Laser Stapedotomy for Otosclerosis
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Today this patient is a 44 year old male who presented with progressive hearing loss in the left ear. He was seen about 5 years ago and noted to have a very mild conductive hearing loss on the left side with apps and acoustic reflexes, but at that time was not felt to be a surgical candidate yet for stapedectomy. Over 5 years, his hearing loss has progressed, and he now has about a 35 decibel conductive airbone gap in the low and mid frequencies, and he presents today for a left stapedectomy with laser. This is being done with the patient under Mac anesthesia, so he is receiving IV sedation but can be actually lightened up and awakened if we need to talk to him or to assess his hearing.
Alright, we are good to start prepping, so who's prepping? Are you prepping? A Betadine prep - so big Betadine prep, and then it's okay to squirt some prep into the ear canal. Scrubbing solution? Yes, yes.
So we're going to begin our stapes procedure with a 4 quadrant or circumferential canal block, which we begin right at the - just inside the meatus, just prior to where it transitions from hair bearing to non hair bearing skin. Occasionally, if the patients are a little bit more light, I'll warn them before injecting this as they may feel a little bit of the local anesthetic. And we're just going to march around the meatus. And as you're injecting, you want to see that sort of thicker meatal tissue expanding a little bit from the anesthetic.
Okay, now the five Lorna. Next time I’m going to use a little bit smaller speculum to dilate the canal a little bit, but as I push in, it will milk this anesthetic down the canal wall. Suction. And you can now see some of this local anesthetic has kind of infiltrated down the vascular strip here towards the malleus handle. Okay, back to a… There we go. Table towards me please.
This is a 6mm speculum that we have in right now. Ideally, if you can get at least at 6, or even larger, that's a good working space. We’re using a transcanal - okay that's great - transcanal approach. Other approaches that can be used are endaural approach or post auricular approach. I prefer to do stapes surgery through a transcanal approach using an ear speculum. Okay injection now. Next time I’m - I’ll inject a little bit more along the vascular strip. So in the posterior superior quadrant of the ear canal, just at about the level of the bony cartilaginous junction, I'm going to go in until I feel the needle hit bone, and then very slowly I will infiltrate. And if you can see down, you'll now see blanching of the malleus handle and the malleus all the way down to the umbo will slowly blanch. And now we have a nice injection of our vascular strip. Injection back Lorna. Now, suction again. We can go to a 3 now.
And to begin the surgery, we’ll make our canal incisions for a tympanomeatal flap. One knife please. We’ll make an inferior incision at approximately the 6 o’clock location or is far anterior as we can. This is down to the level of the tympanic membrane. I'm going to make this incision just lateral to the annulus and then come straight out in the canal. And we’ll make three passes along this incision line right down on bone. A large round knife.
And with our round knife, we will now make our tympanomeatal flap incision. As this cut is being made, we're kind of making small cuts and then lifting up, and then connecting those cuts. So almost like perforating the skin successively, and then connecting the - suction - connecting the - the guts. If you ever forget these instruments on here they're labeled - suction back. Suction. And we’re going to continue all the way around, and I'm - as I'm making these cuts, I'm going right down to bone.
Then I'm going to gently start elevating here. We're going to curve this cup up - cut up superiorly. Oftentimes, you can cut this with a pair of scissors where it gets thicker up top. Suction now. Okay.
Next, I’m going to start elevating the the temp of the tympanomeatal flap, and as I elevate, I'm keeping this round knife right down on bone and pushing forward, and I'm going to actually get under the thicker part of the flap up top here and elevate. It’s a little bit swollen with our local anesthetic. And we’re just pushing forward. Beluccis to the right. Occasionally, the - the tissue more superiorly is a little bit thicker, and it’s helpful to trim some of this with a pair of scissors. There we go. Okay. Now the lar - large round knife again.
We're going to now elevate the flap inferiorly. And as I'm elevating, I'm going to suction on the back side of my round knife. You would like to avoid suctioning on the flap as much as possible to prevent it from getting more swollen or from possibly perforating it if it's very thin skin.
So I'm elevating now all the way down to the level of the annulus. I'm looking for the annulus inferiorly. There’s our tympanomastoid suture line, and then once I get down into about the level of the annulus - table towards me. Okay.
I'm going to continue elevating this flap all the way down to the level of the annulus, and then I'm going to slowly start pushing up with this round knife to try to get this underneath the edge of the annulus. There we go. I can see the annual ligament right there. There is a little bony ledge still there. Here I've got - there’s the edge of the annulus here, and now I'm going to slip this underneath the annulus, and then I'm going to lift forward and up.
And now I am under the annulus, and I'm going to keep an elevating the annulus inferiorly to about the 6 o’clock, 7 o’clock location. That will allow us to really get our tympanomeatal flap up in over. Now a small BB-like cottonoid.
At this point, I'm going to take a small cotton ball soaked in epinephrine and place this inferiorly. Gimmick now. This - often you'll have bleeding from the inferior aspect where you've elevated your annulus, so this serves as a way of just tamponading some of that bleeding, and the epinephrine helps control that as well. It's like some skin along there. We’ll sort of just press that into that inferior sulcus.
