Controversies about the management of otosclerosis, which began with the first report by Johannes Kessel in Jena in 1876¹ on stapedectomy, through the fenestration era, beginning in 1910,² did not end with the resurrection of the stapedectomy operation by John Shea, Jr., in 1956.³ Once stapedectomy and reconstruction of the sound-conducting mechanism of the middle ear were demonstrated by surgeons all over the world to restore hearing in most patients (with only a small number made worse), the question of what operation to do was settled. Mobilization of the stapes and fenestration of the lateral semicircular canal were no longer performed, and everyone began to perform the stapedectomy operation. Now the controversies concern on whom to perform stapedectomy, at what age, what degree of hearing loss, whether to perform the procedure on the only hearing ear, how much of the footplate of the stapes to remove, how to seal the oval window, and how to reconstruct the sound-conducting mechanism of the middle ear. What to do after a good hearing improvement, whether or not to give sodium fluoride, when and if to operate on the other ear, when to recommend a hearing aid rather than stapedectomy, and other questions continue to be debated.

Background

Controversies about the management of otosclerosis are now influenced by a dramatic change in the patient population coming for operation. When stapedectomy was resurrected in 1956, there were many patients with all degrees of hearing loss that previously had not been operated on, but that were suitable for stapedectomy. As the number of stapedectomies performed increased each year, the number performed peaked in 1962; it has since undergone a gradual decline but has not yet reached a plateau. As a result, the number of patients coming for stapedectomy is now so small that many residents do not perform even one stapedectomy during their residency, and the teachers of these residents have done so few stapedectomies as to lack sufficient experience to teach them properly. Many of the patients coming for operation now have localized anterior otosclerosis with slight or moderate hearing loss or have had one or more prior unsuccessful stapedectomy operations. There is less likelihood of achieving a good result in these previously operated ears and, more important, the chance of further hearing loss is much greater. Accordingly, the likelihood of a good result after revision operation is less, which must be explained to the patient in great detail, with a witness present, and documented in writing given to the patient.

Most importantly, failed stapedectomy, especially a bad result from revision stapedectomy, is one of the most important causes of malpractice lawsuits against otolaryngologists. Therefore, the risk of having a worse outcome must be explained to the patient in great detail, and the protocol to conduct the operation must be followed very carefully to avoid litigation. Several inflexible rules must be followed. Do not remove a wire loop from the vestibule. Do not reopen bony closure of the oval window. If a perilymph fistula is present, do not enlarge the fistula, but seal it with a living oval window seal, such as vein or fascia, and insert a prosthesis.

More than 43 years after the resurrection of the stapes operation, the sad fact is that about one-third of those who attain a good initial hearing gain, with closure or overclosure of the air–bone gap, will develop sensorineural hearing loss in excess of what would be expected from presbyacusis and therefore must return to the use of a hearing aid. This further hearing loss is due to the invasion of the margins of the cochlea by the otosclerotic focus, as in cochlear otosclerosis. To prevent this problem, we give 7.6 mg of sodium fluoride (Florical; Mericon Industries, Peoria, IL) with 200 mg of calcium carbonate with the two largest meals to all patients with extensive otosclerosis or severe sensorineural hearing loss. This is administered especially in the young or female patient to prevent invasion of the margins of the cochlea by otosclerosis.

Diagnosis

To make the diagnosis of otosclerosis suitable for operation, the following conditions must be present: (1) a history of progressive hearing loss; (2) a normal ear canal, drum, and middle ear; (3) conductive hearing loss with air–bone gap of ≥20 dB and an air conduction level of ≥30 dB for the three speech frequencies with good speech discrimination; and (4) a type A (stiff) impedance audiogram with absent stapedial reflexes.

Discussion

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