Stapedectomy/ Stapes Surgery

Introduction

If you have been told that your hearing loss is caused by otosclerosis, or that the small bones in your middle ear are not moving the way they should, stapedectomy may have come up as one of your treatment options. Stapedectomy — also called stapes surgery — is a microsurgical procedure that aims to restore the conduction of sound through the middle ear by replacing or bypassing the stapes bone with a tiny prosthesis.

This guide is written for people who already have a diagnosis (or a strong suspicion) of stapes-related hearing loss and are now weighing surgery as the next step. It explains what the procedure involves, who is considered a good candidate, what alternatives exist, what to expect on the day of surgery and during recovery, the risks, and what life tends to look like after stapes surgery. It does not replace the conversation with your ENT surgeon, but it should help you arrive at that conversation prepared.

What Is Stapedectomy?

Stapedectomy is a microsurgical operation on the middle ear. It is performed to treat a specific type of hearing loss called conductive hearing loss — hearing loss caused by a mechanical problem in the outer or middle ear that stops sound vibrations from reaching the inner ear effectively.

The stapes is the smallest bone in the human body. It is the last in a chain of three tiny bones (the malleus, the incus, and the stapes) that transmit sound from the eardrum to the inner ear. The footplate of the stapes sits in an opening called the oval window, where it pushes against the fluid of the inner ear with every sound vibration. If the stapes becomes stiff or fixed, this transmission breaks down and hearing drops.

By far the most common reason the stapes becomes fixed is otosclerosis, a condition in which abnormal bone growth around the stapes footplate gradually locks it in place. Stapedectomy addresses this directly. The surgeon removes part or all of the fixed stapes and places a small prosthesis (often made of titanium, platinum, or a plastic polymer such as Teflon) that connects the incus bone to the inner ear, allowing sound vibrations to travel through again.

A closely related and now more commonly performed variation is stapedotomy. Instead of removing the entire stapes footplate, the surgeon makes a small precise opening in the footplate (often with a laser or a micro-drill) and places the prosthesis through that opening. In everyday use, “stapedectomy” and “stapes surgery” are often used as umbrella terms that include both techniques. The choice between them is made by the surgeon based on your anatomy and the appearance of the footplate during surgery.

Why Is Stapedectomy Performed?

Stapedectomy is performed almost exclusively for hearing loss caused by a fixed or immobile stapes. The most common indications are:

• Otosclerosis — the dominant indication. Otosclerosis tends to develop slowly in adulthood, often beginning in the twenties or thirties, and is more common in women. It may affect one or both ears.
• Tympanosclerosis involving the stapes — scar-like calcified tissue in the middle ear that fixes the stapes, usually as a long-term consequence of chronic middle ear inflammation.
• Congenital stapes fixation — rare, where the stapes is fixed from birth.
• Selected cases of stapes discontinuity — where the stapes has been disrupted by trauma or previous middle ear disease and needs to be reconstructed with a prosthesis.

The goal of surgery is to restore the mechanical pathway of sound. When successful, it typically improves the air-conduction hearing threshold and closes most of the gap between air and bone conduction on a hearing test.

Who Is a Candidate?

Stapes surgery is not appropriate for every kind of hearing loss. It is specifically a treatment for conductive hearing loss due to stapes fixation, and candidacy is decided through a careful audiological and ENT evaluation.

Doctors typically consider stapes surgery when most of the following are true:

• Hearing testing confirms a conductive or mixed hearing loss, with a measurable air-bone gap on pure-tone audiometry.
• The pattern of hearing loss and the clinical picture are consistent with otosclerosis or another cause of stapes fixation.
• The eardrum looks normal on examination.
• Tympanometry (impedance testing) shows reduced or absent stapedial reflexes, consistent with a fixed stapes.
• The inner ear (cochlea) still has reasonable function — bone-conduction thresholds are not severely depressed.
• Speech discrimination is preserved, meaning the patient can still understand words when sound reaches the inner ear.
• Hearing aids have not been satisfactory, or the patient prefers a surgical option after weighing both.

