Effect of stapedotomy on pre-operative tinnitus and its psychosomatic burden

Retrospective Evaluation of Otosclerosis and Stapes Surgery: Changing Trends Over 50 Years

To assess the post-operative cases of stapes surgery. To determine correction in hearing loss post surgery and changing trends over 50 years. In a retrospective observational study, 234 cases otosclerosis who underwent surgical management between 1973 and 2023 were assessed. A total of 234 cases were seen. Male:female ratio was 0.8:1. Most patients were in the age group 21-30. Left > right ear involvement was seen. Stapedotomy > stapedectomy was the surgical procedure done. More than 50% patients had around 30db improvement in audiometric evaluation post surgery. Most common complications were vertigo and nystagmus which were seen more post stapedectomy as compared to stapedotomy. Sensorineural hearing loss is a rare complication and was seen exclusively post stapedectomy. We conclude that stapes surgery is beneficial in improving hearing capabilities with no difference as per change in surgical approach. Stapedectomy being more radical has more predisposition to vertigo and nystagmus post surgery. Post-operative complications has reduced with course of time due to improvement in surgical equipments and pre-op investigations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04499-w.

Tinnitus and Otosclerosis: An Exploratory Study about the Prevalence, Features and Impact in Daily Life

Introduction  Tinnitus is experienced by a significant part of the patients suffering from otosclerosis.

Objective  To assess the prevalence of tinnitus in otosclerosis, its main features, and the impact on the daily life.

Methods  Patients diagnosed with otosclerosis in 2019 in a tertiary hospital were enrolled in the study. Demographic data were retrieved and, besides a regular audiometric evaluation, the patients underwent acuphenometry to assess the psychoacoustic measurements (pitch and loudness), and the Tinnitus Handicap Inventory (THI).

Results  In total, 66 patients fulfilled the inclusion criteria, with a female predominance (63.6%; n = 42), and a mean age of 48.7 years. The mean air-bone gap was of 26.3 dB. A total of 72.7% complained of tinnitus; it was mostly unilateral, identified in the low frequencies, namely 500 Hz, with median loudness of 7.5 dB. The median score on the THI score was of 37; most patients had a mild handicap (33.3%, n = 16), followed by those with a severe handicap (22.9%; n = 11). The female gender had a statistically significant association with the presence of tinnitus. The THI scores were higher in middle-aged patients (age groups: 40 to 49 and 50 to 59 years), which was statistically significant. No correlation was found between audiometry results and the prevalence of tinnitus or score on the THI. On the other hand, high-pitched tinnitus, compared to low pitched-tinnitus, was associated with larger air-bone gaps.

Conclusion  The prevalence of tinnitus in our population was in line with the prevalences reported in the literature. It caused a catastrophic handicap in 22.9% of the patients. High-pitched tinnitus was associated with higher handicap. Nonetheless, the existence of tinnitus and its severity were not associated with the degree of hearing loss.

The spatial percept of tinnitus is associated with hearing asymmetry: Subgroup comparisons

The spatial percept of tinnitus is hypothesized as an important variable for tinnitus subtyping. Hearing asymmetry often associates with tinnitus laterality, but not always. One of the methodological limitations for cross-study comparisons is how the variables for hearing asymmetry and tinnitus spatial perception are defined. In this study, data from two independent datasets were combined (n=833 adults, age ranging from 20 to 91 years, 404 males, 429 females) to investigate characteristics of subgroups with different tinnitus spatial perception focusing on hearing asymmetry. Three principle findings emerged. First, a hearing asymmetry variable emphasizing the maximum interaural difference most strongly discriminated unilateral from bilateral tinnitus. Merging lateralized bilateral tinnitus (perceived in both ears but worse in one side) with unilateral tinnitus weakened this relationship. Second, there was an association between unilateral tinnitus and ipsilateral asymmetric hearing. Third, unilateral and bilateral tinnitus were phenotypically distinct, with unilateral tinnitus being characterized by older age, asymmetric hearing, more often wearing one hearing aid, older age at tinnitus onset, shorter tinnitus duration, and higher percentage of time being annoyed by tinnitus. We recommend that careful consideration is given to the definitions of hearing asymmetry and tinnitus spatial perception in order to improve the comparability of findings across studies.

