Reversal versus classic stapedotomy for otosclerosis: a systematic review and meta-analysis

Stapedotomy is the standard surgical intervention for otosclerosis, but the optimal sequence of surgical steps remains debated. This systematic review and meta-analysis aims to compare the efficacy and safety of reversal versus classic stapedotomy for otosclerosis.

A comprehensive search across five databases was conducted up to February 2026 for randomized controlled trials (RCTs) and non-randomized studies (NRS). The primary outcome was audiological success, defined as air-bone gap (ABG) closure to ≤ 10 dB. Secondary outcomes included continuous audiometric parameters and surgical complications. Risk ratios (RRs) and mean differences (MDs) were pooled using a random-effects model.

Ten studies (2 RCTs, 8 NRS) involving 1,540 patients were included. There was no significant difference between the reversal and classic techniques in achieving an ABG ≤ 10 dB (RR: 1.02, 95% CI [0.93, 1.13]). While statistically significant differences favored the reversal approach for postoperative ABG (MD: -1.57 dB, 95% CI [- 2.59, - 0.54]) and postoperative air conduction pure-tone average (MD: -1.86 dB, 95% CI [- 3.17, - 0.55]), these differences lacked clinical significance. Regarding safety, no statistically significant differences were observed, although the reversal approach showed favorable trends toward reduced floating footplates (RR: 0.23, 95% CI [0.04, 1.24]) and chorda tympani injuries (RR: 0.54, 95% CI [0.29, 1.00]).

Reversal and classic stapedotomy demonstrate comparable audiological outcomes, with no statistically significant differences observed in the assessed safety outcomes. However, the certainty of evidence was low for audiological outcomes and very low for complications, precluding definitive conclusions until further large-scale RCTs are available.