Otology & Neurotology
24:548–559 © 2003, Otology & Neurotology, Inc.
Biomechanics of Stapesplasty: A Review
Karl-Bernd Hüttenbrink
Department of Otorhinolaryngology, University of Technology, Dresden, Germany
Objective: The replacement of an otosclerotic fixed stapes by
a prosthesis significantly modifies the function of the normal
ossicular chain. Because the ear works as a pressure receptor, a
piston prosthesis will both modify the sound pressure transmis-
sion and respond to the ambient air pressure changes in a dif-
ferent way than the normal stapes. Both aspects, the acoustic
transmission and the displacements of the prosthesis with varia-
tions of atmospheric pressures, are reviewed.
Conclusion: The diameter of a piston should not be smaller
than 0.4 mm and it should be inserted into a significantly larger
perforation of the footplate. A low mass is advantageous for
transmission of higher frequencies. Firm attachment at the pro-
cessus lenticularis is necessary for effective energy transmis-
sion. This is of paramount importance in a malleovestibulopexy
Since Shea (1) had replaced an otosclerotic stapes by
a polyethylene tube for the first time in 1956, stapes-
plasty is one of the most fascinating procedures in
otosurgery. There is no other operation to restore the
function of a sensory organ to help patients lead a normal
life with a similar high success rate, with the possible
exception of cataract surgery in ophthalmology. Al-
though the surgical technique has been refined and made
reliable through the performance of thousands of opera-
tions spanning nearly half a century, it is important to
note that some of the acoustic and biomechanical aspects
of stapes replacement remain obscure. This is evident in
the variety of surgical techniques and designs of pros-
thesis available.
New insight into the function of both the normal and
the reconstructed middle ear has been obtained with
modern experimental tools, such as laser Doppler vibro-
metry, which has helped to explain the acoustic back-
ground of stapesplasty and the effects of modifications in
designs of various prostheses. This has also been useful
in understanding the behavior of piston prostheses at
various atmospheric pressures, such as those encountered
in flying or diving.
Address correspondence and reprint requests to Karl-Bernd
Hüttenbrink, M.D., Department of Otorhinolaryngology, University of
Technology, Fetscherstr. 74, D-01307 Dresden, Germany; Email:
huettenb@rcs.urz.tu-dresden.de
548
because of the oblique position of the piston. A piston can be
displaced up to 0.5 mm in the vestibule at ambient air pressure
changes, as it is not attached to the annular ligament. These
large movements explain why a short piston can be lifted out of
the footplate fenestration (i.e., after sneezing) and why a piston
with excessive length can impale the structures of the mem-
branous labyrinth, causing vertigo (i.e., in a retraction of the
tympanic membrane). However, flying or diving should be
allowed generally, provided that a test with tympanometry,
applying variable pressures of ± 400 mm H2O, is tolerated
without evoking vertigo. Key Words: Atmospheric pres-
sures— Diving—Flying—Piston diameter—Piston prosthe-
sis—Stapedectomy—Stapedotomy
Otol Neurotol 24:548–559, 2003.
ACOUSTIC BACKGROUND OF STAPESPLASTY
The rigidity of the annular ligament represents 90% of
the total impedance of the human middle ear at lower
frequencies and thus dominates the sound transmission
for speech frequencies through the normal middle ear,
contrary to the middle ear in many research animals, like
guinea pigs, in which the impedance is dominated by the
air in the bulla (2). Its solid collagen fibers determine the
amplitude of stapedial vibration in low-frequency acous-
tic stimulation. The sound pressure at the entrance of the
cochlea is directly proportional to the volume velocity of
the stapes. This corresponds to the volume of the liquid
that is displaced by the vibration of the footplate. This
volume velocity is defined as the product of area and
amplitude of the vibrating structure: the footplate with its
area of approximately 3.2 mm2 exerts vibrations with
amplitudes of only a few nanometers for displacement of
a sufficiently large amount of volume of liquid to trans-
mit sound pressure into the cochlea at physiologic sound
pressures (3). This amplitude is determined by the total
impedance of the middle ear for low frequencies, and it
is constant with a defined sound pressure at the tympanic
membrane (Fig. 1).
Replacement of an otosclerotic stapes by a piston
prosthesis eliminates the annular ligament as the domi-
nating factor of the impedance of the middle ear. The
amplitudes of vibration of the ossicles can increase at
equivalent sound pressures at the tympanic membrane.
Thus, a piston prosthesis with its much smaller contact
 BIOMECHANICS OF STAPESPLASTY
FIG. 1. A piston prosthesis can vibrate with a larger amplitude
when the annular ligament as the dominating factor of the im-
pedance of the middle ear is eliminated. The volume velocity and
thus the transfer of energy to the cochlea remains the same with
pistons of different diameters.
area (in comparison with the stapes footplate: 0.12 mm2
in a 0.4-mm piston) can vibrate with a much larger am-
plitude at equivalent sound pressures. This increased lin-
ear velocity of the smaller piston compensates for the
decrease in the surface area.
Reduction of the diameter of a piston is limited be-
cause of the restrictions of the maximal vibrational ca-
pacity of the tympanic membrane and the ossicles. Ex-
perience from animal experiments suggests that the
maximal vibrational amplitude of the sound-transmitting
structures is attained at a diameter less than 0.4 mm, and
volume velocity will decrease with smaller diameters (2).
Clinical experience confirms this lower limit of the di-
549
ameter: Grolman et al. (4) reported a significantly de-
creased sound transmission, especially at frequencies be-
low 1 kHz for a 0.3-mm piston as compared with a
0.4-mm piston.
