Stapedectomy

I had a stapedectomy on January 9, 2008. Here is the story of my diagnosis, surgery with fortunately no complications, and the major hearing improvement.

So far I think the hearing is very good with some tinnitus in the operated ear. But I am very curious if I am slowly developing any otosclerosis in the other ear.

I finally had a follow-up hearing test in August 2014 scroll down or click here to see it. I sent the results to the doctor, and he is pleased that the results are holding out well.

The background information that I previously posted is here:

• An explanation of otosclerosis
• Counting down now to the stapedectomy

If you want to see a diagram and detailed description of the middle ear go to this Wikipedia page.

Disclaimer: The information I am giving here should not be interpreted as medical advice. I am not a doctor. The story below is just my experience told for anyone interested.

In 2005 I discovered I had a hearing problem. I was listening to music through headphones, and it seemed to me that one side was not working right: the sound was too quiet in one ear. So I swapped the right and left headphones and determined that one of my ears was not working as well as the other. Then I went to see an Otolaryngologist (ENT – ear, nose, and throat specialist) who diagnosed otosclerosis of the right ear.

The doctor told me that otosclerosis is a progressive disease and the only proven, effective treatment is surgery. In late 2007 I decided to get the surgery done. At the time I was living in Kuwait; having the surgery done locally was not an option. On top of that, my medical insurance did not cover the surgery as it is deemed the otosclerosis to be a pre-existing condition.

I found out after the surgery that my insurance covers pre-existing conditions, but not for non-emergency treatments in the United States. I assumed I was going to be paying for the surgery.

Having to cover the cost of the surgery myself was both good and bad. It was my money getting spent, but I had the freedom to choose where in the world I could go for the surgery. My research into the procedure showed that the successful outcome of stapedectomy surgery is mostly dependent on the number of previous operations the surgeon has performed.

I checked out whatever I could find online, plus I contacted the surgeon in Canada who made the original diagnosis. The surgeon was not able to accommodate me probably because as a non-resident of Canada I had no Government medical insurance coverage in Canada.

I also looked into various medical tourism places in India and Thailand and determined that they do not do stapedectomies. They do other procedures such as hips, knees, and hearts. I did get one response from a surgeon in Chennai, India who said he would do it for less than $2000, but I was not comfortable with trying this option. I also checked out one place in Europe but got no response.

I approached the House Ear Clinic in Los Angeles, California and they were very responsive. I sent them copies of my hearing exams, and they confirmed the need for a stapedectomy. Dr. Jose Fayad phoned me from LA while I was in Kuwait, to discuss the operation. He said if I had to fly home immediately after the surgery, I could, even the next day and have follow-up elsewhere. I was not keen on this. I planned to stay for three weeks after the surgery for any follow-up.

I was an avid SCUBA diver, and Dr. Fayad had good news: he said I could SCUBA dive after successful surgery as long as I practiced proper equalization techniques. Note: Please check with your doctor before deciding to SCUBA dive. I take no responsibility for your results. Do note that even flying after a stapedectomy can put a strain on the ear if you are overly congested and can’t equalize on the descent.

The clinic was quite flexible about the dates for the surgery which was good because I had to juggle many commitments to make time for the surgery. Finally, my operation was booked for January 9, 2008.

The House Clinic does the operation under local anesthesia. It is also done elsewhere, depending on the surgeon and local surgical practices, under a general anesthetic.

Dr. Fayad said a major disadvantage of the general anesthetic is that an airway tube is inserted into the throat to ensure the patient can breathe. After the surgery removing this tube often causes coughing which stresses the ear. Coughing should be avoided after a stapedectomy. Also, an advantage of the local anesthetic is that the surgeon can check the placement of the prosthesis during surgery by asking the patient if they can hear. Obviously this can’t be done if you are under general anesthesia.

As of March 2015, Dr. Fayad is no longer at the House Ear Clinic. I checked directly with the clinic, and they do not have any contact information for him.

View House Ear Institute in a larger map

The total cost which included the surgeon’s fee and the hospital cost was about $9000 US. Fortunately, I had friends in the area that I could stay with, so I didn’t have hotel costs. The only other costs were car rental and the flights to and from Los Angeles.

I was Emailed forms to fill out before arriving at the clinic. They also sent me a list of potential side effects which they are obliged to inform the patients about. They assured me that the side effects are rare.

