Patients' perceived outcomes after stapedectomy for otoscierosis.

Abstract

We conducted a retrospective study of 29 patients who had undergone stapedectomy for otoscierosis to determine how well their subjective perceptions of hearing improvement correlated with objective audiometric measurements. Patients expressed their assessments of hearing function by completing two versions of the Hearing Disability and Handicap Scale (HDHS). One version of the HDHS was based on patients' retrospective recollections of their hearing impairment prior to surgery, and the other reflected their assessment of their current function. We evaluated these HDHS data both separately and in conjunction with pre- and postoperative audiometric findings. Following surgery, the group's mean pure-tone average improved significantly, from 58 to 27dB--that is, the average patient had a moderately severe hearing loss preoperatively and only a mild hearing loss postoperatively. Significant improvement was also reflected in the difference between the mean pre- and postoperative HDHS scores, although some patients i ndicated that they experienced almost no improvement. Overall, our findings indicated that there was a relationship between objective and subjective assessments of hearing improvement following surgery, but that it was weak. Although most patients perceived significant improvement, the degree of that perceived improvement cannot be predicted from the pure-tone audio gram. We conclude, therefore, that a significant difference between audiometric findings and HDHS self-assessments is useful in identifying patients who might benefit from additional counseling and/or aural rehabilitation.

Introduction

Stapedectomy for otoscierosis has a high success rate, and surgical and audiologic outcomes are well described. [1-5] Patients with a moderate to moderately severe conductive hearing loss preoperatively usually improve to the point where their postoperative hearing loss is only mild (air bone gap:[less than or equal to]10 dB). [2-5] Customarily, outcomes are measured by the basic audiometric test battery, particularly the pure-tone audiogram. Measurement of the difference in the extent of pre- and postoperative hearing loss and the degree of the closure of the air-bone gap provides an objective means of evaluating surgical outcomes.

However, little is known about the effect of surgery on patients' day-to-day lives. Patients' opinions of their improvement and any residual difficulties are important in determining the success of stapedectomy. Inherently, patients' self-evaluations provide information that is different from but complementary to audiometric data. In fact, studies have shown that patients' self-assessments do not correlate strongly with audiometric data. [6-9]

The World Health Organization distinguishes between hearing disability and hearing handicap. It defines disability as a diminished ability to use hearing in performing everyday tasks, such as understanding speech. It defines handicap as the disadvantage that the disability imposes on the individual patient in the social environment for which the patient cannot compensate physically or psychologically, to the detriment of the patient's sense of self-worth and quality of life. [8,10,11] The degree of difference between a patient's hearing impairment and a patient's disability and handicap are highly individual and dependent on behavioral and psychosocial factors. [9,12]

Audiometric tests are direct measurements of hearing loss and impairment. Self-reports are indirect assessments designed to gauge typical performance in terms of hearing disability and handicap. [13] Awareness of the importance of hearing disability and handicap led to the development of various self-report instruments, [14,15] which have been used extensively in the evaluation of hearing aids and in aural rehabilitation. [16-18] However, they have not been included as a measure of surgical outcome.

The addition of a self-evaluation to the customary postoperative audiometric test battery has potential benefits for the patient. The patient with a psychosocial adjustment difficulty could be identified and counseled, which could result in a more positive perception of the outcome of surgery. Surgeons and audiologists could benefit from the results of self-reports by identifying problems in their patients that are not revealed in postoperative audiometric data. This could result in better patient selection and preparation, better delivery of clinical services, and thus better outcomes. The aim of this study was to assess the outcome of stapedectomy as judged by the patient.

Materials and methods

We identified 39 consecutive patients with otosclerosis who had undergone surgery performed by a single surgeon (C.A.M.) between 1995 and 1998. Preoperative and one or more postoperative audiograms were available on each patient.

All patients had undergone the small fenestra (stapedotomy) procedure with a hand-held argon laser device. All patients received a Teflon-platinum-wire prosthesis with a diameter of 0.6 mm and a length of 4.25 to 4.50 mm (Richards Corp.; Memphis, Tenn.). Preoperatively, all patients underwent a Rinne's test with a 512-Hz tuning fork, and in all cases, bone conduction was better than air conduction. All procedures were performed on an outpatient basis. None of these cases was a revision surgery, and all patients underwent surgery on only one ear.

We mailed surveys to all 39 patients, and 29 (74%) returned usable responses. This group consisted of 24 women and five men, aged 31 to 70 years (mean: 47). Three patients were retired, five were homemakers, and the remaining 21 were active in the work force. The length of time that had passed since their surgery ranged from 8 weeks to 3 years.

