Stapedectomy

What Is a Stapedectomy?

A stapedectomy is a delicate microsurgical (using a microscope and fine instruments) procedure performed to improve hearing in patients with conductive hearing loss due to otosclerosis. Otosclerosis is a condition in which abnormal bone changes leads to fixation of the stapes (the third and smallest hearing bone), impairing sound transmission from the middle ear to the inner ear. To learn more about otosclerosis, please read this article.

The procedure is entirely done through the ear canal (no outside incisions) and involves removing the fixed stapes bone and replacing it with a surgical implant (a "piston") that transmits sound vibrations to the inner ear, thereby bypassing the diseased bone and restoring conductive hearing.

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Who Should (and Shouldn't) have a Stapedectomy

You may be a good candidate if (Indications):

1. You have conductive hearing loss
   This means the problem is in the middle ear, not the inner ear or hearing nerve. It can be caused by the stapes bone being "fixed" in place. This is confirmed by a hearing test (audiogram) showing a large air-bone gap (ABG) — typically 20 decibels (dB) or more.

   • Air-bone gap means there’s a difference between how well you hear sounds through the air (headphones) vs. through your bones (bone conductor placed behind the ear). A big gap suggests a mechanical blockage in the middle ear — like otosclerosis. To learn more about conductive hearing loss and ABGs, read this article.

2. Your inner ear is healthy

   • The bone conduction thresholds (hearing through the inner ear) are fairly good — ideally better than 50 dB. This is a sign of good "cochlear reserve", meaning your inner ear is healthy. If your inner ear is not working better than 50 dB, stapedectomy is still possible but it involves a deeper discussion with your surgeon regarding expectations. 

   • Speech discrimination scores (how clearly you understand words) are also used to make sure your inner ear and hearing nerve are working well. The speech discrimination should be at least over 50%, but ideally better than 70%

3. You show signs of otosclerosis during a physical exam

   • A tuning fork test (like the Rinne and Weber tests) may show signs consistent with conductive hearing loss.

     • For example, in Rinne test, if you hear the tuning fork better on the bone (behind the ear) than through the air (in front of the ear), it suggests conductive loss.

4. A CT scan supports the diagnosis

   • A high-resolution CT scan of the temporal bones helps confirm otosclerosis and rules out other causes of hearing loss (like malformations, enlarged inner ear structures, or other bone diseases).

   • It can also show if the stapes footplate is thickened or if there’s bone growth around the oval window.

   • The CT scan is not required, as up to 20% of otosclerosis will not be seen on imaging. However, it helps in pre-operative counselling. 
     
     

5. You’ve tried hearing aids but want a more permanent solution

   • Stapedectomy can be a good option for people who don’t benefit from or don’t like wearing hearing aids.

   • A trial of hearing aids is not mandatory before surgery, but for older patients or patients with medical issues that may affect surgery, it can be considered. To learn more about hearing aids, you can visit this article.
     
     

6. You have otosclerosis in both ears

   • Surgeons often operate on the worse ear first, to avoid risk to the better ear.

Who Is Not a Good Candidate? (Contraindications)

Some people may not benefit from the surgery or may face too many risks. It might not be recommended if:

1. Your inner ear hearing is already poor

   • If your bone conduction thresholds are very poor, or your speech understanding is low, surgery may not help much or may even make hearing worse.

2. You only have one good hearing ear

   • Surgery carries a small risk of permanent hearing loss. If the ear to be operated is your only hearing ear, extra caution is needed. Some people still go ahead, but it’s a complex decision.

3. You have active ear infections

   • Infections, fluid in the ear, or poor pressure regulation (due to Eustachian tube dysfunction) can affect healing or lead to complications.

4. You have an active inner ear problem like Meniere’s disease or vertigo

   • These conditions cause fluctuating hearing or balance issues and may not improve — or may even get worse — after surgery.

5. You’re pregnant

   • Elective surgeries like stapedectomy are usually postponed until after pregnancy.

6. You have abnormal ear anatomy

   • If your CT scan shows an unusually large inner ear (enlarged vestibular aqueduct) or a dehiscent (exposed) facial nerve, surgery can be risky.

   • If you have superior canal dehiscence, surgery may not help your conductive hearing loss, and may in fact trigger the symptoms of the dehiscence. To learn more about superior canal dehiscence, you can read this article.

