BoneConduction Thresholdsin PatientsWith Otosclerosis

EERO VARTIAINEN, MD, AND SEPPO KARJALAINEN, MD

Purpose: Sensorineural hearing loss in patients with otosclerosis is commonly encountered. This study was conducted to determine if surgery on the otosclerotic ear had an effect on the sensorineural hearing. Methods: A cohort of 262 patients subjected to operation in 311 ears were evaluated. All patients had a minimum of 5 years follow-up and patients over 60 years of age were excluded. Audiograms obtained 1 day before surgery were compared with those obtained
1 year postoperatively and at the last follow-up examination in the study. Results evaluated using the Students t test for statistical analysis of hearing results. were

Results: The mean follow-up was 9.6 years. Deterioration of bone conduction scores occurred in 6.4% of 311 operated ears. Deterioration of bone conduction threshold occurred in the speech frequency in 6 ears (1.9%). Conclusions: Bone conduction scores of operated ears remained quite stable compared
with the otosclerotic ears not subjected to operation. Patients with bilateral may benefit from surgery performed on both ears when indicated. Copyright 0 1992 by W.B. Saunders Company otosclerosis

Sensorineural hearing loss in otosclerosis is a very common problem. Causse et al have shown that sensorineural hearing loss in patients with otosclerosis is caused by hydrolytic enzymes released from otospongiotic foci into labyrinthine fluids. Also, a vascular mechanism has been presented. The effect of the Carharts notch on the.bone conduction (BC) thresholds in otosclerotic ears is well known, and this phenomenon is caused by reduction of the ossicular chain inertia as a result of stapes fixation.3 Although this phenomenon is of great importance in otological practice, it has not been paid so much attention to the long-term course of BC values in otosclerosis. What might be the course of BC values if we compare ears subjected to operation with ears not subjected to operation in otosclerotic patients? MATERIALS AND METHODS
The study consisted of 262 patients with otosclerosis who were treated in the Department of Otolaryngology, University of Kuopio, Kuopio, Fin-

land, between 1970 and 1986. Only patients with a follow-up of at least 5 years were included; the mean follow-up period was 9.6 years. In order to avoid the effect of presbyacusis, patients over 60 years of age were excluded. In 262 patients, 311 ears were subjected to operation. In 146 ears the reconstruction was performed with posterior crus and in 165 ears with teflon piston prosthesis. Large fenestra technique with fascia seal to the oval window was used in all cases. The patients have not received fluoride therapy. Audiological examination was performed using a clinical audiometer calibrated according to the standards of the International Standard Organization (ISO). Audiograms obtained the day before operation [initial), 1 year postoperatively, and at last the follow-up examination were used in the study. Annual deterioration (dB/yr) in BC thresholds of operated ears was assessed for those audiograms obtained 1 year after surgery and at the last followup examination. The Students t test [by the SPSSI PC+ program] was used for statistical analysis of the hearing results.

RESULTS Immediately after surgery BC thresholds at all frequencies (0.5, 1.0, 2.0, and 4.0 kHz) deteriorated by 10 dB or more in 6 ears (1.9%). In addition, BC thresholds at 4 kHz dropped by 15 dB or more in 14 ears (4.5%) whereas BC thresholds at speech frequencies remained unchanged. As a whole, 1 year postoperatively, ears that underwent stapes surgery showed improvement of BC thresholds at 0.5,

From the Department of Otolaryngology, University of Kuopio, Kuopio, Finland. Address reprint requests to Eero Vartiainen, MD, Department of Otolaryngology, University Hospital of Kuopio, SF-70200 Kuopio, Finland. Copyright 0 1992 by W.B. Saunders Company 0196-0709/92/l 304-0005$5.00/O
234 American Journal of Otolaryngology,

Vol 13, No 4 (July-August), 1992: pp 234-236

BONECONDUCTION IN OTOSCLEROSIS

235

TABLE 1. Bone Conduction Thresholds

(dB) of 311

TABLE 3. Bone Conduction Thresholds of 107 Nonouerated Ears Frequency Initial Mean (SD) 15.0(8.6) 17.6 (9.7) 20.2 (10.7) 20.7 (14.6) Follow-up Mean (SD) 21.7 (12.2) 28.3 (12.5) 32.7 (15.4) 33.0(17.1)

