Far-Advanced Otosclerosis: Cochlear Implantation vs Stapedectomy

Abstract

\s=b\In 1981, our group, as part of a Food and Drug Administration investigator team directed by William House, performed Illinois' first cochlear implantation. We have since performed cochlear implantations in ten other persons. Since May 1980, approximately 35 severely to profoundly deaf persons per year have been referred to our clinic for evaluation. A small number of these patients had far-advanced otosclerosis. In these cases, exploratory tympanotomy and stapedectomy followed by rehabilitation with a hearing aid was a more appropriate management than cochlear implantation. Case histories and a temporal bone study of far-advanced otosclerosis are presented. (Arch Otolaryngol Head Neck Surg 1987;113:299-302) Persons with postlingual, profound sensorineural deafness who can¬ not significantly benefit from hearing aids may be candidates for cochlear implantation. Since 1981, when we first performed the procedure, 11 of our patients have received singlechannel or multichannel devices with satisfactory results. A careful review of patients referred for possible implantation has confirmed Sheehy's observation1 that patients with faradvanced otosclerosis (FAO) are bet¬ ter suited to stapedectomy and hear¬ ing aid rehabilitation than to cochlear implantation. Physicians in cochlear implantation programs should be aware of the signs that may indicate FAO, a condition that frequently goes undiagnosed. Provided there is suffi¬ cient hair-cell function, peripheral axon, and ganglion cells, surgical exploration may be beneficial in a limited number of cases. PATIENTS AND METHODSThe case records of 175 patients referred for cochlear implantation were reviewed to identify cases of FAO, defined as advanced otosclerosis where air conduction level exceeds 85 dB and bone conduction is not measurable in any of the speech frequen¬ cies on a standard clinical audiometer.2Patients with FAO are easily confused with those having conditions that may be successfully treated by cochlear implanta¬ tion, and FAO must be diagnosed with care. REPORT OF CASESCase 1.-A 62-year-old woman had suf¬ fered a progressive hearing loss on the left side over several years. She had undergone a right-sided stapedectomy in 1977, with excellent results. Physical and otoscopie examinations were normal. A profound hearing loss was present bilaterally, with absent stapedial reflexes. The patient could, however, hear with a speaking tube in the left ear. Computed tomography of the left middle ear capsule revealed mar¬ ginal thickening of the stapes footplate with otosclerotic foci in the capsule of the basal turn of the cochlea, suggesting FAO.A left-sided stapedectomy was performed with an argon laser. Findings at surgery included a rather thick footplate. The post¬ operative audiogram showed considerable improvement, from a 100+-dB level with no discrimination to a 60-to 70-dB level with 60% discrimination (Fig 1).Case 2.-A 74-year-old man described bilateral, slowly progressive hearing loss, more pronounced on the right side. He also experienced bilat...

Decision making in advanced otosclerosis: An Evidence-Based Strategy

“…The results after stapedotomy were variable: 46% to 100% of the patients achieved an improvement in hearing 5, 6, 14–25. The SD scores after stapedotomy were between 38% and 75% 5, 6, 17, 18, 21–24. Shea et al25 divided their patients into different cohorts based on the air‐ and bone‐conduction thresholds.…”

Stapedotomy in Cochlear Implant Candidates With Far Advanced Otosclerosis

“…Binaural speech recognition measurement demonstrates the benefit of binaural processing as the binaural speech recognition increased to 88% (F 3 ). and better performance in the presence of background noise (20).…”

“…The standard criterion for measuring the success of stapedotomy, closure of the air-bone gap to 10 dB or less, is not relevant in patients with FAO because bone conduction levels are often immeasurable even postoperatively (18,20,21). Likewise, the commonly used Belfast Rule of Thumb (stating that patients are likely to benefit from stapedotomy if the hearing threshold in the operated ear is brought to 30 dB HL or better or within 15 dB of contralateral ear) does not seem to be applicable for estimating the effect of stapedotomy in patients with FAO (22).…”

Stapedectomy for far-advanced otosclerosis

“…Schuknecht and Barber (1985) showed no correlation between bone-conduction thresholds and size of the lesion, activity of the lesion, involvement of endosteum or presence of a round window lesion. On the other hand, Wiet et al (1987) reported moderate diffuse loss of hair cells and loss of cochlear neurons in the basal turn. Myers and Myers (1968) found atrophy of the spiral ligament with basilar membrane rupture.…”

“…The patients must be aware not only of the risks of the procedure, but also of the relatively limited goals. Normal hearing is not expected and the patient should be cautioned that amplification via a hearing aid will probably be needed after surgery to receive the optimum potential benefit (Wiet et al, 1987). Sheehy (1978) found that in FAO the success rate was higher in those patients who had been wearing a hearing aid pre-operatively, ie.…”