Very far-advanced otosclerosis: stapedotomy or cochlear implantation

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1 Acta Oto-Laryngologica, 2007; 127: ORIGINAL ARTICLE Very far-advanced otosclerosis: stapedotomy or cochlear implantation MARIE-NOËLLE CALMELS 1, CORINTHO VIANA 1,2, GEORGES WANNA 1, MATHIEU MARX 1, CHRIS JAMES 1, OLIVIER DEGUINE 1, & BERNARD FRAYSSE 1 1 Department of Otology-Neurotology and Skull Base Surgery, Purpan Hospital, CHU Toulouse, Toulouse, France and 2 Department of Otolaryngology, Hospital das Clinicas, Universidade Federal de Pernambuco, Recife, Brazil Downloaded By: [CDL Journals Account] At: 13:36 10 April 2009 Abstract Conclusion. Every patient with severe or profound hearing loss must have a temporal bone high-resolution computed tomography (CT) scan. Stapedotomy is a simple, safe and low-cost procedure compared with cochlear implantation and can provide very good results. This can justify our decision to propose stapedotomy at the initial treatment in patients with very far-advanced otosclerosis. In cases of hearing failure after stapes surgery, cochlear implantation is an option. Objective. This study aimed to find the best first intention treatment of very far-advanced otosclerosis. Materials and methods. This was a retrospective study and included 14 patients with non-measurable preoperative bone and air conduction thresholds and otosclerosis on temporal bone high-resolution CT scan. Stapes surgery followed by a well fitted hearing aid was the initial treatment in 11 patients and cochlear implantation in 7 patients, including 4 patients who had poor results after stapedotomy. Objective and subjective audiometric results were studied and compared between stapedotomy and cochlear implantation groups. Results. Objective and subjective results were statistically better in the cochlear implant group than in the stapedotomy group. However, four patients in the stapedotomy group had comparable results to the patients with cochlear implants. Keywords: Otosclerosis, stapes surgery, cochlear implant, hearing loss, speech perception Introduction Far-advanced otosclerosis was first described by House and Sheehy in 1961 [1]. This diagnosis described patients suffering from a long-term otosclerosis, with an air conduction threshold of 85 db or worse and a non-measurable bone conduction threshold, due to the limitation of audiometric equipment. Iurato et al. [2] proposed the term very far-advanced otosclerosis, for otosclerotic patients with non-measurable air and bone conduction thresholds on a standard clinical audiometer resulting in a blank audiogram. In the present study we defined very far-advanced otosclerosis by audiometric and radiological criteria as follows. Audiometric criteria: dissyllabic words speech discrimination score below 30% at 70 db with a well fitted hearing aid (corresponding to the indication for cochlear implantation in a patient with severe hearing loss) and a blank audiogram. Radiological criteria: otosclerosis lesion on the temporal bone high-resolution computed tomography (CT) (Figure 1). The main goal of this study was to analyse whether very far-advanced otosclerosis patients who are also candidates for a cochlear implantation may benefit from a stapedotomy as the first option of treatment. Materials and methods A retrospective study was performed. Between 1993 and 2003, 14 patients with very far-advanced otosclerosis have been treated in our Department of Otology. These patients presented a severe or profound hearing loss with dissyllabic words discrimination below 30% at 65 db with a hearing aid and otosclerotic foci in temporal bone CT (Table I). Two surgical options were proposed to these patients: stapedotomy under local anesthesia or cochlear implantation. It was explained that the stapedotomy Correspondence: M.N Calmels, MD, ENT Department, Hôpital Purpan, 1 Place du Dr Baylac, Toulouse Cedex, France. Tel: / Fax: / calmels.mn@chu-toulouse.fr (Received 27 April 2006; accepted 10 August 2006) ISSN print/issn online # 2007 Taylor & Francis DOI: /

2 Treatment of very far-advanced otosclerosis 575 Downloaded By: [CDL Journals Account] At: 13:36 10 April 2009 Figure 1. Pericochlear focus on CT scan. can be sufficient and that in case of failure of the first option, the second surgery can be carried out without any more difficulties. The patients were divided into two groups. The first group, group A, was composed of 11 patients, 6 women and 5 men. Every patient had a 0.6 mm calibrated stapedotomy and received a titanium piston prosthesis. They were fitted with an appropriate hearing aid 2 months after the surgery and received care from a speech therapist. The second group (B) was composed of seven patients, five women and two men, who were cochlear implant recipients. In this group, four patients (three women and one man) had a stapedotomy without any benefit before their implantation and three persons (two women and one man) were directly implanted according to their choice and our surgical indication. The four patients with an initial stapedotomy had the same surgical and follow-up conditions as group A, before the implantation. Cochlear implantation was performed by a conventional posterior tympanotomy approach; the insertion of the electrodes was made by an anteroinferior cochleostomy or by the round window into the scala tympani. Four patients received a Nucleus system 22 and three received a Nucleus system 24. Implanted patients started their rehabilitation 4 weeks after the surgery. Preoperative audiogram and speech discrimination were evaluated as well as the extension of the otosclerotic foci on the CT scans. The otosclerotic lesion was classified in four localizations: vestibular, pericochlear, pericochlear with round window involvement and pericochlear with endosteum involvement. Postoperative objective measures, threshold and speech recognition, were studied and compared with Table I. Audiological, surgical and biographic details of patients. Mean postoperative bone conduction Postoperative dissyllabic words speech discrimination at 70 db Duration of sound deprivation CT scan Surgery side Type of surgery Speech discrimination Age (years) Patient Group 1 A 72 0% L/20% R 5 years RW Left Stapedotomy 60% 70 db 2 A 52 0% 5 years PC Right Stapedotomy 80% 70 db 3 A 75 0% 6 months PC Right Stapedotomy 80% 65 db 4 A 73 0% L/20% R 5 years PC Right Stapedotomy 20% Vib 5 A 77 20% 1 year S/V Left Stapedotomy 100% 50 db 6 A 73 0% 6 months RW Left Stapedotomy 20% Vib 7 A 74 0% 1 year EN Left Stapedotomy 20% Vib 8 B 60 0% 1 year RW Left Stapedotomy/ CI, % 30 db 9 B 59 0% 1 year S/V Left Stapedotomy/ CI, % 35 db 10 B 70 0% L/20% R 39 years PC Left Stapedotomy/ CI, % 35 db 11 B 68 0% 14 years S/V Left Stapedotomy/ CI, % 35 db 12 B 65 0% 1 year S/V Left CI, % 40 db 13 B 53 0% 10 years S/V Left CI, % 35 db 14 B 72 0% 6 years EN Left CI, % 35 db CT, high-resolution computed tomography; PC, pericochlear focus; RW, pericochlear and round window focus; EN, pericochlear and endosteum involvement; S, stapes focus; V, vestibular focus; STAPEDO, stapedectomy; CI, cochlear implantation.

3 576 M.N. Calmels et al. preoperative values in the same group and between the two groups. Postoperative subjective measures were analysed by sending a questionnaire to every patient. The questionnaire used the APHAB Abbreviated Profile of Hearing Aid Benefit. We evaluated the quality of life after the surgery, the facility of communication, telephone use and the degree of hearing status satisfaction. The influence of the duration of deprivation, speech recognition before surgery, extension of the otosclerotic lesion on the CT scan and previous ear surgery was studied to research prognostic factors of outcome. Results In our department, 14 patients (6 males and 8 females) satisfied the inclusion criteria for very faradvanced otosclerosis. The mean age was 67 years (range 5277 years) and the mean time of hearing deprivation was 77 months (range 6 months to 39 years). Preoperative bone and air conduction thresholds were not measurable in any of the patients. Preoperatively 13 patients had 0% speech recognition at 70 db with well fitted hearing aids and one patient had 20%. For group A (stapedotomy group), recognition of disyllabic words at 70 db was statistically significantly better after surgery (p B/0.001). However, preoperative and postoperative bone conduction thresholds were not statistically significantly different (p/0.02). As regards subjective results in group A (stapedotomy group), three patients used the telephone and two complained of tinnitus. Overall general satisfaction varied from 30% to 90%. Age, time of deprivation and site of otosclerotic foci did not affect the outcome of the stapedotomy (p /0.08 and p /0.1, respectively). In group B (cochlear implant group), the objective evaluation demonstrated a highly statistically significant difference between the preoperative and postoperative results for bone conduction thresholds and for speech discrimination at 70 db (p B/0.001). In this group, five patients used the telephone and three complained of tinnitus. The overall general satisfaction was /95%. If we compared the objective results between groups A and B, bone conduction thresholds and speech discrimination in the cochlear implant group were statistically better than for the stapedotomy group (p B/0.001 and p /0.0018, respectively). Similarly, the implant group showed statistically better subjective results (p/0.001) (Table II). In analysing individual results of the patients in group A (Tables I and II), four patients had objective and subjective outcome comparable to those of the patients in group B: patient 5 had 100% of speech discrimination at 70 db, 50 db of bone conduction level and used the telephone; patients 2 and 3 had 80% of dissyllabic word speech discrimination