O analiză retrospectivă a abordurilor nonchirurgicale ale tinitusului și otosclerozei pe cazuri clinice complexe – review de literatură

Introduction

Otosclerosis is a condition characterized by abnormal bone growth in the middle ear and bone remodeling in the otic capsule, most often leading to conductive hearing loss and, in some cases, to neurosensory hearing loss⁽¹⁾. Its prevalence varies between populations, with estimates ranging from 0.3% to more than 10% in specific demographic populations, such as individuals with Caucasian descent, highlighting its role as a concern of public health⁽¹⁾. The pathophysiology of otosclerosis is complex, involving genetic predispositions, hormonal factors and environmental interactions, which can culminate in a progressive auditory deficit that severely affects a patient’s quality of life. At the same time, tinnitus, the perception of sound in the absence of external stimuli, usually accompanies otosclerosis and affects approximately 40-80% of those with this condition⁽²⁾. The coexistence of tinnitus and hearing loss has unique challenges for doctors and patients, ensuring a broad area of research opening up for its efficient management and for proper patient care.

The meaning of these two interrelated conditions lies not only in their individual morbidity, but also in their effects composed of patients’ psychosocial well-being. Individuals with otosclerosis usually suffer from anxiety, depression and social withdrawal, exacerbated by the distressing effects of tinnitus. This complexity is aggravated by the variability in symptom expression, in which different patients may report different manifestations of tinnitus, further complicating the treatment scenario⁽³⁾. This emphasizes the need for a custom approach to patient management, particularly one that emphasizes nonsurgical strategies, allowing personalized treatments that accommodate patients’ individual needs.

Materials and method

This review was conducted by analyzing peer-reviewed literature on otosclerosis and tinnitus, focusing on nonsurgical management strategies. A comprehensive search was performed across multiple medical and scientific databases, including PubMed, Scopus, Web of Science and Google Scholar, to identify relevant studies. The search strategy incorporated a combination of Medical Subject Headings (MeSH) terms and keywords, including: “otosclerosis”, “tinnitus”, “hearing loss”, “nonsurgical management”, “cognitive behavioral therapy (CBT) and tinnitus”, “pharmacological treatments for otosclerosis”, “sound therapy for tinnitus”, “bisphosphonates and otosclerosis”, “fluoride therapy for otosclerosis” and “hearing aids and otosclerosis”.

Our inclusion criteria were:

• Articles published between 1973 and 2025 to provide a historical and contemporary perspective.
• Studies focusing on nonsurgical treatments, including hearing aids, pharmacological interventions, sound therapy, CBT and neuromodulation.
• Both systematic reviews and clinical trials evaluating treatment efficacy.
• Studies published in English and indexed in peer-reviewed journals.
• Our exclusion criteria were based on the following:
• Studies focusing exclusively on surgical interventions (e.g., stapedectomy) without nonsurgical comparisons.
• Case reports and small-scale studies with limited sample sizes (
• Articles not accessible through institutional databases or open-access platforms.

Current literature reflects the growing role recognition that nonsurgical strategies can play in the management of complex cases of otosclerosis and tinnitus. When considering a broad spectrum of treatment modalities, doctors may be involved in shared decision making with patients, promoting adhesion and improving the overall quality of life. This literature review focused on analyzing existing studies on nonsurgical approaches, elucidate patients’ experiences and reflect on the effectiveness of integrated management strategies along the challenges presented by otosclerosis and tinnitus. The goal is to provide a comprehensive overview of the evidence base, recognizing the different interaction of these conditions and the need for custom care for each patient. Otosclerosis management has evolved remarkably, particularly focused on surgical strategies, which aim to relieve symptoms associated with the condition, such as hearing loss and tinnitus. Currently, oral supplementation, pharmacological treatments and alternative therapies are among the predominant nonsurgical approaches used in clinical practice, their importance growing progressively to the point where they may equal the standing of surgery.

Results and discussion

Exploring nonsurgical management options becomes fundamental to addressing the multiple disorders which otosclerosis presents with, disorders like associated tinnitus. Although surgical interventions such as stapedectomy have been effective for a patient subset, they are not viable or appropriate for everyone, requiring alternative strategies to manage symptoms^(4,5). Nonsurgical interventions – including hearing aids, hearing rehabilitation, cognitive behavioral therapy and sound therapy – attracted attention in recent literature as viable options to improve patient results.

Given the interaction between otosclerosis and tinnitus-induced hearing loss, nonsurgical treatments can address auditory deficits and simultaneously associated anguish. For example, amplification through hearing aids can improve hearing input, simultaneously reducing the perception of tinnitus by increasing ambient sound. The hearing rehabilitation programs that incorporate tinnitus management techniques also showed promises by relieving the patient’s anguish or anxiety, thus promoting a more holistic treatment paradigm⁽⁶⁾. However, adherence to these therapies can be influenced by individual factors, including individual levels of health literacy, personal tinnitus beliefs and previous health experiences, which can complicate the therapeutic process.