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How a Stapedectomy Is Done – Step by Step

Stapedectomy is done under a microscope, either with the patient awake but numb in the ear (local anesthesia, with or without mild sedation), or asleep (general anesthesia). I always perform my stapedectomie under local anesthesia, because this allows me to talk to the patient once the surgical implant is placed and confirm that the hearing is better and that there is no vertigo.  The entire procedure usually takes around 60 minutes. Here's what the surgeon does:

1. Patient Preparation 

The patient lies on their back on the surgical bed with the head turned towards the non-operated ear (for example, if the surgery is on the left ear, the head will be turned to the right).  Mild sedation can be given at this point, and then the ear is frozen by injecting local anesthesia via a small needle. Once this part is done, the rest of the surgery is pain-free. The ear is then cleaned with an anti-septic solution to make the area sterile. Surgical drapes are then used to cover the head and body, leaving the ear exposed. 

2. Getting to the Middle Ear

A small incision is made within the ear canal (nothing on the outside), and the surgeon gently lifts the skin of the ear canal along with part of the eardrum (called a tympanomeatal flap). By raising the eardrum up (like a veil), we can get look inside the middle ear. This allows the surgeon to clearly see the tiny bones that carry sound to the inner ear.

3. Checking the Hearing Bones

There are three small bones in the middle ear: the malleus, incus, and stapes. The surgeon carefully tests how these bones move. If the first two bones (malleus and incus) are moving normally, but the last one (the stapes) is stuck, it confirms the problem is with the stapes.

4. Freeing the Stapes

• The connection between the stapes and the incus (called the incudostapedial joint) is gently separated.

• A tiny tendon attached to the stapes (the stapedius tendon) is cut.

• Then the upper part of the stapes bone (called the superstructure) is carefully removed, leaving just the flat base (called the footplate) behind.

5. Creating a Small Opening

• A tiny hole is made in the center-back of the stapes footplate. This is usually done with a very fine drill, laser, or another surgical tool.

• In older techniques, the whole footplate was removed (stapedectomy), but today most surgeons prefer to just make a small hole (stapedotomy) to reduce the risk of damaging the inner ear.

6. Inserting the Surgical Implant

• A tiny artificial part (called a prosthesis), often made from materials like plastic and titanium is then selected for insertion. 

• Prostheses come in various sizes. To select the right one, the surgeon uses a special tool to measure the distance between the incus and the opening. The most common prosthesis sizes are 4.25 mm or 4.5 mm in length and 0.6 mm in width (yes, less than 1 mm in width!).

• The prosthesis is carefully placed into the hole made in the footplate, and the top end is gently attached to the incus, connecting the middle ear bones back together so sound can travel again.

7. Hearing check

• After securely attaching the prosthesis to the incus, I reposition the eardrum and whisper three words to the patient, asking them to repeat them to confirm improved hearing. I also check to ensure the patient is not experiencing dizziness. These steps confirm that the prosthesis is the correct length.

8. Sealing and Closing Up

• The eardrum is lifted up once again, and the hole around the prosthesis is sealed to prevent fluid leakage from the inner ear and resulting dizziness. I do this with a soft reservable material called "Gelfoam", but other surgeons may use soft tissue graft (often taken from a nearby area like fat from the ear lobule or perichondrium) to prevent fluid leakage from the inner ear.

• The skin and eardrum are then carefully placed back in position.

• The ear canal is gently packed with gelfoam to support healing and antibiotic ointment. 

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What Are the Benefits and Risks of Stapedectomy?

If you're considering a stapedectomy, you're likely hoping to hear better — and in many cases, the results are excellent. But like any surgery, there are potential risks and complications to be aware of.

Here’s what you should know about what the surgery can do for you, and what to keep in mind before making your decision.

What Are the Benefits?

1. Better hearing — often dramatically better

   • Over 90% of patients have a major improvement in hearing, restoring it to it's full or near-full potential.

   • 9% of patients have a partial hearing improvement, meaning it's better than before surgery but full potential was not achieved.

   • Many patients report that voices sound clearer, music is richer, and they hear better in noisy environments.

2. Removing (or reducing) the need for hearing aids

   • The majority of people no longer need hearing aids after surgery.

   • Others may still use them, but at lower volumes or only in certain situations, like noisy group conversations.

