Mr Jeremy Lavy is a Consultant Ear Surgeon at the Royal National Throat, Nose & Ear Hospital (RNTNEH) in London. He specialises entirely in ear surgery and in particular in the surgical restoration of hearing. As well as undertaking many stapedectomies he also is the surgical director of the UCL/RNTNEH Cochlear Implant Programme.
Over 50 stapedectomies a year are carried out under his care.
Over 95% of patients will experience an improvement in their hearing. 85% of patients will get closure of their air bone gap to within 10dB of their bone conduction thresholds (average of four frequencies: 0.5,1,2 & 4kHz). The risk of losing the hearing completely is approximately 0.5%.
Mr Lavy consults at 107 Harley Street for private patients or at the RNTNEH for NHS patients. NHS patients will need a formal referral from their GP in the conventional way or via the NHS Choose and Book option. New directives within the NHS mean that the patient can choose where and to whom they want to be referred. With private patients a GP letter is also useful and is essential to ensure cover under most private medical insurance schemes. The consultation will consist of a discussion of the problem, examination of the ears and a hearing test. Occasionally other investigations such as a scan may be required. Following this a discussion of the treatment options can occur (See above – Surgery – What can be done about otosclerosis?)
The surgery is carried out under local anaesthetic in over 90% of cases. Many people have concerns about lying still for long enough but this is rarely a problem. An anaesthetist is on hand to administer mild sedation which enables most people to relax and often quite enjoy the whole procedure! (see Patients comments). The surgery is carried out through the ear canal and so no external scars are visible. Occasionally, where the opening of the ear is exceptionally narrow, a small cut at the top of the canal is necessary to provide access for surgery. A flap of ear canal skin is raised and the ear drum is folded forward to reveal the structures of the middle ear. The view of these structures can vary and in most cases a small amount of bone will need to be removed to provide sufficient space to carry out the procedure. Whilst this may sound uncomfortable it is completely painless and most patients simply describe a scratching sensation. The nerve of taste (Chorda Tympani) is carefully displaced out of the way at this stage. It is now possible to visualise the stapes bone and the diagnosis of otosclerosis can be confirmed. Using the laser and other instruments, all the attachments of the stapes are divided and the upper part of the bone is removed. A tiny hole (0.6mm diameter) is then made in the remaining, fixed, part of the stapes and a piston around 4.5mm long is carefully placed into the hole and hooked around the adjacent incus bone. The wire hook is closed to ensure a secure connection and the eardrum can then be replaced and the hearing improvement confirmed (see video). The ear is then packed with an antiseptic dressing which will stay in place for two weeks.
After the operation
The vast majority (over 90%) of patients go home the same day as the surgery. When the local anaesthetic wears off there can be a little discomfort but this is generally controlled by simple pain killers (paracetamol, ibuprofen). It is advisable to take things very easy for the next four to five days. Fast head movement can induce a sensation of dizziness. You should avoid anything that might put pressure on the ear. Nose blowing, sneezing and popping the ear should be avoided. It is normal for popping, clicking and squelching sounds to be heard in the ear. This is a normal part of the healing process. In the event of a sudden onset of severe, continuous dizziness and/or a loud roaring or whistling sound developing you should immediately contact the hospital. This is an indication that the inner ear is “not happy” and medication and, occasionally, readmission to hospital may be required. It is common for there to be a metallic taste on one side of the tongue relating to manipulation of the taste nerve. This usually settles after a week or so and will rarely persist longer than a couple of months.
A review consultation takes place two weeks after the surgery. The packing in the ear is removed and some ear drops may be prescribed. The hearing over the next few weeks may fluctuate a great deal and for this reason a formal hearing test is not performed until six weeks after the operation.
The longer term
The ear should be kept dry for at least a month after the surgery. After this the ear can be treated pretty much normally. It is advisable to avoid flying at least until after the hearing has been retested. Activities associated with large pressure changes (sky diving, scuba diving etc) do carry a higher risk after the operation and it is probably safer to avoid these. Numerous studies show, in general, good maintenance of the hearing results over the long term. It is possible for the piston to dislocate and become displaced and any change of hearing, sudden or gradual, should be reported. In the event of displacement revision surgery generally carries a good chance of a successful restoration of hearing.