Included in our survey was the Hearing Disability and Handicap Scale (HDHS) developed by Hetu et al. [15] This 20-item questionnaire was developed to measure the severity of the most common hearing disabilities and hearing handicaps in a general adult population.

The HDHS is made up of 20 statements, for which there are four possible responses: never (1 point), seldom (2), often (3), and always (4). Half of the statements concern hearing disabilities, and the other half deal with hearing handicaps. The statements on disabilities concern the patient's ability to hear both speech (questions 1, 5, 9, 13, and 17) and nonspeech sounds (questions 2, 6, 10, 14, and 18). The statements on handicaps deal with the patient's sense of self-worth (questions 3, 7, 11, 15, and 19) and quality of life (questions 4, 8, 12, 16, and 20). For each circumstance covered by each statement, the absence of difficulty is reflected by a score of 1 and frequent difficulty is indicated by a score of 4.

Patients were instructed to complete two versions of the HDHS. One version pertained to each patient's current postoperative condition, and the other version reflected each patient's memory of his or her preoperative condition. Patients with hearing aids were instructed to base all responses on their unaided condition.

Results

We tabulated the HDHS responses and analyzed them along with each patient's pre- and postoperative air and bone conduction results.

Audiometric studies. According to air and bone conduction studies, the average degree of hearing impairment improved from moderately severe preoperatively (pure-tone average [PTA]: 58 dB) to only mild postoperatively (PTA: 27 dB; p = 0.0001) (figure 1). All surgical outcomes were considered to be successful (postoperative air-bone gap: [less than]15 dB). These results are typical in terms of both preoperative status and expected postoperative outcomes. [2-5,19]

Total HDHS scores. Preoperatively, the mean total HDHS score was 52.6 ([plus or minus]12.2). Following surgery, the score improved significantly to 32.7 ([plus or minus]9.96; p[less than]0.0005) (figure 2). However, it is important to note that the postoperative score did not indicate the complete absence of any self-perceived disabilities or handicaps; if such were the case, all patients would have had the minimum score of 20.

Subset HDHS scores. Surgery significantly improved each of the four HDHS subset scores: hearing speech and nonspeech sounds, the two measures of disability, and self-worth and quality of life, the two measures of handicap (p = 0.000 1 for all differences) (figure 3). Despite the fact that the preoperative responses were based on memory and the postoperative responses reflected current status, patients clearly indicated that their ability to function auditorily had improved noticeably.

Hearing disability. Patients perceived that their ability to hear speech (mean pre- and postoperative scores for each individual statement: 3.2 and 1.8, respectively) was slightly worse than their ability to hear nonspeech sounds (mean scores: 3.2 and 1.7). Surgery improved their ability in both areas substantially, but it did not eliminate all sense of disability. In view of the fact that the average postoperative hearing loss was only mild, these results confirmed the finding that patients react differently to the impact of even a mild hearing loss. [9]

Hearing handicap. Patients perceived their hearing handicap to be less acute than their hearing disability. The mean scores for each of the ten statements that deal with handicap were 2.2 preoperatively and 1.5 postoperatively. This finding might be attributable to the fact that the hearing loss was gradual and asymmetric. [20] In general, patients had time to adjust slowly and perhaps more thoroughly to their progressive hearing loss. [21] Furthermore, the onset of hearing loss occurred during their adulthood. When family, social, and professional conditions are stable, adult patients have the advantage of an environmental support system that can lessen the effects of hearing loss. [21] The loss can therefore be less detrimental to a patient's sense of self-worth and quality of life than might be the case earlier in life. Even so, not all patients adapt well to a hearing loss. It has been suggested that patients' pre-hearing-loss emotional status, coping capabilities, and quality of life determine how well they adjust. [21]

Ten patients (patients 2, 9, 10, 13, 17, 18, 20, 24, 25, and 27) judged their pre-operative hearing disability and handicap as significant, as their HDHS scores added up to 60 and more (figure 4). Postoperatively, there was a general decrease in HDHS scores, but most patients still maintained some perception of disability and/or handicap. Three patients (2, 19, and 26) had almost no change in their scores, and some others still had relatively high postoperative HDHS scores. These are the scores that can identify those patients who might benefit from additional counseling or treatment.

