Otosclerosis

Introduction

If you have been told that your hearing loss is caused by otosclerosis, or if your doctor is investigating this possibility, you are reading the right guide. Otosclerosis is a condition of the middle ear that causes hearing to fade gradually, often over many years. It is one of the most common causes of hearing loss in young and middle-aged adults, and it is also one of the most studied. There is a clear set of options for managing it — from monitoring and hearing aids to a well-established surgery called stapes surgery.

This article explains what otosclerosis is, why it happens, how it is diagnosed, and the choices you and your ENT specialist may discuss. It also covers what surgery involves, what recovery looks like, and what to expect over the longer term. The aim is to help you feel informed and confident as you plan the next steps in your care.

What Is Otosclerosis?

Otosclerosis is a condition in which abnormal bone growth develops inside the middle ear. To understand it, it helps to picture how the ear works. Sound waves enter the ear canal and hit the eardrum, which vibrates. These vibrations pass through three tiny bones in the middle ear — the malleus, incus, and stapes — which together are called the ossicles. The stapes is the smallest bone in the human body. It pushes into the inner ear (the cochlea), where vibrations are turned into nerve signals the brain understands as sound.

In otosclerosis, new spongy bone slowly grows around the base of the stapes (called the footplate). Over time this bone hardens and fixes the stapes in place. When the stapes cannot move freely, sound vibrations no longer pass efficiently into the inner ear. The result is a type of hearing loss called conductive hearing loss — sound is being “blocked” on its way in, even though the inner ear and hearing nerve may still be working.

In some people, otosclerosis also affects the cochlea itself, damaging the delicate hair cells that detect sound. This adds a sensorineural component to the hearing loss. When both types of hearing loss are present together, it is described as mixed hearing loss.

A few things are useful to know about otosclerosis:

• It is not an infection and is not contagious.
• It tends to progress slowly over years.
• It usually starts in early adulthood, often between the ages of 20 and 40.
• It is more common in women than in men, and pregnancy sometimes seems to make it worsen more quickly.
• It often runs in families, suggesting a genetic basis.
• Most people eventually develop hearing loss in both ears, though usually one ear is worse than the other.

The exact cause is still not fully understood. Current research points to a mix of genetic factors, hormonal influences, and possibly a long-ago viral exposure (such as measles) as contributors. None of this is anything a patient could have prevented.

Types and Patterns of Otosclerosis

Doctors sometimes describe otosclerosis by where the abnormal bone forms and what kind of hearing loss it produces.

Stapedial (fenestral) otosclerosis

This is the most common pattern. Abnormal bone forms around the stapes footplate and gradually fixes it in place. It causes conductive hearing loss and is the form most commonly treated with stapes surgery.

Cochlear (retrofenestral) otosclerosis

In this form, abnormal bone affects the cochlea itself. It causes sensorineural hearing loss, sometimes without much conductive component. Surgery on the stapes is less helpful here, and management focuses more on hearing aids and, in advanced cases, cochlear implants.

Mixed otosclerosis

Many patients have both stapes fixation and some cochlear involvement, producing a mixed hearing loss. Treatment decisions in this group depend on which component is more prominent.

Otosclerosis is also described by its activity. “Active” or “otospongiotic” phases involve softer, growing bone; “inactive” or mature phases involve harder, stable bone. Most people pass through both stages over many years.

Causes and Risk Factors

Otosclerosis does not have a single cause, but several factors are known to raise the risk.

Genetics

Otosclerosis often runs in families. If a close blood relative (parent, sibling) has the condition, the risk of developing it is higher. The pattern of inheritance is complex and not everyone in a family will be affected to the same degree.

Sex and hormones

Women are diagnosed roughly twice as often as men. Some women notice that hearing loss worsens during or after pregnancy, which suggests that hormonal changes may influence how the condition progresses.

Age

Symptoms most often begin between the ages of 20 and 40. It is uncommon to develop noticeable otosclerosis for the first time in older age, although the condition can continue to progress through life.

Ethnicity

Otosclerosis is more common in people of European ancestry and less common in people of African and East Asian ancestry, though it occurs worldwide.

