Window of Opportunity: New time frame suggested for cochlear implant surgery in advanced otosclerosis

That’s not to say that CI surgery should be pushed too far, Dr. Haynes stressed. “In patients with very good word scores, you have to be more conservative: They have too much residual hearing to really be considered for implants.”

Lit Review and Algorithm Not a Good Mix

Michael Ruckenstein, MD, professor of otorhinolaryngology: head and neck surgery at the University of Pennsylvania in Philadelphia, agrees that stapes surgery is a viable option when patients have stronger SD scores, specifically, equal to or greater than 70 percent. Such scores suggest that the patient has significant preservation of speech discrimination, “and it’s reasonable to use that as an indication that there is significant cochlear reserve present.” In such patients, “a primary or revision stapedectomy that preserves some of that function would be a good first intervention.”

But Dr. Ruckenstein expressed some reservations about the algorithm developed by Merkus and colleagues. “I’m just not sure CT scans correlated strongly enough with surgical outcomes” to give the scans so much weight in the decision tree. “Speech discrimination scores are a better guidepost,” he said. Additionally, the algorithm and literature review “don’t really mesh well. I don’t see anything in the data they cite that truly validates the steps they included,” he added. “It’s a well-done lit review, with useful information on the results of stapes surgery and CI. But I don’t think it supports their stepwise approach.”

Dr. Merkus acknowledged that his team needs to conduct further research in order to fully assess the merits of the algorithm in clinical practice. “That’s actually the next phase of our investigation,” he said.

“Our stepwise approach in itself has not yet been investigated by others, so there is no literature that directly supports the flowchart,” Dr. Merkus acknowledged. Additionally, “we agree with Dr. Ruckenstein that there is no consensus on exact cut-off points in the current literature for audiological performance nor for disease extension as seen on CT scan.

We have used the available literature on the outcome of stapedotomy and cochlear implants in otosclerosis of various degrees of severity in order to come to a reasonable strategy.

We feel that the systematic review does support the choices that are made in the algorithm. However, our approach can only really be validated by a prospective validation study, which is currently being conducted.”