1. Otosclerosis Alan L. Cowan, MD Tomoko Makishima, MD, PhD Department of Otolaryngology University of Texas Medical Branch Galveston, TX October 18, 2006

2. Introduction Otosclerosis Otosclerosis Primary metabolic bone disease of the otic capsule and ossicles Primary metabolic bone disease of the otic capsule and ossicles Results in fixation of the ossicles and conductive hearing loss Results in fixation of the ossicles and conductive hearing loss May have sensorineural component if the cochlea is involved May have sensorineural component if the cochlea is involved Genetically mediated Genetically mediated Autosomal dominant with incomplete penetrance (40%) and variable expressivity Autosomal dominant with incomplete penetrance (40%) and variable expressivity

3. History of Otosclerosis and Stapes Surgery 1704 – Valsalva first described stapes fixation 1704 – Valsalva first described stapes fixation 1857 – Toynbee linked stapes fixation to 1857 – Toynbee linked stapes fixation to hearing loss hearing loss 1890 – Katz was first to find microscopic 1890 – Katz was first to find microscopic evidence of otosclerosis evidence of otosclerosis 1893 – Politzer described the clinical entity of 1893 – Politzer described the clinical entity of “otosclerosis” “otosclerosis” 1890 – Bacon describes medical therapy for the condition, and supports the common view that “surgery should not be considered for a moment.“ 1890 – Bacon describes medical therapy for the condition, and supports the common view that “surgery should not be considered for a moment.“

4. History of Otosclerosis and Stapes Surgery Gunnar Holmgren (1923) Gunnar Holmgren (1923) Father of fenestration surgery Father of fenestration surgery Single stage technique Single stage technique Sourdille Sourdille Holmgren’s student Holmgren’s student 3 stage procedure 3 stage procedure 64% satisfactory results 64% satisfactory results

5. History of Otosclerosis and Stapes Surgery Julius Lempert Julius Lempert Popularized the single staged fenestration procedure Popularized the single staged fenestration procedure John House John House Further refined the procedure Further refined the procedure Popularized blue lining the horizontal canal Popularized blue lining the horizontal canal

6. History of Otosclerosis and Stapes Surgery Fenestration procedure for otosclerosis Fenestration procedure for otosclerosis Fenestration in the horizontal canal with a tissue graft covering Fenestration in the horizontal canal with a tissue graft covering >2% profound SNHL >2% profound SNHL Rarely complete closure of the ABG Rarely complete closure of the ABG May exhibit vestibular disturbances May exhibit vestibular disturbances

7. History of Otosclerosis and Stapes Surgery Samuel Rosen Samuel Rosen 1953 – first suggest mobilization of the stapes 1953 – first suggest mobilization of the stapes Immediate improved hearing Immediate improved hearing Re-fixation Re-fixation

8. History of Otosclerosis and Stapes Surgery John Shea John Shea 1956 – first to perform stapedectomy 1956 – first to perform stapedectomy Oval window vein graft Oval window vein graft Nylon prosthesis from incus to oval window Nylon prosthesis from incus to oval window

9. Epidemiology 10% overall prevalence of histologic otosclerosis 10% overall prevalence of histologic otosclerosis 1% overall prevalence of clinically significant otosclerosis 1% overall prevalence of clinically significant otosclerosis

10. Epidemiology Race Incidence of otosclerosis Caucasian10% Asian5% African American1% Native American0%

11. Epidemiology Gender Gender Histologic otosclerosis – 1:1 ratio Histologic otosclerosis – 1:1 ratio Clinical otosclerosis – 2:1 (W:M) Clinical otosclerosis – 2:1 (W:M) Possible progression during pregnancy (10%-17%) Possible progression during pregnancy (10%-17%) Studies which have demonstrated changes during pregnancy are often retrospective or lack audiometric data. Studies which have demonstrated changes during pregnancy are often retrospective or lack audiometric data. Studies comparing multigravid vs. nulligravid women with otosclerosis have failed to show audiometric differences. Studies comparing multigravid vs. nulligravid women with otosclerosis have failed to show audiometric differences. Bilaterality more common (89% vs. 65%) Bilaterality more common (89% vs. 65%)

