A 28-year-old woman with a 2-year history of progressive hearing loss presents to the ENT clinic. She reports that her mother and maternal grandmother both had hearing loss requiring hearing aids in their 30s. Otoscopy is unremarkable. Audiometry shows bilateral low-frequency conductive hearing loss with an air-bone gap of 35 dB. High-resolution CT temporal bones reveals lucent foci around the oval window with stapes footplate thickening and fixation. She is counseled about management options. Which of the following is the definitive surgical treatment for her conductive hearing loss?

Explanation

## Definitive Surgical Management of Otosclerosis ### Clinical Context **Key Point:** Stapedectomy (or stapedotomy) with prosthetic stapes replacement is the gold standard surgical treatment for conductive hearing loss due to stapes fixation in otosclerosis. ### Why Stapedectomy Is Definitive | Aspect | Rationale | |--------|----------| | **Pathology** | Stapes footplate is fixed in the oval window due to abnormal bone growth | | **Surgical Goal** | Remove the fixed stapes and restore ossicular chain continuity | | **Technique** | Partial or total removal of stapes; insertion of prosthesis (piston, wire, or TORP) | | **Success Rate** | 90–95% achieve air-bone gap closure to <20 dB | | **Hearing Improvement** | Immediate restoration of conduction through the prosthesis | ### Surgical Technique Overview ```mermaid flowchart TD A[Otosclerosis with stapes fixation]:::outcome --> B[Surgical Indication: Significant conductive loss]:::decision B --> C[Stapedectomy approach]:::action C --> D[Elevate tympanic membrane]:::action D --> E[Identify stapes footplate]:::action E --> F[Fenestrate oval window]:::action F --> G[Remove fixed stapes]:::action G --> H[Insert prosthesis]:::action H --> I[Restore ossicular continuity]:::outcome I --> J[Hearing improvement]:::outcome ``` ### Prosthetic Options - **Piston prosthesis** (most common): Titanium or stainless steel; 0.4–0.6 mm diameter - **Wire prosthesis**: Connects incus to oval window - **TORP** (Total Ossicular Replacement Prosthesis): Used if incus is also damaged ### Preoperative Assessment **High-Yield:** Patients must have: - Conductive or mixed hearing loss (air-bone gap ≥20 dB) - Stapes fixation confirmed on imaging or intraoperative findings - Adequate cochlear reserve (bone conduction threshold <45 dB) - Realistic expectations about outcomes ### Complications (Important for Exam) - **Sensorineural hearing loss** (1–2%): Due to oval window trauma - **Prosthesis extrusion**: Requires revision surgery - **Vertigo/dizziness**: Usually transient - **Facial nerve injury**: Rare but serious - **Perilymphatic fistula**: If oval window seal is breached **Clinical Pearl:** Revision stapedectomy may be needed if the prosthesis extrudes or if the contralateral ear becomes symptomatic (bilateral otosclerosis occurs in ~70% of cases). **Mnemonic: STAPEDECTOMY = Stapes fixation, Treatment definitive, Approach transcanal, Prosthesis inserted, Excellent outcomes, Dizziness (temporary), Ear canal approach, Conductive loss resolved, Technique refined, Ossicular continuity, Mobilization of incus, Year-long follow-up** [cite:Dhingra 8e Ch 10]