Evaluation of Outcomes Related to Hearing and Tinnitus After Ossicular Chain Reconstruction

OBJECTIVE

The aim of this study was to evaluate both audiological and tinnitus related results in patients with tinnitus undergoing ossicular chain reconstruction (OCR) for ossicular chain injury.

METHODS

Between January 2015 and January 2019, patients who underwent OCR due to ossicular chain pathology and developed tinnitus symptoms were included in the study group. Middle ear pathologies were standardized using the middle ear risk index (MERI) scoring system and the tinnitus handicap inventory (THI) was used to determine the severity of tinnitus. The surgical methods used for reconstruction were partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP), depending on the patient's pathology.

RESULTS

The study group consisted of 43 patients aged between 34 and 65 years. Mean MERI score of the patients was 6.42 ± 2.52. When assessed categorically, 18.6% of the study group was identified in the 'mild', 46.5% were in the 'moderate', and 34.5% were in the 'severe' MERI category. Patients in the TORP group and those who were undergoing second session OCR had higher MERI and preop THI scores. Post-operative tinnitus levels were higher in patients who had OCR in the second session and were in the severe risk group. The ABG and tinnitus scores of patients were found to improve with OCR. In patients who underwent TORP, both ABG and tinnitus scores decreased significantly. Whereas, in patients who underwent PORP, only ABG values decreased significantly. After OCR, both ABG value and tinnitus scores significantly decreased compared to pre-operative results. ABG recovery rate was 100% in the study group.

CONCLUSION

It can be said that OCR positively changes both audiological parameters and tinnitus levels in ossicular chain pathologies.

Prevalence and Severity of Tinnitus in Otosclerosis: Preliminary Findings from Validated Questionnaires

OBJECTIVES

In addition to progressive hearing loss, subjective tinnitus is one of the primary symptoms of the otosclerosis development. The aim of this study was to evaluate the prevalence and severity of preoperative tinnitus among a group of consecutive adult patients with otosclerosis, using standardized research tools.

MATERIALS AND METHODS

The study included 157 cases of clinical otosclerosis (106 women, 51 men). All patients were tested using pure-tone audiometry. The preoperative prevalence and severity of tinnitus were tested using three validated questionnaires: The Tinnitus and Hearing Survey (THS-POL), Tinnitus Handicap Inventory (THI-POL), and Tinnitus Functional Index (TFI-Pl).

RESULTS

Preliminary results showed that 107 of 157 patients with otosclerosis (68.2%) had preoperative tinnitus. Of them, 51 (47.7%) had unilateral tinnitus (in the ear that qualified for stapes surgery), and 56 (52.3%) had bilateral tinnitus. The THS results showed that for 23.4% patients, tinnitus was a problem equal to or greater than hearing loss. The average result of the TFI-Pl questionnaire was 31.6 points, and for THI-POL, it was 38.6 points, indicating that preoperative tinnitus was moderately severe. The statistical analysis did not reveal a correlation between the tinnitus severity and audiometric results (p>0.05). The severity of tinnitus did not differ significantly between men and women (p>0.05), although the TFI-Pl and THI-POL questionnaires indicated that the tinnitus severity generally increased with age in women, while it decreased in men.

CONCLUSION

This is a scientific study conducted to evaluate the prevalence and severity of preoperative tinnitus in Polish patients with otosclerosis, using three validated questionnaires.

The clinical characteristics of otosclerosis and benefit from stapedotomy: our experience of 48 patients (58 ears)

Background: Stapedotomy has been proved to be one of the most efficient procedure to treat otosclerosis, various factors contribute to the diversity of the outcomes and controversial results exist from previous studies. Objectives: We evaluated clinical characteristics and outcomes of stapedotomy, as well as possible predictive factors of a successful outcome. Materials and methods: This retrospective study evaluated 58 ears from 48 patients with demographic data, plus short-term follow-up of hearing outcomes of 28 ears, and evaluated variables using univariate general linear regression analyses. Results: The average operation age was 41.54 years. A total of 87.5% (42/48) patients presented with bilateral otosclerosis. 39.66% (23/58) ears had CT finding before the surgery. Patients with persistent tinnitus accounted for 53.45% (31/58) and the average preoperative ABG of the 58 ears was 32.22 dB. We achieved good postoperative air-bone gaps (ABGs) overall but poor ABG closure at 4 kHz. No predictive factors were identified in the 28 ears that were followed up. Conclusions and significance: Delayed surgery may be attributable to insufficient recognition of otosclerosis. The fenestration size could be the reason for poor ABG closure at high frequency. However, more cases and longer follow-ups are required to confirm our findings.