Pistons with sufficiently large diameter, 0.4 mm and
above, should have similar sound transmission properties
if the vibrational capacity of the middle ear structures is
unrestricted. However, inconsistent findings on the
acoustic results after stapesplasty with different piston
diameters are reported in the literature.
Fisch (5) and Shabana et al. (6) found equally good
hearing in the speech frequencies with 0.4- and 0.6-mm
pistons. Böheim et al. (7) compared 0.4- and 0.6-mm
gold pistons and observed a significant advantage for the
lager diameter only for 500 Hz. In higher frequencies of
2 kHz and 4 kHz, both pistons performed equally well.
Häusler (8) also found practically no difference between
0.4- and 0.6-mm pistons. Mann and Beck (9) reported a
significantly superior performance of 0.4-mm pistons in
the higher frequencies as compared with 0.6-mm pistons.
Coletti et al. (10), Schuknecht and Bentkover (11),
Sennaroglu et al. (12), and Teig and Lindemann (13),
however, reported better results with increasing piston
diameter (0.6 and 0.8 mm in Schuknecht and Bentkover
(11) and Sennaroglu et al. (12); 0.4–0.8 mm in Merchant
et al. (14) and Teig and Lindemann (13)). The acoustic
outcomes become even more contradictory if the sound
transmission is analyzed in separate frequencies.
Teig and Lindemann’s results (13) showed an ad-
vantage of a larger diameter only for the lower fre-
quencies; above 2 kHz, the 0.4-mm piston gave similar
results as the 0.8-mm piston. In the comparative study by
Shabana et al. (6), the transmission in the higher frequen-
cies of a 0.4-mm piston was worse than the 0.6-mm
piston, although both performed equally well in the
low frequencies.
Overall, audiologic results give the impression that a
larger diameter may have a small but clinically and not
significant effect on hearing results. In contrast, reduced
potential inner-ear trauma with a smaller diameter has to
be considered (5,15–17).
Some comparative studies used different piston mate-
rials in addition to the various diameters (4,18,19). It was
shown that heavier prostheses (e.g., steel with a weight
of 12.5 mg (19), or gold with a weight of 10 mg (18))
gave better results in the lower frequencies; those with a
lower mass (e.g., Teflon, with a weight of 3 mg) trans-
mitted better in the high frequencies. This influence on
the frequencies by the mass of the piston is caused by a
shift of the resonance frequency of the reconstructed
middle ear.
Nevertheless, these minor changes of the mass of the
vibrating ossicular chain are of negligible importance in
otherwise normal middle ear parameters. In a mathemati-
cal model, even a 16-fold increase of the mass of the
stapes results in a reduction of transmission of less than
10 dB (14,20).
This minor influence of the mass had already been
shown early in animal experiments with cats, by loading
Otology & Neurotology, Vol. 24, No. 4, 2003
550 K. B. HÜTTENBRINK
the footplate with mercury and registering the cochlear
microphonics (21). Temporal bone experiments, how-
ever, gave contradictory data; in one experiment, an ad-
ditional mass of 22.5 mg reduced transmission by only 3
dB (22), whereas in another study the addition of 5 mg
resulted in a decrease of 13 to 15 dB for the high fre-
quencies (23).
Mathematical models also show the advantage of a
larger diameter of the piston diameter on sound trans-
mission (20). However, even precise calculations rely on
experimental data with inherent methodologic discrepan-
cies. This may explain why a loss of 15 to 20 dB was
calculated for a 0.4-mm piston. Clinical audiology, in
contrast, does not register such a large deficit after
stapesplasty with a 0.4-mm piston.
A Finite Element Model (FEM) also seemed to dem-
onstrate an advantage of a larger piston diameter (24).
Nevertheless, the assumed 19-dB increase of sound pres-
sure with a prosthesis area of 3.6 mm2 (the same size as
the footplate) cannot be accepted. In FEM, any single
incorrect parameter can distort the result. Also, in this
model, several parameters had only been roughly esti-
mated, for example, the rigidity of the annular ligament.
Furthermore, this model used pressures instead of forces
as a stimulation. The authors increased the surface area
of the piston but kept the pressure constant. This will
enlarge the force, which is not correct for the hydraulic
mechanism of middle ear transmission. They also pre-
served the impedance of the annular ligament, even
though this major impedance factor is eliminated af-
ter stapesplasty.
The vibrating and thus energy-transmitting area, how-
ever, is not solely defined by the diameter of the piston,
as the surrounding connective tissue membrane vibrates
too (20) (Fig. 2). Thus, the whole sound-transmitting
area of a 0.4-mm piston is equivalent to the surface area
of a 0.5- to 0.6-mm piston. This membranous component
explains why a stapedectomy with its partial or complete
replacement of the footplate by a connective tissue mem-
brane gives good acoustic results (17), even though the
wire in the classic wire-tissue prosthesis has a diameter
FIG. 2. The connective tissue seal around the piston in the
perforation of the footplate vibrates too, and thus adds vibrational
energy for the stimulation of the cochlea. This component be-
comes especially important for thinner pistons.
Otology & Neurotology, Vol. 24, No. 4, 2003
FIG. 3. The perforation should be larger than usual in a thick
footplate, to prevent a lateral contact with the bony edges and
thus an attenuation of the vibrations in cases of an oblique posi-
tioning of the piston.
of only 0.2 to 0.3 mm. In a study by Fucci et al. (25), 0.4-
and 0.6-mm steel pistons, which had been inserted into
fenestrations of identical size, performed equally well.
Unfortunately, most published studies comparing acous-
tic results with different piston diameters do not mention
the size of the footplate fenestra. Most surgeons perforate
the footplate just a bit larger than the piston diameter, to
minimize the inner ear trauma (5,16,17).