Pharmacological treatments were also investigated; however, the evidence that supports their effectiveness remains mixed. Nutraceuticals such as vitamins B and D were exploited due to their neuroprotective properties, which may indirectly influence the perception of tinnitus in patients. Certain medications, including oral corticosteroids, have shown effectiveness in reducing inflammation, but their usefulness remains controversial due to the risk of side effects and limited long-term benefits. Literature data highlights the varied responses to pharmacological interventions, highlighting the need for personalized treatment strategies^(7,8).

Alternative therapies, including sound therapy and cognitive behavioral therapy (CBT), serve to address the psychological and perceptual aspects of tinnitus. Sound therapy, which incorporates the use of white noise or specialized devices or sound generators, aims to mask the perception of tinnitus and improve rational sound processing in the auditory cortex. Studies suggest that these approaches can lead to significant improvements in the patient’s quality of life, despite the subjective nature of tinnitus. In addition, CBT has gained traction as a psychological intervention that enables patients to manage their responses to tinnitus, thus reducing perceived anxiety and anguish. Literature evidence points out that patients using CBT reported more levels of anxiety related to their tinnitus, emphasizing the importance of addressing the psychosocial dimension in treatment protocols^(9-11).

However, the application of these nonsurgical strategies is not exempt from limitations. Individual patient responses to supplementation, pharmacotherapy and alternative interventions may vary widely, which complicates the development of universal treatment protocols. In addition, there is a lack of large-scale multicenter studies to universally validate these interventions, which usually leads to uncertainties about their effectiveness in various population subsets. In addition, the psychological component of tinnitus, which may include comorbidities such as anxiety and depression, requires a multidisciplinary treatment approach that is not always viable in standard clinical environments.

Liktor et al.⁽¹²⁾ conducted a fundamental study that evaluated the effectiveness of bisphosphonates in the management of otosclerosis. These agents, traditionally used for osteoporosis, work by inhibiting osteoclastic activity, thus theoretically stopping the pathological bone changes observed in otosclerosis. The results of his research indicated a reduction in the symptoms of hearing loss in a subset of patients, although the broader implications of bisphosphonates treatment remain an ongoing research issue.

In addition to the bisphosphonates, studies have explored the use of fluoride as a therapeutic agent for otosclerosis. While the proposed mechanism implies promoting bone density and stabilizing the pathology of the otic capsule, clinical evidence was mixed. Reviews of literature^(13,14) emphasize the lack of consensus regarding the effectiveness of fluoride or bisphosphonates, illustrating the different treatment responses between patients. These discrepancies highlight the need for personalized treatment approaches and a deeper understanding of the underlying mechanisms of individual cases.

Tinnitus, often found in patients with otosclerosis, further complicates the clinical standing. Liktor et al.⁽¹²⁾ also considered the impact of pharmacological interventions on tinnitus relief. Specific agents, such as antidepressants and anticonvulsant drugs, have been used for management, however, their effectiveness remains anecdotal when studied in the context of otosclerosis. To complicate this problem further, we may address the subjective nature of tinnitus, which may require a multiapproach strategy, integrating pharmacological treatment with CBT and sound therapy for a more positive outcome.

In addition, individual patients often have unique challenges in the choice and implementation of pharmacological therapies. For example, a patient with otosclerosis and comorbid conditions, such as anxiety or depression, can benefit from a holistic approach that considers the psychological and physical dimensions of their health. Research observed that some patients experienced exacerbation of tinnitus symptoms with certain medications⁽¹²⁾, which leads to the need to adapt the treatment to balance efficacy with tolerability. This also requires a collaborative management approach that involves otorhinolaryngologists, audiologists and mental health professionals.

In general, the panorama of pharmacological treatment for otosclerosis remains complex, with challenges mostly depending on varied patient responses to fluctuating symptoms, particularly in relation to tinnitus. As literature data continue to evolve, it is crucial that future research clarifies the mechanisms by which these medications exert their effects on otosclerosis and rigorously evaluate the interface between pharmacology and comprehensive care centered on the patient. The historical evolution of treatments for otosclerosis reveals a progressive but notable passage of invasive surgical techniques to a broader acceptance of nonsurgical strategies, in particular in response to the patient centered care models and to a more nuanced understanding of various presentations of this condition. The existing medical literature⁽¹⁵⁾ identifies the key stages that highlight the trajectory of otosclerosis management, emphasizing a paradigm change which recognizes the limits and risks associated with traditional surgical interventions.

