STAPEDECTOMY, STAPEDOTOMY, MIDDLE EAR EXPLORATION
Informed Consent
Purpose: The above procedures are used to diagnose and possibly treat various middle ear conditions.

Potential Indications:

Conductive hearing loss from otosclerosis, birth abnormalities, head trauma, or infection
Persistent vertigo caused from inner ear membrane rupture
Removal of a tumor confined to the middle ear space
Removal of a foreign body
Possible Adverse Effects:

Known potential adverse effects include:

Dizziness: Some unsteadiness is common during the first few days after surgery. Dizziness on sudden head motion may persist for several week following surgery. On rare cases the dizziness is prolonged.

Taste disturbance: Taste disturbance is not uncommon for a few weeks following surgery. In 5 percent of the patients this disturbance is prolonged.

Loss of hearing: Further hearing loss develops in 2 percent of patients due to some complication in the healing process. In 1 percent this hearing loss is severe and may prevent the use of an aid in the operated ear.

Tinnitus: Should the hearing be worse following surgery, tinnitus (head noise) likewise may be more pronounced.

Eardrum perforation: A perforation (hole) in the eardrum develops in less than 1 percent and is usually due to an infection. The eardrum may heal spontaneously. If healing does not occur, surgical repair may be required.

Facial weakness: Facial nerve weakness is a very rare complication and is usually temporary. This may occur from abnormal position or from swelling of the nerve.
I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I/we have sufficient information to give this informed consent. I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

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Patient / Legal Guardian Witness
Date:__________________________
Time:___________________________