In cases of an increased thickness of the otosclerotic
footplate, however, the size of the perforation should be
large enough to prevent a lateral contact of an angled
piston with the surrounding bone (Fig. 3). This contact
would result in an attenuation of the vibration, with con-
sequential decrease of sound transmission (8).
This angulation of the piston is evident in the malleo-
vestibulopexy, in cases of absent or nonusable incus, as
the malleus handle is located anteriorly in relation to the
oval window (Fig. 4), which might be the cause for in-
ferior acoustic results (15). Loose coupling of the wire of
the prosthesis to the malleus handle might be an addi-
tional cause for reduced sound transmission. If the wire
is attached to the incus’ long process, which hovers di-
rectly above the perforation, the piston will vibrate
mainly in the direction of its long axis, as the processus
lenticularis vibrates mostly like a piston in the low and
mid frequencies. For this unidirectional energy transmis-
sion, the contact of the wire loop to the incus should be
sufficiently stable.
The attachment to the malleus results in angulation of
the piston, especially if the fenestration of the footplate is
located in its posterior part. This will induce an addi-
tional lateral force at the wire loop, as the malleus handle
vibrates in a piston-like fashion. This lateral force may
result in a tilting movement of the prosthesis, if the wire
loop is not rigidly attached to the malleus handle, and
which will be lost for sound transmission. Therefore,
firm attachment of the wire loop at the malleus handle,
which prevents any tilting movement, is of paramount
importance for a malleovestibulopexy. Acoustic results
are improved by pulling the wire loop tightly around the
malleus or with a drop of bone cement (15).
 BIOMECHANICS OF STAPESPLASTY 551

of a contraction of the stapedius muscle. In a normal

FIG. 4. In a malleovestibulopexy, the direction of vibration of the
piston is oblique. A significantly more stable attachment to the
malleus handle is necessary to prevent unwanted and energy-
consuming tilting movements.
middle ear, the pull of the muscle rotates the footplate
around its transverse axis and stretches the annular liga-
ment (29). This increase of tension of the collagen fibers
results in a shift of the resonance to the higher frequen-
cies (30). Thus, the acoustic reflex induces a decrease of
larger movements and low-frequency transmission but
an improved transmission of the deleterious higher fre-
quencies of the noise.
Although the annular ligament is not functioning in a
piston prosthesis, a contraction of the stapedius muscle
might still be registered as an impedance change of the
tympanic membrane, but the change of stiffness at the
annular ligament cannot be estimated. Other subjective
factors might be responsible for the pleasant hearing im-
pression expressed by some patients with preserved sta-
pedial tendon.
The restoration of middle ear transmission by the
stapesplasty not only improves air conduction but also
can lower the characteristic depression in the bone-
conduction threshold in the mid-frequency region in
pure-tone audiometry in some patients. This Carhart
notch (31) does not represent the true cochlea perfor-
mance, as it becomes evident in the “over-closure” after
successful stapesplasty with its shift of bone-conduction
threshold. It is rather a manifestation of a reduced stimu-
lation of the cochlea in bone conduction because of the
obstructed middle ear transmission with an otosclerotic
stapes. Bone-conducted sound is transmitted mainly
through the temporal bone directly into the cochlea (32–

Interposition of a venous or connective tissue graft

beneath the piston as a cover for the perforation of the
footplate is a further biomechanical point of interest
(Fig. 5). This connection between the piston and the
edge of the perforation is considered to restore the stiff-
ness of the annular ligament (26). A FEM simulation
calculated a reduction of lateral vibrations for this as-
sembly (27). An additionally introduced stiffness, how-
ever, would not be favorable for a maximal volume-
velocity of the piston, because of the induced reduction
of vibrational amplitude. However, it can be assumed
that no significant additional impedance is created, or
that this parameter has only a minimal influence on over-
all transmission, considering the excellent acoustic re-
sults that were reported by Causse (26) with this tech-
nique. This underlay technique, however, could stabilize
the piston against atmospheric pressure changes, which
are discussed below.
Some surgeons preserve the stapedial muscle when
they remove the stapes suprastructure (8,28). In addition
to a reduced risk of incus erosion because of preserved
blood supply to the lenticular process, they postulate a
more physiologic sound transmission for high sound
pressure levels and a reduction of discomfort in noisy FIG. 5. A venous or connective tissue underlay graft under the
environment because of the preservation of the acoustic piston will attenuate the free vibrations, but it will also reduce
reflex. Nevertheless, unrestricted movements of the an- the displacements of the piston as induced by atmospheric pres-
nular ligament are prerequisite for these acoustic effects sure changes.

Otology & Neurotology, Vol. 24, No. 4, 2003

552 K. B. HÜTTENBRINK

34). However, a significant component of this vibration

energy is radiated from the walls of the tympanic cavity
and external ear canal and reaches the cochlea by means
of the tympanic membrane and the ossicular chain.
If the stapes is ankylosed, this part is missing. This
phenomenon is the essential component of the “Gellé
test,” which serves as a diagnostic tool for confirmation
of a stapedial ankylosis. (Alteration of meatal atmo-
spheric pressure by pneumatic otoscopy reduces the per-
ception of a tone, produced by a tuning fork, and which
is applied by bone conduction, in the normal middle ear,
as the tympanic membrane and the ossicular chain are
stretched and the middle ear component of the bone-
conducted sound is attenuated. This effect is not seen if
the stapes is fixed.)
This middle ear component of bone conduction in the
mid frequencies at 1 to 2 kHz corresponds to the reso-
nance frequency of the middle ear, which explains the
location of the Carhart notch in this frequency region.