Some patients are not considered good candidates, or are advised to delay or avoid surgery, including:

• People with only one hearing ear, where the operated ear is the better-hearing or only-hearing ear (because of the small but real risk of complete hearing loss in the operated ear).
• People with active middle ear infection, perforated eardrum, or cholesteatoma in the same ear — these need to be treated first.
• People with significant inner ear (sensorineural) hearing loss, where a hearing aid will usually serve them better.
• People whose work involves frequent significant pressure changes (for example, professional divers or fighter pilots) — this is a discussion to have explicitly with the surgeon.
• People with Ménière’s disease or significant balance disorders in the same ear, where the risks may outweigh the benefits.

Stapes surgery is overwhelmingly an adult operation. Otosclerosis can rarely present in children (“juvenile otosclerosis”), and in those cases the timing of surgery is decided cautiously by a paediatric ENT surgeon, often after a period of observation and hearing aid use.

Alternatives to Stapedectomy

Surgery is rarely the only option for stapes-related hearing loss. Alternatives are real and important, and the right choice depends on the severity of the hearing loss, the patient’s lifestyle, and personal preference.

Hearing Aids

Modern hearing aids are highly effective for the kind of hearing loss caused by otosclerosis, particularly in earlier stages. They amplify sound so that the inner ear “hears” it despite the stiff stapes. Hearing aids carry no surgical risk and can be adjusted over time as hearing changes. Many people use hearing aids successfully for years and never require surgery. Some choose to use hearing aids first and consider surgery later if the loss progresses or if they find aids unsatisfactory.

Observation

For very mild hearing loss, or when otosclerosis is detected incidentally, simply monitoring hearing over time with periodic audiograms is a reasonable approach. Treatment is added when hearing loss begins to affect daily life.

Medical Therapy

Sodium fluoride and bisphosphonates have been studied as treatments to slow the progression of active otosclerosis, particularly when the inner ear is becoming involved. Evidence of benefit is limited and these are not standard treatment for everyone; they may be considered by some specialists in specific situations.

Bone-Conduction Hearing Devices

Bone-anchored hearing systems and similar bone-conduction devices bypass the middle ear entirely and deliver sound to the inner ear through bone vibration. They are sometimes considered when conventional hearing aids do not work well or when stapes surgery is not an option.

Cochlear Implants

For patients whose otosclerosis has progressed to severe sensorineural hearing loss involving the inner ear, a cochlear implant may eventually become the more appropriate option rather than stapes surgery.

Whether stapes surgery or one of these alternatives is the better path is a clinical decision made together with an ENT surgeon and audiologist, based on your specific test results, lifestyle, and preferences.

Surgical Approaches and Variations

Although “stapedectomy” is used as a single term, several surgical techniques fall under it. The surgeon will recommend a specific approach based on your anatomy, the appearance of the stapes during surgery, and their own training.

Total Stapedectomy

In a classical total stapedectomy, the surgeon removes the entire stapes footplate from the oval window. A small graft (often a piece of tissue such as vein, perichondrium, or fat) is placed over the opening, and a prosthesis is positioned on top, connecting the incus bone to the graft. This was the original technique and is still used in some cases, particularly when the footplate is unusually fragile or floating.

Stapedotomy (Small-Fenestra Technique)

In stapedotomy, the surgeon makes a small precise hole in the stapes footplate rather than removing it. A piston-shaped prosthesis is placed through this hole, with one end attached to the incus and the other end extending into the inner ear fluid. Stapedotomy has become the more commonly performed variant in many centres because it tends to cause less disturbance to the inner ear and is associated with a lower risk of post-operative dizziness.

Laser-Assisted vs Microdrill vs Manual Techniques

The opening in the stapes footplate can be created in different ways:

• Laser (such as CO₂ or KTP lasers) — allows a very precise, no-touch opening with minimal mechanical pressure on the inner ear.
• Microdrill — uses a tiny rotating burr to create the opening.
• Manual perforator — a fine instrument is used to make the opening mechanically.

Each technique has its advocates and its evidence base. Laser-assisted stapes surgery is widely used where the equipment is available, but excellent results are reported with all three methods in experienced hands.

Revision Stapedectomy

If a previous stapes surgery has not produced the expected hearing improvement, or if hearing has deteriorated again over time, a revision operation may be considered. Revision surgery is technically more demanding than primary stapes surgery, success rates are generally lower, and the risk of inner ear injury is higher. It is usually performed by surgeons with specific experience in revision otologic surgery.

