Decision making in advanced otosclerosis: an evidence-based strategy.

OBJECTIVES/HYPOTHESIS To propose an evidence-based strategy for the management of patients with advanced otosclerosis accompanied by severe to profound hearing loss. STUDY DESIGN Systematic review of the literature and development of treatment guidelines. METHODS A systematic review was conducted on (advanced) otosclerosis and cochlear implantation or stapedotomy. We focused on hearing results, radiological findings, and surgical complications. Based on the results of the literature review and our own experience, we suggest a strategy to make decisions for the treatment of patients with advanced otosclerosis. RESULTS In cases of severe mixed hearing loss due to advanced otosclerosis, hearing aids may not result in optimal hearing rehabilitation, and cochlear implantation can be considered. However, there could be specific surgical dilemmas concerning cochlear implantation in advanced otosclerosis due to otospongiotic foci around, and otosclerotic foci within, the cochlea. Decision making in these patients can be difficult, especially because a stapedotomy may still be an effective treatment next to hearing aids. An algorithm is presented, based on the speech discrimination score, computed tomography classification and the air-bone gap, which will guide the surgeon to either cochlear implantation, stapedotomy, or a hearing aid and follow-up. CONCLUSIONS To achieve optimal hearing with minimal disadvantages in patients with otosclerosis and severe to profound hearing loss, an algorithm can help in the selection of patients for either cochlear implantation, stapedotomy, or hearing aids and follow-up.