Possible viral link

Some research has suggested a link with past measles infection, which is one reason why otosclerosis appears to be becoming slightly less common in populations with high measles vaccination rates. This link is not definitive but is widely discussed in the ENT literature.

Signs and Symptoms

Most people reading this article will already recognise these patterns. They are listed here so that you can compare them with your own experience and discuss any new or changing symptoms with your ENT doctor.

Gradual hearing loss

Hearing typically fades slowly over months and years. It often starts in one ear and later affects the other. Low-pitched sounds (such as men’s voices) may be harder to hear in the early stages. Conversations in quiet rooms may feel surprisingly difficult.

Paracusis Willisii

A classic feature of otosclerosis is that some people hear better in noisy environments than in quiet ones. The reason is that people around them speak more loudly in noisy places. This pattern is called paracusis Willisii and can help point to the diagnosis.

Tinnitus

Many people with otosclerosis experience tinnitus — a ringing, buzzing, or humming sound in the ear that does not come from outside. Tinnitus can be mild or distressing and may be the symptom that first prompted you to seek help.

Balance changes

Some people notice mild unsteadiness or brief dizziness. True spinning vertigo is less common but can occur, particularly when there is more cochlear involvement.

Voice changes

Diagnosing otosclerosis is mainly a clinical process based on history, hearing tests, and sometimes imaging. There is no blood test for the condition.

History and ear examination

An ENT specialist will ask about the pattern of your hearing loss, family history, tinnitus, dizziness, and any history of ear infections or surgery. The ear canal and eardrum are examined with an otoscope. In otosclerosis, the eardrum usually looks normal because the problem lies deeper in the middle ear. Occasionally, a faint pink tint can be seen behind the eardrum (called Schwartze sign), which suggests active disease.

Pure tone audiometry

This is the central hearing test. You listen to tones at different pitches through headphones (air conduction) and through a small vibrator placed behind the ear (bone conduction). The pattern in otosclerosis is typically:

• Reduced air conduction (sound going through the outer and middle ear is blocked).
• Better bone conduction (sound bypassing the middle ear reaches the inner ear more normally).
• A characteristic dip in bone conduction at 2000 Hz called the Carhart notch, which often improves after successful surgery.

Tympanometry and acoustic reflexes

These tests measure how the eardrum and middle ear respond to changes in pressure and sound. In otosclerosis, the eardrum typically moves normally, but the stapedial reflex (a tiny protective muscle contraction) is often reduced or absent because the stapes is fixed.

Speech audiometry

This test checks how well you can understand spoken words at different volumes. It helps estimate how much benefit hearing aids or surgery might offer.

CT scan

A high-resolution CT scan of the temporal bones is not always needed, but it is often ordered before surgery. It can show areas of abnormal bone, rule out other causes of conductive hearing loss (such as a problem with the middle ear bones from past infection), and help the surgeon plan the operation.

Ruling out other causes

Other conditions can mimic otosclerosis, including chronic middle ear fluid, eardrum problems, or fixation of other middle ear bones. Part of the diagnostic process is making sure these are excluded.

Treatment Options

There is currently no medication that reliably stops or reverses the abnormal bone growth of otosclerosis. Treatment focuses on restoring hearing. There are three broad paths, and which one suits you best is a decision to make with your ENT specialist and audiologist, based on how much your hearing loss affects daily life, the type of hearing loss you have, and your personal preferences.

Observation and monitoring

If hearing loss is mild and not interfering with daily life, regular hearing checks may be all that is needed at first. Many people with otosclerosis live well without treatment for years. Monitoring usually involves an audiogram every year or two, with treatment considered if hearing worsens or starts to affect work, relationships, or safety.

Hearing aids

• Do not require surgery and carry no surgical risks.
• Can be tried at any stage and adjusted as hearing changes.
• Are often used in both ears for better balance and clarity.
• Can be the long-term solution for people who prefer to avoid surgery, who have medical conditions that increase surgical risk, or who have significant sensorineural hearing loss.

An audiologist will fit and program the device to match your hearing loss and lifestyle. Different styles — behind-the-ear, in-the-ear, and others — have different trade-offs in comfort, visibility, and battery life.

