The Footplate

All of the previous steps were preparatory to addressing the stapes footplate. These previous steps should have been completed without difficulty prior to proceeding. The reason for this caution is clear: No harm has been done to this point. If something

FIGURE 15-4 (A) Cutting the incudostapedial joint. (B) Dividing the stapedial tendon.

FIGURE 15-3 Curetting the bone from the scutum.

FIGURE 15-4 (A) Cutting the incudostapedial joint. (B) Dividing the stapedial tendon.

has gone awry, the procedure can be terminated, and the patient is no worse for the adventure.

In general, in addressing the footplate, there are two techniques that are used: those using the laser, and those using manual techniques. Because of the necessity to be able to directly expose certain portions of the stapes or the footplate, or because of heat transfer to surrounding structures, there are occasions where the laser cannot be used. To meet this need, two methods of dealing with the stapes footplate are described: one using the laser, and the other using manual technique.

For the first method, the posterior crus is cut using an argon laser (Fig. 15-5). The anterior crus is similarly cut using the hand-held oto-endo probe to touch the anterior crus and vaporize it directly. The superstructure is easily removed, once the crura are cut (Fig. 15-6). The footplate itself is now exposed completely. Again using the oto-endo probe, a rosette is created at the junction of the middle and the posterior one third of the footplate. This will adequately vaporize all of the bone of the footplate using 1 to 2 W and 0.1- to 0.2-second bursts (Fig. 15-7). It is easier to create the rosette by overlapping each laser burst slightly. The rosette should be two thirds of the width of the footplate, or approximately 0.8 mm. When the rosette has been completed, using a gentle motion and a small hook, the surgeon can appreciate that the bone has been vaporized, but the endosteum has not been violated. The area should be soft to touch.

If the laser cannot be used, a control hole can be created in the blue footplate at the junction of the posterior one third and the anterior two thirds of the footplate, using a Barbara needle. The control hole is enlarged across the footplate (Fig. 15-8). This frees the portion to be removed. The posterior third to one half of the footplate is removed using small hooks (Fig. 15-9). A special strong hook has been developed for this maneuver. The smaller the footplate area, the greater the proportion of the footplate that should be removed (a very small footplate should be removed entirely). This ensures the proper placement of the prosthesis and vein. Care is taken not to suction perilymph from the vestibule. Small fragments of bone falling into perilymph are left untouched, as is any bleeding or clot. More damage may be done by removing these pieces, and they cause no harm. After the footplate is removed, further mucosa is removed from the facial nerve and the area anterior to the footplate (Fig. 15-10). This further secures bleeding and provides for purchase of the graft.

Thus, the footplate can easily be handled in one of two ways. The footplate can be partially or completely removed, or a small opening can be created using a laser with a molded graft. Either technique yields satisfactory and comparable results.25

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