12. Epidemiology Age Age 15-45 most common age range of presentation 15-45 most common age range of presentation Youngest presentation 7 years Youngest presentation 7 years Oldest presentation 50s Oldest presentation 50s 0.6% of individuals <5 years old have foci of otosclerosis 0.6% of individuals <5 years old have foci of otosclerosis

13. Pathophysiology Osseous dyscrasia Osseous dyscrasia Resorption and formation of new bone Resorption and formation of new bone Limited to the temporal bone and ossicles Limited to the temporal bone and ossicles Inciting event unknown Inciting event unknown Hereditary, endocrine, metabolic, infectious, vascular, autoimmune, hormonal Hereditary, endocrine, metabolic, infectious, vascular, autoimmune, hormonal

14. Pathology Two phases of disease Two phases of disease Active (otospongiosis phase) Active (otospongiosis phase) Osteocytes, histiocytes, osteoblasts Osteocytes, histiocytes, osteoblasts Active resorption of bone Active resorption of bone Dilation of vessels Dilation of vessels Schwartze’s sign Schwartze’s sign Mature (sclerotic phase) Mature (sclerotic phase) Deposition of new bone (sclerotic and less dense than normal bone) Deposition of new bone (sclerotic and less dense than normal bone)

15. Pathology Most common sites of involvement Most common sites of involvement Fissula ante fenestrum Fissula ante fenestrum Round window niche (30%-50% of cases) Round window niche (30%-50% of cases) Anterior wall of the IAC Anterior wall of the IAC

16. Non-clinical foci of otosclerosis

17. Anterior footplate involvement

18. Annular ligament involvement

20. Bipolar involvement of the footplate

21. Round Window

22. Labyrinthine Otosclerosis 1912 – Siebenmann described labyrinthine otosclerosis 1912 – Siebenmann described labyrinthine otosclerosis Suggested otosclerosis may cause SNHL via Suggested otosclerosis may cause SNHL via Toxic metabolites Toxic metabolites Decreased blood supply Decreased blood supply Direct extension Direct extension Disruption of membranes Disruption of membranes

23. Hyalinization of the spiral ligament

24. Erosion into inner ear

27. Organ of Corti

28. Cochlear Otosclerosis Audiometric studies Audiometric studies Some studies have shown that in cases of unilateral otosclerosis ~ 60% may have decreased sensory thresholds even after stapes surgery Some studies have shown that in cases of unilateral otosclerosis ~ 60% may have decreased sensory thresholds even after stapes surgery Histiologic studies Histiologic studies Cases of documented otosclerosis and a large sensory loss have shown large foci of otosclerosis in the otic capsule. Cases of documented otosclerosis and a large sensory loss have shown large foci of otosclerosis in the otic capsule. Many cases of large otic capsule foci without sensory loss or of sensory loss without foci have also been described. Many cases of large otic capsule foci without sensory loss or of sensory loss without foci have also been described. Biochemical studies Biochemical studies Some authors have noted increased levels of perilymph protein during stapedotomy in patients with radiographic evidence of otic capsule foci and sensory hearing loss. Some authors have noted increased levels of perilymph protein during stapedotomy in patients with radiographic evidence of otic capsule foci and sensory hearing loss. Conclusion Conclusion Many experts believe that extensive involvement of the cochlea will produce sensorineural hearing deficits, although it is not known how this occurs or why it only occurs in a subset of patients with cochlear foci. Many experts believe that extensive involvement of the cochlea will produce sensorineural hearing deficits, although it is not known how this occurs or why it only occurs in a subset of patients with cochlear foci.

