original article

Otosclerosis – analysis of factors influencing the

improvement of hearing after surgical treatment
Authors’ Contribution:
A – Study Design Agnieszka Wiatr1ABCD, Kamila Szpak2BEF, Jacek Składzień1ADF, Maciej Wiatr3ABEF
B – Data Collection
C – Statistical Analysis
D – Data Interpretation
1
Chair and Clinic of Otolaryngology, Jagiellonian University Collegium Medicum, Krakow, Poland; Head: Jerzy Tomik MD PhD, prof. UJ
E – Manuscript Preparation 2
Clinical Department of Otolaryngology, University Hospital in Krakow, Poland
F – Literature Search
G – Funds Collection
3
Audiological Laboratory, Department of Otolaryngology, Jagiellonian University Collegium Medicum, Krakow, Poland;
Head: Maciej Wiatr MD PhD, prof. UJ

Article history: Received: 11.04.2022 Accepted: 12.04.2022 Published: 13.04.2022

ABSTRACT: Introduction: Otosclerosis is a disease that occurs only in humans, in the course of which there are foci of pathological
ossification in the temporal bone. The etiology of the dise ase is not fully understood. Treatment of the conductive
component of hearing loss is surgical. The results of the treatment are influenced by factors related to the surgery, the local
condition of the middle ear and the function of the inner ear.
Aim: The aim of the study is to identify factors influencing the improvement of hearing in patients treated surgically due to
otosclerosis.
Material and methods: The study included patients who underwent otosclerosis for the first middle ear surgery and under-
went stapedotomy. Considering the factors that may affect the outcome of surgical treatment, the patients qualified for the
analysis were divided into subgroups. All patients underwent a medical history and physical examination of otorhinolaryn-
gology and a complete set of audiological examinations.
Results: A statistically significant reduction in cochlear reserve was observed in all patients after stapedotomy. The be-
neficial effect of the performed treatment on the improvement of threshold values of bone conduction in patients with
mild sensorineural hearing loss was also confirmed. Intraoperative removal of adhesions present in the tympanic cavity
significantly improved hearing in terms of bone conduction values, especially at 500 Hz.
Conclusions: (1) The conducted study confirmed the influence of factors related to the local condition of the middle ear lining
on the final result of otosclerosis surgery; (2) Audiometric markers of cochlear otosclerosis, observed before surgical treat-
ment, are an unfavorable factor in the improvement of hearing after the performed treatment.
KEYWORDS: hearing improvement, otosclerosis, prognostic factors

INTRODUCTION The disease can be determined genetically or develop as a conse-

quence of persistent measles virus infection, as well as biochemi-
Hearing loss significantly reduces the quality of life and often leads to cal, immune and hormonal disorders. Despite various factors being
social isolation. Otosclerosis is one of the related causes of acquired considered in the etiology of otosclerosis, the exact pathogenesis
hearing impairment. remains unknown. Genetic studies performed to date, failed to
identify a specific gene responsible for otosclerosis, and theories
Otosclerosis is a primary focal osteodystrophy of the temporal bone. of viral infections, autoimmunity, or a link to generalized bone dis-
This disease occurs only in humans, is progressive and bilateral. Abnor- eases have not been able to explain why otosclerosis occurs only
mal bone remodeling usually takes place asymmetrically. in the structure of the temporal bone, while the rest of the human
skeleton remains completely unaffected. Recent studies on the role
Clinical manifestation of otosclerosis – conductive hearing loss, results of the RANKL/OPG/RANK triad in the formation of otosclerotic
from immobilization of the stapes in the oval window, most often in the foci suggest that the change in expression of the OPG gene (SNP
fissula ante fenestram. Otosclerotic changes may also affect the fossa of – Single Nucleotide Polymorphism rs3102734 and rs2073618) is
the round window, the labyrinth of the cochlea, the base of the stapes, associated with the onset of otosclerosis. Despite advanced re-
the posterior part of the oval window fossa, the internal auditory canal, search on the etiology and course of the disease, there is no effec-
the cochlear aqueduct and the atrial aqueduct or semicircular canals [1]. tive conservative treatment of otosclerosis [4–6].