Now we’re going to look back up superiorly and elevate the remaining portion of our tympanomeatal flap. Can I have a round knife please? Okay, now I - a small Crabtree dissector. There is our chorda tympani nerve, and I’m going to carefully separate this fibrous tissue from the chorda tympani. One knife please.
There is the chorda tympani and a little remnant of the posterior malleolar fold. Let’s have a footplate hook now. We can start to see our incus and capitulum of the stapes. Can I just come through this little fold here and also free up this chorda a little bit? Where is the chorda tympani. Chorda tympani nerve. Now a house curet.
So next to improve our exposure, I’m going to - we're going to remove some bone from the posterior canal wall. Ideally you'd like to be able to see the facial nerve above the oval window and the pyramidal process of the stapedial tendon posteriorly. Wipe.
This is a - as you curet, we’re - it's a rotational movement of the wrist. Just sort of scoop that bone out. Suction. And now a gimmick. And I gently push this flap forward a little bit more - give us some more exposure. And if we gently lift up on the malleus, I have good movement of the incus, but the stapes does not seem to move. The stapes is fixed. Suction.
And I'm looking now for a round window reflex, but I really am not seeing much of one. So the stapes is fixed. We can open the laser fiber. Curet. It’s still on the screen - it’s just been a little high. Just tell - cuz a lot of times I won’t notice it. Just started drifting. Suction. Can’t quite see. This thing has a mind of it’s own. Let’s have a - we have a curet Lorna?
You see the anterior arch very prominently. Oftentimes, you can't - you will not see the anterior arch that well. Just a little bit. Wipe. Lorna, wipe. Thank you. What you don't want to do on this right here is to break any of these fibers in this thing, so I don’t usually put it with a hemostat or anything, I just put it on the sticky guys like that in there. And it’s so it doesn’t flip up on anyone - just put it there like that. Okay.
Yeah, I’m just curetting a little bit of additional bone to really try to be able to see the - more of the posterior aspect of the stapes. It’s not a real easy one to see. Not quite yet. Yeah, he’s got a weird looking stapes actually - and a very thin incus, very flimsy. Curet one more time. Alright, now suction. Okay. Alright, so can I now have a - how about just Barbara needle?
So now we have improved exposure. I can see we have incus here, the incudostapedial joint. When you gently touch, you can see the joint stretch right here. The stapedial tendon, the anterior cruz, and the posterior cruz back here. Facial nerve can be seen medial to the incus here. Laser.
Next going to separate the incudostapedial joint. This is the - a - this is a - CO2 laser carried through a fiber optic cable, and we are using settings of 4 watts and 100 milliseconds pulses. Laser on. I like to use laser to first sort of vaporize the mucosa surrounding the joint. Sometimes it can be quite thick, and when you're trying to cut through it with a knife, you can be pulling on the stapes quite a bit. So I’m firing right at the level of the capitulum between the incus and the capitulum of the stapes. Incudostapedial joint knife now.
Next we’ll use an IS joint knife to further separate the incudostapedial joint. If I lift up now ,I get a nice clean plane between the two. Again, we have good movement of the incus and malleus. Laser back.
Next we’ll cut the stapedial tendon. Laser on. Suction in my left hand. Very thick stapedial tendon. Once the tenant is cut, I can now have a nice direct line of sight at the posterior cruz. I’m going to now use the laser to cut the cruz as close to the footplate as I can. And Lorna, we’ll go to a 24 suction now. 24 suction. Laser standby. Laser back. Laser on.
So we still have a few more areas of this posterior cruz we’re going to laser now. And then this is an unusual - somewhat unusual - situation where we actually have a very clear view of the anterior arch. Often just due to the angle, you can't see the anterior arch as well. Laser. So this affords us the opportunity actually go ahead and cut the anterior arch with the laser as opposed to actually fracturing it. Laser on. So now I'm going to use the laser to go through the anterior arch. Again, we want to try to cut through as close to the footplate as possible, so we're not leaving too much of a remnant of the Kura still attached. Now a Barbara needle.
So next I'll use an instrument just to kind of break up these this char that's still attaching the stapes. Now the anterior arch is separated, and next we’ll separate the posterior cruz and actually remove the - there’s still a little bit there. Laser. Okay. Now the - the carotid is completely separated. Can I have a suction now? And we’ll just remove the arch of the stapes here. A pair of cups. I don’t think there’s enough suction on here. Okay, now a micro footplate hook. There is a little remnant of the Kura, so with a small hook we can kind of free that - clean that up a little bit. What’s that? Okay. Can I have the suction again? And then we’ll need a measuring rod next. Man, he is moving.
Okay, next we’re going to measure the distance from the incus to the footplate. This is a 4.5 mm measuring rod, so it's 4.5 mm from the tip of this instrument to the small barb. So when measuring, this small barb should reach the top of the incus, and it might be just a little bit - just a hair short. But just about right actually. Can we have a 5.0? It’s going to be a little big. Let’s have that 4.5 one more time. It’s probably going to need about a - do we have a 4.75 by .5?