29. Diagnosis of Otosclerosis

30. History Most common presentation Most common presentation Women age 20 - 30 Women age 20 - 30 Conductive or Mixed hearing loss Conductive or Mixed hearing loss Slowly progressive, Slowly progressive, Bilateral (80%) Bilateral (80%) Asymmetric Asymmetric Tinnitus (75%) Tinnitus (75%)

31. History Age of onset of hearing loss Age of onset of hearing loss Progression Progression Laterality Laterality Associated symptoms Associated symptoms Dizziness Dizziness Otalgia Otalgia Otorrhea Otorrhea Tinnitus Tinnitus

32. History Family history Family history 2/3 have a significant family history 2/3 have a significant family history Particularly helpful in patients with severe or profound mixed hearing loss Particularly helpful in patients with severe or profound mixed hearing loss Prior otologic surgery Prior otologic surgery History of ear infections History of ear infections Vestibular symptoms Vestibular symptoms 25% 25% Most commonly dysequilibrium Most commonly dysequilibrium Occasionally attacks of vertigo with rotatory nystagmus Occasionally attacks of vertigo with rotatory nystagmus

33. Physical Exam Otomicroscopy Otomicroscopy Most helpful in ruling out other disorders Most helpful in ruling out other disorders Middle ear effusions Middle ear effusions Tympanosclerosis Tympanosclerosis Tympanic membrane perforations Tympanic membrane perforations Cholesteatoma or retraction pockets Cholesteatoma or retraction pockets Superior semicircular canal dehiscence Superior semicircular canal dehiscence Schwartze’s sign Schwartze’s sign Red hue in oval window niche area Red hue in oval window niche area 10% of cases 10% of cases Pneumatic otoscopy Pneumatic otoscopy Distinguish from malleus fixation Distinguish from malleus fixation

34. Physical Exam Tuning forks Tuning forks Hearing loss progresses form low frequencies to high frequencies Hearing loss progresses form low frequencies to high frequencies 256, 512, and 1024 Hz TF should be used 256, 512, and 1024 Hz TF should be used Rinne Rinne 256 Hz – negative test indicates at least a 20 dB ABG 256 Hz – negative test indicates at least a 20 dB ABG 512 Hz – negative test indicates at least a 25 dB ABG 512 Hz – negative test indicates at least a 25 dB ABG

35. Differential Diagnosis Ossicular discontinuity Ossicular discontinuity Congenital stapes fixation Congenital stapes fixation Malleus head fixation Malleus head fixation Paget’s disease Paget’s disease Osteogenesis imperfecta Osteogenesis imperfecta Superior semicircular canal dehiscence Superior semicircular canal dehiscence

36. Audiometry Tympanometry Tympanometry Impedance testing Impedance testing Acoustic reflexes Acoustic reflexes Pure tones Pure tones

37. Tympanometry Jerger (1970) – classification of tympanograms Jerger (1970) – classification of tympanograms Type A Type A Type As Type As Type Ad Type Ad Type B Type B Type C Type C

39. Acoustic Reflexes Result from a change in the middle ear compliance in response to a sound stimulus Result from a change in the middle ear compliance in response to a sound stimulus Change in compliance Change in compliance Stapedius muscle contraction Stapedius muscle contraction Stiffening of the ossicular chain Stiffening of the ossicular chain Reduces the sound transmission to the vestibule Reduces the sound transmission to the vestibule

40. Acoustic Reflexes Otosclerosis has a predictable pattern of abnormal reflexes over time Otosclerosis has a predictable pattern of abnormal reflexes over time Reduced reflex amplitude Reduced reflex amplitude Elevation of ipsilateral thresholds Elevation of ipsilateral thresholds Elevation of contralateral thresholds Elevation of contralateral thresholds Absence of reflexes Absence of reflexes

41. Pure Tone Audiometry Most useful audiometric test for otosclerosis Most useful audiometric test for otosclerosis Characterizes the severity of disease Characterizes the severity of disease Frequency specific Frequency specific Carhart’s notch Carhart’s notch Hallmark audiologic sign of otosclerosis Hallmark audiologic sign of otosclerosis Decrease in bone conduction thresholds Decrease in bone conduction thresholds 5 dB at 500 Hz 5 dB at 500 Hz 10 dB at 1000 Hz 10 dB at 1000 Hz 15 dB at 2000 Hz 15 dB at 2000 Hz 5 dB at 4000 Hz 5 dB at 4000 Hz

