Poststapedectomy reparative granuloma.

A 61 year-old man presented with the classic history of otosclerosis. After a trial with a hearing aid for several months, he opted for surgery. The diagnosis of otosclerosis was confirmed at surgery, and a total stapedectomy was performed. A 0.8-mm fluoroplastic prosthesis was inserted, and the oval window niche was sealed off with fat.

Postoperatively, the patient developed persistent mild dizziness and fluctuating sensorineural deafness. Examination did not reveal any significant abnormality until 4 weeks postoperatively, when a reddish intratympanic mass was seen on otoscopy. A clinical diagnosis of reparative granuloma was made, and tympanotomy and revision stapedectomy were performed. At surgery, a brownish intratympanic mass was found encasing the stapes prosthesis and the incus (figure). This is a typical finding with a reparative granuloma.

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Management of a reparative granuloma involves early surgical intervention and complete removal of the granuloma, with or without prosthesis replacement. In the case described herein, the patient's deafness did not resolve despite early surgical intervention and revision surgery. This finding is compatible with other reports in the literature. (1)

The formation of reparative granuloma is one of the leading causes of sensorineural hearing loss following stapedectomy. Estimates of its incidence range from 0.1 to 3%. (1,2)

The pathogenesis of poststapedectomy reparative granuloma is unclear, but it is believed to be the result of a host response to trauma of the middle ear mucosa. The condition is known to be more common in patients whose oval window was sealed with Gelfoam; it has also occurred when fat and fascia have been used. Patients who undergo stapedotomy tend not to experience this complication. (1)

The typical presenting symptom is sensorineural hearing loss in the operated ear within 6 weeks of stapes surgery following a period of initial improvement. Otoscopic examination usually shows a reddish intratympanic mass, typically located in the posterosuperior quadrant. The patient's speech discrimination score is usually less than 60%. A few patients will experience disequilibrium. When a diagnosis of reparative granuloma is made, early surgical intervention is indicated.

References

(1.) Schuknecht HF. Otosclerosis surgery. In: Nadol JB Jr., Schuknecht HE eds. Surgery of the Ear and Temporal Bone. New York: Raven Press: 1993:238.

(2.) Kaufman RS, Schuknecht HF. Reparative granuloma following stapedectomy: A clinical entity. 1967. Ann Otol Rhinol Laryngol 1997;106:5-14.

Willis S.S. Tsang, FRCS (ORL); John K.S. Woo, FRCS (ORL); Michael C.F. Tong, MD