ENT Department Timisoara

2nd Timisoara International Course on

Middle Ear Surgery with
Temporal Bone Dissection

TEMPORAL BONE
DISSECTION
 TEMPORAL BONE DISSECTION

B. Stapedotomy

General considerations
Stapedotomy means the creation of a small calibrated fenestration
into the stapes footplate. The same name is frequently used to
indicate the introduction of a stapes prosthesis between the incus
and vestibule, regardless of whether the opening into the footplate
is well calibrated or consists of a partial removal of the footplate
(“small fenestra stapedectomy”). The definition of “stapedotomy”
should be limited to the former situation and the latter should be
called a “partial stapedectomy”.
The introduction of a stapes prosthesis from the malleus to the
vestibule has been called “vestibulopexy”. This term does not
address whether the prosthesis reaches the vestibule through a
calibrated opening, or through a partial or total stapedectomy.
To avoid the confusion, are used the terms incus-stapedotomy
and malleo-stapedotomy for the exclusive use of a stapes
prosthesis from the incus or malleus handle in conjunction
with a stapedotomy opening.
To achieve a stapedotomy opening through the footplate on a
regular basis, it has been proven of value to reverse the classic
steps of stapedotomy and to create the calibrated opening
before removing the stapes arch. In this case, the diameter of
the stapedotomy opening should not exceed 0,5mm, and the
corresponding diameter of the stapes piston should be of
0,4mm.
B.1. Incus-Stapedotomy
Endaural Skin Incision
The endaural skin incision (A-B) is made using a no. 15 blade at
the 12 o‘clock position between the tragus cartilage and root of
the helix. The soft tissue are cut to the level of the bony entrance
of the canal (remove excess soft tissue over the bony external ear
canal to gain sufficient exposure in the temporal bone specimen).
Tympanomeatal Flap
The tympanomeatal incisions are made with a no 11 blade
mounted in a special rounded scalpel handle.
The posterior limb of the tympanomeatal flap begins at 8 o‘clock,
ascending spiraly from the tympanic annulus to the lateral edge
of the external auditory canal (C-A). The anterior limb is carried
out from the 1 o‘clock position to the inferior edge of the
endaural incision (D-A).
Tympanomeatal Flap

NOTE: A larger tympanomeatal flap (as for malleo-

stapedotomy) is used whenever total or partial
fixation of the malleus is suspected.
Canalplasty

While elevating the tympanomeatal flap, the bony overhang of a

proeminent tympanosquamous spine or a protruding antero-
superior canal wall needs to be removed to adequately inspect
the anterior malleal process and ligament. A curette or
diamond burr is used for this purpose ( do not separate the
tympanomeatal flap from the tympanic sulcus and incisura
Rivini during this step to avoid irrigation of the middle ear
with contaminated Ringer‘s solution).
Canalplasty
Elevation of Tympanomeatal Flap
The most important landmark in this step is the posterior
tympanic spine (posterior end of the incisura tympanica
Rivini). The tympanomeatal flap is elevated first from the
posterior spine using a Fisch microraspatory. Care is taken to
keep the chorda attached to the flap.
Enlargement of the Supero-
Posterior Canal Wall
The bone covering the oval
window, the inferior edge of the
incudo-malleal joint and the
anterior malleal process are
removed using a curette. The
rotational movements of the
curette should be directed from
medial to lateral to avoid trauma
to the chorda and incus.
Exposure of the Oval Window

The exposure of the oval window is correct when the following

structures are visible:
Pyramidal process with the stapedial tendon
Oval window with the stapes and incudo-stapedial joint
Tympanic segment of the facial nerve
Inferior incudo-malleal joint
Lateral (short) process of the malleus
Anterior malleal process and ligament
Exposure of the Oval Window
Perforation of the Footplate
A calibrated opening of o,5mm diameter is made in the safe area
(the central area between the middle and inferior third of the
stapes footplate) where the saccule and the utricle lie more than
1mm below footplate level.
The stapedotomy opening
should be positioned in
such a way that
the prosthesis will
remain perpendicular
to the footplate.
A set of four manual perforators (o,3, 0,4, 0,5 and 0,6mm
diameters) is used to create a stapedotomy opening. The
perforators are rotated back and forth between thumb and
index finger. The tip of each perforator is only partially
introduced into the vestibule. The correct size of the opening
(0,5mm) is confirmed with a 0,4mm calibre rod.
Introduction and Fixation
of the Stapes Prosthesis

