What are the treatment options for otosclerosis?

Treatment Options for Otosclerosis

For otosclerosis causing conductive or mixed hearing loss, stapedotomy is the superior first-line treatment over hearing aids, providing better quality of life, hearing outcomes, and patient satisfaction, with hearing aids reserved for surgical non-candidates or as adjunctive therapy. 1

Diagnostic Confirmation

• Audiometric evaluation must include air and bone conduction thresholds to distinguish conductive from sensorineural components, as this directly determines treatment selection 2
• CT imaging of the temporal bones should be obtained to assess the extent of otosclerotic involvement, particularly to identify cochlear involvement (retrofenestral otosclerosis) which affects surgical planning 3, 4
• Speech discrimination scores at 60 dB must be measured with well-fitted hearing aids, as this is the most critical factor in determining candidacy for stapedotomy versus cochlear implantation in advanced disease 4

Treatment Algorithm by Disease Severity

Mild to Moderate Conductive Loss (Air-Bone Gap <40 dB, PTA <60 dB)

Stapedotomy should be offered as first-line treatment for patients with:

• Pure conductive hearing loss or minimal sensorineural component 1, 4
• Air-bone gap ≥30 dB 1
• Good speech discrimination scores 4

Stapedotomy provides superior outcomes compared to hearing aids, including:

• Improved quality of life scores (+10.4 points on Glasgow Health Status Inventory) 1
• Better pure-tone averages (11.1 dB improvement) and air-bone gap closure (11.8 dB) 1
• Superior binaural hearing with improved sound localization (14.5 degrees better accuracy) 1
• Significant tinnitus reduction (28.7-point improvement on visual analog scale) 1
• Higher patient satisfaction 1

Hearing aids are appropriate for:

• Patients who decline surgery 5
• Those with medical contraindications to surgery 3
• Bilateral disease where staged surgery is planned (temporary use in contralateral ear) 5

Far-Advanced Otosclerosis (PTA 60-85 dB, Mixed Loss)

Stapedotomy with hearing aids should be attempted first, even in far-advanced disease 4:

• 60% of patients achieve word recognition scores >50% with stapedotomy alone, requiring no further intervention 4
• This approach avoids the surgical complexity and risks of cochlear implantation in otosclerotic bone 4
• Preoperative factors (PTA, air-bone gap, CT staging) do not reliably predict stapedotomy success, so surgical trial is justified 4

Cochlear implantation should be considered when:

• Word recognition scores remain ≤50% at 60 dB despite well-fitted hearing aids after stapedotomy 4
• Severe to profound bilateral sensorineural hearing loss (PTA >85 dB) with inadequate benefit from hearing aids 3
• Primary cochlear implantation may be considered if extensive retrofenestral involvement is documented on CT, though stapedotomy should still be discussed 3, 4

Important surgical consideration: Advanced radiological staging (extensive cochlear otosclerosis on CT) significantly increases surgical difficulty during cochlear implantation, favoring an initial stapedotomy approach when feasible 4

Hearing Aid Considerations in Otosclerosis

Hearing aids face specific challenges in otosclerotic mixed hearing loss 5:

• Patients with mixed-type impairment have significantly more difficulty utilizing amplification compared to pure conductive losses 5
• Pure conductive losses ≤60 dB generally use hearing aids well, provided adequate power and gain 5
• Post-stapedotomy patients with residual sensorineural loss may experience severe recruitment, requiring compression-type hearing aids and patient counseling about adjustment period 5

Audiologic Rehabilitation and Counseling

Counseling must address realistic expectations 6:

• Stapedotomy typically closes the air-bone gap but does not restore normal hearing if sensorineural component exists 1
• Tinnitus improves significantly with stapedotomy but may not completely resolve 1
• Hearing aids improve communication but do not provide the same quality of life benefits as successful surgery 1

Referral to support organizations such as the Hearing Loss Association of America should be offered for adjustment counseling 7, 6

Follow-Up Protocol

• Audiometric evaluation should be obtained at 3-6 months post-treatment to assess outcomes and determine if communication goals are met 6
• Annual audiometry is recommended to monitor for disease progression, as otosclerosis can be progressive 6
• For stapedotomy patients, long-term follow-up monitors for late conductive recurrence or progression of sensorineural component 4

Critical Pitfalls to Avoid

Do not assume all otosclerosis patients are good hearing aid candidates - mixed losses perform poorly with amplification alone 5

Do not proceed directly to cochlear implantation in far-advanced disease without considering stapedotomy first - 60% achieve excellent results with the simpler procedure 4

Do not rely on preoperative audiometric or radiological factors to exclude patients from stapedotomy - no reliable predictive factors exist for surgical success in advanced disease 4

Do not neglect tinnitus assessment and counseling - stapedotomy provides significant tinnitus relief that hearing aids do not 1