at 70 db and bone conduction level at 70 and 65 db, respectively. Patient 3 used the telephone without difficulty. Patient 1 had 60% of speech discrimination at 70 db and 70 db of bone conduction level. These four patients showed a general satisfaction median of 80%. Also in group A, three patients had only 20% speech discrimination at 70 db (Tables I and II). We did not find predictive factors of results between these two groups of patients. In group B, four patients had a speech recognition score/80% at 70 db, and the other three patients scored between 60% and 70%. Only two patients Table II. Subjective results in group A (stapedotomy) and group B (cochlear implantation). Patient no. Group Gender Satisfaction Telephone use Tinnitus 1 A F 50% / / 2 A M 90% / 3 A F 90% / / 4 A F 40% / / 5 A M 60% /// / 6 A M 60% / / 7 A M 30% / / 8 B M 100% / / 9 B F 90% /// / 10 B F 90% /// / 11 B F 100% / / 12 B F 100% / / 13 B F 90% / / 14 B M 90% / /

4 (patients 11 and 12) could not use the telephone. All the patients had indicated /90% satisfaction on the questionnaire (Tables I and II). Preoperative stapes surgery did not change the results of patients in group B. Discussion Usually, post-lingually deafened adults with severe to profound hearing loss are candidates for cochlear implantation. In our department at the time of the study, a speech recognition score of 30% on an open set dissyllabic word test is considered an appropriate upper limit for preoperative performance in determining cochlear implant candidacy [3]. Under these conditions, temporal CT should be performed to detect far-advanced otosclerosis. Similarly, patients with personal or familial history of otosclerosis and severe to profound hearing loss must have a radiological examination to evaluate the extension of the lesion and the degree of endosteal involvement [4]. In case of intra-labyrinthine involvement, an MRI can be performed to explore cochlear status. In our study, patients with very far-advanced otosclerosis were within the audiometric criteria of cochlear implantation and radiological criteria of otosclerosis. Fourteen patients were included in the series since Eleven of these patients were treated initially by stapedotomy. The usual criteria for success of stapedotomy (i.e. closure of the airbone gap to 10 db or less) cannot be used in very far-advanced otosclerosis cases, because the air and bone conduction levels are immeasurable before the surgery. However, we estimated the success of the surgery with objective and subjective parameters: improvements in speech recognition, aidable hearing level and patient satisfaction. Within our population, patients in the stapedotomy group showed a statistically significant postoperative improvement of speech discrimination after surgery (p B/0.001), and 36% of them had useful hearing after the surgery with a well fitted hearing aid. After stapedotomy surgery, seven patients hearing was improved (64%), four patients (36%) have a disyllabic word recognition at 70 db of /60%, five patients (45%) have a percentage of global satisfaction /50% and three of them can use the telephone. Some studies have also reported results of stapedotomy for far-advanced otosclerosis. Shea et al. [5] demonstrated that 42% of 60 patients with absent preoperative bone conduction thresholds had measurable thresholds after the surgery and the hearing was restored to an aidable level. In the latter Treatment of very far-advanced otosclerosis 577 population, discrimination after stapedotomy improved by 15%. In the study by Khalifa et al. reported in 1998, the word recognition scores improved in 67% of cases (six operated ears) and 50% of the patients were satisfied with the result [6]. Lippy et al. showed in a group of 24 patients with far-advanced otosclerosis that word recognition scores had improved in 16% at 1 month after the stapes surgery and continued to improve to reach 32.7% after 2 years. They attributed these additional increases of word recognition score to acclimatization [7]. In the same way, Frattali and Sataloff reported that 67% of the patients were aidable after stapedectomy for far-advanced otosclerosis; however, three patients had a measurable preoperative bone conduction level [8]. In 1996, Glasscock et al. showed that stapedectomy was effective in 60% of patients with advanced and far-advanced otosclerosis [9]. We tried to find some predictive factors of results of stapedotomy in our series, and studied the influence of age, duration of auditory deprivation and extension of otosclerotic lesions on CT scan. None of these factors appeared to systematically influence the results. We also compared the stapedotomy outcome and the localization of the otosclerotic foci at CT, but no statistically significant difference was found. So we agree that the site of the otosclerotic foci is not a negative predictive factor for the surgery outcome in very far-advanced otosclerosis. This