Disease located in other parts of temporal bone than the oval window The basis for the treatment of otosclerosis is an operative pro-
fossa remains asymptomatic or leads to dysfunction of the inner ear, cedure that restores bilateral hearing. In the case of conductive
responsible for the clinical picture of cochlear otosclerosis. Sensori- hearing loss, the most commonly performed procedure – sta-
neural hearing loss, tinnitus and vestibular symptoms are observed in pedotomy, improves hearing but unfortunately does not cure the
the clinical picture [2, 3]. disease, which progresses further. The observed postoperative
OTOLARYNGOL POL, 2022: 76 (3): 1-6 DOI: 10.5604/01.3001.0015.8248 1
 original article

Tab. I. Study group characteristics.

GROUP NO. GROUP SIZE CHARACTERISTICS OF THE GROUP

Reference group

Group 0 20 Reference group – bone conduction value 0–20 dB, stapes completely immobilized in the oval window, without any
changes within the middle ear. Stapedotomy was performed.
Stapedotomy – 106 patients

Group A01 29 Stapedotomy (no other changes in the middle ear, Baseline mean bone conduction [dB]: 21–40).

Group A02 26 Stapedotomy (no other changes in the middle ear, Baseline mean bone conduction [dB]: >40 dB).

Group A1 16 times Stapedotomy. Adhesions in the middle ear spaces.

Group A2 17 Stapedotomy. Abnormalities in the lining of the space of the middle ear.

Group A3 18 Stapedotomy. Oval window obscured by the canal of the facial nerve.

Stapedectomy – 14 patients

Tab. II. Mean values of cochlear reserves and mean values of bone conduction at the beginning of treatment and after 12 months of follow-up in groups with varying degrees of
sensorineural hearing loss. in the absence of other abnormalities of the middle ear. p < 0.005.

GRUPA AVG 0 SD AVG 12 SD PK0 SD PK12 SD

Group 0 33.12 10.54 14.23 8.39 18.05 2.63 18.61 6.21

Group A 01 30.43 8.94 12.14 10.62 31.80 7.15 26.91 11.03

Group A 02 32.16 9.44 15.61 15.47 46.50 4.61 45.96 18.96

AVG average cochlear reserve before surgery. AVG12 average cochlear reserve after 12 months of observation. PK0 mean bone conduction values before surgery. PK12 mean bone conduction values
after 12 months of follow-up. In bold, statistically significant changes after 12 months of follow-up..

improvement in hearing is the result of factors directly related to All operated patients consented to surgery and participation in
the surgical procedure, function of the inner ear and possible ab- the study; the approval of the Bioethical Committee to conduct
normalities of the middle ear [7, 8]. the study was also obtained (No. 122.6120.206.2016).

Due to the inability to create a control group constituting of healthy

AIM people, a reference group (group 0) was designated, which con-
sisted of patients with otosclerosis and without other changes in
The aim of the study is to analyze selected prognostic factors af- the middle ear, in whom stapedotomy was performed. Moreover,
fecting hearing improvement in patients treated surgically for in these patients, mean value of bone conduction measurement in
otosclerosis. the operated ear was in the range: 0–20 dB. The reference group
consisted of 20 patients, including 16 women and 4 men. The
youngest patient in this group was 27 years old and the oldest was
MATERIAL AND METHODS 46 years old. Mean age was 37.53 years.

The analysis included 140 patients operated on for otosclerosis in Considering the factors that could affect the outcome of surgical
the years 2014–2020. The youngest patient was 19 years old, the treatment, patients qualified for analysis were divided into sub-
oldest 62 years old. The median age was 39.31 years. groups (Tab. I.).

Only patients who underwent stapedotomy due to otosclerosis Medical interview and physical examination of the ear, nose and
and it was their first surgery on the middle ear (126 patients) were throat as well as a set of audiological examinations were carried
included in the study. The study group consisted of 106 women out, including acoumetry, Rinne’s tests, impedance audiometry,
aged 19 to 62 years (mean age 40.33 years) and 20 men aged 27 to and threshold tonal audiometry.
59 years (average age 38.23 years).
The threshold values for air and bone conduction were determined
The remaining operated patients who underwent stapedectomy with MIDIMATE® 622 Madsen audiometer equipped with TDK 39®
(14 patients) were not included in the analysis due to the statisti- headphones. The audiometer met the ISO standards for air con-
cally small size of the group. ductivity ISO0389-1985 and for bone conduction ISO7566-1987.
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Tonal audiogram was performed immediately before surgery and Tab. III. Change in mean cochlear reserve and mean bone conduction value 12 months
after surgery in groups with varying degrees of sensorineural hearing loss, in the absence
12 months after stapedotomy. The obtained data were analyzed in of other middle ear abnormalities, p < 0.005.
accordance with the guidelines developed by the Committee on
Hearing and Equilibrium of the American Academy of Otolaryn- GROUP Δ WED SD Δ PK SD