42. Pure Tone Audiometry Low frequencies affected first Low frequencies affected first Below 1000 Hz Below 1000 Hz Rising air line Rising air line “Stiffness tilt” “Stiffness tilt” Secondary to stapes fixation Secondary to stapes fixation With disease progression With disease progression Air line flattens Air line flattens

43. Pure Tone Audiometry Carhart’s notch Carhart’s notch Proposed theory Proposed theory Stapes fixation disrupts the normal ossicular resonance (2000 Hz) Stapes fixation disrupts the normal ossicular resonance (2000 Hz) Normal compressional mode of bone conduction is disturbed because of relative perilymph immobility Normal compressional mode of bone conduction is disturbed because of relative perilymph immobility Mechanical artifact Mechanical artifact Reverses with stapes mobilization Reverses with stapes mobilization

44. Pure Tone Audiometry Committee on Hearing and Balance Committee on Hearing and Balance Set standards for reporting results in cases of otosclerosis procedures. Set standards for reporting results in cases of otosclerosis procedures. Operative hearing results should be reported using post-operative data, specifically, the post-operative air-bone gap. Operative hearing results should be reported using post-operative data, specifically, the post-operative air-bone gap. This prevents exaggeration of surgical results and “overclosure.” This prevents exaggeration of surgical results and “overclosure.” Adopted by the AAOHNS in 1994 Adopted by the AAOHNS in 1994 Important in reviewing literature regarding surgical outcomes Important in reviewing literature regarding surgical outcomes Studies prior to this time often use pre-op bone lines and post-op air conduction measurements which may exaggerate results. Studies prior to this time often use pre-op bone lines and post-op air conduction measurements which may exaggerate results. This convention is not uniform in all parts of the world, so the methods is very important in determining the consistency of data. This convention is not uniform in all parts of the world, so the methods is very important in determining the consistency of data.

45. Imaging Computed tomography (CT) of the temporal bone Computed tomography (CT) of the temporal bone Proponents of CT for evaluation of otosclerosis Proponents of CT for evaluation of otosclerosis Pre-op Pre-op Characterize the extent of otosclerosis Characterize the extent of otosclerosis Severe or profound mixed hearing loss Severe or profound mixed hearing loss Evaluate for enlarge cochlear aqueduct Evaluate for enlarge cochlear aqueduct Post-op Post-op Recurrent CHL Recurrent CHL Re-obliteration vs. prosthesis dislocation Re-obliteration vs. prosthesis dislocation Vertigo Vertigo

47. “Halo sign”

48. Paget’s disease

49. Osteogenesis Imperfecta

50. Management Options Medical Medical Amplification Amplification Surgery Surgery Combinations Combinations

51. Patient Selection Factors Factors Result of tuning fork tests and audiometry Result of tuning fork tests and audiometry Skill of the surgeon Skill of the surgeon Facilities Facilities Medical condition of the patient Medical condition of the patient Patient wishes Patient wishes

52. Surgery Best surgical candidate Best surgical candidate Previously un-operated ear Previously un-operated ear Good health Good health Unacceptable ABG Unacceptable ABG 25 to 40 dB 25 to 40 dB Negative Rinne test Negative Rinne test Excellent discrimination Excellent discrimination Desire for surgery Desire for surgery

53. Surgery Other factors Other factors Age of the patient Age of the patient Elderly Elderly Poorer results in the high frequencies Poorer results in the high frequencies Congenital stapes fixation (44% success rate) Congenital stapes fixation (44% success rate) Juvenile otosclerosis (82% success rate) Juvenile otosclerosis (82% success rate) Occupation Occupation Diver Diver Pilot Pilot Airline steward/stewardess Airline steward/stewardess

54. Surgery Other factors Other factors Vestibular symptoms Vestibular symptoms Meniere's disease Meniere's disease Concomitant otologic disease Concomitant otologic disease Cholesteatoma Cholesteatoma Tympanic membrane perforation Tympanic membrane perforation

