Is This Patient Operable?

Survey of otologists reveals differences of opinion on treatment, surgery for otosclerosis with vertigo

CHICAGO-There is a general unease among otologists when presented with a patient who has probable otosclerosis and symptoms of vertigo because of deafness as a possible complication of surgery, according to a survey conducted by John W. Seibert, MD, and colleagues at University of Arkansas for Medical Sciences in Little Rock. He presented the survey findings in a presentation title Current Otologic Opinion on the Treatment of Hearing Loss in Patients with Intermittent Disequilibrium, here at the American Otologic Society section of the Combined Otolaryngology Spring Meetings (COSM).

Regarding surgical instruments, the instrument of choice for 49% was the laser, while 20% preferred the hand drill and 28% chose the mechanical drill.

Otologists typically fall into one of three camps, explained Dr. Siebert, who was a resident at the University of Arkansas the during the research and is now Assistant Professor of Otolaryngology-Head and Neck Surgery at Washington University School of Medicine in St. Louis, Mo. One camp refuses to perform stapes surgery on anyone with symptoms of vertigo; another proceeds with the surgery only if certain criteria are met such as a normal electronystagmography (ENG); and the third performs a stapedotomy regardless of the vertigo symptoms.

The researchers mailed a survey to 250 members of the American Otologic Society in the spring of 2005. The survey included a very brief case study describing a 45-year-old with a history of balance problems and hearing loss suggestive of otosclerosis. Survey respondents were asked to indicate if they would immediately proceed with a stapedectomy/stapedotomy or would decide on further management and work-up. They were also asked to indicate which important history and physical findings would influence their decision-making process for stapes surgery.

The Survey

A total of 71 physicians responded to the survey, resulting in a 28% response rate.

Sixteen otologist respondents, or 22%, indicated that they would proceed with the stapedectomy after assuring that the presence of a balance disorder in the patient was not due to a retrocochlear cause.

Forty-nine otologist respondents, or 69%, said that they would recommend further work-up or treatment that might include a diuretic trial, electrocochleography, trial of fluoride, electronystagmography, and/or CT scan. (Six respondents didn’t answer this question.)

Regarding overall initial management of the case, respondents were allowed to select all or none of the treatment choices listed above. Thirty-one physicians (44%) said that they would consider diuretics as an initial management. Twenty-two (31%) agreed with using some form of fluoride prior to intervention. Thirty-one (43%) chose electronystagmography, and 20 (28%) went with electrocochleography. Lastly, 27 (38%) would order a CT scan preoperatively.

Use of Diuretics

Eighteen respondents (25%) said that they would not consider using diuretics. Of the 44% who indicated that they would proceed with diuretics, four (13%) recommended a trial for one month; five (16%) said they would recommend diuretics for six to eight weeks; 17 (55%) recommended a trial for at least three to six months; and only three (10%) recommended diuretics for over six months.