3. Long-lasting results

   • The improvement in hearing is usually permanent (excluding natural causes of hearing loss such as aging).

   • The prosthesis (the surgical implant) is meant to be permanent and does not need to be replaced ever (unless any complications arise).

4. Improved quality of life

   • People often say they feel more confident, more connected socially, and more independent after hearing is restored.

What Are the Risks?

Stapedectomy is a delicate and highly specialized ear surgery — and while serious complications are rare, they do exist. Understanding them helps you make an informed choice.

1. Permanent hearing loss 

• • This is the most serious risk — although very rare - which can happen in 1% of cases.

  • In those cases, the inner ear (cochlea) may be damaged during the surgery (rarely) or suffer from an inflammatory response (more common) from the manipulation during surgery.

  • The hearing loss can be mild, moderate or severe, or can even be total deafness (the risk of total deafness is even less than 1% chance but not zero).

  • Surgeons take great care to prevent this, but it’s a known risk, especially in revision surgeries.

2. Dizziness or vertigo

• • It’s normal to feel dizzy or unsteady for a few days after the operation.

  • This usually settles within a week or two.

  • Rarely, some patients have lingering balance issues — if so, further tests and rehab may be needed.

3. Tinnitus (ringing in the ear)

• • In many cases, the tinnitus actually improves after the surgery.

  • But in some people, it stays the same or becomes more noticeable — especially if there’s nerve damage.

4. Taste changes or dry mouth

• • A small nerve that controls taste on part of the tongue runs through the middle ear, directly in the surgical field.

  • It’s often stretched or moved during surgery.

  • Some people experience temporary changes in taste or a dry metallic feeling, but this usually improves over weeks or months. Rarely, the taste changes can be permanent. 

5. Infection or eardrum issues

• • As with any surgery, there’s a small risk of infection.

  • Rarely, the eardrum may not heal fully, or may form a small hole (perforation).

  • These issues can usually be treated with drops or minor procedures.

6. The prosthesis might shift or fail over time

• • If the small artificial part becomes dislodged or scar tissue builds up, hearing may get worse again later.

  • A revision surgery can often fix the problem, though it’s more complex.

7. Facial weakness (very rare)

• • The nerve that moves the muscles of the face (facial nerve) passes near the surgical area.

  • It is extremely rare for this nerve to be injured during stapedectomy — but it's a known risk, especially in people with unusual anatomy.

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Putting It All Together: Is It Worth It?

For most people with otosclerosis, the answer is yes — the benefits of surgery far outweigh the risks. Here is a summary table of the pros-and-cons.

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What to Expect after Surgery - Healing and Recovery 

First 48 hours:

• Mild pain or fullness is expected, but stapedectomy is not a very painful surgery 
• Some dizziness, especially with head movement, would also be normal at that point.

First 7 days:

• Dizziness, if present, gradually improves.

• Hearing is usually muffled due to packing and swelling.

• Mild pain or fullness gradually resolves.

• Avoid nose-blowing, heavy lifting, or air travel to prevent pressure changes.

• Antibiotics and corticosteroids may be prescribed.

• Light activity is allowed; rest is encouraged.

First 30 Days:

• Your first follow-up visit will typically take place about 14 days after surgery. 

• Most of the packing in the ear will be resorbed, and what remains will be removed at the first visit.

• Hearing begins to improve as inflammation subsides.

• Dizziness, if still present, usually resolves by now.

• Patients may return to most activities, including light work.

At 6 Months:

• The first post-operative audiogram will take place between 4-6 months after surgery.

• Hearing gains are near their final level (can take up to 1 year for the final result).
  
  

• Persistent symptoms (e.g., tinnitus or imbalance) are evaluated further if still present, which would be rare.

• Patients typically report significantly improved sound clarity and quality.

At 1 Year:

• Long-term results confirmed via a final audiometry.

• Excellent stability in most cases unless disease progression occurs.

• Revision surgery considered only if significant hearing decline or mechanical failure is noted.

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Conclusion

Stapedectomy remains a highly effective and technically refined surgery for restoring hearing in patients with otosclerosis. With appropriate patient selection, meticulous surgical technique, and close follow-up, outcomes are excellent and durable. Patients considering the procedure should be well-informed of both its benefits and potential risks, as well as realistic timelines for recovery and hearing improvement.