1. Taste disturbance and mouth dryness are not uncommon for a few weeks following surgery in some cases prolonged.
2. There may be further loss of hearing in up to 2% of cases. Up to 1% may have severe loss and may prevent the use of an aid in the operated ear. Should the hearing be worse following stapedectomy tinnitus may be pronounced.
3. A perforation in the eardrum develops in less than 1% of cases and is usually is due to an infection and may heal spontaneously. If healing does not occur surgical repair may be required.
4. A very rare complication of stapedectomy is temporary weakness of the face. This may occur as the result of an abnormality or swelling of the facial nerve.

Upon arrival in Los Angeles, I went to the House Clinic for my pre-surgery appointment. There I reviewed the paperwork, had a hearing test and met Dr. Fayad. They advised the following post-operative instructions.

1. Do not blow your nose and do not pop your ears by holding your nose. If it is necessary to sneeze do so with the mouth open.
2. Do not allow water to enter the ear until advised by the doctor. They recommend lambs wool or cotton placed in the outer ear opening covered with Vaseline. I purchased some silicone earplugs which I used instead (disclaimer, take you own chances, if they leak it isn’t my fault). They are putty-like, and you can mold them into the outer ear without inserting them into the ear. They worked with no leaks, though I have short hair and washed my hair very carefully trying to get minimal water on my ear.
3. Do not take any unnecessary chance of catching a cold. Avoid undue exposure or fatigue. I feel this should not be overlooked. I felt very good after the surgery and probably overdid it a little the day after, as I did some driving around doing some shopping and felt quite fatigued by the end of the day. I think a full day or two of quiet rest would have been better to speed the recovery.
4. Do not have dental work requiring drilling of the teeth until three weeks after surgery.
5. You may anticipate pulsation, popping, clicking and a feeling of fullness or occasional sharp shooting pains. You may feel as if there is liquid is in the ear. I had some of this, but it was not too annoying, and there was no pain.
6. Do not plan to drive a car home from the hospital. In fact, they won’t let you drive home. Somebody has to get you. And they will not let you take a taxi alone.
7. Patients often experience dizziness, with nausea and vomiting. Some unsteadiness is common during the first few days but should subside in a week. There may be brief dizziness on sudden head motion or in bending. I had none.
8. You may notice some hearing gain at the time of surgery, but in the next few hours, normal post-operative swelling will reduce your hearing. Exactly what I experienced.
9. The maximum improvement in hearing occurs at four months. I did not feel any change at four months. My hearing one month after the surgery was good and has stayed the same.
10. The cotton ball in the ear canal should be changed daily and as needed when bleeding occurs. Some bleeding is normal. If the ball has to be changed more than four times in a day, you should notify the doctor. I had no bleeding.
11. Slight water discharge is normal for a week after surgery. If discharge lasts longer or is yellow (infected) contact the doctor. I had none.
12. There may occasionally be shooting pain. You should not have continual pain. There was no pain.
13. Four days before the three-week post-operative appointment put a few drops of baby oil in the ear canal twice daily to soften any encrustation. Allow oil to remain five minutes. I didn’t do this. And I should have. Read on.

I went to the clinic the day before the pre-surgery appointment. The photograph below is the hospital across the street from the clinic.

Dr. Fayad explained the procedure. He said there is just one time during the procedure when he is drilling through the footplate of the stapes (oval window) into the inner ear when I absolutely should not move. The doctor said he would tell me before he starts drilling. He also said it would be very loud when he does the drilling.

I received my final pre-surgical advice, nothing to eat or drink after midnight. So the next morning I started the day very early because I was supposed to be at the hospital by 6:00 a.m.

I took a wrong turn on the freeway on the way to the hospital but managed to find my way without a GPS. I arrived early at the hospital and parked. I feared there would incur massive parking charges because I could not find any street parking. Then later I found out that with a paper from the nurse the parking would be free.

So the time had come.

They asked me to take off all clothes and jewelry (better leave it at home) and put on a hospital gown. I laid down and rested while they started an IV. The nurse couldn’t find any veins in my elbow, so I got the IV in the top of my hand which isn’t the most comfortable spot. But it was well done, and I had only mild discomfort. In fact, it turned out to be the only real, but minor, discomfort during the whole procedure. They said the IV was to keep me hydrated and was also used later for the sedative. They took a small vial of blood from which they used a drop to seal off the piston of the prosthesis where it goes through the oval window into the inner ear.

I was wheeled upstairs into the pre-operative room and got some Versed (I think about 1 mg) which is a like super Valium and commonly used for sedation. I felt very focused and not nervous though I’m not the nervous type. Who knows how much of this cool composure was due to the drug? Speaking of cool, I did notice that the operating room was cold and the nurse told me it is kept cold to keep the germs down. But they do have blankets if you need them.

As I was being prepared for the operation, they made a sort of tent over my head so I couldn’t see up. Then they washed my ear out with a cool feeling disinfectant and suctioned it out.