[Development and validation of the Stapesplasty Outcome Test 25 (SPOT-25)]

BACKGROUND

Otosclerosis affects health-related quality of life (HRQOL). Until now, measurements have only been performed using audiometric data or non-validated quality of life questionnaires.

OBJECTIVE

The objective of this study was to develop the first validated disease-specific HRQOL measuring instrument to determine HRQOL in otosclerosis.

MATERIALS AND METHODS

After sequential analysis and item reduction of the initial Stapesplasty Outcome Test 47 (SPOT-47), the SPOT-25 was validated prospectively on 52 otosclerosis patients undergoing stapes surgery. In addition to the overall score, four subscores were defined (hearing function, tinnitus, social restrictions, mental condition).

RESULTS

The SPOT-25 showed a high internal consistency (Cronbach's α > 0.7), allowed discrimination between otosclerosis patients and healthy subjects, and demonstrated acceptable test-retest reliability (r = 0.85). After stapes surgery, the HRQOL improved significantly. The responsiveness was high.

CONCLUSION

The SPOT-25 is the first validated disease-specific instrument for HRQOL measurement in otosclerosis patients. It should be used routinely for quality control.

Prevalence and severity of tinnitus in Polish otosclerosis patients qualified for stapes surgery

Purpose

To assess the prevalence and severity of tinnitus among a group of Polish patients with otosclerosis who qualified for stapes surgery. A secondary objective was to gauge the relationship between tinnitus severity and hearing thresholds.

Methods

Based on the eligibility criteria, 460 adults with otosclerosis (236 women, 134 men) were included in the study. The Tinnitus Functional Index (TFI) was used to assess tinnitus severity. Hearing thresholds for air and bone conduction were established using clinical pure-tone audiometry in a soundproof cabin.

Results

Based on the medical interview, tinnitus was the first symptom of otosclerosis in 35% of the participants and 65% of all patients with otosclerosis experienced clinically significant, chronic tinnitus before stapes surgery. For 59% of patients, tinnitus was a significant or severe problem. The degree of hearing loss seemed to be marginally related to the severity of tinnitus reported by the patient.

Conclusions

Tinnitus is a common complaint among patients with otosclerosis, being a significant or severe problem for more than half of them. For this reason, it is worth considering in the future the implementation of standardized questionnaires for the assessment of tinnitus severity as a routine procedure in the diagnostic process of patients with otosclerosis, as well as in the postoperative period, which will be the next stage of our study.

Clinically important change in tinnitus sensation after stapedotomy

Background

When measuring the treatment effect in tinnitus with multi-item outcome instruments, it is crucial for both clinical and research purposes to take into consideration clinical importance of the outcome scores. The aim of the present study is to determine minimal important change (MIC) in tinnitus which is clinically meaningful to patients with otosclerosis.

Methods

The study population was 95 patients with otosclerosis, suffering from tinnitus. They completed the Tinnitus Functional Index before stapedotomy and 3 months after the surgery. The minimal important change was estimated with the Clinical Global Impression Scale as the external criterion (anchor). The mean change method and the receiver operating characteristic (ROC) method were used to determine minimal important change in tinnitus sensation.

Results

The improvement in tinnitus after stapedotomy was reported by 69.4% of the patients with otosclerosis. Minimal important change in tinnitus was estimated as reduction of 8.8 points in the Tinnitus Functional Index.

Conclusions

The anchor-based approach using an external criterion (anchor) allows to determine change in tinnitus sensation which is meaningful to patients after stapedotomy. The value of 8.8 points in Tinnitus Functional Index could be used as benchmark of stapedotomy effectiveness in otosclerosis patients suffering from tinnitus. Hearing difficulties comorbid with tinnitus could affect the perception of tinnitus change.

New chamber stapes prosthesis - A preliminary assessment of the functioning of the prototype

Piston-stapedotomy is the most common method for hearing restoration in patients with otosclerosis. In this study, we have experimentally examined a prototype of a new chamber stapes prosthesis. The prototype was implanted in a human cadaver temporal bone. The round window vibrations before and after implantation were measured for the acoustic signal (90 dB SPL, 0.8–8 kHz) in the external auditory canal. In comparison with a 0.4-mm piston prosthesis, the chamber prosthesis induced significantly higher vibration of the round window, especially for frequencies above 1.5 kHz. Based on the results, it can be surmised that stapedotomy with a chamber stapes prosthesis could provide better hearing results in comparison with the piston-stapedotomy.