Preparing for Stapes Surgery

Preparation for stapes surgery is relatively straightforward, but a few steps make a meaningful difference to safety and outcome.

Investigations Before Surgery

Before scheduling surgery, your ENT team will usually arrange:

• Pure-tone and speech audiometry in both ears, to document baseline hearing and confirm the air-bone gap.
• Tympanometry and acoustic reflex testing.
• A high-resolution CT scan of the temporal bones in selected cases — particularly when the diagnosis is uncertain, when there has been previous ear surgery, or to look for anatomical variations.
• Routine pre-operative blood tests and an anaesthesia review.

Medications and Health Conditions

Your surgeon and anaesthesia team will give you specific instructions, which often include:

• Stopping or adjusting blood-thinning medicines (such as aspirin, clopidogrel, warfarin, or direct oral anticoagulants) for a defined period before surgery. Do not stop any prescribed medicine without medical advice.
• Letting the team know about diabetes, high blood pressure, heart disease, or any chronic condition.
• Treating any active cold, sinus infection, or ear infection before surgery — these are usually a reason to postpone.
• Avoiding alcohol for a day or two before surgery.

Logistics

Stapes surgery is usually done as a short-stay procedure. Practical preparation includes:

• Arranging someone to bring you home after surgery and stay with you for the first day.
• Planning a quiet recovery period at home, ideally with a few days off work.
• Avoiding air travel in the immediate post-operative period — usually for several weeks.
• Understanding the discharge instructions, including what activities to avoid.

What Happens During Stapes Surgery

Anaesthesia

The operation can be performed under local anaesthesia with sedation or under general anaesthesia. Local anaesthesia allows the patient to remain awake, which lets the surgeon test hearing improvement during the procedure and reduces certain anaesthesia-related risks. General anaesthesia is often preferred for patient comfort, in anxious patients, in children, and when the surgery is expected to be lengthy. Both are widely used and the choice is made together with the surgeon and anaesthetist.

Accessing the Middle Ear

Almost all stapes surgery is performed through the ear canal, with no external incision visible on the face or behind the ear. The surgeon lifts the eardrum forward like a small flap to gain access to the middle ear space. Some surgeons now use an endoscope rather than a microscope, especially when the anatomy of the ear canal limits the view.

Confirming the Diagnosis

Once the middle ear is visible, the surgeon gently tests the mobility of the three small bones. A fixed stapes confirms the diagnosis and the decision to proceed.

Removing or Opening the Stapes

Depending on the planned technique:

• In stapedotomy, the upper part of the stapes (the “arch” or superstructure) is removed, and a small precise opening is made in the footplate using a laser, microdrill, or perforator.
• In total stapedectomy, the whole footplate is carefully removed, and a tissue graft is placed to seal the oval window.

Placing the Prosthesis

A tiny prosthesis — often a piston only a few millimetres long — is then placed. One end is attached securely to the incus bone (the bone just above the stapes), and the other end extends into the opening in the footplate or onto the tissue graft. This restores the mechanical connection from the eardrum to the inner ear.

Closing Up

The eardrum is gently returned to its normal position. A small piece of absorbable packing may be placed in the ear canal to support healing. There are no external stitches in a standard transcanal approach.

If the surgery is done under local anaesthesia, many patients notice an improvement in hearing on the operating table itself, although some of that early improvement is masked later by swelling and packing.

Recovery and Healing

The First Few Days

In the first days after surgery, it is common to experience:

• A feeling of fullness or blockage in the operated ear — partly due to swelling and the ear-canal packing.
• Muffled or distorted hearing in the operated ear at first. Hearing improvement often becomes clearer once the packing is removed and swelling settles.
• Some dizziness or imbalance, particularly with quick head movements. This is usually mild and improves over a few days.
• Mild discomfort or a dull ache in or around the ear, usually controlled with simple pain relief.
• A metallic or altered taste on the side of the operated ear, because a small nerve called the chorda tympani that carries taste runs across the middle ear and can be stretched or temporarily affected during surgery. This usually resolves over weeks to months.

