1. STAPEDECTOMY Kelsey Carter

2. A NATOMY Ear Stapes Tympanic membrane Ossicles Incus concha

3. PATHOPHYSIOLOGY Stapedectomy is the surgical intervention of choice for patients with otosclerosis. Otosclerosis: Bony over growth of the stapes Foot plate becomes fixed in the oval window preventing normal sound vibrations from entering the ear. Hereditary, mostly in women.

4. S URGICAL INTERVENTION Positioning: Supine. Patient’s arm on the operative side may be tucked while other arm may be extended on an arm board. A donut may be placed under head. Instruments: Ear instrument set Sterile components of ear drill Universal ear speculum holder

5. S URGICAL INTERVENTION Supplies: Basic pack Basin set Gloves Head and neck drapes Fenestrated adhesive plastic drape Microscope drape Micro wipe Suture accodring to surgeon’s preference Dressing materials according to surgeon’s preference Pharmaceuticals according to surgeon’s preference Bulb syringe Prostheses Blade #15

6. S URGICAL INTERVENTION Draping: Patient may be draped with 3-4 sterile towels placed around the operative ear. A sterile adhesive drape may be placed Head is draped with a disposable sheet. Two folded towels may be placed at the patient’s neck. A split or drape sheet is placed to cover the patient’s body.

7. S URGICAL INTERVENTION Prep: Cleanse the operative ear, extending form the hairline to the shoulder and well beyond the midline of the face. Prep well behind the ear on the operative side. Caution should be taken to avoid the pooling of prep solution in or around the eyes and ears. Surgeon may request that 1” of hair be clipped/shaved behind the ear and that the remaining hair be taped out of the operative field. Prepped site should be dried well in order for the adhesive ear drape to stick. Cotton may be placed inside the operative ear.

8. PROCEDURAL STEPS 1) A graft may be harvested from the ear, hand, or a portion of the abdomen prior to the start of the procedure. The graft will be used to cover the oval window. A fat, perichondrium, vein, or fascia graft may be utilized. 2) External ear canal is injected with local anesthetic. 3) The operative microscope is used to visualize the middle ear. 4) The external ear canal is irrigated and suctioned with a 7-Fr Frazier suction for further visualization 5) Surgeon inserts an ear speculum, starting with a small speculum and advancing to a larger one. 6) Surgeon may elect to suction with a 5-Fr Frazier or microscution tip to remove any fluid from the ear 7) The tympanomeatal flap is created by using a roller knife, sickle knife, or flap knife. 8) The tympanic membrane is elevated and the posterior bony ledge removed using a house knife, duckbill elevators, or a drum elevator. Once the tympanic membrane is elevated. The surgeon is able to visualize the ossicular chain. 9) If surgeon is unable to visualize the ossicles due to a bony ledge, a drill may be used to remove enough bone for proper visualization. 10) Surgeon may elect to measure the distance from the incus to the stapes footplate or may wait until after the stapes is removed.

9. 11)Incostapedial joint is disarticulated using a house or guilford-wright joint knife. Laser may be used to perform this step of the procedure. The stapedial tendon is severed with bellucci scissors 12) A fine rosen needle and microcupped forceps are utilized to fracture the stapes superstructure. 13) Surgeon may ensure hemostasis by using tiny sponges that have been soaked in epinephrine. 14) Surgeon creates an opening in the footplate with a laser, drill, or sharp footplate pick. 15) Surgeon inspects the oval window and the graft is placed with an alligator forceps. 16) The prosthesis is introduced into the middle ear on alligator forceps to be positioned so it rests against the oval graft. 17) Wire is positioned over the incus by using a Hough hoe, picks, or footplate hooks. Once surgeon is satisfied with the position, the wire is crimped onto the long process of the incus. 18) At this point surgeon may test patients hearing by whispering to patient 19) Moistened gelatin squares may be placed around the site of the prosthesis for stability. 20) Tympanomeatal flap is replaced using a duckbill elevator, rosen needle, or drum elevator 21) The external ear canal may be packed with moistened gelatin sponge, antibiotic gel, or antibiotic ointment 22) Cotton is placed in the concha of the ear and the graft site is dressed. 23) A glasscock or mastoid dressing may be utilized.

10. P ROGNOSIS Patient is expected to return to normal activities within 2 weeks.

11. COMPLICATIONS Dizziness Tinnitus Taste disturbances Loss of hearing Eardrum perforation Temporary weakness of the facial muscles

12. A LTERNATIVE P ROCEDURE Stapedotomy Small opening is created in the fixed stapes footplate with a small drill or a laser. Allows for transmission of sound waves or placement of the prosthesis.