Stapes surgery

Stapes surgery is one of the most refined operations in ENT and has been performed since the 1950s. The aim is to bypass the fixed stapes so that sound vibrations can again reach the inner ear. There are two main techniques.

Stapedotomy. This is the technique most commonly used today. The surgeon makes a tiny precise hole in the stapes footplate and places a small prosthesis (a wire or piston) that connects the incus to the inner ear. Sound vibrations now pass through the prosthesis. Stapedotomy is technically demanding but is associated with a slightly lower risk to the inner ear than older techniques.

Stapedectomy. In this older technique, a larger portion of the stapes footplate is removed and replaced with a prosthesis and a small graft. Many surgeons now prefer stapedotomy, but stapedectomy remains a valid option in certain situations and is still used by some experienced ENT surgeons.

Both operations are usually performed under local or general anaesthesia through the ear canal — there is no visible cut on the outside of the head. The procedure typically takes one to two hours. Most patients go home the same day or after one overnight stay.

Surgery is usually offered when:

• Hearing loss is significant and conductive (or mainly conductive).
• Hearing aids are not tolerated or not providing enough benefit.
• The patient is medically fit for the procedure.
• The ear is otherwise healthy and free of infection.

If both ears are affected, surgery is generally performed on one ear at a time, usually starting with the worse-hearing ear. The second ear may be operated on later if needed, typically after at least six months of stable results in the first ear.

Cochlear implants

For people with very advanced otosclerosis that has caused severe sensorineural hearing loss, particularly when hearing aids no longer provide useful benefit, a cochlear implant may be considered. This is a more involved surgery that bypasses the damaged inner ear and stimulates the hearing nerve directly. It is a less common path in otosclerosis but is well established when needed.

Medications under discussion

Sodium fluoride and bisphosphonates have been studied as ways to slow active otosclerosis. The evidence is mixed and these medications are not part of standard treatment in most settings. Your ENT specialist can explain whether they are relevant for your specific situation.

Preparing for Stapes Surgery

If you decide, together with your ENT surgeon, to proceed with stapes surgery, several steps usually happen before the operation.

Confirming the diagnosis and plan

Hearing tests are reviewed, and a CT scan may be performed if not already done. The surgeon explains what to expect, including the likely improvement in hearing, the risks involved, and what would happen if the operation does not improve hearing as hoped.

Medical assessment

Routine pre-operative checks include blood tests, an ECG if indicated, and a review of any medications you take. Blood thinners may need to be adjusted in advance under medical supervision. Any active ear infection should be fully treated before surgery.

Discussion of anaesthesia

Stapes surgery can be done under general anaesthesia (you are fully asleep) or local anaesthesia with sedation (the ear is numbed and you are relaxed but awake). Each has advantages, and the choice depends on the patient, the surgeon, and the operating theatre’s usual practice.

Practical preparation

You will usually be asked to:

• Fast for several hours before surgery.
• Arrange transport home, as you should not drive immediately after.
• Plan for a few days of rest at home afterward.
• Avoid flying for at least one to two weeks after the operation, as advised by your surgeon.
• Bring a list of your current medications and any prior hearing test results.

What Happens During Stapes Surgery

The surgeon uses an operating microscope or an endoscope to look through the ear canal. The eardrum is gently lifted to expose the middle ear. The surgeon confirms that the stapes is fixed, then either creates a small opening in the footplate (stapedotomy) or removes part of it (stapedectomy). A tiny prosthesis — usually made of titanium, platinum, or other biocompatible material — is placed so that it transmits vibrations from the incus into the inner ear. The eardrum is laid back in place, and a small dressing is placed in the ear canal.

The operation usually takes one to two hours. Most patients are surprised by how little discomfort they feel afterward, although the ear may feel blocked or full for some time.

Recovery and Healing

Recovery after stapes surgery is usually straightforward, but the ear is delicate and needs to be protected during healing.

The first few days

You may feel:

• Mild ear pain or pressure, usually controlled with simple painkillers.
• A feeling of fullness or muffled hearing due to packing and swelling.
• Some dizziness or unsteadiness as the inner ear adjusts.
• An altered sense of taste on one side of the tongue, because a small taste nerve passes through the middle ear. This usually settles over weeks to months.

