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

And lest anyone conclude from his paper that CI is pushed heavily at his clinic in all patients with advanced otosclerosis, “that is definitely not the case,” Dr. Merkus said. “For example, when we have a patient who has around a 50 percent speech performance and has a 40 db air-bone gap and is not doing well with hearing aids, we do need to offer them something else. Yes, they would be within the criteria for CI, but we would counsel such a patient that stapes surgery is a better first choice,” he said.

Stapedectomy Not a Slam-Dunk

Alan G. Micco, MD, associate professor and program director of otolaryngology head and neck surgery at Northwestern Feinberg School of Medicine in Chicago, also advocates stapes surgery in patients whose SD scores are in the 50 percent to 70 percent range. But he cautioned that stapedectomy is not necessarily as easy as the paper written by Merkus and colleauges, or many otologic surgeons, suggest. In fact, this is a procedure that is now only routinely done by fellowship-trained surgeons in the United States, he noted. And, according to a recent study conducted by Dr. Ruckenstein (Laryngoscope. 2008;118(7):1224-1227), there is a growing gap in the number of surgeons who can perform the procedure.

In the 1970s, only 10 percent of graduating surgeons indicated that they had never performed stapedectomies. By the 2000s, that number has soared to 90 percent (P<0.001).

Cochlear implants can also be problematic, Dr. Micco stressed. “There’s a significant amount of drilling that may be involved, and that can cause problems such as facial nerve stimulation,” he told ENT Today. “I do lots of these procedures, and it does happen. Sometimes the audiologist can program the stimulation out, but sometimes you may have to turn off half of the channels. That’s not ideal.” (In the literature review by Merkus and colleagues, the incidence of facial nerve stimulation ranged between 0 percent in a study of 20 patients [Am J Otol. 1990;11(3):196-200] to 75 percent in a study of four patients [Am J Otol. 1998;19(2):163-169]. In the largest study cited, of 53 patients, the incidence of the surgical complication was 38 percent [Otol Neurotol. 2004;25(6):943-952].)

Dr. Micco said that the algorithm developed by the Dutch team “makes some sense,” but its lack of any mention of MRI “is a major omission.” Often, he said, a CT scan will suggest that a patient is a good candidate for CI, “and then you go in and immediately see much more ossification than you had expected, and lots of additional drilling, with its attendant sequelae, is needed. So I’d recommend that you do MRI in cases where you really need the most diagnostic information.”