Activity Restrictions

To protect the healing middle ear and the position of the prosthesis, doctors typically advise:

• Avoiding heavy lifting, straining, and vigorous exercise for several weeks.
• Not blowing the nose forcefully — sneezing with the mouth open is preferred.
• Keeping the ear dry: no water in the ear canal until the surgeon clears it. Showering is usually fine if the ear is protected.
• Avoiding swimming and diving for the period advised by the surgeon.
• Avoiding air travel for several weeks, because of cabin pressure changes. Your surgeon will give you specific timelines.
• Avoiding very loud noise exposure in the early healing phase.

Follow-up and Hearing Tests

A follow-up visit is usually scheduled in the first one to two weeks after surgery to remove any remaining packing and check the eardrum. A repeat audiogram is typically performed several weeks to a few months later, once swelling has fully settled and the ear has had time to heal. Hearing often continues to improve over that period.

Return to Work and Daily Life

Many people return to office-based work within about one to two weeks. Jobs that involve heavy lifting, significant physical exertion, loud environments, or pressure changes may require a longer pause. Driving is usually possible once dizziness has settled and the patient feels confident.

Risks and Complications

Stapes surgery is generally considered safe when performed by an experienced ear surgeon, and most patients do well. However, like any operation on the ear, it carries specific risks that should be understood before consenting.

Common, Usually Temporary Effects

• Dizziness and vertigo in the first hours to days. The inner ear is in direct contact with the surgical field, and short-lived imbalance is expected.
• Altered taste on one side of the tongue, usually improving over weeks to months.
• Tinnitus (ringing or noise in the ear) that is temporarily louder. For many patients, tinnitus actually improves after surgery as hearing improves; for some it may persist or change.
• Temporary fullness, hearing dullness, or mild ear pain.

Less Common Complications

• Inadequate hearing improvement — in a small minority of cases, the air-bone gap is not closed as much as hoped. This may be due to prosthesis position, scar tissue, or anatomical factors.
• Prosthesis displacement or extrusion — the prosthesis may shift over time, which can cause hearing to deteriorate again. Revision surgery may be considered.
• Eardrum perforation — uncommon, and usually heals on its own or with a minor repair.
• Persistent vertigo — rarely, balance problems last longer than expected and need additional treatment.
• Infection of the middle ear or surgical site — uncommon, usually treated with antibiotics.
• Facial nerve injury — rare, because the facial nerve runs very close to the operative field.

The Most Serious Risk: Sensorineural Hearing Loss

The most serious complication of stapes surgery is significant sensorineural hearing loss in the operated ear — including, in rare cases, total loss of hearing in that ear (“dead ear”). This can happen because the inner ear is directly opened during the procedure. In large published series with experienced surgeons, this serious outcome is uncommon, but it is the reason surgeons usually operate first on the worse-hearing ear, and the reason stapes surgery is approached very cautiously in someone with only one hearing ear.

Discussing these risks honestly with your surgeon, and asking about their personal experience and results, is part of informed consent.

Life After Stapes Surgery

For the large majority of patients who have stapes surgery for otosclerosis, the result is meaningful and durable improvement in hearing in the operated ear. Conversations become easier, the need for hearing aids may be reduced or removed for that ear, and many people report less hearing-related fatigue.

What Hearing Improvement Looks Like

Hearing improvement is usually measured by closure of the air-bone gap on audiometry. Published series in experienced centres typically report successful closure of most of this gap in the majority of patients, with stable results over years. Your individual outcome depends on factors including the severity of disease, your inner ear function, the specific technique used, and the healing process. Personalised expectations should come from your own surgeon based on your tests.

The Second Ear

Otosclerosis often affects both ears. If your other ear is also affected, surgery on that side is normally considered only after the first ear has fully healed, hearing has stabilised, and the result is satisfactory — usually at least six to twelve months later. Some patients are happy with hearing aid use on the second side and never have second-ear surgery.

Long-term Care

After successful stapes surgery, most people do not require ongoing medical treatment. Sensible long-term habits include:

• Periodic hearing tests to monitor both ears.
• Protecting hearing from loud noise exposure.
• Promptly treating ear infections and seeking advice for sudden hearing changes.
• Mentioning the prosthesis to anyone organising an MRI scan in future — most modern stapes prostheses are MRI-safe at standard field strengths, but it is good practice to inform the radiology team.