Most people can return to light activities within a few days and to office work within one to two weeks. Heavy lifting, straining, and strenuous exercise are usually avoided for several weeks to protect the new prosthesis.

Protecting the ear

During the early weeks of healing, your surgeon will usually advise you to:

• Keep the ear dry — no swimming or letting water enter the ear canal.
• Avoid blowing your nose forcefully; sneeze with your mouth open.
• Avoid air travel for at least one to two weeks (longer in some cases).
• Avoid loud noise exposure.
• Take any prescribed antibiotics or ear drops as directed.

When hearing improves

Hearing may seem worse at first because of packing and swelling. Most patients begin to notice improvement within two to four weeks. The final result is usually clear by two to three months after surgery, when a follow-up audiogram is performed. Some people describe the change as dramatic, especially when surgery is on the worse ear.

Follow-up

Follow-up visits typically include ear examinations and repeat hearing tests at intervals decided by your surgeon. Long-term follow-up is helpful because the other ear may also need attention over time, and the prosthesis itself can occasionally need revision years later.

Risks and Complications

Stapes surgery is generally safe in experienced hands, but it is delicate work in a very small space, and complications are possible. Discussing these openly with your surgeon before the operation is an important part of informed consent.

Common, usually temporary

• Mild dizziness for days to weeks.
• Change in taste on one side of the tongue.
• Ear fullness or muffled hearing in the early weeks.
• Tinnitus that may persist or, in many cases, improve.

Less common, more significant

• Failure to improve hearing. A small proportion of patients do not gain useful hearing improvement. The prosthesis can also shift over time and need revision surgery.
• Worsening of hearing. In a small percentage of cases, hearing in the operated ear becomes worse than before surgery. In rare cases (less than 1 in 100 in most series), the operated ear loses all useful hearing — called a “dead ear.” This is the main reason surgery is usually performed on the worse ear first.
• Persistent vertigo. Most dizziness settles, but rarely it can be longer lasting.
• Facial nerve injury. The facial nerve passes through the middle ear. Injury is very rare but serious when it happens.
• Perforation of the eardrum. Small tears usually heal but may occasionally require further treatment.
• Infection. Uncommon but possible, usually treated with antibiotics.

Choosing an experienced ENT surgeon who performs stapes surgery regularly is one of the most important factors in reducing risk. It is reasonable to ask your surgeon how many of these operations they perform each year and what their typical results are.

Outcomes and What to Expect Over Time

Stapes surgery has a long track record, and most patients gain meaningful hearing improvement. In published series from experienced centres, a large majority of patients (often around nine out of ten) achieve a useful closure of the “air–bone gap” on hearing tests, meaning that conductive hearing loss is substantially corrected. Tinnitus often improves as well, though it does not always disappear.

Several points are worth keeping in mind:

• Surgery corrects the conductive part of hearing loss but cannot reverse sensorineural damage. If the inner ear is already affected, the result will be limited by that.
• The other ear can continue to be affected by otosclerosis. Regular hearing checks remain important.
• The prosthesis is durable but not always permanent. Some patients need revision surgery years later if the prosthesis loosens or shifts.
• Hearing aids remain an option at any time — before surgery, instead of surgery, or in addition to surgery if needed for the other ear.

Living with Otosclerosis

Whether you choose observation, hearing aids, or surgery, daily life with otosclerosis is something you can manage well with some practical strategies.

Communication

• Tell family, friends, and colleagues about your hearing. Most people respond well when they understand.
• Face the person you are speaking with and reduce background noise where possible.
• In meetings, ask to sit where you can see the speaker clearly.
• Use captions on video calls and television.

Protecting your hearing

• Avoid prolonged loud noise exposure; use ear protection in noisy environments.
• Have your hearing checked regularly so changes are picked up early.
• Tell any future doctor — including dentists and anaesthetists — about your ear surgery if you have had it.

Emotional well-being

Hearing loss can be tiring and isolating, especially when it develops slowly enough that family and friends do not notice. Many people describe relief after diagnosis simply because there is a name for what they have been experiencing. Support groups, online communities, and counselling are all reasonable sources of help if hearing loss is affecting your mood.