The stapes prosthesis is picked

up from the cutting block
using large straight smooth
alligator forceps.
Introduction and Fixation of the Stapes Prosthesis

The piston is first placed over the stapes footplate and aligned with
the long process of the incus. The length of the prosthesis is
correct if the piston loop exceeds the lateral surface to the incus by
0,5mm.
Introduction and Fixation of
the Stapes Prosthesis

If the prosthesis is the correct

length, it is moved over the
stapedotomy opening with a
1,0mm, 45° hook and carefully
advanced into the vestibule. The
loop is then crimped over the
incus with small straight smooth
alligator forceps.
Removal of the Stapes Suprastructure

With the prosthesis in place, the incudo-stapedial joint is

separated with a joint knife, the stapedial tendon is sectioned with
tympanoplasty microscissors, the posterior crus is cut with
crurotomy scissors that are controlled with both hands, and the
anterior crus is crushed at the level of the footplate with a 2,5mm,
45° hook.
The stapes arch is removed, and final mobility of the ossicular
chain is confirmed. There should be no free movement of the
prosthesis loop when either the incus or malleus is moved.
Removal of Stapes Suprastructure
Sealing of the Stapedotomy Opening and Repositioning
of the Tympanomeatal Flap
Three connective tissue pledgets from the endaural incision are
placed around the stapedotomy opening.Venous blood obtained
from the cubital vein of the patient prior to surgery and one drop
of fibrin glue are used to seal the oval window niche
Sealing of the Stapedotomy Opening and Repositioning
of the Tympanomeatal Flap
The tympanomeatal flap is repositioned, and two small Gelfoam
pledgets soaked in corticosporin are used to keep the flap in
position.
B.2. Malleo-Stapedotomy

Endaural Approach
This surgical step is identical to incus stapedotomy.
Tympanomeatal Flap
The tympanomeatal flap used for malleo-stapedotomy is larger
than that described for incus-stapedotomy. The posterior limb is
the same, but the anterior limb extends to 4 o‘clock on the right
side and 8 o‘clock on the left.
 Tympanomeatal Flap

The soft tissues are elevated from the underlying bone using a
Key raspatory. At this stage, the endaural retractors are replaced
to obtain maximal exposure without injuring the skin margins
(this surgical step does not apply to the temporal bone). The
tympanomeatal flap is raised from the underlying bone with a
Fisch microraspatory and a microsuction tube. The
tympanomeatal flap should not be separated from the incisura
tympanica Rivini before completing the canalplasty to avoid
contamination of the middle ear cavity with contaminated saline
solution used for irrigation while drilling.
Malleo-Stapedotomy
Antero-superior Canalplasty

The canal skin is elevated from the wall of the ear canal with a
Fisch microraspatory. The antero-superior overhang of bone is
then removed with sharp and diamond burrs until the anterior and
posterior tympanic spines can be identified . The tympanomeatal
flap should remain attached to the bone at the entrance of the
middle ear until drilling is completed to avoid contaminating the
cavum tympani with irrigation fluid.
Elevation of the Tympanomeatal Flap

