Which ear should be operated on first in a patient with otosclerosis and a 70 dB hearing loss in one ear and a 56 dB hearing loss in the other, with a small central perforation in the ear with the 70 dB hearing loss?

Surgical Management of Otosclerosis with Concurrent Tympanic Membrane Perforation

Direct Recommendation

You should operate on the ear with 56 dB hearing loss first, performing stapedotomy alone, and defer any intervention on the 70 dB ear with perforation until after assessing the functional outcome of the first surgery. The small "insignificant" anterior perforation in the worse-hearing ear does not require closure before stapedotomy if you ultimately decide to operate on that ear, as both procedures can be performed simultaneously if needed 1.

Rationale for Operating on the Better Ear (56 dB) First

Hearing Preservation and Optimization

• The 56 dB ear represents moderately-severe hearing loss with significantly better baseline function than the 70 dB ear (severe loss) 2.
• Stapedotomy in the better-hearing ear offers superior probability of achieving serviceable hearing (Class A or B: discrimination ≥50%, pure tone average ≤50 dB), which is critical for quality of life 2.
• Operating on the better ear first maximizes the chance of achieving binaural hearing, which is essential for speech perception in noise, sound localization, and overall communication function 2.

Surgical Success Rates Favor Better Baseline Hearing

• Stapedotomy yields more stable long-term hearing results compared to stapedectomy, with less deterioration over time 3.
• Ears with better preoperative hearing (56 dB versus 70 dB) have higher success rates for air-bone gap closure to ≤10 dB and meaningful functional improvement 4.
• In far-advanced otosclerosis (>70 dB), hearing improvement occurs in only 42-67% of cases depending on bone conduction measurability, compared to much higher success rates in moderate losses 4.

Risk Mitigation Strategy

• If complications occur during surgery on the 56 dB ear (cochlear hearing loss, complete sensorineural loss), the patient still retains the 70 dB ear as a backup 3, 5.
• Conversely, operating first on the 70 dB ear risks leaving the patient with only the unoperated 56 dB ear if complications arise—a less optimal outcome.
• Unilateral hearing loss, even after successful surgery, leaves 33% of patients with severe hearing disabilities requiring amplification 6.

Management of the Perforation in the 70 dB Ear

Perforation Does Not Require Staged Repair

• Small central perforations in the anterior quadrant do not necessitate separate tympanoplasty before stapedotomy 1, 7.
• If you later decide to operate on the 70 dB ear, both the perforation closure and stapedotomy can be performed in a single procedure using standard tympanoplasty techniques with ossicular reconstruction 1, 7.
• Tympanoplasty alone (without addressing the otosclerotic stapes fixation) would not improve the conductive hearing loss from otosclerosis, making staged procedures unnecessary 1.

Considerations for the 70 dB Ear

• The 70 dB hearing loss represents severe hearing impairment, where stapedotomy success rates are lower and functional outcomes less predictable 4.
• If bone conduction thresholds are poor (>60 dB) or unmeasurable in this ear, the likelihood of achieving serviceable hearing drops to 42-50% 4.
• The presence of a perforation adds minimal additional surgical complexity but does not change the fundamental decision-making about which ear to operate first 7.

Surgical Technique Recommendation

Stapedotomy Over Stapedectomy

• Stapedotomy (0.4-0.6 mm fenestra with piston prosthesis) should be your technique of choice for both ears 3.
• While partial or total stapedectomy may show slightly better short-term hearing gains at 1 year, stapedotomy provides more stable results over 3+ years with less sensorineural deterioration 3.
• No cases of cochlear hearing loss (>15 dB) occurred in a series of 162 stapedotomy procedures, demonstrating excellent safety 3.

Long-Term Hearing Expectations

Realistic Counseling Points

• Both air and bone conduction thresholds deteriorate over 10+ years post-stapedectomy, with operated ears showing worse thresholds than age-matched controls 5.
• At 10 years, 70% of operated ears maintain hearing ≤30 dB and 88% maintain ≤40 dB at speech frequencies (500-2000 Hz) 5.
• In 90% of patients with bilateral otosclerosis who undergo unilateral surgery, the operated ear maintains better hearing than the unoperated ear long-term 5.
• Postoperative symptoms include mild dizziness (33%), sound quality changes (80%, usually temporary), and hyperacusis (20%) 6.

Common Pitfalls to Avoid

• Do not operate on the worse ear first simply because it has "more to gain"—this ignores the lower probability of success and higher risk of leaving the patient with inadequate bilateral hearing 4, 6.
• Do not stage the perforation repair separately from stapedotomy if you ultimately operate on the 70 dB ear—combined procedures are safe and effective 1, 7.
• Do not assume that closing the air-bone gap alone defines success—functional hearing for speech discrimination and binaural processing are the true outcomes that matter for quality of life 2, 6.
• Ensure preoperative tuning fork testing (256 Hz Rinne test) to confirm conductive component, especially in the 70 dB ear where sensorineural contribution may be significant 2, 4.