gology – Head and Neck Surgery. Group 0 18.89 14.58 –0.56 16.77

Group A 01 18.29 14.11 4.89 13.90

Fisher test, also known in the literature as the analysis of variance
test, was used in the statistical analysis of hearing improvement. Group A 02 16.55 12.01 0.54 9.33
This test examines the influence of the classification factor on the
Δ AVG change in mean cochlear reserve after 12 months of follow-up; Δ PK change in mean bone
results of the test. conduction value after 12 months of follow-up. In bold, statistically significant changes.

Multi-field contingency tables (multi-way tables), the c2 test, were

Tab. IV. Changes in bone conduction (Δ PK) in the reference group (group 0) and in
used for verification of non-parametric hypotheses. groups A1. A2 and A3 for the 500 Hz frequency at 12 months after surgical treatment.
Δ PK statistically significant in bold, p < 0.05.
In this work, significance level of 5% (alpha = 0.05) was assumed,
GROUP Δ PK 500 HZ N SD
which means that the risk of error of rejecting the true hypoth-
esis is 5%. Group 0 –0.75 20 9.63

Group A 1 6.36 11 8.68

Statistically significant results were reported for p < 0.05.
Group A 2 0.91 11 9.43

Group A 3 4.16 18 8.89

RESULTS
Total 2.96 71 9.08
In preoperative assessment, all patients reported hearing loss, and
81.42% (N =114 patients) complained of tinnitus. 27.15% (N = 38
Tab. V. Changes in bone conduction (Δ PK) in the reference group (group 0) and in groups
patients) of participants subjectively reported unilateral hearing
A1, A2 and A3 for the 1000 Hz frequency at 12 months after surgery.
loss, and 72.85% (N = 102) – bilateral.
GROUP Δ PK 1000 HZ N SD

Mean cochlear reserve and mean bone conduction parameters Group 0 1.00 20 9.54
were collected in the analysis at the beginning of treatment and
Group A 1 5.00 11 8.36
after 12 months of follow-up in groups with varying degrees of
sensorineural hearing loss, in the absence of other middle ear ab- Group A 2 4.09 11 7.35
normalities. They are presented in Tab. II.
Group A 3 5.55 18 11.49

Based on the obtained results, it was demonstrated that 12 months Total 2.96 71 9.74
after surgery, the change in the mean value of cochlear reserve in
individual bone conduction groups was statistically significant. Tab. VI. Changes in bone conduction (Δ PK) in the reference group (group 0) and in groups
Simultaneously, analysis of changes in mean cochlear reserve be- A1, A2 and A3 for the 2000 Hz frequency at 12 months after surgery.
tween individual groups showed no statistical differences.
GROUP Δ PK 2000 HZ N SD