This component is again available after a successful res-
toration of middle ear transmission, resulting in an im-
proved bone conduction with an evident improvement of
cochlear function.
Solid attachment of the prosthesis to the long process
of the incus is a dominant factor for effective energy
transmission. For this purpose, the choice of material
(e.g., platinum, steel, or gold wire loops; whole Teflon
loop) is rather irrelevant, provided that it enables firm
anchoring. An FEM analysis demonstrated that loose
coupling results in additional lateral, ineffective vibra-
tions (27,35).
Loosening of the attachment because of the erosion of
the bone is one of the most common causes for a post-
operative recurrent air-bone gap (8,36–38). It is assumed
that this erosion is caused by reduction in blood supply
of the lenticular process, if the vessels through the sta-
pedial tendon are eliminated. Animal experiments, how-
ever, did not confirm this hypothesis (37). In any event,
the blood supply of the bone is maintained through the
bone marrow, which continues down to the tip of the
long process (39).
Another assumption is that there is an increased force FIG. 6. Crimping the wire loop of a piston will not induce a
at the wire loop with atmospheric pressure-induced circular grove, as pressure is built up only locally.
movements of the incus, if the piston is tightly fastened
in connective tissue in the oval window niche (37,40).
coiling elastic loop, which could exert permanent force,
The lenticular process, however, is displaced only a few
this force would end after a superficial erosion of the
micrometers at atmospheric pressure variations, as the
bone, and only a shallow groove would occur.
malleus-incus joint attenuates the movements of the tym-
The characteristic finding in incus erosion is a deep,
panic membrane (41). These displacements are too small
circular bony defect, filled with granulation tissue (Fig.
for building up a force that could cause bone resorption.
7). Sometimes, even the bony connection to the tip is lost
An elastic loop, such as in a total Teflon prosthesis,
(8). This leads to the assumption that the bony erosion is
could exert permanent force because of its “memory ef-
caused by a sort of foreign body reaction.
fect” (38). This mechanism is not evident in the wire
loop prostheses, as a force only builds up in highly lo-
calized spots with the typical crimping procedure with a THE BEHAVIOR OF STAPEDIAL PROSTHESES
microforceps (Fig. 6). Furthermore, because of the elas- AT ATMOSPHERIC PRESSURE VARIATIONS
ticity of the metal, a tiny but significant loosening of the
loop will follow the crimping procedure, preventing any The ear works as a pressure receptor. Its main purpose
force buildup. However, even in a prosthesis with a self- is to transmit the acoustic sound pressure to the inner ear.

Otology & Neurotology, Vol. 24, No. 4, 2003

 BIOMECHANICS OF STAPESPLASTY
FIG. 7. The typical finding in a loosening of a piston prosthesis
is a circular bony erosion with granulation tissue in the bony
defect. This is more consistent with a foreign body reaction than
with a mechanical origin.
However, it is also exposed to the enormous changes of
ambient atmospheric pressures (Fig. 8): at the hearing
threshold, the sound pressure is 20 ␮P; at the pain thresh-
old at 114 dB, it reaches 10 million ␮P, which corre-
sponds to a static pressure of a 1-mm water column
(daPa). Nevertheless, atmospheric pressures of a several-
FIG. 8. The ear as a pressure receptor not only transmits the
sound pressures but is also permanently exposed to the million-
times larger variations of ambient air pressure.
553
hundred-millimeter water column are tolerated by the ear
without any problem. It is important to consider that the
ear is constantly exposed to these pressure changes in
daily life, for example, during swallowing, at every tubal
opening, at wind gusts at the external ear, in flying, in
diving, and so forth.
In tympanometry, with its pressure changes of ± 400
mm H2O the tympanic membrane and the malleus are
displaced inward and outward up to 1 mm. In the normal
ossicular chain, these forces induce a gliding in the
malleus-incus joint. Because of the intricate construction
of the joint and the supporting ligaments of the ossicles,
this gliding movements forces the incus predominantly
upward or downward. This results in a gliding in the
incudostapedial joint. Because of this change of the in-
ward-outward movement of the malleus to a perpendicu-
lar movement at the lenticular process, the stapes and in
consequence the inner ear are uncoupled from the exten-
sive displacements of the tympanic membrane at ambient
air pressures (42). The maximal piston-like inward or
outward movement of the stapes never exceeds 10 to 30
␮m, regardless of the pressure in the external ear canal
(41) (Figs. 9 and 10).
The solid attachment of the stapes in the annular liga-
ment, which is the strongest ligament in the middle ear
(43), is crucial for the induction of this gliding process in
the joint. The placement of a stapedial prosthesis elimi-
nates this resistance. Atmospheric pressure changes,
which induce displacements of the tympanic membrane,
can now move a piston practically unrestrictedly in the
vestibule (Fig. 10).
These movements were analyzed in temporal bone ex-
periments with a three-dimensional microscopic mea-
surement technique (41,44). Pressures of 50, 100, 200,
and 400 mm H2O, like in tympanometry, were applied to
the external ear canal of nine fresh temporal bones (1–3
days postmortem). The middle ear walls were opened for
viewing and illumination by enlarging the tubal orifice
FIG. 9. The gliding movement in the malleus-incus joint
changes the inward-outward movement of the tympanic mem-
brane, resulting in a gliding of the incus-stapes joint. This reduces
the inward-outward movement of the stapes significantly.