Then Dr. Fayad came and said it was time for the local anesthetic. This was a needle into my outer ear area, but I barely felt it. So the Versed might be magic, or I’ve got a high pain tolerance. (And generally when I am ready for something I can keep good focus and not be too bothered by pain) I’ve had a fair bit of dentistry, and some of the dental needles are rather unpleasent! Particularly for the root surgeries I’ve had on my top front teeth, which feel like the needle is going up through the gum all the way up into my nose. But I digress …

Then the surgery started. First, the eardrum was cut and moved away. Then he took some time in the ear to remove the stapes. It seemed to take longer than I expected, but there are tendons and nerves in there to be careful about! I heard the odd loud crunching sound as he was working to remove the stapes from the footplate.

Before drilling the footplate, the doctor asked me to hold steady. He did the drilling again warning me that it could be a bit loud. This also turned out to be not too bad. Then he put in the prosthesis. It is put into the hole drilled through the footplate which is situated over the oval window and projects into the inner ear. They used the LASER to heat shrink the other end of the prosthesis onto the incus. Then Dr. Fayad whispered in my ear and asked if I could hear him, and I certainly could: loud and clear!

After the operation, I stayed in a private hospital room and took a short nap. Then I watched some mediocre daytime TV while waiting for my friend to arrive to drive me to their home. I left the hospital around 11:30 a.m.

The implant is made by Olympus.

Note that the piston is nitinol. Different surgeons will use different pistons. The clamping of the piston is a very important step in the surgery and has a major effect on the final results. The nitinol part of this piston is for how it clamps to the incus. There are some studies showing that this clamping method has better outcomes.

• Superiority of Nitinol Piston Over Conventional Prostheses in Stapes Surgery: First Comparative Results in the Chinese Population in Taiwan
• Laser-assisted stapedotomy with a Nitinol heat-crimping prosthesis: Outcomes compared with a platinum fluoroplastic prosthesis

They let me take home the stapes. Note the ruler marks are 1 mm apart.

I did not experience any dizziness, and there was no post-operative pain. I was given a subscription for Darvocet-N I took one the night after anticipating that the pain would build, but it didn’t.

For the first week, there was very little hearing. The packing fell out about four days after the operation. There was a bit of cracking in the hearing during this time also. Then about one week after the operation my hearing improved drastically, and I went for follow up two weeks after. The usual follow-up time is after three weeks, but I could not take more time out of Kuwait.

The above photo is from a strenuous 3.5-hour hike I did ten days after the surgery.

When I was going in for the hearing test they first looked into the ear and saw that there was dried blood and gunk covering my ear drum. I had not followed the instructions about putting baby oil in my ear. So I waited for the doctor who put drops in and then removed the gunk so I could go back for the hearing test. Now the ear was working, and the hearing was even better!

The yellow area shows the main areas where I gained in hearing after the surgery. The operation was very successful!

Now I have two functioning ears again. I can have greater enjoyment listening to music, use the phone on either ear, no longer miss parts of conversations and can enjoy watching TV with my family without deafening them. I am also reminded of how good the surgery was whenever I have a shower and hear the loud gurgling of the water splashing near my fixed ear.

So now I should go annually for a hearing exam and send the results to the House Clinic for their records, but I look forward to continued good hearing with no problems for many years.

I did not get annual hearing tests done as I was living overseas and was not confident in the accuracy and calibration of the testing equipment at the local clinics. I ordered a hearing test CD which is quite good and played with it a bit, but it isn’t accurate enough to compare to professionally done hearing tests. I’ve also tried out some Apple iOS applications that do hearing tests. The CD and apps aren’t bad for finding the thresholds and relative frequency sensitivities, but there is a large error margin. The output of each electronic device varies in volume over the range of hearing frequencies. And, more significantly, headphones vary widely on their output levels at different frequencies. Plus, they can vary on how they fit on your head or in your ears. So you can’t accurately know the dB difference in your hearing at different frequencies.

Now I am back residing in Canada and had a hearing test in August 2014 as shown below.

The red line is the left (good) ear. I thought I might have some loss but if you look the right ear is very similar to the post-surgery one with still loss around 1000 Hz.

I still have more tinnitus in the right ear and may in the future look into the latest treatments. Here is a good TEDx talk on the latest knowledge of tinnitus.

And note regarding SCUBA diving. As I’m back in Canada and don’t live near the warm seas, I have decided to not SCUBA dive anymore. There are so many other things to do, and it isn’t worth risking my hearing.

If there are any queries or corrections to this article, please comment.