55. Surgical Steps Subtleties of technique and style Subtleties of technique and style Local vs. general anesthesia Local vs. general anesthesia Stapedectomy vs. partial stapedectomy vs. stapedotomy Stapedectomy vs. partial stapedectomy vs. stapedotomy Laser vs. drill vs. cold instrumentation Laser vs. drill vs. cold instrumentation Oval window seals Oval window seals Prosthesis Prosthesis

56. Canal Injection 2-3 cc of 1% lidocaine with 1:50,000 or 1:100,000 epinephrine 2-3 cc of 1% lidocaine with 1:50,000 or 1:100,000 epinephrine 4 quadrants 4 quadrants Bony cartilaginous junction Bony cartilaginous junction

57. Raise Tympanomeatal Flap 6 and 12 o’clock positions 6 and 12 o’clock positions 6-8 mm lateral to the annulus 6-8 mm lateral to the annulus Take into account curettage of the scutum Take into account curettage of the scutum

58. Separation of chorda tympani nerve from malleus Separate the chorda from the medial surface of the malleus to gain slack Separate the chorda from the medial surface of the malleus to gain slack Avoid stretching the nerve Avoid stretching the nerve Cut the nerve rather than stretch it Cut the nerve rather than stretch it

59. Curettage of Scutum Curettage a trough lateral to the scutum, thinning it Curettage a trough lateral to the scutum, thinning it Then remove the scutum (incus to the round window) Then remove the scutum (incus to the round window)

60. Curettage of Scutum Exposure Exposure Vertical: Vertical: Facial nerve to round window Facial nerve to round window Horizontal: Horizontal: Pyramidal process to malleus Pyramidal process to malleus Preservation of bone over incus Preservation of bone over incus

61. Middle ear examination Mobility of ossicles Mobility of ossicles Confirm stapes fixation Confirm stapes fixation Evaluate for malleus or incus fixation Evaluate for malleus or incus fixation Abnormal anatomy Abnormal anatomy Dehiscent facial nerve Dehiscent facial nerve Overhanging facial nerve Overhanging facial nerve Deep narrow oval window niche Deep narrow oval window niche Ossicular abnormalities Ossicular abnormalities

62. Measurement for prosthesis Measurement Measurement Lateral aspect of the long process of the incus to the footplate Lateral aspect of the long process of the incus to the footplate

63. Total Stapedectomy Uses Uses Extensive fixation of the footplate Extensive fixation of the footplate Floating footplate Floating footplate Disadvantages Disadvantages Increased post-op vestibular symptoms Increased post-op vestibular symptoms More technically difficult More technically difficult Increased potential for prosthesis migration Increased potential for prosthesis migration

68. Stapedotomy/Small Fenestra Originally for obliterated or solid footplates Originally for obliterated or solid footplates Europe Europe 1970-80 1970-80 First laser stapedotomy performed by Perkins in 1978 First laser stapedotomy performed by Perkins in 1978 Less trauma to the vestibule Less trauma to the vestibule Less incidence of prosthesis migration Less incidence of prosthesis migration Less fixation of prosthesis by scar tissue Less fixation of prosthesis by scar tissue

69. Drill Fenestration 0.7mm diamond burr 0.7mm diamond burr Motion of the burr removes bone dust Motion of the burr removes bone dust Avoids smoke production Avoids smoke production Avoids surrounding heat production Avoids surrounding heat production

70. Laser Fenestration Laser Laser Avoids manipulation of the footplate Avoids manipulation of the footplate Argon and Potassium titanyl phosphate (KTP/532) Argon and Potassium titanyl phosphate (KTP/532) Wave length 500 nm Wave length 500 nm Visible light Visible light Absorbed by hemoglobin Absorbed by hemoglobin Surgical and aiming beam Surgical and aiming beam Carbon dioxide (CO2) Carbon dioxide (CO2) 10,000 nm 10,000 nm Not in visible light range Not in visible light range Surgical beam only Surgical beam only Requires separate laser for an aiming beam (red helium-neon) Requires separate laser for an aiming beam (red helium-neon) Ill defined fuzzy beam Ill defined fuzzy beam

