Is Preoperative Computed Tomography Necessary for Primary Stapes Surgery?

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Background

Stapedotomy or stapedectomy is commonly performed to treat conductive (CHL) or mixed hearing loss (MHL), most often due to otosclerosis. Pneumatic otoscopy, tuning fork tests, diagnostic audiometry, and acoustic reflex testing are widely accepted to be sufficient for preoperative assessment. High-resolution computed tomography (CT) may reveal hypodense foci or bone deposition within the oval window and otic capsule. CT may also reveal other causes of the hearing loss. Use of preoperative CT varies widely. Some surgeons routinely obtain preoperative CT, whereas others reserve this for atypical presentations or when considering revision surgery. Preoperative CT incurs added cost and radiation exposure. Though there are a number of potential roles of CT prior to stapedotomy, the relative indications are poorly defined in the literature.

Best Practice

Literature review does not support routine use of CT prior to planned primary stapedotomy in patients with adult-onset CHL/MHL, and clinical findings consistent with otosclerosis. Factors influencing the decision to obtain preoperative CT are summarized in Table 1. Selective use of CT is recommended, and symptoms accompanying progressive hearing loss (i.e., atypical cases), patient age, age of hearing loss onset, and a family history of early-onset hearing loss should all be considered.

Table 1: Factors Influencing the Decision to Obtain Preoperative Computed Tomography Prior to Planned Stapedotomy.

Defer Preoperative Imaging	Consider Preoperative Imaging	Favor Preoperative Imaging
Adult-onset hearing loss	Adolescent-onset hearing loss	Childhood-onset hearing loss
Bilateral conductive hearing loss	Unilateral conductive or mixed hearing loss	Intact stapedial reflex Autophony
Progressive hearing loss	Unknown time course of hearing loss	Vertiginous complaints
Absent stapedial reflex	Abnormal stapedial reflex	Family history of childhood- onset hearing loss
Nonpulsatile tinnitus	Pulse synchronous tinnitus	Abnormal otoscopy*
No vestibular complaints	Nonvertiginous balance complaints
Family history of surgically confirmed otosclerosis	Family history not known
Normal otoscopy
Progressive hearing loss
*Excluding Schwartze sign.