Is This Patient Operable?

Survey of otologists reveals differences of opinion on treatment, surgery for otosclerosis with vertigo

CHICAGO-There is a general unease among otologists when presented with a patient who has probable otosclerosis and symptoms of vertigo because of deafness as a possible complication of surgery, according to a survey conducted by John W. Seibert, MD, and colleagues at University of Arkansas for Medical Sciences in Little Rock. He presented the survey findings in a presentation title Current Otologic Opinion on the Treatment of Hearing Loss in Patients with Intermittent Disequilibrium, here at the American Otologic Society section of the Combined Otolaryngology Spring Meetings (COSM).

Regarding surgical instruments, the instrument of choice for 49% was the laser, while 20% preferred the hand drill and 28% chose the mechanical drill.

Otologists typically fall into one of three camps, explained Dr. Siebert, who was a resident at the University of Arkansas the during the research and is now Assistant Professor of Otolaryngology-Head and Neck Surgery at Washington University School of Medicine in St. Louis, Mo. One camp refuses to perform stapes surgery on anyone with symptoms of vertigo; another proceeds with the surgery only if certain criteria are met such as a normal electronystagmography (ENG); and the third performs a stapedotomy regardless of the vertigo symptoms.

The researchers mailed a survey to 250 members of the American Otologic Society in the spring of 2005. The survey included a very brief case study describing a 45-year-old with a history of balance problems and hearing loss suggestive of otosclerosis. Survey respondents were asked to indicate if they would immediately proceed with a stapedectomy/stapedotomy or would decide on further management and work-up. They were also asked to indicate which important history and physical findings would influence their decision-making process for stapes surgery.

The Survey

A total of 71 physicians responded to the survey, resulting in a 28% response rate.

Sixteen otologist respondents, or 22%, indicated that they would proceed with the stapedectomy after assuring that the presence of a balance disorder in the patient was not due to a retrocochlear cause.

Forty-nine otologist respondents, or 69%, said that they would recommend further work-up or treatment that might include a diuretic trial, electrocochleography, trial of fluoride, electronystagmography, and/or CT scan. (Six respondents didn’t answer this question.)

Regarding overall initial management of the case, respondents were allowed to select all or none of the treatment choices listed above. Thirty-one physicians (44%) said that they would consider diuretics as an initial management. Twenty-two (31%) agreed with using some form of fluoride prior to intervention. Thirty-one (43%) chose electronystagmography, and 20 (28%) went with electrocochleography. Lastly, 27 (38%) would order a CT scan preoperatively.

Use of Diuretics

Eighteen respondents (25%) said that they would not consider using diuretics. Of the 44% who indicated that they would proceed with diuretics, four (13%) recommended a trial for one month; five (16%) said they would recommend diuretics for six to eight weeks; 17 (55%) recommended a trial for at least three to six months; and only three (10%) recommended diuretics for over six months.

If the patient responded to the diuretics, 84% of the otologists said that they would consider the patient an operative candidate; 16% said they still would not operate on the patient, even with improvement. In this case, regarding the time period for intervention after diuretics, three otologists (10%) indicated that they would wait one month; seven (23%) would wait six to eight weeks; 13 (42%) would consider three to six months an appropriate amount of time; and only seven (23%) thought waiting for longer than six months was appropriate.

ENG with Initial Management

Twelve participants (16%) thought that electronystagmography was not recommended with initial management. Of the 43% who thought ENG was appropriate, 22 (71%) indicated that they would consider a patient a surgical candidate if the difference was less than 20%. Seven others (23%) said a difference of less than 20% did not make the patient a candidate for operative intervention.

Survey respondents were asked to indicate if they would immediately proceed with a stapedectomy/stapedotomy or would decide on further management and work-up.

If the difference on the ENG was greater than 20%, suggesting an abnormality, seven otologists (23%) said that they would operate, but 13 (42%) would not.

Symptom-Free Interval

Forty-three otologists responded to a survey question on requiring an imbalance symptom-free interval before operating. Within that group, 36 (84%) agreed that an interval was needed. A smaller number, seven (16%) disagreed, saying that no such interval is needed. Of the majority who thought a waiting period was needed, 14% agreed less than three months was appropriate; however, 8% indicated that they would wait three months to a year or longer.

Since chronic sinusitis is an inflammatory, perhaps systemic disorder, the use of anti-inflammatory medication plays an important treatment role prior to surgery.

Quality of Balance Disorder

The survey asked which disorders or symptoms respondents would class as indicating poor candidate for surgery. Forty-four physicians (61%) said that they would avoid patients with a history of recurrent vertiginous attacks with hearing loss, aural fullness, tinnitus, and nausea. Twenty-two (30%) said that a history of true vertigo was also a contraindication, and 39 (55%) indicated that patients with a history of Ménière’s disease were poor candidates.

As for appropriate candidates for stapes surgery, 56 otologists (78%) said that patients with dizziness or mild imbalance would be appropriate. Only 4% would operate on a patient with active Ménière’s disease. Roughly one-half (49%) said that positional or gaze induced nystagmus was an acceptable pre-operative symptom.

Forty-eight physicians (68%) indicated that they prefer to do a stapedotomy and 19 (27%) performed mostly stapedectomy.

Conclusions

Even though opinions within the field differ, current standards of practice for these cases can be drawn from these questions and responses. Standards of care might include use of ENG, a trial of diuretics, and a CT scan prior to stapes surgery in patients with a balance problem and hearing loss suggestive of otosclerosis.

This research is under consideration for publication in the journal Otology and Neurotology.

©2006 The Triological Society