scar tissue formation. In some cases, revision surgery may be considered.

When to Contact Your Doctor

While some discomfort and symptoms are expected after surgery, certain warning signs warrant immediate medical attention. Contact your surgeon or seek emergency care if you experience:

• Severe or worsening pain not relieved by prescribed medications
• High fever (above 38.5°C/101.3°F)
• Significant discharge, especially if foul-smelling
• Sudden hearing loss after initial improvement
• Severe, persistent vertigo with nausea and vomiting
• Signs of facial weakness

What If Both Ears Are Affected by Otosclerosis?

When otosclerosis affects both ears, surgeons operate on one ear at a time, typically starting with the ear that has worse hearing. The second ear can be addressed at least 6 months later, allowing full recovery from the first surgery and ensuring hearing is preserved in at least one ear.

Bilateral otosclerosis (affecting both ears) is common, occurring in approximately 70-80% of patients with the condition. The management of bilateral disease requires careful planning to ensure the best possible outcome while minimizing risks.

The standard practice is to perform stapedectomy on one ear first, typically the ear with worse hearing. This approach has several advantages. First, it allows patients to recover fully and experience the benefits of surgery before deciding to proceed with the second ear. Second, if an unexpected complication were to occur, the patient would still retain hearing in the unoperated ear. Third, it provides an opportunity to assess how well the patient tolerates surgery and anesthesia.

The decision about which ear to operate on first is made collaboratively between the patient and surgeon. In addition to hearing levels, factors considered include which ear causes more difficulty in daily life, the configuration of hearing loss, and patient preference. Some patients have asymmetric disease where one ear is much worse than the other, making the choice straightforward.

Timing of Second Ear Surgery

Most surgeons recommend waiting at least six months to one year between surgeries. This interval allows complete healing of the first ear, stabilization of hearing results, and time to evaluate the success of the initial procedure. Some patients find that surgery on one ear provides sufficient hearing improvement and may choose to delay or forgo surgery on the second ear.

The success rate for second ear surgery is generally similar to the first, though some patients have slightly different outcomes due to variations in anatomy or disease extent. The experience of the first surgery also helps patients know what to expect during recovery from the second procedure.

What Are the Alternatives to Stapedectomy?

Alternatives to stapedectomy include hearing aids (effective for many patients), observation with monitoring (for mild cases), and in advanced cases with inner ear involvement, cochlear implants. The choice depends on hearing loss severity, patient preference, and overall health.

Stapedectomy is not the only treatment option for otosclerosis, and the best choice depends on individual circumstances. Understanding all available options helps patients make informed decisions about their care.

Hearing aids represent a non-surgical approach that works well for many patients, especially those with mild to moderate hearing loss or those who prefer to avoid surgery. Modern hearing aids are small, comfortable, and technologically sophisticated, capable of providing excellent sound amplification. They can be adjusted as hearing changes over time and carry no surgical risks. However, hearing aids require ongoing maintenance, battery replacement, and may not fully restore natural hearing quality.

Observation (watchful waiting) may be appropriate for patients with very mild hearing loss that does not significantly impact daily life. Regular hearing tests monitor for progression, and treatment can be initiated if hearing worsens substantially. This approach avoids the costs and risks of intervention while the disease remains manageable.

Cochlear Implants

For patients with advanced otosclerosis involving significant sensorineural hearing loss, cochlear implants may be an option. A cochlear implant bypasses the damaged middle and inner ear structures entirely, directly stimulating the auditory nerve with electrical signals. While more invasive than stapedectomy, cochlear implants can provide hearing for patients who would not benefit sufficiently from traditional surgery or hearing aids.

The choice between stapedectomy, hearing aids, and other options should be made after thorough discussion with an otolaryngologist or otologist who can assess your specific situation. Factors including hearing test results, lifestyle, occupation, general health, and personal preferences all play roles in determining the optimal treatment approach.

How Does Pregnancy Affect Otosclerosis and Treatment?

Pregnancy can accelerate otosclerosis progression due to hormonal changes, and many women first notice hearing loss during pregnancy. Stapedectomy is typically postponed until after delivery due to anesthesia risks, but hearing aids can be used safely during pregnancy.

The relationship between pregnancy and otosclerosis has been recognized for decades. Hormonal changes during pregnancy appear to accelerate the bone remodeling process that characterizes otosclerosis, leading to more rapid hearing deterioration. Many women with undiagnosed otosclerosis first become aware of their hearing loss during pregnancy.

The exact mechanism is not fully understood, but elevated estrogen levels during pregnancy are believed to stimulate the abnormal bone growth. Studies have shown that women with otosclerosis who become pregnant may experience faster hearing decline compared to non-pregnant women. This observation has led some specialists to counsel women with known otosclerosis about potential hearing changes during pregnancy.

Despite these concerns, most women with otosclerosis successfully complete pregnancies and can address their hearing loss after delivery. Stapedectomy is generally postponed until after pregnancy to avoid exposing the developing fetus to anesthesia and surgical stress. Hearing aids provide a safe, effective interim solution for managing hearing loss during pregnancy and breastfeeding.

Post-Pregnancy Considerations

After delivery, women can safely undergo stapedectomy once they have recovered from childbirth. There is no need to wait until breastfeeding is complete, though some women prefer to do so. The usual pre-operative medications and post-operative care are compatible with breastfeeding, though you should inform your surgeon if you are nursing so appropriate medications can be selected.

Women who experienced significant hearing decline during pregnancy may be particularly motivated to pursue surgical correction. The good news is that stapedectomy success rates are similar regardless of whether hearing loss progressed during pregnancy. Most women achieve excellent hearing improvement and can fully enjoy the experience of caring for their new baby.

What Is the Long-Term Outlook After Stapedectomy?

The long-term outlook after stapedectomy is excellent, with most patients maintaining improved hearing for decades. The titanium prosthesis is permanent and typically functions well lifelong. However, regular hearing monitoring is recommended as otosclerosis can continue to progress in other parts of the ear.

Stapedectomy provides long-lasting results for the vast majority of patients. Studies following patients for 20 years or more demonstrate that the hearing improvement achieved with surgery is generally stable over time. The prosthesis, made from durable biocompatible materials like titanium, can function effectively for a lifetime.

However, it's important to understand that stapedectomy addresses the mechanical problem in the middle ear but does not cure the underlying otosclerotic process. The abnormal bone remodeling can continue to affect other parts of the ear, potentially causing progressive sensorineural hearing loss over time. This is why ongoing monitoring is valuable - regular hearing tests can detect changes early.

For patients who maintain excellent hearing after surgery, annual or biennial audiograms are typically sufficient for monitoring. If hearing begins to decline, the cause can be investigated - it might be progression of otosclerosis to the cochlea, prosthesis displacement, or unrelated age-related hearing loss. Each scenario has different management implications.

Quality of Life Improvements

Beyond the measurable hearing improvement, stapedectomy often dramatically improves quality of life. Patients frequently report enhanced ability to participate in conversations, enjoy music and entertainment, and engage in social activities. The freedom from hearing aid dependency is particularly valued by many patients. Work performance and personal relationships often benefit from restored hearing.

Patient satisfaction with stapedectomy is consistently high in research studies. When successful, the surgery can transform the daily experience of someone who has struggled with progressive hearing loss, restoring a sense of connection with the auditory world. For many patients, the benefits far outweigh the temporary discomfort and recovery period.