confirms the results of Schuknecht and Barber, who failed to show any correlation between bone conduction thresholds and size of lesion, activity of lesion, involvement of the endosteum, or presence of round window lesion in 164 temporal bone examinations [10]. Since 1996, the treatment of very far-advanced otosclerosis in our department has changed from cochlear implantation to an initial stapedotomy, and we reserve cochlear implantation for failed cases. Failure was defined by no improvement of threshold levels or speech recognition with well fitted hearing aids at 3 months after the surgery and when the patient is not satisfied [9]. The seven patients who received a cochlear implant (group B) had an improvement in all the objective measured parameters: bone conduction level and dissyllabic words speech discrimination scores. Ruckenstein et al. studied cochlear implanted patients with advanced otosclerosis with an excellent hearing benefit [11]. Successful outcomes after cochlear implantation can be explained by the physiopathology of the otosclerosis, which first affects the lateral wall of the cochlea, resulting in degeneration of the spiral

5 578 M.N. Calmels et al. ligament and stria vascularis, and secondarily the organ of Corti [8,11,12]. When we compare objective and subjective results between the two groups, bone conduction levels and dissyllabic words speech discrimination are statistically better in the implanted group than in those patients with stapedotomy alone. In the same way, subjective outcomes are better after cochlear implantation. However, when we analysed the stapedotomy group on an individual basis, we found four patients with similar results to the implanted group. The incidence of successful stapedotomy for very far-advanced otosclerosis was near to 30% [5]. In our stapedotomy group, 36.4% (4 of 11) of the patients had comparable results to the cochlear implant group, which is also comparable to results in the literature to date. Although the hearing results after cochlear implantation in otosclerosis are consistent and stable with time, the authors agree that the stapedotomy can be the first procedure for very far-advanced otosclerosis, because it is a simple, cost-effective procedure and will not affect the outcome if cochlear implantation proves necessary. Certainly, all the patients should be informed about the possibility of a second procedure after the stapedotomy, depending on the results. Conclusion Very far-advanced otosclerosis is a difficult diagnosis. All patients who are candidates for cochlear implantation, who present a severe or profound hearing loss and a long history of a progressive hearing loss, should have a CT scan at preoperative evaluation, to rule out the diagnosis of otosclerosis. The purpose of a stapedotomy in very faradvanced otosclerosis is to improve the hearing to an effective level with a hearing aid. However, cochlear implantation could be performed with good hearing results in this type of patients. It seems that stapedotomy could be the initial treatment in very far-advanced otosclerosis, to restore the hearing level by a simple, safe and a lowcost procedure. Nevertheless, patients should be informed that the results can be insufficient or can deteriorate with time. In these cases, a cochlear implant must be proposed. References [1] House HP, Sheehy JL. Stapes surgery: selection of the patient. Ann Otol Rhinol Laryngol 1962;/70:/ [2] Iurato S, Ettorre GC, Onofri M, Davidson C. Very faradvanced otosclerosis. Am J Otol 1992;/13:/4827. [3] Fraysse B, Dillier N, Klenzner T, Laszig R, Manrique M, Morera Perz C, et al. Cochlear implant for adults obtaining marginal benefit from acoustic amplification. A European study. Am J Otol 1998;/19:/5917. [4] Shin YJ, Fraysse B, Deguine O, Cognard C, Charlet JP, Sevely A. Sensorineural hearing loss and otosclerosis: a clinical and radiological survey of 437 cases. Acta Otolaryngol (Stockh) 2001;/121:/2004. [5] Shea PF, Ge X, Shea JJ Jr. Stapedectomy for far-advanced otosclerosis. Am J Otol 1999;/20:/4259. [6] Khalifa A, El-Guindy A, Erfan F. Stapedectomy for faradvanced otosclerosis. J Laryngol Otol 1998;/112:/ [7] Lippy WH, Burkey JM, Arkis PN. Word recognition score changes after stapedectomy for far advanced otosclerosis. Am J Otol 1998;/19:/568. [8] Frattali MA, Sataloff RT. Far-advanced otosclerosis. Ann Otol Rhinol Laryngol 1993;/102:/4337. [9] Glasscock ME, Storper IS, Haynes DS, Bohrer PS. Stapedectomy in profound cochlear loss. Laryngoscope 1996;/106:/ [10] Schknecht HF, Barber W. Histologic variants in otosclerosis. Laryngoscope 1985;/95:/ [11] Ruckenstein MJ, Rafter KO, Montes M, Bigelow DC. Management of far advanced otosclerosis in the era of cochlear implantation. Otol Neurotol 2001;/22:/4714. [12] Kwok OT, Nadol JBJ. Correlation of otosclerotic foci and degenerative changes in the organ of Corti and spiral ganglion. Am J Otolaryngol 1989;/10:/112.