Otosclerosis: Symptoms, Hearing Tests, and Stapes Surgery
Diagnosis and treatment of progressive conductive hearing loss
Otosclerosis is a disorder of abnormal bone remodeling in the otic capsule, the bone surrounding the inner ear. It most often affects the area around the stapes, the third bone that looks like a stirrup, When the stapes becomes fixed, sound cannot pass efficiently into the inner ear, causing progressive conductive hearing loss.
Otosclerosis often begins in early or middle adulthood and may affect one or both ears. Some patients also develop sensorineural hearing loss when the inner ear is involved. Treatment can include observation, hearing aids, or stapes surgery, depending on the hearing test, symptoms, and personal goals.
What are the Symptoms of Otosclerosis?
- Gradually progressive hearing loss, often worse in one ear at first
- Difficulty hearing soft or low-pitched sounds
- Needing others to repeat themselves or increasing television volume
- Tinnitus, such as ringing, buzzing, or humming
- Hearing speech relatively better in a noisy environment, called paracusis Willisii
- Mild imbalance in some patients
Ear pain, drainage, and repeated infections are not typical of otosclerosis and suggest another diagnosis.
What Causes Otosclerosis?
The exact cause is not fully understood. Genetics play an important role, and the condition may occur in several members of a family. Otosclerosis involves abnormal cycles of bone breakdown and rebuilding in an area that normally remains very stable.
Hormonal and viral factors have been studied, but their roles remain uncertain. Some patients notice hearing worsens during pregnancy, while others do not. Pregnancy alone does not establish the diagnosis.
How Otosclerosis Affects Hearing
The exact cause is not fully understood. Genetics play an important role, and the condition may occur in several members of a family. Otosclerosis involves abnormal cycles of bone breakdown and rebuilding in an area that normally remains very stable.
Hormonal and viral factors have been studied, but their roles remain uncertain. Some patients notice hearing worsens during pregnancy, while others do not. Pregnancy alone does not establish the diagnosis.
How Otosclerosis Is Diagnosed
Ear examination
The ear canal and eardrum usually look normal. A reddish appearance behind the eardrum, known as Schwartze sign, can occur in active disease but is uncommon and is not required for diagnosis.
Comprehensive audiogram
Pure-tone testing measures air- and bone-conduction thresholds and identifies the conductive component. Speech testing evaluates clarity and helps estimate how much useful inner-ear hearing remains.
Tympanometry and acoustic reflexes
Tympanometry assesses eardrum and middle-ear function. Acoustic reflexes are often absent or abnormal when the stapes is fixed, although results must be interpreted with the complete hearing test.
Tuning-fork tests
Weber and Rinne testing can support the diagnosis and confirm the conductive hearing loss during the office examination.
Temporal-bone CT scan
CT may show changes around the stapes or cochlea and can identify other causes of conductive hearing loss. It is useful in selected cases, especially when symptoms or tests are atypical or surgery is being planned, but it is not necessary for every patient. Dr. Djalilian’s philosophy is to generally get a CT if the patient decides to do surgery as we want to rule out other conditions such as superior canal dehiscence, malleus fixation, or other third window abnormalities.
Conditions That Can Resemble Otosclerosis
Other problems can produce an air-bone gap or similar symptoms, including ossicular discontinuity, tympanosclerosis, superior semicircular canal dehiscence, enlarged vestibular aqueduct, middle-ear fluid, congenital ossicular fixation, and prior trauma. Accurate diagnosis is essential because these conditions are treated differently. CT scan can differentiate these conditions.
Otosclerosis Treatment Options
Observation
Mild, stable hearing loss may be followed with periodic audiograms. Treatment can be reconsidered if communication becomes more difficult or the hearing changes.
Hearing aids
Modern hearing aids amplify sound and avoid surgical risk. They can be used in one or both ears and remain an option before or after surgery.
