Treatment of Tympanosclerosis with Conductive Hearing Loss
For a patient with tympanosclerosis causing decreased hearing in the right ear, surgical intervention should be offered when the hearing loss is functionally significant, with the specific procedure determined by the extent and location of sclerotic involvement found during surgery.
Initial Assessment and Confirmation
Before proceeding with treatment decisions, you must:
Obtain formal audiometry to quantify the degree of conductive hearing loss 1. The physical exam findings suggest conductive pathology (unilateral decreased hearing with normal tympanic membrane appearance), but objective measurement is essential.
Perform pneumatic otoscopy and consider tympanometry to assess middle ear function and confirm the conductive component 1.
Document the air-bone gap, as this will guide treatment decisions and serve as a baseline for surgical outcomes 2.
Treatment Algorithm Based on Hearing Loss Severity
If Hearing Loss is Minimal or Absent
- No surgical intervention is indicated 3. Isolated myringosclerosis (tympanic membrane involvement only) without hearing loss requires no treatment.
- Surveillance with repeat audiometry at 3-6 month intervals if there are concerns about progression 1.
If Conductive Hearing Loss is Present and Functionally Significant
Surgical treatment is the primary management approach 2, 3, 4. The specific procedure depends on intraoperative findings:
Surgical Options by Location of Involvement:
Tympanic membrane or lateral ossicles only:
- Straightforward tympanoplasty with removal of sclerotic plaques and ossicular chain reconstruction as needed 2, 4.
- Expected success rate for tympanoplasty: approximately 67% 2.
Stapes involvement (most challenging):
- Stapedectomy is preferred over mobilization techniques 2, 3. While mobilization may provide initial improvement, fibrous scarring typically causes refixation 5.
- Both procedures show similar hearing outcomes at 6 months, 2 years, and 5 years, with 72% achieving air-bone gap <20 dB and 90% achieving <30 dB 4.
- Stapedectomy with prosthesis (e.g., Teflon piston) provides more durable results 2, 3.
Oval window involvement with chronic inflammation:
- Two-stage surgery is usually required 3.
- First stage addresses the inflammatory process; second stage addresses the stapes fixation.
Important Surgical Considerations:
- Sclerotic plaques are most commonly found in the attic (72% of cases) 2.
- Do not remove tympanosclerotic deposits that are asymptomatic or not contributing to hearing loss 3.
- Surgical treatment is safe with no reported cases of profound hearing loss in the largest series 4.
- Recurrence of tympanosclerosis itself is uncommon, though refixation from fibrous scarring can occur with mobilization procedures 5.
Non-Surgical Management Options
If Surgery Fails or is Not Feasible:
Audiological rehabilitation with hearing amplification should be offered 1, 6, 3:
- Conventional hearing aids are appropriate for unilateral conductive loss 1.
- Contralateral routing of signal (CROS) hearing aids can be considered, which place a microphone on the affected ear and transmit sound to the better-hearing ear 1.
- Implantable hearing devices may be an option if conventional amplification fails 3.
Counseling Points:
Educate the patient about 1:
- The nature of tympanosclerosis as a sequela of prior middle ear inflammation 2, 5.
- Expected surgical outcomes: hearing improvement occurs in the majority, but results vary by location of involvement 4.
- Stapes footplate fixation has the worst prognosis for hearing restoration 2.
- The possibility that hearing aids may be needed if surgery is unsuccessful or declined 3.
Common Pitfalls to Avoid
- Do not assume all tympanosclerosis requires surgery—only functionally significant cases warrant intervention 3.
- Do not perform stapes mobilization as definitive treatment—stapedectomy provides more durable results due to inevitable fibrous refixation after mobilization 2, 5.
- Do not remove all visible tympanosclerosis—only address deposits causing functional impairment 3.
- Ensure audiometry is performed before and after treatment to objectively document outcomes 2.
Expected Outcomes
- Type 1 tympanoplasty (no ossicular involvement) has the best hearing results 2.
- Overall, 27% of patients achieve air-bone gap of 0-20 dB postoperatively 2.
- For stapes surgery specifically, 72% achieve air-bone gap <20 dB at 6 months 4.
- Hearing results are comparable to other chronic ear diseases requiring ossicular reconstruction 4.