A 38-year-old woman with a 2-year history of progressive hearing loss undergoes high-resolution CT temporal bone, which shows a lucent lesion at the oval window with demineralization of the otic capsule. Audiometry reveals a 35 dB air–bone gap at 2 kHz with a characteristic Carhart notch. She is counseled about treatment options. Which of the following is the definitive surgical treatment for her condition?

## Surgical Management of Otosclerosis **Key Point:** Stapedectomy (or stapedotomy) with prosthesis placement is the gold standard surgical treatment for otosclerosis, offering excellent functional outcomes and hearing restoration. ### Indications for Surgery **High-Yield:** Surgery is considered when: 1. Air–bone gap ≥30 dB (as in this patient with 35 dB gap) 2. Patient desires hearing improvement 3. Medical management (hearing aids) is inadequate or unacceptable 4. Conductive or mixed hearing loss confirmed on audiometry ### Surgical Technique: Stapedectomy **Clinical Pearl:** The procedure involves: 1. **Transcanal approach** — endaural or postauricular incision 2. **Tympanomeatal flap elevation** — to access the middle ear 3. **Stapes removal** — the fixed stapes footplate is removed 4. **Prosthesis placement** — a small piston (typically 0.4–0.6 mm diameter) is inserted between the incus and the oval window niche 5. **Oval window seal** — fat, fascia, or bone pate seals the window around the prosthesis ### Prosthesis Materials | Material | Advantages | Disadvantages | |----------|------------|---------------| | Teflon (PTFE) | Biocompatible, durable | Risk of extrusion | | Stainless steel | Excellent visualization | Corrosion risk (rare) | | Titanium | Biocompatible, strong | Cost | | Hydroxyapatite | Osteoconductive | Limited long-term data | ### Expected Outcomes **High-Yield:** Stapedectomy success rates: - **Air–bone gap closure** to <20 dB: 90% of cases - **Hearing improvement** of 20–30 dB: typical - **Revision surgery rate** (for prosthesis extrusion/failure): 5–10% over 10 years ### Complications **Warning:** Potential intraoperative and postoperative complications: - Sensorineural hearing loss (0.5–1%) - Facial nerve injury (<1%) - Prosthesis extrusion or displacement - Perilymphatic fistula - Vertigo (transient in most cases) - Tinnitus (may persist or worsen) ### Why Stapedectomy Is Definitive 1. **Directly addresses the pathology** — removes the fixed stapes and restores ossicular continuity 2. **Restores sound transmission** — prosthesis conducts vibrations from incus to perilymph 3. **High success rate** — 90%+ achieve air–bone gap closure 4. **Durable** — long-term stability with modern prostheses 5. **Bilateral cases** — second ear can be operated on if needed (staged or simultaneous) ### Mnemonic for Stapedectomy Indications **"STAPES"** — **S**urgery indicated, **T**ympanomeatal flap, **A**ir–bone gap ≥30 dB, **P**rosthesis placement, **E**xcellent outcomes, **S**tapes removal [cite:Dhingra 8e Ch 12]