What is the treatment for otosclerosis?

Treatment for Otosclerosis

For otosclerosis causing conductive hearing loss, stapedotomy surgery is the primary treatment option, with hearing aids as an alternative for those who decline surgery or have contraindications; advanced cases with severe-to-profound mixed hearing loss may require cochlear implantation. 1, 2

Initial Diagnostic Confirmation

Before treatment, confirm the diagnosis through:

• Audiometry showing conductive or mixed hearing loss with characteristic air-bone gap, particularly at lower frequencies 2, 3
• Carhart notch (bone conduction dip at 2000 Hz) present in approximately 81% of cases 2
• Gelle test (negative in 92% of otosclerosis cases) 2
• High-resolution CT of temporal bone showing otosclerotic foci in approximately 46% of cases, though imaging is not required for diagnosis 2, 4
• Tympanometry typically showing Type A (68%) or Type As (22%) patterns 2

Treatment Algorithm Based on Hearing Loss Severity

For Mild-to-Moderate Conductive Hearing Loss

Stapedotomy with piston prosthesis implantation is the definitive surgical treatment 2, 4:

• Achieves air-bone gap closure to 13-16 dB at speech frequencies (500 Hz-2 kHz) 2
• Improves bone conduction thresholds at 250 Hz, 1 kHz, and 2 kHz by 2-4 dB 2
• Laser-assisted stapedotomy provides excellent outcomes with minimal trauma 2

Hearing aids are appropriate for patients who:

• Decline surgery 5, 4
• Have medical contraindications to surgery 1
• Prefer non-invasive management 6
• Have unilateral disease with adequate contralateral hearing 6

For Advanced Otosclerosis with Severe-to-Profound Mixed Hearing Loss

Decision-making requires systematic evaluation 1:

1. Assess speech discrimination score: Poor scores (<50%) suggest cochlear involvement 1
2. Review CT classification: Extensive cochlear otosclerosis (retrofenestral involvement) indicates higher surgical risk 1
3. Measure air-bone gap: Significant conductive component (>30 dB) may still benefit from stapedotomy 1

Treatment options based on assessment 1:

• Cochlear implantation for severe-to-profound hearing loss when hearing aids provide insufficient benefit, particularly with poor speech discrimination 1, 7
• Stapedotomy plus hearing aids may still be effective if significant air-bone gap persists and speech discrimination is preserved 1
• Hearing aids alone for patients declining surgery or with contraindications 1, 5

Conservative Medical Management

Sodium fluoride therapy may have a role in preventing progression of hearing loss, though evidence is limited 5. This is not a primary treatment but may be considered as adjunctive therapy in progressive cases 5.

Audiological Rehabilitation

All patients require counseling about 7, 6:

• Impact on communication, safety, and quality of life 7
• Benefits of audiological rehabilitation regardless of treatment choice 7
• For surgical candidates: realistic expectations about outcomes and potential complications 4

Follow-up audiometry should be obtained 7:

• At conclusion of treatment 7
• Within 6 months of treatment completion 7
• At 3-6 month intervals if surveillance is chosen for minimal hearing loss 6

Important Clinical Considerations

Common pitfalls to avoid:

• Delaying audiological rehabilitation leads to auditory deprivation and poorer outcomes 7
• Failing to distinguish otosclerosis from other causes of conductive hearing loss (otosclerosis typically presents with normal otoscopy, no imbalance symptoms, and progressive bilateral involvement) 3
• Not obtaining formal audiometry before treatment decisions—physical examination alone is insufficient 6

Surgical complications specific to otosclerosis include difficulty with cochlear implant electrode insertion due to cochlear otosclerosis, requiring careful preoperative CT evaluation 1, 4.