Frequency W-W 0.5 1 2 4

Preoperative Mean (SD) 18.0 22.0 26.3 22.8 (10.2) (10.7) (12.5) (15.4)

1 Year Postop Mean (SD) 13.9 15.4 18.3 22.8 (8.0) (9.7) (11.7) (14.4)

Follow-up Mean (SD) 16.4 19.1 24.2 29.1 (10.0) (11.6) (14.6) (17.4)

(H-k) 0.5 1 2 4

1.0, and 2.0 kHz but not at 4.0 kHz (Table 1). Later during follow-up, BC thresholds deteriorated slightly at all frequencies (0.5 to 4.0 kHz). When comparing BC thresholds of operated ears for various age groups, the youngest patients (~30 years of age) had significantly better thresholds at all frequencies than the older patients, both preoperatively and at long-term follow-up examination (Table 2). In 107 patients with bilateral otosclerosis, only one ear was subjected to operation. The ears not operated on showed remarkable deterioration of BC thresholds at all frequencies during the follow-up (Table 3). The youngest patients (~30 years of age) had significantly better BC values than the others, both initially and later (Table 4). When comparing BC values between operated and not operated otosclerotic ears (Tables 1 and 3), the ears not subjected to operation showed initially significantly better BC thresholds at 0.5, 1.0, and 2 kHz than the operated ears. Later, during the last follow-up examination, operated ears had significantly better inner ear function than the ears not subjected to operation. No significant difference was stated at 4.0 kHz. During follow-up the annual decay (dB/yr) of BC values in the ears not subjected to operation was significantly greater than in the operated ears at all frequencies (0.5 to 4.0

kHz) (Table 5). Operated ears of patients under 30 years of age had significantly (P < 65) smaller annual impairment at 0.5 and 4.0 kHz than operated ears of patients over 50 years of age. The age group of 30 to 49 years had a significantly smaller (P < .05) annual deterioration of BC values in the operated ears at 2.0 and 4.0 kHz than those of patients aged 50 to 60 years; otherwise there were no significant differences between various age groups in annual decay of BC values, neither in the operated ears nor in the ears not operated [data not shown). DISCUSSION The improvement of BC thresholds in otosclerotic ears immediately after stapes surgery is due to the disappearance of the Carharts notch. The effect of the Carharts notch has been stated to be 5 to 10 dB at 500 Hz, 10 to 20 dB at 1 kHz, 15 to 30 dB at 2 kHz, and 5 to 20 dB at 4 kHz.3 Our patients who received stapes operation showed a mean postoperative improvement of 4.1 dB at 500 Hz, 6.6 dB at 1 kHz, and 8.0 dB at 2 kHz, but no change at 4 kHz (Table 1). Another factor influencing BC thresholds is the surgical trauma that may result in cochlear damage. Our series included 6 ears (1.9%) in which BC thresholds deteriorated immediately after operation by 10 dB or

TABLE 2. Bone Conduction Thresholds of Operated Earsin Various AgeGroups <30Yrs Frequency
WW Preop (n = 50) Mean (SD) Follow-up (n = 50) Mean (SD)

30-49 Yrs
Preop (n = 178) Mean (SD) Follow-up (n = 178)

50-60 Yrs
Preop (tl = 83) Mean (SD) Follow-up (n = 83)

Mean (SD)

Mean (SD)

0.5 1 2 4

13.9 (8.4) 16.0 (7.2) 17.3(7.2) 13.7 (8.4)

11.3(6.6) 13.9(8.1) 17.3 (7.2) 21.1 (12.7)

18.6 (9.9) 22.5 (11.0) 27.1 (13.0) 22.7 (15.5)

15.9 (8.6) 18.2 (10.8) 23.1 (15.1) 27.4 (17.6)

19.2(11.4) 24.5 (10.7) 30.1 (11.5) 28.7 (15.7)

20.9 (12.5) 24.5 (13.1) 30.9 (14.6) 38.5 (15.5)

236

VARTIAINEN

AND KARJALAINEN

TABLE 4.