In the analysis of changes in mean bone conduction threshold val- Group 0 2.55 20 12.85
ues after a period of 12 months, a statistically significant improve- Group A 1 3.64 11 5.95
ment was observed in group A 01. The change in mean bone con-
Group A 2 7.72 11 7.20
duction in groups 0 and A 02 after the same time period was not
statistically significant (Tab. III.). Group A 3 8.89 18 11.70
Total 6.07 71 9.74
In the further part of the study, the impact of additional abnor-
malities observed during stapedotomy on the results of surgical
treatment in groups A1, A2 and A3 in the comparison of the ref- Tab. VII. Change in the mean cochlear reserve (Δ AVG) in the analyzed groups: 0, A1, A2, A3
after 12 months of observation.
erence group (group 0) was investigated.
GROUP Δ AVG N SD
The effects of investigated factors on the change in bone conduc- Group 0 10.66 20 9.75
tion (Δ PK) at frequencies of 500, 1000, 2000 Hz and the change in
Group A 1 10.91 11 5.84
mean cochlear reserve in the study groups at 12 months after surgi-
cal treatment were analyzed. Results are presented in Tab. IV.–VI. Group A 2 8.48 11 4.43
Group A 3 13.46 18 15.37
Statistically significant differences were found between mean
Total 10.96 71 9.08
threshold values for the change in bone conduction at 500 Hz
OTOLARYNGOL POL, 2022: 76 (3): 1-6 3
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frequency in group 0 and group A1. The differences between other Finding of adhesions in the spaces of the middle ear may reflect the
mean threshold values for bone conduction changes at 1000, 2000 tendency towards immobilization of auditory ossicles and could
Hz frequencies were statistically insignificant. be associated with worse functional outcome of surgical treatment
in the future, manifesting as conductive hearing loss.
Changes in mean cochlear reserve values in groups A1, A2 and A3
after 12 months of observation are shown in Tab. VII., p < 0.05. Pathologies of the middle ear lining observed during stapedotomy
should direct one’s attention to the patency of the auditory tube.
Analysis of patients in all subgroups showed no statistically sig- In these patients, it is necessary to focus on the function of the
nificant differences between mean cochlear reserves. The best clo- auditory tube in the postoperative period and possible further di-
sure of the cochlear reserve <10 dB was obtained in the subgroup agnostics with regard to factors that may interfere with its proper
of patients (A2) who, in addition to stapedotomy, also underwent functioning, such as chronic rhinosinusitis [17].
correction of abnormalities of the tympanic lining and in the sub-
group of patients who had adhesions removed from the middle The course of the CN VII canal obscuring the oval window is of-
ear during the procedure (A1). The worst results were observed in ten associated with the need for greater reduction of bone fram-
patients with the oval window obscured by the canal of nerve VII. ing of the external auditory canal (hood) above the oval window
in order to obtain adequate view of the niches of the oval win-
dow. The use of a milling cutter when reducing the hood over
DISCUSSION the oval window can lead to hearing losses at higher frequencies,
i.e., 6 and 8 kHz. Despite the redundancy phenomenon described
In all operated patients, a statistically significant reduction in the by Bocca and Calearo in 1963, according to which hearing loss
cochlear reserve was observed after stapedotomy within the groups above 2 kHz has little impact on understanding of speech, ad-
created for the purpose of the analysis. The study also confirms the verse thermal and acoustic effects on inner ear function as well
beneficial effects of restoring mobility of the auditory ossicles on as lack of postoperative improvement in speech band cannot be
improving bone conduction threshold values. A statistically sig- excluded [18, 19].
nificant Carhart effect was present in patients with minor bone
conduction disorders (in the group with a mean preoperative bone
conduction values between 20 and 40 dB) [9–11]. CONCLUSIONS
In the case of profound sensorineural hearing loss associated with 1. The study confirmed the influence of factors related to the con-
otosclerotic changes in the oval window, the improvement in mean dition of middle ear lining on the outcomes of surgical treat-
bone conduction values after surgical treatment was not statistically ment of otosclerosis;
significant. Deterioration of bone conduction observed preoperatively
directs the focus towards cochlear otosclerosis. In these patients, the 2. The multifactorial basis of the Carhart effect may explain bone
effects of surgical treatment were worse due to the initial degenera- conduction disruption in the course of otosclerosis at frequen-
tion of internal ear function in the course of otosclerosis [12–14]. cies other than typical 2000 Hz;

In the analysis of other factors that could potentially affect treat- 3. Audiometric manifestations of cochlear otosclerosis observed
ment outcomes, it was found that removal of adhesions, further before surgical treatment constitute an unfavorable factor for
limiting the mobility of the auditory ossicles, during stapedoto- improvement of hearing after surgery.
my significantly influenced hearing improvement as evidenced by
changes in the bone conduction values. In these patients, a statis-
tically significant result was observed at 500Hz. Observed results FUNDING
point to multifactorial etiology of the Carhart effect, manifesting
as impairment of the inner ear function by various disease enti- This research was supported by statutory funds of the Department
ties located in the middle ear [15, 16]. of Otolaryngology of the Jagiellonian University, Krakow, Poland.

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Table of content: https://otolaryngologypl.com/issue/14605 Tables: 7 Figures: – References: 19

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Corresponding author: Maciej Wiatr MD PhD, prof. UJ; Audiological Laboratory, Department of Otolaryngology, Jagiellonian University Collegium
Medicum, Krakow, Poland; Jakubowskiego street 2, 30-688 Krakow, Poland; Phone: +48 12 400 27 50; E-mail: [email protected]

Cite this article as: Wiatr A., Szpak K., Skladzien J., Wiatr M.: Otosclerosis – analysis of factors influencing the improvement of hearing after
surgical treatment; Otolaryngol Pol 2022; 76 (3): 1-6; DOI: 10.5604/01.3001.0015.8248

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