The first otosclerosis treatments mainly focused on stapedectomy, a procedure which sought to restore hearing by replacing the stapes immobilized in the middle ear with a prosthetic device. This invasive approach was based on the dominant hypothesis that surgery was the only effective way to manage the driver’s hearing loss associated with otosclerosis. However, as Tange⁽¹⁵⁾ points out in a comprehensive publication, complications resulting from these surgeries often prevail over the advantages, which prompted clinicians and patients to seek alternative treatment methods. The potential risks, associated with variable success rates, highlighted the need for additional strategies, especially for patients who were not willing or unable to undergo surgical intervention.

The evolution of the recognition of noninvasive alternatives dates back to the end of the 20^th century, when research began to focus on auditory rehabilitation techniques and psychosocial aspects of the management of tinnitus. The growing understanding of the relationship between otosclerosis and tinnitus has paved the way for innovative therapeutic approaches. Tange⁽¹⁵⁾ notes significant progress in CBT, sound therapy and other nonsurgical interventions that have since become integral with some management plans. These approaches not only target hearing symptoms, but also deal with psychological distress often felt by patients, reflecting the complex nature of otosclerosis and its impact on quality of life.

In addition, the historical context reveals a liberalization of treatment philosophies, influenced by the biopsychosocial model which emerged at the end of the 20^th and early 21^st century. This model stresses that health and disease are determined by a combination of biological, psychological and social factors. While healthcare has turned more and more towards a more holistic approach, healthcare providers have become more attentive to the individual needs and preferences of patients, incorporating these prospects in the planning of treatment. Nonsurgical strategies are now more widely recognized as viable options for patients with otosclerosis, especially for those who have softer forms of the disease or for those who undergo contraindications to surgery.

Patient expectations have also evolved in response to these historical changes. Modern patients are more informed of their state and their processing options, often looking for collaborative decision-making with their healthcare providers. There is a growing demand for less invasive management strategies⁽¹⁵⁾ that correspond to their personal values, their lifestyle and their health objectives.

In recent years, the relationship between temporomandibular disorders (TMD) and otosclerosis has caught public medical attention, particularly in the light of emerging research, such as that conducted by Stepan et al.⁽¹⁶⁾ This study highlights the complexity in the management of patients who have both conditions, emphasizing the need for an interdisciplinary approach that accommodates the nature of these disorders. Otosclerosis, characterized by abnormal bone remodeling in the middle ear, significantly affects hearing function and is often accompanied by tinnitus. On the other hand, TMD cover a range of musculoskeletal disorders that affect the temporomandibular joint (TMJ) and the surrounding structures, which can lead to pain and dysfunction that may exacerbate auditory symptoms. TMD symptomatology – such as jaw pain, clicks and restricted movement – usually overlaps with hearing issues present in otosclerosis, leading to potential diagnostic confusion. The challenge of differential diagnosis is aggravated by the variability of clinical presentation in individual patients, which may result in incorrect symptoms interpretation. The research reported the significant functional and psychological implications of coexisting TMD and otosclerosis⁽¹⁶⁾, indicating that patients often have compound symptoms that complicate treatment strategies. These challenges extend beyond immediate clinical symptoms to cover broader psychosocial factors, as patients may experience greater anxiety and decreased quality of life due to their double diagnoses and poor response to treatment.

Given these complexities, the growing implications for clinical practice become evident. Nonsurgical management strategies require careful consideration of more than one conditions to develop an effective treatment plan. The interdisciplinary collaboration between otorhinolaryngologists, dentists specializing in TMD and audiologists is imperative. For example, the management protocols may include occlusal splints, TMD-focused physiotherapy and cognitive behavioral therapy designed to manage tinnitus. Each of these approaches showed moderate promising outcomes when addressing symptoms in target patient groups.

The complexities inherent in the management of tinnitus associated to otosclerosis are exemplified through various cases of study, highlighting the need for customized strategies. Larger studies⁽¹⁷⁾ provide a noteworthy analysis of patients with different otosclerosis presentations, ultimately leading to the idea that individualized treatment plans must adapt to the unique hearing profiles and psychosocial factors that the patients present. The study underlines the importance of in-depth audiometric assessments and history of patients in determining adequate plans of intervention, such as hearing aids and/or CBT.

Similarly, other studies follow Jackler and Jan’s example and expand on the implications of patient management by illustrating the complex relationship between auditory function and the psychosocial burden. Dziendziel et al., Andersson and Larsen, and Reavis et al.^(18-20) outline complex case studies in which patients present tinnitus alongside the fluctuation of hearing levels. They underline a multidisciplinary approach for challenges faced by such patients, supporting the integration of therapy with psychology, CBT, sound therapy and relaxation techniques. The results indicate promising outcomes with CBT, and some patients with significant improvement with strategies like masking or other sound therapies. These inconsistent but promising results suggest the need for an adaptable treatment plan. Clinicians must know and be prepared to face the potential limited results on tinnitus management, as no single therapy plan can fully eradicate tinnitus.