Otology & Neurotology, Vol. 24, No. 4, 2003
554 K. B. HÜTTENBRINK
FIG. 10. Inward-outward displacements of umbo, stapes, and a
piston prosthesis in a temporal bone during application of tym-
panometric pressures.
and removing parts of the dorsal tegmen and parts of the
medial wall of the vestibule, as these structures are not
essential for statics and function of the middle ear. All
ossicular ligaments were left untouched. Measurements
of the ossicular positions at various static pressures were
carried out using technical objectives (Bausch & Lomb)
in a measuring microscope. With an objective magnifi-
cation of 9×, 25×, and 50×, corresponding to a total
magnification of 200×, 625×, and 1,250×, displacements
down to 1 ␮m could be measured in the three planes of
space with the ocular micrometers and the microscope’s
microbody fine adjustment. Relevant parts of the ossicles
and the piston were marked with aluminium powder,
dotted on the surface by a needle. These aluminium
grains of 1 ␮m size weigh only 0.03 mg/cm2, thus posing
no significant additional mass. These grains appeared as
bright spots when illuminated obliquely.
In a first step, the mechanics of the normal middle ear
were examined by measuring the displacements of the
umbo, lenticular process, and stapes. Then, an 0.8-mm
perforation was drilled into the footplate, the crura were
cut with a microscissors, and a 0.6 × 4.5-mm platin-
Teflon piston (Richards) was attached to the long process
of the incus (Fig. 11). The displacements of the piston
were measured through the medial opening of the wall of
the vestibule.
The cochlea was drained for these experiments. This
“unloading” can be a methodologic weakness in mea-
surements of sound transport, as it modifies the vibra-
tional characteristics of the stapes footplate. However, it
is insignificant if a displacement of a piston in a change
of static pressure is measured. In the experiments, the
pressure was increased stepwise and maintained. The
new position of the piston was measured at each step.
Thus, no movements (which could be influenced, if the
piston pushes on air or on liquid) but only positions in
steady state with pressure equalization in the vestibule
were measured.
On average, the pistons were displaced 232 ␮m in-
ward and outward at pressures of ± 400 mm H2O, with
large interindividual variations (114–403 ␮m). Because
of the friction of the piston at the edges of the perfora-
tion, larger values were not reached.
Otology & Neurotology, Vol. 24, No. 4, 2003
When the friction between piston and the edge is
greater than the frictional resistance of the malleus-incus
joint of 10 mN (1 mg) (45), only a fraction of the inward
and outward movement of the malleus is transmitted to
the prosthesis. Therefore, much larger displacements of
the prosthesis can be expected if the gliding capacity of
the ossicular joints is impaired. Histologic studies
showed that degenerative changes with ankylosis can
develop in the joints in 50% of otosclerotic middle
ears (46–48).
This abnormality was simulated in the temporal bone
experiments by fixation of the malleus-incus joint with
cyanoacrylate glue (Histoacryl, Braun, Germany). With
this ankylosis of the joint and resulting elimination of the
protective gliding mechanism, the movement of the pis-
ton in the vestibule increased nearly twofold at ± 400
mm H2O, with an average of 407 ␮m (range, 288–548
␮m). In two temporal bones, this movement even ex-
ceeded 0.5 mm (41). This comparatively large displace-
ment is the reason why a very short piston can be lifted
out of the perforation by simple sneezing or with a Val-
salva maneuver. It will resettle on the fixed footplate, a
finding that is often reported in revision surgeries for
recurrent air-bone gap (8). A very long piston can contact
or even pierce the underlying structures of the membra-
nous labyrinth (utricle, saccule) at an increased pressure
in the external ear canal with a retraction of the tympanic
membrane and cause vertigo (Figs. 12 and 13). Relating
these displacements to the anatomy of the vestibule, the
piston should be inserted into the posterior section of the
footplate, as this location guaranties the largest distance
to the saccule (49,50).
Because of the potential displacements and the vicin-
ity of the piston to the inner ear structures, surgery under
local anesthesia is recommended. If the insertion depth
of the piston is 0.5 mm, as has been proposed to prevent
its outward dislocation with sneezing (36), a gentle pres-
FIG. 11. Temporal bone with simulated stapesplasty. A pis-
ton prosthesis is inserted into a perforation of the footplate.
The vestibule is opened for registration of the pressure-induced
displacements.
 BIOMECHANICS OF STAPESPLASTY
FIG. 12. At a positive pressure of 400 mm H2O in the external
ear canal (analogue to tympanometry), the piston protrudes
deeply into the vestibule and nearly touches the white saccule.
sure downward of the long process of the incus can
test the maximal inward movement of the piston. Short-
ening of the piston is necessary if the patient reports
vertigo with this movement. By analogy, removing the
tamponade of the external ear canal can lateralize an
inwardly displaced tympanic membrane together with
the piston in cases of postoperative vertigo, even with
nystagmus. Such an irritation by an impaling piston is
confirmed if the vertigo ceases instantly after a cautious
Valsalva maneuver.
Irritation of the inner ear by a piston prosthesis is not
uncommon, even in asymptomatic patients. We tested 53
patients 6 months after stapesplasty with a piston pros-
thesis, by applying pressures of 400 mm H2O, with tym-
panometry and simultaneous registration of eye move-
ments by electronystagmography. One-third of the
FIG. 13. At a negative pressure of −400 mm H2O in the external
ear canal (analogue to tympanometry), the piston is nearly lifted
out of the perforation. Only its lower in end merely visible, flush
with the footplate bottom.
555
patients presented some nystagmus, although they did
not complain of vertigo.
These pressure-induced displacements of the piston in
the vestibule can cause inner-ear irritations or even dam-
age the inner ear. This danger is even more evident for a
malleovestibulopexy (51), considering the movements of
the malleus of up to 1 mm. Therefore, a piston should be
attached adjacent to the short process of the malleus, near
the rotation axis of the malleus in ambient air pressures
to reduce the pressure-induced displacements. This
position has only a minor influence on the audiologic
results, as the malleus handle vibrates mostly in a piston-
like fashion at sound transmission; its acoustic rotation
axis changes its position, depending on the frequency (3).