Next we’ll use the laser to make our fenestra. We're going to make the fenestra in - in approximately the mid portion of the footplate. He does have a lot of little blood vessels, so we’ll actually use the laser to coagulate these. Laser on. And then… His footplate is actually pretty thick.
Let's have the prosthesis next - prosthesis now. And a little bit of water. Now the ozonator. Okay Lorna, hold that. And then a Barbara needle next. Thick stuff still. I’m actually scraping some of the char off of where we’ve lasered. This back part is thicker than it is anteriorly. Now a 24 section, and then I'll take the laser back. And when I'm suctioning, I have my hand off of the control hole, so we have low suction. Okay, laser back. Laser on.
Now the footplate hook back - I mean the Barbara needle back please. Yeah, that’s very thick. I don’t know how easily that will come out. See how it’s a little moble with the… Yeah. Try to break up and get that char off of there. Suction now. Lorna, can I have an IS joint knife? That’s a footplate, but that’s okay. That’s okay. It’s a weird footplate. Suction now and then the laser. It's a lot thicker than it looked.
Okay, now I'm starting to get through. Lorna, let me have a round window - the four millimeter rasp. We use it to actually make the opening a little bigger. Wipe Lorna. He’s got a pretty big - yeah, I mean a very thick footplate.
So with this rasp, I'm going around the margins of our fenestra and just sort of smoothing out these edges. As much as I can. Fortunately, we have not had any bleeding. Quite a - we have our fenestra now. Can I have a 6 mm now? Our piston we’re going to be using is a 5 mm piston, so we want to make sure it's going to fit in there. This is a 6mm rasp. Wipe. No, I want to get that through there. Okay. The plate is trying to come out. Let’s have a suction now.
And next we’ll take the prosthesis. Now can I have a footplate hook? A small one Lorna. Laser on, 4 watts, gas off. Small, the micro footplate hook first.
So now the - the piston is through our fenestra, and now we're just going to reposition the - the wire loop kind of where we want it on the incus. Maybe scoot it up a little bit cuz it's... Usually, you want it at about the distal one 3rd, but his incus tapers a little bit towards the tip, and so you want to give yourself some distance so it doesn't get - have a tendency to slide off the bottom. And then I'm going to also just gently before we crimp, make sure that it moves and it does move freely within our fenestra.
Okay, laser. This is a nitinol memory shape piston, so it is a wire loop that has a combination of titanium and nickel and will it - when heated, will reassume a preformed shape. So we use the laser to actually crimp the prosthesis. Laser on.
And we’ll just touch it a couple times, and then that should do it. Barbara needle. And we’ll just check and make sure that it's pretty secure on there. And there’s good movement of it with movement of the incus. Yes, the problem with most stapes prostheses - wire-loop type prostheses - is that if they’re crimped too tight, they'll strangulate the incus and you'll get necrosis of the tip of the incus, or if they're too loose the vibratory motion will gradually saw through the incus, and they will then fail. Bucket handle prostheses avoid this problem just by their - the inherent way that they sit onto the incus, so that is a - a different alternate. Although, they can have issues as well with - with other problems. Unfortunately, no one has developed a one-hundred-percent, foolproof stapes prosthesis.
Next going to take a little bit of subcutaneous tissue from the thicker area underneath our tympanomeatal flap and just put a little bit of tissue around the base of this prosthesis, and then we will be done. Can I have a pair of cups to the right and Beluccis? Yeah, can we wake him up a little bit guys - that’d be kind of cool. Cups to the right - Beluccis to the left.
So I usually will - I’ll go just to this thicker area of the tympanomeatal flap vascular strip area. You can also take subcutaneous tissue from just inside the meatus - make a small incision - or you can take some subcutaneous fat from the earlobe. So just a small amount of tissue from here - gimmick please. Fascia press. Gimmick first. Bulb irrigator Lorna. And then we’re going to press this small amount of tissue out. You don't have to do this necessarily, but I like to divide it into a couple small pieces. 59 10. Okay, now a Barbara needle. Here’s your knife Lorna. I’m going to need to leave that down for one second.
And I'm just going to place a little bit of this substance issue around the the base of the prosthesis just to help form a seal. And that other piece. Move fat around to the front side. Okay. Suction one more time - 24.
And then finally, the last thing we will do - Lorna, let me have that Barbara one more time - is we’ll just induce a little bit of bleeding to also form a blood patch around this prostheses. Just want to check one thing… Hold that one.
So the final thing we're going to do is just anterior to the of a window, find a little blood vessel and just avulse that a little bit to induce some bleeding, and then we'll form a little blood patch around this prosthesis as well. I just get that blood to come down. Alright Lorna, let me have a 3 suction.
So we have now soft tissue around the prosthesis as well as blood patch. And we’re going to get our cotton ball out, and then we’ll be all done. Lorna, can I have a - can I have a pair of cups? Take that. Lorna, do you have another 3?
Next, table away, and the ointment now. And then for filling the ear canal, we use Bacitracin ointment loaded into a 3ml syringe with a blunt tip needle and basically fill the whole ear canal with this ointment, and the weight of the ointment will just hold that flap down and allow things for healing.
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