Bone Conduction

Thresholds <30 Yrs

of Nonoperated

Ears in Various 30-49 Yrs

Age Groups 50-60 Yrs

Frequencies
N-W

Initial

(n = 14)

Follow-up

(n = 14)

Initial

(n = 64)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

0.5 1 2 4

0.9 10.4 13.2 9.6

(4.9) (6.6) (8.2) (8.2)

16.8 20.7 21.4 20.0

(10.1) (8.3) (6.6) (11.8)

15.2 17.3 19.2 20.1

(6.9) (7.4) (9.1) (13.9)

21.9 28.4 31.8 32.4

(11.2) (11.6) (14.8) (17.3)

17.4 21.6 25.7 27.2

(11.7) (13.0) (12.7) (15.3)

23.6 31.7 40.0 40.5

(14.6) (14.7) (16.3) (15.2)

more at speech frequencies and 14 ears (4.5%) in which BC at speech frequencies remained unchanged but BC at 4 kHz dropped by 15 dB or more. In the rest of the operated ears, the improvement of BC thresholds obviously parallels the theoretical recovering of Carharts notch at least in the speech frequency region. During a mean follow-up of 9.6 years, BC thresholds of the operated ears remained quite stable, the annual impairment being only 0.2 dB/yr (at 500 Hz) to 0.6 dB/yr (at 2 and 4 kHz). This result is in agreement with the study of Langman et al4 who found that the decline observed in the BC thresholds after stapedectomy was similar to the decline due to presbyacusis alone. The stability of BC thresholds after stapes surgery is an encouraging finding for all ear surgeons and their patients. Otosclerotic foci have a tendency to be more active in young persons and less active in older people, with diminished bone remodeling in the older age group.5 Therefore, one might assume that BC thresholds of young patients with otosclerosis should show greater impairment than those of an older age group. Our study demonstrated that this was not the case. BC thresholds of the youngest age group
TABLE 5. Annual Change (dB/yr) of Bone Conduction Thresholds in Operated and Nonoperated Ears Unoperated Ears (n = 107) Mean (SD) 0.7 1.2 1.3 1.4 (1.2) (1.1) (1.3) (1.4)

taken before operation and at the last followup examination were significantly better than those of the older age groups. Annual impairment (dB/yr) in BC thresholds at some frequencies was significantly less in the young patient group than in the oldest patient group. It seems that the sensorineural component in otosclerosis follows the duration of the disease and may also be influenced by the age of the patient, even though patients over 60 years of age were excluded from the study. The fate of the nonoperated otosclerotic ear is a most interesting and important topic. During follow-up, the BC thresholds of nonoperated ears in patients with bilateral otosclerosis showed significantly greater annual impairment than operated ears. At the last follow-up examination, the nonoperated ears had significantly worse BC thresholds at speech frequencies than the operated ears, although the situation had been reverse before surgery. This finding indicates that it is best to operate on both ears in patients with bilateral otosclerosis in the hope of achieving many years of good hearing.
REFERENCES 1. Causse JR, Chevance LG, Bretlau P, et al: Enzymatic concept of otospongiosis and cochlear otospongiosis. Clin Otolaryngol 2:23-32, 1977 2. Ruedi L: Otosclerotic lesion and cochlear degeneration Arch Otolaryngol Head Neck Surg 89:180-187, 1969 3. Beales PH: Otosclerosis, in Kerr AG, Groves J (eds]: Scott-Browns Otolaryngology, vol 3. London, England, Butterworths, 1987, pp 301-339 4. Langman AW, Jackler RK, Sooy FA: Stapedectomy: Long-term hearing results. Laryngoscope 101:810-814, 1991 5. Beales PH: Otosclerosis. Bristol, England, John Wright & Sons Ltd, 1981

Frequency W-W 0.5 1 2 4

Operated Ears (n = 311) Mean (SD) 0.2 0.4 0.6 0.6 (1.3) (1.2) (1.4) (1.8)

SD Between Groups P P P P < < < < ,001 .OOl .OOl .OOl