What is the treatment for otosclerosis?

Treatment of Otosclerosis

For otosclerosis causing conductive hearing loss, stapedotomy is the primary treatment and should be offered as first-line therapy, as it provides superior outcomes compared to hearing aids in quality of life, hearing thresholds, binaural function, and tinnitus relief. 1

Initial Diagnostic Confirmation

• Obtain formal audiometry to quantify the degree and type of hearing loss, distinguishing conductive from sensorineural components 2
• Perform pneumatic otoscopy and tympanometry to confirm middle ear pathology and conductive hearing loss 2
• Obtain high-resolution temporal bone CT scan in all patients with severe or profound hearing loss to assess the extent of otosclerotic involvement and guide surgical planning 3, 4

Treatment Algorithm Based on Hearing Loss Severity

Mild to Moderate Conductive Hearing Loss (Air-Bone Gap Present, PTA <85 dB)

Primary recommendation: Stapedotomy

• Stapedotomy is superior to hearing aids with demonstrated improvements in quality of life scores (+10.4 points on Glasgow Health Status Inventory), pure-tone averages (-11.1 dB improvement), air-bone gaps (-11.8 dB closure), speech-in-noise recognition, sound localization, and tinnitus severity 1
• Patient satisfaction is significantly higher with stapedotomy compared to hearing aids 1
• Stapedotomy is a simple, safe, and low-cost procedure compared to cochlear implantation and can provide excellent results 3

Alternative: Hearing aids

• Conventional hearing aids are appropriate for patients who decline surgery, have medical contraindications, or prefer non-surgical management 2
• CROS hearing aids can be considered for unilateral conductive loss 2

Far-Advanced Otosclerosis (PTA <85 dB, Word Recognition Score ≤50% at 60 dB with hearing aids)

Primary recommendation: Stapedotomy as first-line treatment

• Stapedotomy should be proposed as initial treatment even in far-advanced disease, as 60% of patients achieve word recognition scores >50% requiring no further intervention 4
• Four out of 11 patients with very far-advanced otosclerosis (non-measurable bone and air conduction) achieved results comparable to cochlear implant recipients after stapedotomy 3
• Stapedotomy is justified as first-line therapy due to its simplicity, safety, and low cost compared to cochlear implantation 3

Salvage therapy: Cochlear implantation

• Cochlear implantation should be offered for incomplete recovery after stapedotomy, with 85% of patients achieving word recognition scores >50% 4
• Secondary cochlear implantation after failed stapedotomy provides excellent results with mean word recognition scores of 72% 4

Very Far-Advanced Otosclerosis with Severe Cochlear Involvement

Decision-making algorithm based on:

1. Speech discrimination score at maximum comfortable loudness with optimally fitted hearing aids 5
2. CT classification of otosclerotic involvement (otospongiotic foci around cochlea, otosclerotic foci within cochlea) 5
3. Air-bone gap magnitude 5

Primary cochlear implantation should be considered when:

• Hearing aids fail to provide optimal rehabilitation despite severe mixed hearing loss 5
• Advanced radiological stage is present on CT (note: surgical difficulties are significantly higher with advanced disease) 4
• Word recognition scores remain ≤50% with well-fitted hearing aids 4

Surveillance and Follow-Up

• Repeat audiometry at 3-6 month intervals for patients with minimal hearing loss or those under observation 2
• Annual audiometry to monitor for progression 6

Important Caveats

• Cochlear implantation gives better overall results than stapedotomy in far-advanced disease (mean WRS 75% vs 50.6%), but stapedotomy's simplicity and lower cost justify its use as first-line therapy 4
• Surgical complications during cochlear implantation are significantly higher in patients with advanced radiological stages of otosclerosis 4
• All patients with severe or profound hearing loss must have temporal bone CT before treatment decisions are made 3