When Hearing Changes Again

If hearing in the operated ear deteriorates months or years after surgery, possible causes include prosthesis displacement, scar tissue, progression of otosclerosis into the inner ear, or unrelated causes such as noise damage or age-related hearing loss. These changes are worth evaluating with your ENT specialist rather than assumed to be inevitable, because some are treatable.

Choosing a Surgeon and Setting

Stapes surgery is a highly specialised microsurgical procedure with a meaningful learning curve. Outcomes are strongly linked to the surgeon’s experience with this specific operation. Rather than focusing on certifications alone, useful things to look for when choosing a surgeon include:

• Specific training and experience in otology and middle ear microsurgery.
• Regular volume of stapes cases, not just occasional procedures.
• Willingness to share their own results and complication rates in conversation.
• Availability of appropriate equipment (high-quality operating microscope, endoscope where used, laser or microdrill if planned).
• Access to good audiology services for thorough pre-operative testing and post-operative follow-up.
• Clear communication about realistic outcomes for your specific situation.

Meeting more than one surgeon before making a decision is reasonable and common.

Frequently Asked Questions

Is stapes surgery a permanent solution?

For most patients, the hearing improvement from stapes surgery is durable, lasting many years or for life. A small proportion will experience hearing changes over time due to prosthesis position changes, scarring, or progression of otosclerosis into the inner ear, and may need further evaluation.

Will I still need a hearing aid after surgery?

Many patients no longer need a hearing aid in the operated ear after successful surgery, particularly when the underlying loss was purely conductive. Patients with a mixed loss (conductive plus a sensorineural component) may still benefit from a hearing aid, but often at a lower amplification setting than before.

Is the surgery painful?

Most patients describe the post-operative discomfort as mild and easily managed with simple pain relief. The operation itself is performed under anaesthesia and is not painful.

How quickly will my hearing improve?

Some hearing improvement is often noticeable in the first one to two weeks once packing is removed and initial swelling settles. Hearing usually continues to improve over the following weeks to a few months, with the final result assessed at a follow-up audiogram several weeks after surgery.

Can both ears be operated on?

Yes, when both ears are affected. Surgeons almost always operate on one ear at a time, with a gap of at least several months in between, so that the first ear can fully heal and the hearing result can be confirmed before proceeding on the other side.

Is stapes surgery done with a laser?

It can be. Many surgeons use a laser to create the small opening in the stapes footplate. Others use a microdrill or a manual instrument. All three techniques are well established. The choice depends on the surgeon’s training and the equipment available.

Will I be able to fly after surgery?

Air travel is generally avoided for several weeks after stapes surgery, because cabin pressure changes can affect the healing middle ear. Your surgeon will tell you when it is safe to fly based on your healing.

Can I have an MRI with a stapes prosthesis?

Most modern stapes prostheses are made of materials that are compatible with MRI at standard clinical field strengths. It is still important to inform the radiology team about your surgery and, if possible, share details of the specific prosthesis used (from your surgical records) so they can confirm safety for the scan being planned.

What if my hearing does not improve after surgery?

If the expected improvement does not occur, your ENT team will reassess with a repeat audiogram and examination. Depending on the findings, options may include continued observation, hearing aid use, or revision surgery in selected cases.

Is otosclerosis hereditary?

Otosclerosis often runs in families, and a family history is common, although not everyone with the gene develops the condition. Pregnancy and hormonal changes may influence its progression in some women. Other family members with hearing loss may benefit from their own ENT evaluation.

Conclusion

Stapedectomy, or stapes surgery, is a well-established microsurgical option for hearing loss caused by a fixed stapes, most often from otosclerosis. When the diagnosis is clear, the inner ear is healthy, and the surgery is performed by an experienced ear surgeon, it can restore much of what has been lost — not just measurable hearing thresholds, but the ease of conversation and connection that goes with them.

Surgery is not the only path. Hearing aids, observation, and other devices remain valid choices, and many people move between these options over time. Understanding what stapes surgery involves, what it can and cannot do, and what the recovery and risks look like is the foundation for a meaningful conversation with your ENT specialist about which approach fits your life and your hearing.