Reconsidering surgical thresholds for stapedotomy: multicenter outcome analysis

Stapedotomy provides excellent audiological outcomes in otosclerosis, yet no universally accepted criteria exist for surgical indication. Current recommendations vary substantially across countries, particularly regarding audiometric thresholds. This study aimed to evaluate whether performing stapedotomy at lower preoperative hearing thresholds compromises postoperative outcomes.

A retrospective multicenter cohort study was conducted including adult patients undergoing primary stapedotomy for otosclerosis. Preoperative and postoperative audiometric data were collected according to AAO-HNS reporting guidelines. Patients were stratified according to preoperative air-bone gap (ABG) thresholds (≤ 20 vs. > 20 dB; ≤30 vs. > 30 dB), with additional subgroup analyses based on pure-tone average (PTA) thresholds (≤ 30 vs. > 30 dB; ≤40 vs. > 40 dB). Postoperative ABG and complication rates were compared between subgroups.

A total of 615 stapedotomies were included. Median postoperative ABG was 5 dB (IQR 2.5-8.1), with significant improvement in all audiometric parameters (p < 0.0001). Patients operated at lower preoperative ABG thresholds achieved postoperative ABG values comparable to those with larger gaps. Using a 30 dB threshold, slightly better postoperative ABG closure was observed in patients with smaller preoperative conductive components (p = 0.017). Similar findings were confirmed in analyses based on PTA thresholds. Complication rates were low and did not significantly differ across audiometric subgroups.

Stapedotomy provides excellent postoperative hearing outcomes across a broad range of preoperative hearing levels. Earlier surgical intervention in patients with smaller air-bone gaps does not appear to compromise audiological results or increase complication rates. These findings question the need for rigid threshold-based surgical indications and support a more individualized, patient-centered approach to timing of surgery.