The pieces of connective tissue that are often placed
around the piston in the oval window niche serve as a
seal to prevent a perilymphatic leakage. In addition, their
frictional resistance will attenuate the pressure-induced
displacements of the piston after healing and scarring, as
soon as it surpasses the frictional resistance of the
malleus-incus joint (Fig. 14). The same mechanics apply
to the venous or connective tissue graft under the piston
in the fenestration. Therefore, flying should not be per-
mitted 2 weeks after a stapesplasty (52), until this con-
nective tissue covering has matured. In modern passen-
ger jets flying at an altitude of 41,000 ft, the pressure
FIG. 14. The connective tissue, which is inserted into the oval
window niche as a sealing, attenuates the pressure-induced dis-
placements of the piston because of the friction.
Otology & Neurotology, Vol. 24, No. 4, 2003
556 K. B. HÜTTENBRINK
differential relative to sea level is 2,000 mm H2O (53),
which induces excessive displacements of the tympanic
membrane even with repeated tubal openings.
A test applying tympanometric pressures to the ear
with simultaneous recording of nystagmus can reveal
whether flying or diving could be hazardous to patients
after a stapesplasty. If no vertigo or pathologic eye
movements are evoked with pressures of 400 mm H2O,
even larger pressures should not cause inner-ear irrita-
tion. Larger pressures are not transmitted by the ossicular
chain because of the tympanic membrane stiffening with
increasing tension of its radial collagen fibers, behaving
like a solid wall at pressures above 400 mm H2O (3,54).
Thus, a prosthesis attached to the ossicles will not be
displaced significantly with further increasing pressure
(compare Fig. 10). These experimental results are con-
firmed by the experience of military jet pilots from sev-
eral nations who continued to fly after a stapesplasty
without problems, and who were exposed to even larger
decompressions in action (55–57).
Pressure chamber experiments in monkeys (58), cats
(59), and guinea pigs (60) also did not demonstrate any
inner-ear damage after stapesplasty. Stapesplasty pa-
tients even performed diving, which causes much larger
pressure changes, without any problems (61).
Therefore, it does not seem justified to ban pilots,
divers, parachutists, or other people who are exposed to
excessive pressure variations from performing their
work or sport after stapesplasty. Prerequisite for safe
exposure to excessive pressure variations is, however,
the above-mentioned pressure test with tympanometry
without symptoms. Furthermore, a normal, stable, tym-
panic membrane without atrophic areas should be con-
firmed in otomicroscopy. For divers, a greater danger is
hidden in a reduced mechanical stability of the tympanic
membrane, as a rupture of an atrophic drum under water
can cause a life-threatening loss of orientation and vom-
iting because of the thermal stimulation by the inflow-
ing water.
Acknowledgment: Special thanks to R. Kayarkar for her
linguistic refinement of the manuscript.
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INVITED COMMENT
The authors are to be complimented on compiling a
comprehensive review of the biomechanics of stapedec-
tomy. As aptly stated in their introduction, “…Although
the surgical technique [of stapedectomy] has been
refined…through the performance of thousands of
operations spanning nearly half a century, it is important
to note that some of the acoustic and biomechanical
aspects of stapes replacement remain obscure.” The re-
view is unique and noteworthy in two ways: first, both
basic science and clinical aspects of stapedectomy are
presented; second, responses of stapes prostheses to
both acoustic stimulation and changes in middle-ear
static pressure are discussed. Nonetheless, we take issue
with the author’s conclusion regarding the size of a
stapes prosthesis.
The authors concluded that the 0.4-mm-diameter
stapes piston is optimum, and that smaller and larger
diameter pistons have disadvantages. We respectfully
disagree. In our opinion, there is no single “optimum”
piston diameter; rather, there is a continuum wherein
larger piston diameters give better acoustic results after
stapedectomy. The reasons for our belief are as follows.
We examined the relationship between piston diam-
eter and hearing results after small fenestra stapedectomy
using a simple, lumped-element mathematical model of
the middle ear (1). The output of the middle ear was
quantified by the “volume velocity” of the stapes, where
volume velocity is the product of stapes linear velocity
and area of the footplate. After a small fenestra stape-
dectomy, the “effective” footplate area is reduced to the
area of the prosthesis. This reduction has two effects:
first, it reduces the mechanical load that opposes the
piston motion, resulting in an increase in the linear ve-
locity of the piston for a given ossicular force; and sec-
ond, it reduces the volume velocity produced by a given
stapes linear velocity. The reduction in mechanical load
comes about because the force driving the piston is con-
centrated over a smaller area of the oval window, and the
annular ligament, which normally constrains motion of
the stapes footplate, is eliminated. Although our model
predicted a significant increase in piston linear velocity
(compared with velocity of the normal stapes), this in-
crease was less than the decrease in the effective area,
and the net result was a decrease in stapes volume ve-
locity with decreasing piston area. The decreased post-
stapedectomy volume velocity interacts with normal
acoustic impedance of the inner ear and produces a pro-
portional decrease in cochlear pressure. The reduction in
stapes volume velocity and reduction in cochlear sound
pressure lead to an air-bone gap that is predicted to per-
sist after a small fenestra stapedectomy. The smaller the
area of the stapes prosthesis, the greater the air-bone gap.