74. Oval window seal Tragal perichondrium Tragal perichondrium Vein (hand or wrist) Vein (hand or wrist) Temporalis fascia Temporalis fascia Blood Blood Fat Fat Gelfoam (now discouraged) Gelfoam (now discouraged)

75. Reconstructing the annular ligament

76. Placement of the Prosthesis Prosthesis is chosen and length picked Prosthesis is chosen and length picked Some prefer bucket handle to incorporate the lenticular process of the incus Some prefer bucket handle to incorporate the lenticular process of the incus

77. Stapedectomy vs. Stapedotomy ABG closure < 10dB (PTA) ABG closure < 10dB (PTA)

78. Special Considerations and Complications in Stapes Surgery

79. Overhanging Facial Nerve Usually dehiscent Usually dehiscent Consider aborting the procedure Consider aborting the procedure Facial nerve displacement (Perkins, 2001) Facial nerve displacement (Perkins, 2001) Facial nerve is compressed superiorly with No. 24 suction (5 second periods) Facial nerve is compressed superiorly with No. 24 suction (5 second periods) 10-15 sec delay between compressions 10-15 sec delay between compressions Perkins describes laser stapedotomy while nerve is compressed Perkins describes laser stapedotomy while nerve is compressed Wire piston used Wire piston used Add 0.5 to 0.75 mm to accommodate curve around the nerve Add 0.5 to 0.75 mm to accommodate curve around the nerve

80. Floating Footplate Footplate dislodges from the surrounding OW niche Footplate dislodges from the surrounding OW niche Incidental finding Incidental finding More commonly iatrogenic More commonly iatrogenic Prevention Prevention Laser Laser Footplate control hole Footplate control hole Management Management Abort Abort H. House favors promontory fenestration and total stapedectomy H. House favors promontory fenestration and total stapedectomy Perkins favors laser fenestration Perkins favors laser fenestration

81. Diffuse Obliterative Otosclerosis Occurs when the footplate, annular ligament, and oval window niche are involved Occurs when the footplate, annular ligament, and oval window niche are involved Closure of air-bone gap < 10 dB less common. Closure of air-bone gap < 10 dB less common. Refixation commonly occurs Refixation commonly occurs

82. Perilymphatic Gusher Associated with patent cochlear aqueduct Associated with patent cochlear aqueduct More common on the left More common on the left Increased incidence with congenital stapes fixation Increased incidence with congenital stapes fixation Increases risk of SNHL Increases risk of SNHL Management Management Rough up the footplate Rough up the footplate Rapid placement of the OW seal then the prosthesis Rapid placement of the OW seal then the prosthesis HOB elevated, stool softeners, bed rest, avoid Valsalva, +/- lumbar drain HOB elevated, stool softeners, bed rest, avoid Valsalva, +/- lumbar drain

83. Round Window Closure 20%-50% of cases 20%-50% of cases 1% completely closed 1% completely closed No effect on hearing unless 100% closed No effect on hearing unless 100% closed Opening has a high rate of SNHL Opening has a high rate of SNHL

84. SNHL 1%-3% incidence of profound permanent SNHL 1%-3% incidence of profound permanent SNHL Surgeon experience Surgeon experience Extent of disease Extent of disease Cochlear Cochlear Prior stapes surgery Prior stapes surgery Temporary Temporary Serous labyrinthitis Serous labyrinthitis Reparative granuloma Reparative granuloma Permanent Permanent Suppurative labyrinthitis Suppurative labyrinthitis Extensive drilling Extensive drilling Basilar membrane breaks Basilar membrane breaks Vascular compromise Vascular compromise Sudden drop in perilymph pressure Sudden drop in perilymph pressure

85. Reparative Granuloma Granuloma formation around the prosthesis and incus Granuloma formation around the prosthesis and incus 2 -3 weeks postop 2 -3 weeks postop Initial good hearing results followed by an increase in the high frequency bone line thresholds Initial good hearing results followed by an increase in the high frequency bone line thresholds Associated tinnitus and vertigo Associated tinnitus and vertigo Exam – reddish discoloration of the posterior TM Exam – reddish discoloration of the posterior TM Treatment Treatment ME exploration ME exploration Removal of granuloma Removal of granuloma Prognosis – return of hearing with early excision Prognosis – return of hearing with early excision Associated with use of Gelfoam Associated with use of Gelfoam