Pregnancy

Some women notice that otosclerosis progresses more quickly during pregnancy. If you are planning a pregnancy, it can be helpful to discuss this with your ENT specialist, including the timing of any planned surgery.

Otosclerosis in Children and Adolescents

Otosclerosis is much less common in children, but it does occur. When it begins in childhood or the teenage years it is sometimes called juvenile otosclerosis. Several points are different in this group:

• The condition can progress more quickly than in adults.
• There is often a stronger family history.
• Hearing loss can be more severe by the time it is detected.
• Hearing loss in children can affect speech and language development and learning at school, so early detection matters.

Diagnosis follows the same general path as in adults — clinical assessment, audiometry, and sometimes imaging — but other causes of hearing loss in children must be carefully excluded first. Management often starts with hearing aids, with stapes surgery considered later in adolescence or adulthood. Decisions about timing of surgery in children are individualised and discussed in detail with the family.

If your child has been diagnosed with otosclerosis or has hearing loss that may be related, an ENT specialist with paediatric experience and an educational audiologist can help plan support at home and at school.

When to Contact Your Doctor

Whether you are being monitored, using hearing aids, or have had surgery, it is reasonable to contact your ENT team if you notice:

• A sudden drop in hearing in one or both ears.
• New or worsening dizziness or balance problems.
• Severe ear pain, drainage from the ear, or fever after surgery.
• Facial weakness on the side of an operated ear.
• A clear, watery discharge from the ear after surgery.

Sudden hearing loss in particular is treated as urgent in ENT care because earlier evaluation gives the best chance of a useful response.

Frequently Asked Questions

Is otosclerosis curable?

The underlying bone changes cannot be reversed, but the hearing loss they cause is highly treatable. Stapes surgery can restore much of the hearing that has been lost, and hearing aids can do so without surgery. In that sense, the practical effects of otosclerosis can be very effectively managed.

Will I definitely need surgery?

No. Many people with otosclerosis never need surgery. Some choose observation; others use hearing aids for many years. Surgery is one option among several, and the choice depends on how much hearing loss is affecting you and on your personal preferences.

How quickly does otosclerosis get worse?

It varies widely. For most people, hearing changes over years rather than months. Some periods can be more active than others. Pregnancy may speed progression in some women. Regular hearing tests help track changes.

Can both ears be operated on?

Yes, but not at the same time. Surgeons usually operate on one ear at a time, starting with the worse ear, and wait at least several months — often six months or longer — before considering surgery on the other ear, only if the first ear has healed well.

Will surgery cure my tinnitus?

Tinnitus often improves after successful stapes surgery, but it does not always disappear. It is not possible to guarantee that tinnitus will resolve, and this is an important point to discuss with your surgeon.

Can I fly after stapes surgery?

Flying is usually avoided for one to two weeks, and sometimes longer, after surgery to allow the middle ear to heal and avoid pressure changes that could affect the prosthesis. Your surgeon will give you specific advice based on your case.

Can otosclerosis come back after surgery?

The disease itself can continue in other parts of the temporal bone, and the prosthesis can sometimes shift over many years. A small number of patients need revision surgery later. Long-term follow-up with hearing tests helps detect any change early.

Will hearing aids make my otosclerosis worse?

No. Hearing aids do not affect the underlying disease. They simply amplify sound so the inner ear receives it more clearly. They are a safe and effective option at any stage.

Is otosclerosis genetic? Will my children get it?

There is a clear genetic component, and otosclerosis is more common in families where someone already has it. However, not everyone in a family is affected, and the severity varies. If there is a strong family history, it is reasonable to have your own and your children’s hearing checked periodically.

Conclusion

Otosclerosis is a slow, progressive cause of hearing loss, but it is also one of the best understood and most treatable conditions in ENT care. With careful diagnosis, you and your ENT specialist can weigh the choices that fit your hearing, your lifestyle, and your goals — whether that is watchful monitoring, well-fitted hearing aids, or stapes surgery. Most people who go through this journey return to clearer hearing and easier daily communication, and many find that the diagnosis itself is the first step toward feeling more in control of their hearing health.