Stapedotomy or stapedectomy
Stapes surgery bypasses the fixed stapes with a small prosthesis. In a stapedotomy, the surgeon creates a small opening in the footplate. In a traditional stapedectomy, a larger portion is removed. Stapedotomy is commonly used today, although many patients use “stapedectomy” as the general term for otosclerosis surgery.
Treatment when inner-ear hearing loss is significant
Patients with a substantial sensorineural component may still benefit from hearing aids after stapes surgery. In advanced cases, other implantable hearing options or cochlear implantation may be discussed after specialized testing.
Who May Benefit from Stapes Surgery?
A candidate generally has hearing loss that affects daily life, an audiogram consistent with stapes fixation, useful cochlear function, and no active ear infection. The expected benefit is compared with hearing-aid performance and the small but important surgical risks.
The surgeon also considers speech understanding, balance symptoms, hearing in the opposite ear, occupation, prior ear procedures, anatomy, and medical conditions. Surgery on the only hearing ear requires especially careful decision-making.
Expected Results of Otosclerosis Surgery
For appropriately selected patients, stapes surgery often improves the conductive component of hearing and can reduce the need for amplification. The degree of improvement varies, and surgery does not prevent all future age-related or otosclerosis-related inner-ear hearing changes.
Revision surgery is more complex and may have different expectations than a first operation. A detailed review of prior operative reports, audiograms, and imaging can help determine whether another procedure is reasonable.
Risks of Stapes Surgery
Potential risks include temporary dizziness, taste disturbance, tinnitus, eardrum problems, infection, incomplete improvement, recurrent hearing loss, prosthesis displacement, and the need for revision surgery. There is a small risk of severe or complete hearing loss because the operation is performed at the opening of the inner ear. This risk is approximately 1 in 300. This can be treated with a cochlear implant.
Otosclerosis and Tinnitus
Tinnitus is common in otosclerosis. It may improve when conductive hearing is restored or amplified, but it can persist independently of the hearing result. Persistent bothersome tinnitus may need separate counseling, sound-based strategies, hearing rehabilitation, or treatment of contributing conditions.
Why See an Otosclerosis Specialist?
Otosclerosis can be confused with other middle- and inner-ear disorders, and stapes surgery requires precision. Hamid R. Djalilian, MD, is a board-certified, fellowship-trained otologist and neurotologist, professor of otolaryngology and biomedical engineering at UC Irvine, and director of UCI Health Otology, Neurotology and Skull Base Surgery Services.
Dr. Djalilian evaluates new diagnoses, complex conductive hearing loss, primary and revision stapes surgery, and patients seeking a second opinion. Consultations are available through UCI Health in Orange County, California.
Frequently Asked Questions
It often runs in families, but not everyone with a family history develops hearing loss. A person can also develop otosclerosis without knowing of an affected relative.
Hearing aids can treat the hearing loss but do not free the fixed stapes. There is no established medication that reliably reverses stapes fixation.
No. It can affect one ear or both, and the degree of hearing loss may be different between ears.
No. Significant or episodic vertigo may indicate another inner-ear problem and deserves additional evaluation.
The choice depends on hearing-test results, speech understanding, health, risk tolerance, lifestyle, medical conditions, hearing-aid experience, and the expected surgical benefit. A specialist can explain both options without assuming that surgery is best for everyone.
Dr. Djalilian has extensive experience with otosclerosis surgery and uses the latest techniques in surgery using the latest in prostheses and laser technology. He takes extra care to preserve the function of the chorda tympani nerve (taste nerve), that many surgeons sacrifice to make the surgery easier.
Schedule an Otosclerosis Evaluation
To schedule an evaluation with Dr. Hamid R. Djalilian for progressive conductive hearing loss, otosclerosis, or possible stapes surgery, call UCI Health at 714-456-7017. Bring current and previous audiograms and any temporal-bone imaging or prior surgical records.
Written and medically reviewed by Hamid R. Djalilian, MD. Last reviewed July 2026.