The model predicted a continuum of effects of changing
piston diameter. At frequencies of 1,000 Hz and below,
Otology & Neurotology, Vol. 24, No. 4, 2003
558 K. B. HÜTTENBRINK
an 0.8-mm-diameter piston was predicted to cause a
5-dB gap, a 0.6-mm piston was predicted to cause a
10-dB gap, and a 0.4-mm piston was predicted to cause
a 15-dB gap. The increased probability of inaccuracies in
the data sets used to produce the model at higher fre-
quencies limits the model’s utility at frequencies above 2
to 3 kHz.
Our prediction that hearing results improve with in-
creasing piston diameters are in agreement with predic-
tions made by other investigators using more sophisti-
cated three-dimensional and finite element models (2,3).
Our predictions are also supported by experimental tem-
poral bone data by Goode and Hato (4), where measure-
ments of round window velocity were made in an ex-
perimental temporal bone preparation with stapes
prostheses of varying diameter. Round pistons of 0.4 mm
and 0.8 mm diameter, and an oval 1.6 × 0.8-mm piston
were used, whereas all other parameters of the prepara-
tion were kept unchanged. The results showed significant
differences between different piston diameters, with
larger diameters giving larger round window velocities.
An important test of any model, including ours, is the
comparison of model predictions with actual clinical re-
sults. However, multiple factors can confound the
comparison of model predictions with clinical results af-
ter stapedectomy:
1. Our model assumed that the effective vibrating
footplate area after small fenestra stapedectomy is
no more than the area of the lower end of the pros-
thesis. If a fenestra is larger than the prosthesis,
then the effective vibrating surface may be greater
than the area of the prosthesis alone, and hearing
results will be correspondingly better. This is sup-
ported by a clinical analysis of 120 stapedectomy
procedures by Fucci et al. (5), who created a 1.4-
mm-diameter fenestra and used either a 0.4-mm
piston (60 ears) or a 0.6-mm piston (60 ears). There
were no differences in hearing results between the
two groups.
2. The method used to compute the poststapedectomy
air-bone gap may explain why, in some cases,
the observed gaps are not as large as those pre-
dicted by various models. Many published studies
computed the postoperative air-bone gap using the
postoperative air conduction thresholds and the
preoperative bone-conduction thresholds, which
minimizes the postsurgical air-bone gap, because
bone-conduction thresholds generally improve af-
ter stapedectomy.
3. The various models assume that bone-conduction
thresholds are true and accurate reflections of
cochlear function. The problems in accurate deter-
mination of bone-conduction thresholds in otoscle-
rosis are well known. Furthermore, bone-conduc-
tion thresholds show greater improvement for
larger piston diameters than for smaller piston di-
ameters (6,7), which further confounds compari-
sons of clinically measured air-bone gaps and pis-
ton diameters.
Otology & Neurotology, Vol. 24, No. 4, 2003
4. There may be insufficient numbers of cases in a
clinical series to achieve statistical significance in
detecting differences between differing diameter
pistons. For example, in the study by Shabana et al.
(6) cited by the authors where 0.4- and 0.6-mm
pistons were shown to be equivalent in an analysis
of 200 procedures, the raw data showed a trend
toward better results for the 0.6-mm piston, but this
did not reach statistical significance, except at
4 kHz.
The above confounding issues not withstanding, a re-
view of published clinical results after stapedectomy (in
the English language literature) shows that the majority
of clinical studies do indeed report that larger piston
diameters yielded better results for frequencies up to and
including 2 kHz (7–11). The “N” for these studies ranged
from 200 to 1,459, and piston diameters ranged from 0.3
through 0.8 mm. A minority of studies reported no dif-
ference in results between 0.4- and 0.6-mm piston diam-
eters (6,12). There is no study of which we are aware that
supports the 0.4-mm piston resulting in acoustically su-
perior results for frequencies of 2 kHz and lower. In our
opinion, one of the best and most careful analyses of the
effect of piston diameter was the study of Teig and Lin-
deman (7), who compared piston diameters of 0.4, 0.6,
and 0.8 mm, with special attention to the confounding
variables described above. Their data showed clear sta-
tistically significant differences in hearing results, with
larger pistons giving better results for frequencies up to
and including 2 kHz. The mean hearing results for the
0.6-mm piston were better by 4 to 10 dB when compared
with the 0.4-mm piston, whereas the 0.8-mm piston was
better than the 0.6-mm piston by 5 to 7 dB.
The author’s preference for the 0.4-mm piston is also
based in part on the reduced potential for inner ear
trauma with the 0.4-mm piston. Most otologists would
agree that a small fenestra stapedectomy is less traumatic
than a total or large fenestra stapedectomy. However, we
are not aware of any data that indicate differences in
inner ear trauma between a 0.4- and a 0.6-mm piston
(when both pistons are used in the small fenestra tech-
nique). The lack of difference in inner ear trauma with
differing piston diameters, provided that a small fenestra
technique is used, is implicit in the author’s recommen-
dation of placing a 0.4-mm piston in a significantly
larger perforation of the stapes footplate. The author rec-
ommends making the fenestra significantly larger to im-
prove the effective vibrating area of the stapes footplate
(Fig. 2); thus, the author implicitly acknowledges the
importance of making the effective footplate vibrating
area as large as possible.
We emphasize that we are not opposed to smaller
pistons such as the 0.3- or 0.4-mm piston. In fact, there
are certain anatomic situations where these smaller pis-
tons may be advantageous, such as a narrowed oval win-
dow niche caused by otosclerosis or an overhanging fa-
cial nerve. A 0.4-mm piston is also advantageous when
performing a stapedectomy by the Fisch (12) technique,
wherein the prosthesis is placed before removing the
 BIOMECHANICS OF STAPESPLASTY
stapes superstructure, and there is usually not enough
room to place a prosthesis larger than 0.4 mm before the
superstructure is removed.
