What is the best course of action for a patient with active otosclerosis found after opening the middle ear during surgery?

Intraoperative Management of Active Otosclerosis

When active otosclerosis is encountered intraoperatively after opening the middle ear, you should abort the stapedectomy/stapedotomy procedure and close the ear, then reschedule surgery for 6-12 months later after the active disease has become quiescent.

Understanding Active Otosclerosis

Active otosclerosis presents intraoperatively as:

• Highly vascular, reddish-blue discoloration of the promontory and oval window niche (Schwartze sign visible through the tympanic membrane preoperatively) 1
• Increased bleeding from the footplate area and surrounding bone 1
• Soft, spongy bone rather than the typical sclerotic, hard bone of inactive disease 1

The active phase represents ongoing osteoclastic bone resorption with rich vascular proliferation, making the surgical field more prone to bleeding and the inner ear more vulnerable to trauma 1.

Why Aborting Surgery is Critical

Proceeding with stapes surgery during the active phase significantly increases the risk of:

• Sensorineural hearing loss - The hypervascular, metabolically active bone is more susceptible to surgical trauma, with studies showing higher rates of postoperative sensorineural hearing loss when surgery is performed during active disease 1
• Increased intraoperative bleeding - The vascular proliferation makes achieving hemostasis difficult and obscures visualization of critical structures 1
• Footplate fracture - The soft, friable bone of active otosclerosis is more likely to fracture during manipulation, potentially leading to perilymph gusher and profound hearing loss 1
• Poorer long-term outcomes - Even if immediate complications are avoided, hearing results are less stable when surgery is performed during the active phase 2

Recommended Surgical Algorithm

Step 1: Recognize active disease immediately upon opening the middle ear

• Look for the characteristic reddish-blue hue and increased vascularity 1
• Note any excessive bleeding from the promontory area 1

Step 2: Do not proceed with footplate work

• Abort the stapedectomy/stapedotomy before attempting any manipulation of the stapes or footplate 1
• Avoid trauma to the hypervascular tissue 1

Step 3: Close the tympanomeatal flap and ear canal

• Replace the flap in its anatomic position 1
• Pack the ear canal appropriately 1

Step 4: Counsel the patient postoperatively

• Explain that active disease was encountered and surgery was appropriately aborted 1
• Reassure that this does not preclude future successful surgery 1
• Schedule follow-up in 6-12 months when the disease is expected to be quiescent 1

Expected Outcomes After Delayed Surgery

When surgery is performed after the active phase has resolved:

• Air-bone gap closure to ≤10 dB in 94-95% of cases with modern stapedotomy techniques 1, 3
• Significant sensorineural hearing loss risk of only 0.5-0.7% in quiescent disease 1
• Long-term hearing stability with deterioration not exceeding presbyacusis rates 1
• Better high-frequency hearing preservation with stapedotomy compared to stapedectomy 4, 5, 2

Common Pitfalls to Avoid

Do not attempt to "push through" the procedure despite encountering active disease - the increased complication risk is not justified, and excellent results can be achieved with delayed surgery 1.

Do not confuse active otosclerosis with other causes of middle ear hypervascularity such as glomus tumors or aberrant carotid artery, though these should have been identified on preoperative imaging 1.

Do not delay rescheduling indefinitely - 6-12 months is typically sufficient for the active phase to resolve, and prolonged delay only extends the patient's conductive hearing loss 1.