Treatments: Otosclerosis
General information on treatment options for otosclerosis, including observation, hearing aids, stapes surgery, cochlear implantation, and medical therapy.
Overview of treatment options
Otosclerosis is a condition in which abnormal bone growth around the small bones of the middle ear—especially the stapes, the smallest bone in the body—prevents them from vibrating normally. This leads to gradual hearing loss, and sometimes ringing in the ears (tinnitus) or dizziness. More information on the condition itself is available on the page about otosclerosis.
There are several ways to manage otosclerosis, ranging from simply monitoring the condition to surgery. The approach used can depend on how severe the hearing loss is, whether one or both ears are affected, personal preferences, and overall health. Each option is described below.
Observation (watchful waiting)
For people with very mild hearing loss, or for those who do not wish to pursue hearing aids or surgery, one approach is simply to monitor the condition over time. This involves periodic hearing tests (audiometry) to track whether the hearing loss is getting worse. Observation does not stop or slow the underlying disease, but it avoids the risks and costs of other treatments until they are needed. If hearing loss progresses to the point that it interferes with daily life, hearing aids or surgery can be considered at that time.
Hearing aids
Hearing aids are a safe, non-surgical way to improve hearing. They work by amplifying sound so that it can pass more effectively through the stiffened middle ear to the inner ear. Modern hearing aids are effective and are one option for people who prefer to avoid surgery or who are not candidates for it. More general information is available on the page about hearing loss treatments.
Hearing aids do have some drawbacks. They amplify sound but do not correct the underlying problem, so hearing may continue to decline as the disease progresses. They require ongoing maintenance, batteries, periodic cleaning of earwax, and eventual replacement. Some people develop irritation or infection of the ear canal, or find the devices uncomfortable, and some dislike the visibility of wearing a device. Even so, for many people hearing aids provide excellent hearing improvement without any of the risks of an operation.
Stapes surgery: stapedotomy and stapedectomy
Surgery aims to correct the underlying mechanical problem by bypassing or replacing the fixed stapes bone, restoring the normal transmission of sound to the inner ear. There are two closely related operations:
Stapedotomy, the more commonly performed procedure today, involves making a tiny opening in the base (footplate) of the fixed stapes bone and inserting a small prosthesis (an artificial piston).
Stapedectomy involves removing more of the stapes bone and replacing it with a prosthesis.
In both operations, a prosthesis is connected to one of the remaining middle ear bones (the incus) so that sound vibrations can once again reach the inner ear. Compared with stapedectomy, stapedotomy is generally associated with a lower risk of complications and better results in the high-frequency range, which is one reason it has become the preferred approach for many surgeons.
How the surgery is done. Stapes surgery is a delicate microsurgical procedure, usually performed under a microscope or endoscope. The surgeon reaches the middle ear either through the ear canal or through a small incision near the opening of the ear, so there is usually no visible scar. The abnormal, fixed portion of the stapes is removed, an opening is made, and the prosthesis is put in place and secured. The site is then sealed with a small amount of the patient’s own tissue to protect the inner ear. The operation typically takes about an hour and is often done on an outpatient basis, meaning most people go home the same day.
Expected recovery. Hearing may sound muffled at first because of normal swelling, healing, and ointment or packing placed in the ear. A formal hearing test is usually done a few weeks after surgery to measure the final result. Restrictions on heavy lifting, straining, nose-blowing, air travel, and getting water in the ear are commonly used for a period of time after surgery. Temporary dizziness or altered taste is common in the early days and usually resolves. Stapes surgery is highly successful, with roughly 90–95% of people experiencing improved hearing.
Possible risks. Although stapes surgery is considered very safe, it is not without risk. Possible complications include:
Worsening of hearing, and in rare cases (well under 1%) complete loss of hearing in the operated ear
Dizziness or vertigo, usually temporary but occasionally persistent
New or louder tinnitus (ringing in the ear)
Temporary changes in taste, due to a nearby nerve
Rarely, a leak of inner ear fluid or the development of scar tissue that requires additional treatment
The possibility that a repeat (revision) operation may be needed if the prosthesis shifts or hearing loss returns
A sudden drop in hearing or new severe dizziness after surgery can be a sign of a treatable complication, and such changes are generally evaluated promptly by the surgical team.
Cochlear implantation for advanced cases
When otosclerosis becomes very advanced and affects the inner ear (cochlea) as well as the middle ear, hearing loss can become severe or profound. In these situations, hearing aids and stapes surgery may no longer provide adequate benefit. A cochlear implant—a surgically placed device that bypasses the damaged hearing structures and directly stimulates the hearing nerve—can restore useful hearing and speech understanding.
Cochlear implantation in advanced otosclerosis often produces excellent improvements in the ability to understand speech. However, it is a more complex and expensive procedure than stapes surgery. The abnormal bone can make the operation technically challenging, and one particular consideration is unwanted stimulation of the nearby facial nerve, which sometimes requires adjustment of the device’s programming. Despite these challenges, cochlear implantation is a well-established and valuable option for people with far-advanced disease.
Medical therapy
There is no medication that can cure otosclerosis or reverse hearing loss that has already occurred. However, certain medications have been used in an attempt to slow the abnormal bone activity, particularly when the disease appears to be in an active phase. Sodium fluoride is the most commonly used agent and may help stabilize hearing and reduce dizziness in some people, though it can have side effects and requires regular monitoring. Bisphosphonates—drugs also used for other bone conditions such as osteoporosis—are sometimes used as an alternative when sodium fluoride is not tolerated, or as an add-on therapy, and may help with associated tinnitus. The evidence supporting medical therapy is limited, and it does not replace hearing aids or surgery; rather, it is used in selected cases in an effort to slow disease progression.
Factors in choosing an approach
The treatment approach depends on the individual: the degree of hearing loss, whether one or both ears are involved, general health, lifestyle, and personal preference. Many people do very well with either hearing aids or stapes surgery, and these options can be reconsidered over time as the situation changes. Decisions about treatment are individualized and are typically made between a person and his or her own physician.