The patient considered for stapedectomy should have two appropriately masked audiograms to confirm adequate bone thresholds and an air-bone gap in excess of 15 dB. The conductive loss must be confirmed with a reversed (bone conduction greater than air conduction) 512-Hz tuning fork, and a Weber test that lateralizes to the affected ear. The acoustic reflexes will be absent or demonstrate the on-off effect. Concomitant pathology is excluded by examination.
The poorer-hearing ear is appropriately selected for intervention. When hearing levels are similar and one ear had been previously operated, the unoper-ated ear should be treated rather than revising an ear. The surgery will be easier, the benefits greater, and the patient will generally be happier.
Rarely, a patient presents with otosclerosis in an only hearing ear. Much thought and consideration should be given to the decision to operate. Although one should rarely, if ever, operate on an only hearing ear, maintenance of communication and stabilization of hearing are important considerations in otosclerosis, which tends to be a progressive disease. Thus, there may be a rare patient for whom surgery might be considered in an only hearing ear. These cases should be attempted only by very experienced surgeons, and even then with trepidation.
Speech discrimination should be adequate. With a pure conductive loss, discrimination will improve to 100% if the stimulus can be made loud enough. patients should be in reasonable health, although advanced age is not a contraindication to surgery. Stapedectomy in very young children (younger than 5 years of age) may be contraindicated until it is demonstrated that they are not prone to otitis media.
The benefits of surgery for both children and the elderly have been demonstrated.15,16
Stapedectomy can be beneficial in patients with far-advanced otosclerosis. These patients have a severe or profound mixed loss. Surgery may raise their thresholds into the aidable range, when previously a hearing aid could not be worn. Typically they have excellent speech production and air conduction no better than 95 dB with bony thresholds in excess of 60 to 75 dB (the limit of the audiometer). The conductive element may be detectable with the 512-Hz tuning fork applied to the teeth when it is not heard on the mastoid. The upper central incisors and the alveolar ridge give an 11-dB gain over applying the fork to the mastoid. The examiner must be sure that the fork is heard and not felt by the patient.17
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