Many surgical techniques have been proposed so far. Two more than others are at the basis of the Jean-Bernard CAUSSE technique :
John SHEA Technique (1958) : More or less total stapedectomy with vein graft interposition and use of a polythene tube from the tip on the long process of the incus.
The Jean René CAUSSE Technique (1962) combines two techniques of John SHEA (that described above) and the use of the original Shea piston, resulting in a new more efficient technique, which he named " Teflon-Interposition".


Main steps of Jean-Bernard CAUSSE technique

Preparation of the oval window seal:
At the beginning of the procedure, a portion of vein from the anterior of the patient's wrist is harvested and threaded over a gimmick or similar instrument. The loose perivenous connective tissue is removed with forceps pulling on the tissue and a scalpel blade freeing it from the vein. The loose connective tissue is kept in saline for possible later use as "glue" if necessary. The vein is then sectioned along one side and placed in saline for use later as the oval window seal (Fig. 8 a, b, c, d).


Fig.8 abcd : The connective tissue is stripped from the section of vein. The adventicia is connective tissue having adhesive property.

Anaesthesia
Surgery is performed under local anaesthesia with sedation (Xylocaïn or Lidocaïn 1% and Adrenalin or Epinephrin 1/40.000). Sedation is a Valium perfusion. The patient lies on a "vacuum mattress" in order to turn his body instead of turning his neck sharply to one side. Excessive torsion-extension of the neck reduces the blood flow in the vertebral arteries, and thus the blood supply to the inner ear. Moreover, as the proteolytic enzymes hyalinize the spiral ligament of the stria vascularis in the cochlea, reduction of the blood supply to the inner ear is more likely to occur. Jean-Bernard CAUSSE vertebral artery insufficiency nystagmus test, performed under nystagmography recording prior to the operation, will show poor blood supply to the inner ear when the head is sharply turned to one side.


Incision
Increasing sizes of speculae are tried in order to compress the skin and thus avoid bleeding, and in order to achieve the best exposure. The speculae are of nickel and silver and are malleable.
The incision is performed at the limit of the speculum in order to enable the Vaseline wick to press upon the tympano-meatal flap and consequently avoid bleeding in the middle ear even if the patient coughs or strains postoperatively. After the tympano-meatal flap is elevated, the bony canal of the chorda tympani is opened with a strong hook or scraped by the curette.


 Posterior canal wall
The posterior canal wall is removed with a curette to give a good exposure (Fig. 9a). The bone removal should not involve the superior aspect of the canal wall, as draping of the drum may occur postoperatively. Stagnating blood may form adhesions in the middle ear. The drum should rest as far as possible from the long process of the incus. Adhesions may retract, elevating the long process of the incus. The gauge may only be used in the inferior part of the bony rim. The curette (named Super Curette) and gauge are part of the "Causse Instrument Set" as developed by the XOMED-TREACE Company and MICROFRANCE Company.


Fig.9 a :
Only the posterior canal wall is resected.


 Incudo-stapedial joint
The incudo-stapedial joint is divided with a small flat right angle hook (Fig. 9b). The left hand should at the same time hold the long process of the incus to avoid any harm to the spiculae in the incudo-mallear joint, or to the suspensor ligaments of the incus, or to the capsule that surrounds that joint. If the capsule tears, it will incur a leak of the dense fluid contained within which the incudo-mallear joint buffers excessive vibration in case of acoustic trauma with a blast effect.

Fig. 9b Disarticulation with a small flat right angle hook
The ossicles are gently palpated
The ossicles are gently palpated to be sure that only the stapes is fixed, that the incus and malleus are normally mobile. This assessment of ossicular chain proves the diagnosis of stapes fixation to be correct.