Spearman's rank correlation coefficient with regard to patients' preoperative PTA values and their recollection of their preoperative status was significant but weak (rho = 0.47; p = 0.0157). These data confirmed that patients' perceptions do not correlate highly with audio-metric data. [6-9] One reason for this discrepancy might have been the retrospective nature of the rating scale and its reliance on memory. Various other factors might have colored our patients' perceptions--factors such as their individual postoperative experiences, personalities, and expectations. Nevertheless, these are factors that are unavoidably part of all patients' judgments of their satisfaction with any procedure. The assumption that the retrospective nature of this study might have skewed patients' perceptions of their preoperative status was demonstrated by the fact that there was a significantly better, although still weak, relationship between the postoperative audiometric and HDHS values (rho = 0.62; p = 0.0034) than there was between the preoperative values. It is clear that patients' perceptions of surgical outcomes cannot be predicted by PTA.

The difference between pre- and postoperative total HDHS scores ranged from 0 to 49 (figure 5), and the test-retest margin of error was 10. [15] In all, 23 of the 29 patients (79%) said they experienced a significant decrease in hearing disability and handicap and were satisfied with their surgical outcome. Comments on the returned questionnaires illustrated the effect that stapedectomy had on the perception of hearing disability and handicap: "Before having [surgery], I was frustrated and withdrawn." "It has taken me a while to adjust to sound again. I had forgotten little sounds like dripping water or mosquitoes buzzing." "People don't seem like they are sneaking up on me anymore." "I am a better listener now and often catch things others miss." These types of comments confirm that the reversal of hearing loss had a positive impact on daily life. The remaining six patients (1,2,6,8,19, and 26) did not perceive any decrease in their handicap or disability, despite the fact that their surgical and audiologic outcomes were considered to be successful. These are the patients who might benefit from followup counseling or treatment.

In an attempt to determine if PTA can predict how a patient will perceive the outcome of surgery, we plotted the differences between the pre- and postoperative PTAs against the difference in pre- and postoperative perceptions in 27 patients (figure 6). There was a general trend indicating that an increase in the difference between the pre- and postoperative PTA results was accompanied by a corresponding increase in the difference between the pre- and postoperative HDHS scores. However, the correlation was relatively weak (r = 0.5). Therefore, we concluded that PTA does not reliably predict how patients will perceive their surgical outcome. Although an improvement in hearing ability generally results in a better perception of an alleviation of hearing disability and handicap, this is not the case for all patients. We can only speculate as to the reason for the poor relationship. One of the explanations offered by Swan and Gatehouse is that persons who have high expectations for a full life might be more affec ted by a hearing impairment. [8] But overall, we found that the HDHS accurately indicated that most patients perceived the outcome of their stapedectomy favorably and that it was useful in identifying those patients who required additional counseling or rehabilitation services.

Finally, five patients had been using one hearing aid and six patients had two prior to surgery. Afterward, only three patients still used one hearing aid and only one patient used two.

Discussion

Following stapedectomy, our patients experienced a significant reduction in hearing impairment, disability, and handicap, although perceptions of some disability and handicap remained. Perceptions of disability were more pronounced than perceptions of handicap. Even though surgery was generally successful, our patients still had a mild hearing loss, which might explain their perception of disability. Regardless of improvement, some patients still consider even a minimal hearing impairment to be a handicap. This handicap might be prevented by familiarizing patients with the auditory and nonauditory effects of hearing loss so that they might understand how to adjust to their hearing loss and develop techniques that can enhance communication. [10]

The HDHS identified a few patients who still felt disabled and handicapped; these patients were good candidates for counseling and/or aural rehabilitation. Postoperative management decisions should be based on patients' perceptions of disability and handicap rather than on pure-tone audiogram alone. [8]

One potential drawback of this study is that our patients judged the outcome of their surgery according to their recall of their preoperative status. However, this is the yardstick all patients use to measure their satisfaction or dissatisfaction with most forms of treatment for most conditions. It is possible that their recollection was influenced by the length of time that had elapsed since surgery, the outcome of their surgery, their personality, and other factors. A study to compare patients' actual preoperative perceptions of their impairment with their subsequent postoperative recollections of their condition might prove useful for establishing counseling guidelines.

From the Department of Communication Disorders, Worcester State College, and the Department of Audiology, the University of Massachusetts, Worcester (Dr. Meyer), and the Department of Otolaryngology, University of Massachusetts (Dr. Megerian).

Reprint requests: Susanna E. Meyer, PhD, Department of Communication Disorders, Worcester State College, 486 Chandler St., Worcester MA 01602. Phone: [phone]; fax: [phone]; email: [e-mail]

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