But reimbursement isn’t the only issue Dr. Smullen said she has with the Dutch otologists’ desire to push CI a bit earlier in the disease process. “I can see how that ‘window of opportunity’ they point to can be construed as a powerful argument for doing CIs earlier,” she said. “But a main part of their rationale for that approach, the idea that otosclerosis always progresses in severity, is flawed. Sometimes the disease remains stable for long periods of time. Also, data suggest that bisphosphonate therapy can actually halt or slow the disease process.”
Explore this issue:January 2012
Dr. Smullen cited an additional caveat regarding the algorithm in the Dutch paper. Using CT scans and hearing tests to assess patients’ disease progression and need for a particular type of surgery “is a reasonable approach,” she said. “The problem is that they don’t discuss nearly enough the limitations of those hearing tests in giving a true picture of the extent and quality of a patient’s hearing.”
When done correctly, she explained, hearing evaluations give the clinician a picture of conductive and sensorineural hearing loss, both of which can be present in a patient with advanced otosclerosis. Knowing how much of each type is key, Dr. Smullen said, because that determination roughly guides surgical choice: Stapedectomy is used to treat conductive hearing loss, while CI is used for sensorineural hearing loss.
“But you have to test at a high enough decibel level to get a true picture of SD: the ability of the patient to understand words in a sentence,” Dr. Smullen said. “And it’s unclear from their methodology whether the studies they cite, or their clinical experience, takes that into account.”
Dr. Smullen said there are two solutions to this dilemma, and one is “amazingly simple: You communicate with the patient with an ear trumpet. If you talk in a loud voice, you can talk louder than the standard testing equipment that is often used to assess these patients, and if a patient can understand you, that indicates they have a reasonable level of speech discrimination. It’s old school, but it helps us stay true to an important tenet of otology: If you can save a naturally hearing ear and avoid a CI, you do that. And stapedectomy still gives you a naturally hearing ear, whereas CI does not.”
Dr. Smullen said the surgeons in her department always opt for stapedectomy first. “If you do that and the hearing hasn’t improved sufficiently, you haven’t lost anything, you can still go on to a CI,” she said. Stapes surgery, she added, “is a quick, inexpensive outpatient procedure that really needs to be carefully considered for these patients before going to implantation.”