What is the recommended surgical procedure for a young to middle-aged adult with suspected otosclerosis and conductive hearing loss?

Stapedotomy for Otosclerosis

Stapedotomy is the recommended surgical procedure for young to middle-aged adults with otosclerosis and conductive hearing loss, offering superior high-frequency hearing outcomes and lower complication rates compared to stapedectomy. 1

Diagnostic Confirmation

Before proceeding to surgery, confirm the diagnosis with:

• High-resolution CT of the temporal bone as the first-line imaging modality to identify otospongiosis (otosclerosis), ossicular chain abnormalities, and rule out other causes of conductive hearing loss 2
• Comprehensive audiologic evaluation documenting air-conduction and bone-conduction thresholds to establish baseline hearing and quantify the air-bone gap 3

CT provides excellent delineation of the ossicular chain and bony labyrinth, which is essential for surgical planning in otosclerosis. 2 MRI is insufficient for evaluating the bony details needed in conductive hearing loss evaluation. 2

Surgical Approach: Stapedotomy vs Stapedectomy

Stapedotomy is the preferred technique based on comparative evidence:

• Better high-frequency hearing preservation with stapedotomy compared to stapedectomy 1
• Lower complication rates with small fenestra stapedotomy 1
• Comparable overall hearing improvement between both techniques, with significant air-bone gap closure in 70-85% of patients achieving ABG ≤20 dB 3, 4
• Long-term stability of hearing outcomes with both procedures 1

While stapedotomy is favored by most surgeons, if intraoperative findings necessitate conversion to stapedectomy, surgeons should proceed confidently as both techniques yield favorable outcomes. 5

Expected Outcomes

Patients can anticipate:

• Mean air-conduction threshold improvement of approximately 18-24 dB postoperatively 3, 4
• 61-70% achieving complete ABG closure (<10 dB) at speech frequencies (0.5,1,2,4 kHz) 4
• Over 94% experiencing hearing improvement of some degree 4
• Significant improvement in speech recognition thresholds 5

Complication Profile

Stapedotomy is a safe procedure with:

• Low overall complication rates (approximately 13%) 4
• Tympanic membrane perforation as the most common complication (5.6%) 4
• Negligible risk of sensorineural hearing loss when performed by experienced surgeons 3
• No increased risk of vertigo or other vestibular complications compared to stapedectomy 5

Special Considerations

For patients with mixed hearing loss (conductive plus sensorineural components):

• Stapedotomy remains effective and can improve both air-conduction and bone-conduction thresholds 3
• Preoperative counseling should address realistic expectations, as the sensorineural component will persist 3

For very far-advanced otosclerosis with profound hearing loss:

• Stapedotomy with well-fitted hearing aids should be the initial treatment approach, as it is simpler, safer, and lower cost than cochlear implantation 6
• Cochlear implantation remains an option if stapedotomy fails to provide adequate benefit 6
• Temporal bone high-resolution CT is mandatory in these cases to confirm otosclerosis and rule out other pathology 6

Critical Pitfalls to Avoid

• Do not rely on MRI for preoperative evaluation of conductive hearing loss; CT temporal bone is essential 2
• Do not proceed without comprehensive audiometry establishing baseline air and bone conduction thresholds 3
• Do not dismiss patients with mixed hearing loss as poor surgical candidates; they can achieve significant benefit from stapedotomy 3
• Ensure adequate surgical experience, as outcomes are highly dependent on surgical technique and minimizing trauma 4