*Saumil Merchant
and† J. J. Rosowski
*Department of Otolarnyngology and
†Eaton-Peabody Laboratory,
Massachusetts Eye and Ear Infirmary,
Boston, MA
REFERENCES
1. Rosowski JJ, Merchant SN. Mechanical and acoustic analysis of
middle ear reconstruction. Am J Otol 1995;16:486–97.
2. Arnold W, Bohnke F, Scherer E. Influence of the area of stapes
footplate prostheses on perilymphatic pressure and basilar mem-
brane displacement [in German]. Otorhinolaryngol Nova 1999;9:
81–6.
3. Koike T, Wada H, Goode RL, et al. Finite-element method analysis
of transfer function of middle ear reconstructed using stapes pros-
thesis. Abstracts of the Association of Research Otolaryngology.
Mt. Royal, NJ, Association of Research Otolaryngology, 2001;24:
221.
4. Goode RL, Hato N. A temporal bone model of stapedotomy for
otosclerosis. Otolaryngol Head Neck Surg 2000;123:86–7.
5. Fucci MJ, Lippy WH, Schuring AG, et al. Prosthesis size in sta-
pedectomy. Otolaryngol Head Neck Surg 1998;118:1–5.
6. Shabana YK, Ghonim MR, Pedersen CB. Stapedotomy: does pros-
thesis diameter affect outcome? Clin Otolaryngol 1999;24:91–4.
7. Teig E, Lindeman H. Stapedotomy piston diameter: is bigger bet-
ter? Otorhinolaryngol Nova 1999;9:252–6.
8. Smyth GDL, Hassard TH. Eighteen years experience in stapedec-
tomy: the case for the small fenestra operation. Ann Otol Rhinol
Laryngol 1978;87:3–36.
9. Schuknecht HF, Bentkover SH. Partial stapedectomy and piston
prosthesis. In: Snow JB Jr, ed. Controversy in Otolaryngology.
Philadelphia: W.B. Saunders, 1980:281–91.
10. Coletti V, Fiorino FG. Stapedectomy with stapedius tendon pres-
ervation: technique and long term results. Otolaryngol Head Neck
Surg 1994;111:181–8.
11. Sennaroglu L, Unal F, Sennaroglu G, et al. Effect of the Teflon
piston diameter on hearing result after stapedotomy. Otolaryngol
Head Neck Surg 2001;124:279–81.
12. Fisch U. Stapedotomy versus stapedectomy. Am J Otol 1982;4:
112–7.
INVITED COMMENT
Professor Hüttenbrink, a clinician-scientist from
Dresden, Germany, has provided an excellent review of
the pertinent literature on the biomechanics of the middle
ear after stapes replacement surgery (stapesplasty). Al-
though much of the information is from clinical studies
familiar to most otologists, there is a significant amount
of material from measurements in human temporal
bones, animals, and middle ear modeling experiments,
including articles originally written in French and Ger-
man. This latter information may not be as well known to
the clinician.
At the risk of sounding like your mother saying
“eat your spinach, it’s good for you,” I encourage read-
ers of Otology & Neurotology to study this review to
559
better understand the finer points of the operation. As
a bonus, Professor Hüttenbrink has provided input on
the subject based on his considerable clinical and re-
search experience.
I do have some areas in which I disagree with Profes-
sor Hüttenbrink’s conclusions and will briefly summa-
rize them. I do appreciate the opportunity to add my
commentary to this review.
Optimal Piston Diameter and Mass
Acoustically speaking, larger area pistons perform bet-
ter than smaller pistons, particularly at frequencies below
1.5 kHz. The differences are relatively small in the 0.4-
to 0.8-mm diameter range, so the choice may depend on
the suspected decreased risk of cochlear trauma with
smaller pistons. Pistons larger than 0.8 mm in diameter
are not currently available; however, modeling experi-
ments predict they should provide improved transmis-
sion of sound energy into the vestibule compared with
smaller pistons. Recent unpublished experiments in our
laboratory studied a large, oval stapedotomy piston,
equivalent to 1.05 mm diameter using a temporal bone
otosclerosis model. We found a significant increase in
sound transmission into the inner ear with this piston
compared with 0.4- and 0.8-mm-diameter pistons at both
low and high frequencies. Professor Hüttenbrink dis-
counts any advantage of larger pistons but, in fact, the
optimum acoustic area may not be known. Piston mass,
within the available size and material constraints, is not
a factor.
Variations in Atmospheric Pressure and
Prosthesis Displacement
Professor Hüttenbrink describes experiments from his
laboratory using a temporal bone model that shows dis-
placements of stapedotomy pistons up to 0.4 mm with
changes in ear canal pressure of ± 400 mm H2O. In his
model, the cochlea is drained, eliminating both the an-
nular ligament impedance and the cochlear impedance.
In this situation, piston movements would be expected to
be greater than in the clinical case; the impedance of air
is substantially less than that of the cochlear fluids,
something obvious to anyone who has jumped down
from a high place into water. The resistance of air on the
way down is nothing like that when you hit the water.
Another unknown is the impedance of the new piston-
footplate seal. Although probably less than the normal
annular ligament, it is certainly not zero. I agree that
increased piston displacement occurs with changes in ear
canal pressure, particularly in the first weeks after sur-
gery until the new seal forms. However, I do not think his
model can provide an accurate estimate of the amount of
displacement or the true effect of gluing the malleus-
incus joint.
Richard L. Goode
Stanford University School of Medicine,
Palo Alto, CA
Otology & Neurotology, Vol. 24, No. 4, 2003