technique guide: stapedotomy using co2 laser technique

A Novel Technique for CO2 Laser Stapedotomy Using

the FiberLase CO2 Fiber

Case by Professor Stephan Lang | University Hospital Essen, Germany

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ENT Technique Guide Series PB-2003129_Rev.A, November 2015

In this technique, the FiberLase CO 2 fiber is used to perform the fenestration, in order to

faci l i tate removal of the posterior third of the stapes footplate. In addition, using the

non-contact laser fiber prevents mobi l ization of the footplate.

Preoperative

Past Medical History and Presenting Complaint

53 year old female

Progressive hearing loss on the right side

Stapedotomy on the left side in 2006

Relevant Physical Findings and Diagnostics

Tympanic membrane intact, no sign of inflammation

Pure tone audiometry: conductive hearing loss of 30 to 40 dB

Absent stapedial reflex

Diagnosis Otosclerosis

Operative

Surgical Procedure CO2 laser stapedotomy

Anesthesia Laryngeal Airway

Room Setup Surgeon positioned on patient’s right side at head of table

Scrub nurse positioned at patient’s head, facing the surgeon

Anesthesia cart and anesthesiologist positioned on left side of patient

Microscope positioned on left side of patient; working distance set to 200 mm

Titanium hand instruments for prosthesis insertion

Laser positioned on surgeon’s right side, toward foot of table

Laser-Stapedotomy Using AcuPulse DUO CO2 Laser and FiberLase CO2 Fiber Professor Stephan Lang

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Laser Accessories MicroLase CO2 fiber for otology (reusable, up to 25 uses)

MicroLase Micro-G Otology Handpiece (sterile, single-use, comes with a sterile drape for

the fiber)

Smoke Evacuation Minimal smoke is generated during this procedure, no special measures employed.

Laser and Parameters Laser System: AcuPulse DUO CO2 laser

Settings for various structures provided below:

Power mode, Watts Time mode, sec

Stapedius tendon CW, 2 Watts SINGLE, 0.1 sec

Crura CW, 4 Watts SINGLE, 0.1 sec

Footplate CW, 4-5 Watts SINGLE, 0.1 sec

Operative, including Laser Technique

For transection of stapedius tendon and crura, tip position was near contact. On

stapes footplate, tip position was approximately 1 mm away and perpendicular.

Purge air remained ON and two shots were used to perforate the footplate.

A 4.5 mm Kurz K-Piston prosthesis was inserted.

Small flaps of connective tissue harvested from endaural incision were used to seal

the oval window.

Hemostasis Gelita soaked in epinephrine used for minimal bleeding.

Technique Tips

General Pearls for Stapes Surgery

To assure diagnosis of otosclerosis, observe for whitish otosclerotic plaques.

To reduce risk of inner ear infection, change the blade before harvesting tissue for

sealing the perforation.

Removing posterior 1/3 of the footplate reduces the risk of refixation.

To ensure appropriate length, measure distance between incus and footplate.

To reduce piston movements, place tissue at anterior footplate before inserting

the prosthesis.

Fix the piston cramp using a small piece of tissue.


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Operative Photos

Fig. 1 View into the middle ear Fig. 2 Transection of the tendon

Fig. 3 Transection of the crura Fig. 4 Perforation of the footplate

Fig. 5 Posterior third of the footplate is removed Fig. 6 Prosthesis is placed

Fig. 7 Covering with connective tissue flaps


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Post-Operative

Discharge and Postoperative Instructions

Discharged on postoperative day 3

Instructed to keep ear dry, avoid flying for 4 weeks and sports for 6 weeks, no diving.

Removal of tamponade 3 weeks postoperatively.

Recovery and Outcome

Recovery was uneventful and the patient had no complaints.

See the pure tone audiometry results below.

- Normal hearing was restored to right ear immediately after procedure.

- Audiometry data shows ABG closure, with hearing back to normal.

Fig. 8 Preoperative

Fig. 9 Postoperative


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Discussion

The MicroLase Otology handpiece system was easy to use and maneuver in the confined spaces for stapes surgery.

Due to the non-contact nature of the tool, it is ideal for patients with floating footplates – and for preventing floating

footplates. The handpiece is delicate, so care must be taken to preserve the integrity of the tip; it cannot be used to

manipulate tissue. It must be used in near contact, less than one mm – and small increases in working distance, in fact,

produce large changes in spot size. For the footplate, 4-5 Watts of CW energy, applied at 0.1 sec. intervals is

commonly used.

Product Images

Fig. 10 Lumenis Micro-G Otology Handpiece

WARNING

In order to protect the patient and the operating room personnel, operator manuals including the

Clinical, Safety and Regulatory sections, should be carefully read and comprehended before laser operation.

technique guide: stapedotomy using co2 laser technique

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