Does stapes surgery improve tinnitus in patients with otosclerosis?

Introduction

Otosclerosis (OS) is the primary disease of the human temporal bone characterized by conductive hearing loss and tinnitus. The exact pathogenesis of tinnitus in otosclerosis patients is not known and factors affecting the tinnitus outcome in otosclerosis patients are still controversial.

Objectives

To find the effect of stapedotomy on tinnitus for otosclerosis patients.

Methods

Fifty-six otosclerosis patients with preoperative tinnitus were enrolled to the study. Pure tone average Air-Bone Gap values, preoperative tinnitus pitch, Air-Bone Gap closure at tinnitus frequencies were evaluated for their effect on the postoperative outcome.

Results

Low pitch tinnitus had more favorable outcome compared to high pitch tinnitus (p = 0.002). Postoperative average pure tone thresholds Air-Bone Gap values were not related to the postoperative tinnitus (p = 0.213). There was no statistically significant difference between postoperative Air-Bone Gap closure at tinnitus frequency and improvement of high pitch tinnitus (p = 0.427). There was a statistically significant difference between Air-Bone Gap improvement in tinnitus frequency and low pitch tinnitus recovery (p = 0.026).

Conclusion

Low pitch tinnitus is more likely to be resolved after stapedotomy for patients with otosclerosis. High pitch tinnitus may not resolve even after closure of the Air-Bone Gap at tinnitus frequencies.

High-frequency hearing, tinnitus, and patient satisfaction with stapedotomy: A randomized prospective study

Otosclerosis is a common disorder that leads to conductive hearing loss. Most patients with otosclerosis also have tinnitus, and surgical treatment is known to improve hearing as well as tinnitus. Some patients however experience worsening of tinnitus after the operation, but there are no known factors that allow surgeons to predict who will be at risk. In this prospective observational study on 133 patients undergoing stapedotomy, we show that postoperative air conduction thresholds at very high stimulus frequencies predict improvement of tinnitus, as assessed with proportional odds logistic regression models. Young patients were significantly more likely to experience reduction of tinnitus and patients whose tinnitus became better were also more satisfied with the outcome of the operation. These findings have practical importance for patients and their surgeons. Young patients can be advised that surgery is likely to be beneficial for their tinnitus, but a less positive message should be conveyed to older patients.

Clinical Practice Guideline

Objective

Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient’s quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome.

Purpose

The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Action Statements

The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Tinnitus in men, mice (as well as other rodents), and machines

The phantom auditory sensation of tinnitus is now studied in humans, animals, and computer models, and our understanding of how tinnitus is triggered and which neural mechanisms give rise to the phantom sensation in the brain has increased considerably. In most cases, tinnitus is associated with hearing loss, and even tinnitus patients with normal hearing thresholds might have cochlear damage that is not detected through conventional audiometry, as has been recently shown through auditory brainstem response measurements. Animals show behavioural signs of tinnitus after induction of hearing loss, indicating a causal relation. Moreover, surgical reduction of hearing loss in otosclerosis can reduce or even abolish tinnitus. However, hearing loss does not always lead to tinnitus. Psychophysical measurements have indicated that certain types of cochlear damage might be more closely linked to tinnitus than others. Recent animal studies have used behavioural testing to distinguish between animals with and without tinnitus after noise exposure. Comparisons between these groups of animals have helped identify neural correlates of tinnitus as well as factors that could represent a predisposition for tinnitus. Human neuroimaging studies have also begun to separate the neural signature of tinnitus from other consequences of hearing loss. The functional mechanisms that could underlie tinnitus development tinnitus have been analysed in computational modelling studies, which indicate that tinnitus could be a side-effect of the brain's attempt to compensate for hearing loss. Even though causal treatments for tinnitus are currently not available, hearing aids can provide considerable benefit when used in conjunction with counselling, tinnitus retraining therapy or cognitive behavioural therapy. Finally, animal studies demonstrate that the development of chronic noise-induced tinnitus might be prevented through timely interventions after noise exposure. This article is part of a Special Issue entitled <Annual Reviews 2014>.