A 52-year-old woman presents with bilateral hearing loss noticed over the past 3 years. She denies tinnitus or vertigo. Otoscopic examination is normal bilaterally with intact, healthy tympanic membranes. Tympanometry shows bilateral type As (shallow) curves. The audiogram is shown in Image 1. She is medically fit for surgery but strongly wishes to avoid an operation at this time. Which of the following is the most appropriate next step in management?

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Accepted Answer

D. Prescription of bilateral hearing aids as the preferred nonoperative intervention. ***D. Prescription of bilateral hearing aids as the preferred nonoperative intervention***
- The patient presents with **otosclerosis**, characterized by progressive conductive hearing loss, a **Carhart notch at 2 kHz**, and a **Type As tympanogram** indicating stapes fixation.
- Since the patient explicitly **declines surgery**, hearing aids are the most appropriate management as they effectively manage the air-bone gap without operative risks.

*A. Staged stapedectomy beginning with the worse-hearing ear*
- While **stapedectomy** is the definitive surgical treatment for restoring hearing in otosclerosis, it is inappropriate here because the patient **wishes to avoid an operation**.
- This procedure involves replacing the fixed stapes with a prosthesis and is typically performed on the **worse ear first** to minimize the impact of potential complications.

*B. Bilateral myringotomy with grommet insertion*
- Myringotomy and grommets are indicated for **Otitis Media with Effusion**, which classically presents with a **Type B (flat) tympanogram**, not a Type As.
- This intervention addresses fluid in the middle ear and would not bypass the **ossicular fixation** seen in otosclerosis.

*C. Sodium fluoride therapy and annual audiological monitoring*
- **Sodium fluoride** is sometimes used to stabilize active **otospongiosis** (the vascular phase) and prevent sensorineural progression, but it does not restore conductive hearing.
- Relying solely on monitoring and fluoride ignores the patient's symptomatic need for **hearing rehabilitation**, which is better served by hearing aids. [Practice more ENT questions on OnCourse]

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