86. Vertigo Most commonly short lived (2-3 days) Most commonly short lived (2-3 days) More prolonged after stapedectomy compared to stapedotomy More prolonged after stapedectomy compared to stapedotomy Due to serous labyrinthitis Due to serous labyrinthitis Medialization of the prosthesis into the vestibule Medialization of the prosthesis into the vestibule With or without perilymphatic fistula With or without perilymphatic fistula Reparative granuloma Reparative granuloma

88. Recurrent Conductive Hearing Loss Slippage or displacement of the prosthesis Slippage or displacement of the prosthesis Most common cause of failure Most common cause of failure Immediate Immediate Technique Technique Trauma Trauma Delayed Delayed Slippage from incus narrowing or erosion Slippage from incus narrowing or erosion Adherence to edge of OW niche Adherence to edge of OW niche Stapes re-fixation Stapes re-fixation Progression of disease with re-obliteration of OW Progression of disease with re-obliteration of OW Malleus or incus ankylosis Malleus or incus ankylosis

91. Amplification Excellent alternative Excellent alternative Non-surgical candidates Non-surgical candidates Patients who do not desire surgery Patients who do not desire surgery Patient satisfaction rate lower than that of successful surgery Patient satisfaction rate lower than that of successful surgery Canal occlusion effect Canal occlusion effect Amplification not used at night Amplification not used at night

92. Medical Sodium Fluoride Sodium Fluoride 1923 - Escot suggested using calcium fluoride 1923 - Escot suggested using calcium fluoride 1965 – Shambaugh popularized its use 1965 – Shambaugh popularized its use Mechanism Mechanism Fluoride ion replaces hydroxyl group in bone forming fluorapatite Fluoride ion replaces hydroxyl group in bone forming fluorapatite Resistant to resorption Resistant to resorption Increases calcification of new bone Increases calcification of new bone Causes maturation of active foci of otosclerosis Causes maturation of active foci of otosclerosis

93. Medical Sodium Fluoride Sodium Fluoride Reduces tinnitus, reverses Schwartze’s sign, resolution of otospongiosis seen on CT Reduces tinnitus, reverses Schwartze’s sign, resolution of otospongiosis seen on CT OTC – Florical OTC – Florical Dose – 20-120mg Dose – 20-120mg Indications Indications Non-surgical candidates Non-surgical candidates Patients who do not want surgery Patients who do not want surgery Surgical candidates with + Schwartze’s sign Surgical candidates with + Schwartze’s sign Treat for 6 mo pre-op Treat for 6 mo pre-op Postop if otospongiosis detected intra-op Postop if otospongiosis detected intra-op

94. Medical Sodium fluoride Sodium fluoride Hearing results Hearing results 50% stabilize 50% stabilize 30% improve 30% improve Re-evaluate q 2 yrs with CT and for Schwartze’s sign to resolve Re-evaluate q 2 yrs with CT and for Schwartze’s sign to resolve If fluoride are stopped – expect re-activation within 2-3 years If fluoride are stopped – expect re-activation within 2-3 years

95. Medical Bisphosphonates Bisphosphonates Class of medications that inhibits bone resorption by inhibiting osteoclastic activity Class of medications that inhibits bone resorption by inhibiting osteoclastic activity Dosing not standard Dosing not standard Often supplement with Vitamin D and Calcium Often supplement with Vitamin D and Calcium Studies conducted on otosclerosis patients with neurotologic symptoms report the majority of patients with subjective improvement or resolution. Studies conducted on otosclerosis patients with neurotologic symptoms report the majority of patients with subjective improvement or resolution. Future application of this treatment unclear, especially with new reports of bisphosphonate related osteonecrosis. Future application of this treatment unclear, especially with new reports of bisphosphonate related osteonecrosis.

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