The variability in response to the treatment observed in these studies can also be attributed to several factors, including comorbid mental health conditions, social support levels and patient expectations^(19,20). Preexisting anxiety or depression in patients may lead to exacerbated tinnitus symptoms, complicating management efforts. Therefore, the integration of the psychological evaluation in routine audiological assessments can offer professionals a more complete understanding of patients’ needs and improve the general efficacy of treatment. In addition, a collaborative therapeutic alliance can have a significant impact on the results of the treatment⁽⁶⁾, since patients may be more likely to adhere to nonsurgical interventions if they believe that their concerns are recognized and faced.

In all studies that take into account the psychosocial factors alongside tinnitus^(20-23), the authors seem to support a transition from unique and conventional management approaches to a more nuanced approach that embraces the individual variability inherent in the patient’s experiences. This is emphasized by the moderate or poor outcomes of tinnitus control measures by means of single interventional therapy. By cultivating personalized assistance paths that reflect the multifactorial nature of the hearing loss and tinnitus, health workers can better navigate the symptoms that surround these patients. The approach focused on the patient seems not only to improve patient satisfaction, but also aligns the current trends in medical practice that emphasize the importance of holistic and inclusive treatments.

Dillon et al.⁽²⁴⁾ underline the role of audiological rehabilitation in the management of the tinnitus associated with hearing loss of diverse etiologies. The efficiency of cochlear implantation on tinnitus seems to match the multimodal approaches that combine CBT and sound therapy as effective strategies, but it’s worth noting that candidates for cochlear implantation are rare cases amongst the “average” patient with otosclerosis and tinnitus. Combining literature data, we may argue that individualized treatment plans, adapted to the specific needs of the patient, may significantly improve the effectiveness of surgical interventions as well. Other recent studies⁽²⁵⁾ show that technological innovations, such as wearable sound therapy devices, are becoming more accessible, offering patients greater control over their treatment and a potential improvement in final results.

In addition, Ryan and Mullen⁽²⁶⁾ have looked into the pharmacological developments that affect the underlying mechanisms of tinnitus. They investigated drugs aimed at modulating the activity of neurotransmitters implicated in auditory processing. For example, the potential application of glutamate modulators has been discussed, since excessive glutamatergic activity has been connected to the pathophysiology of tinnitus. Their results suggest that pharmacological intervention may be integrated alongside existing nonsurgical strategies, but there is further need of larger support clinical studies to evaluate the safety and effectiveness of these pharmacological agents.

An area of emerging interest is the use of neuromodulation techniques, including transcranial magnetic stimulation and the transcranial stimulation of continuous current. The research by Langguth⁽²⁷⁾ indicates that these noninvasive techniques can alter cortical excitability and may offer symptomatic relief in patients with chronic tinnitus. The mechanism at the base of these therapies remains an ongoing topic of study; however, the preliminary results suggest that these modalities can stop the neural misconduct circuits that are thought of contributing to the perception of tinnitus. The application of these therapies represents an innovative frontier in the panorama of nonsurgical management of underlying causes, deserving further investigation.

Tinnitus often represents a challenge for patients even in the absence of clear auditory deficits. Returning to otosclerosis patients, medical literature reveals significant gaps in the management of complex cases but, in addition, the molecular etiology of otosclerosis is still unclear to clinical practitioners. These information puzzles may still lock away the key to proper management to hearing loss and tinnitus in otosclerosis patients^(28,29).

Conclusions

While collecting the data from literature, the implications for clinical practice become clear: a strategy based on one single dimension is insufficient for the effective management of the tinnitus in otosclerosis patients. Doctors and clinical practitioners must embrace a nuanced understanding of the needs of each patient, incorporating adaptive strategies that also explain the emotional and physical aspects of their conditions, regardless of the fact that these disorders are not life-threatening. Individual treatment plans seem to have worse symptom control than management plans which include one or more measures of therapy. This approach to the patient not only improves the short-term results, but can also inspire adhesion and long-term satisfaction with recommended therapeutic interventions.

Future research in this complex and shifting field must deepen the specific treatment dynamics of target population groups, emphasizing longitudinal studies and randomized clinical trials that follow the results of nonsurgical strategies. Understanding how different cultural backgrounds, socioeconomic status and access to care resources affect the experiences of patients could produce important insights that guide more effective and personalized management options. Rather than categorizing certain patients as “complex cases”, treating each tinnitus patient as a unique individual allows the healthcare community to develop more effective, multi-approach treatment strategies for tinnitus and otosclerosis, as our review suggests is the most beneficial approach.

Autor corespondent: Andrei Osman E-mail: andrei.osman@umfcv.ro; Irina Enache E-mail: irina.enache@umfcv.ro; Mădălina-Gabriela Georgescu E-mail: madalina.georgescu@umfcd.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.