The tympanomeatal flap is first elevated from the posterior

tympanic spine using a left Fisch microraspatory (right ear) that
is introduced under the rim of bone lateral and superior to the
chorda tympani. The Shrapnell membrane is then elevated from
the malleus neck and lateral malleal process until the anterior
tympanic spine and the beginning of the anterior tympanic
annulus become visible.
Exposure for Malleo-Stapedotomy
The correct exposure for malleo-stapedotomy is obtained by
using a curette to enlarge the supero-posterior edge of the bony
external canal.
The following structures should be exposed:
Pyramidal process with the stapedial tendon
Oval window with the stapes and incudo-stapedial joint
Tympanic segment of Fallopian canal
Inferior part of the incudo-malleal joint
Lateral malleal process and malleus neck
Anterior malleal process and ligament
Anterior tympanic spine
The chorda tympani should be kept intact whenever possible.
Remember that an intact chorda is the calling card of the
otologist.
Exposure of Malleo-Stapedotomy
Removal of Incus and Malleus Head
The malleo-stapedotomy is performed when there is total or
partial fixation of the malleus and/or incus. A fixed incus is
removed after cutting its long process with a malleus nipper to
avoid damage to the chorda tympani during extraction. The
malleus nipper is not used to section the malleus neck because
this maneuver would leave the anterior malleal process intact.
A fixed malleus head is removed most effectively by cutting its
neck with a 0.6 or 0.8mm diamond burr. While drilling, the
malleus handle is held with a large toothed straight alligator
forceps controlled by the left hand. The drilling starts over the
anterior malleal process, which is just anterior to lateral process
and continues in a superior and antero-posterior direction across
the malleus neck. This C-shaped line of drilling permits the
anterior malleal process to be included in the resection. Great
care is taken to keep the chorda tympani intact. The chorda
tympani runs under the anterior malleal process from which it
must be separated by using a hook prior to drilling.
Preparation of the Stapes Prosthesis

The Titanium Stapes Prosthesis, 0,4mm diameter and 8,5mm

length, is used for both incus-stapedotomy and malleo-
stapedotomy. The initial steps for preparing the prosthesis are the
same for both types of stapedotomy. The average distance
between the proximal malleus handle and the stapes footplate is
6,5mm (including 0,5mm to allow for protrusion of the piston
into the vestibule).
Preparation of the Stapes Prosthesis

The Titanium Stapes Prosthesis is trimmed on a

titanium cutting block. The surface of the cutting block should
be humidified with saline solution to eliminate unnecessary
movement of the prosthesis. The diameter of the prosthesis loop
is enlarged to the size of the malleus handle by moving it along a
1,5mm, 45° hook with watchmaker forceps and then stored in the
0,4mm hole of the cutting block.
Shaping of Prosthesis-Shaft for the Malleus Handle

The shaft of the prosthesis may be bent along various planes on

the cutting block to accommodate the anterior position of the
malleus. This is done while the prosthesis is in the 0,4mm hole of
the cutting block by gently bending it to the correct extent by
pushing the shaft with watchmaker forceps. This same maneuver
can be performed in a lateral direction if required by the steep
position of the malleus handle.
Perforation of the Footplate
This step is performed using manual perforators as for an incus-
stapedotomy. An Erbium-YAG laser is used in special cases (e.g.
mobile footplate).

Removal of Stapes Arch

The stapes arch is removed after perforation of the footplate.
Both crura are cut using crurotomy scissors. The stapedial tendon
is cut last to insure stability while cutting the crura.
Introduction and Fixation of the Stapes Prosthesis

The picking up and the introduction of the prosthesis in the

middle ear are done in the manner similar to incus-stapedotomy.
The exposure given by the large tympanomeatal flap and the
antero-superior canalplasty is such that both, the malleus handle
and the footplate are visible with one position of the microscope.
.
Introduction and Fixation of the Stapes
Prosthesis

The prosthesis is first placed on the footplate to ensure that the

length and bend are adequate (the prosthesis cylinder must be
perpendicular to the footplate). The prosthesis cylinder is then
introduced into the vestibule for 0,5mm (measured from the
lateral surface of the footplate) using a 1mm, 45° hook.
Fixation of the Stapes Prosthesis
The prosthesis loop is attached to the malleus handle just distal to
the lateral malleal process (extensive separation of the drum from
the malleus handle should be avoided). Crimping the prosthesis
to the malleus handle is performed using large and small smooth
straight alligator forceps. Each forceps is held with both hands.
The prosthesis loop should be immobile after crimping.
Sealing of the Stapedotomy Opening and Repositioning
of the Tympanomeatal Flap
These surgical steps are done as for incus-stapedotomy.