A 28-year-old woman presents with progressive bilateral hearing loss over the past 2 years. She reports tinnitus and occasional vertigo. On examination, Weber test shows lateralisation to the right ear, and Rinne test reveals bone conduction better than air conduction bilaterally. Otoscopy is normal. A faint reddish hue is noted behind the tympanum on the right side. What is the most likely diagnosis?

## Clinical Presentation This case presents the classic triad of otosclerosis: **Key Point:** Progressive bilateral conductive or mixed hearing loss, tinnitus, and vertigo in a young adult (typically 20–40 years old). ## Diagnostic Findings ### Audiological Pattern - **Bone conduction > air conduction** = conductive component - **Weber lateralisation to affected ear** = confirms conductive loss (sound travels better through bone in the affected ear) - **Bilateral involvement** = typical for otosclerosis ### Otoscopic Sign **High-Yield:** The **reddish hue behind the tympanum** is the **Schwartze sign** — a vascular blush indicating active otosclerotic bone remodelling. This is pathognomonic for otosclerosis. ## Pathophysiology 1. Abnormal bone remodelling at the **stapes footplate–oval window junction** 2. Fixation of the stapes → conductive hearing loss 3. If cochlear involvement → sensorineural component (mixed loss) 4. Tinnitus and vertigo from inner ear involvement ## Confirmation **Clinical Pearl:** High-resolution CT temporal bone shows: - Lucent areas around the oval window (cochlear otosclerosis) - Stapes footplate fixation - Demineralisation of otic capsule | Feature | Otosclerosis | SSNHL | CSOM | Meniere's | |---------|--------------|-------|------|----------| | **Onset** | Gradual, progressive | Sudden | Chronic discharge | Episodic | | **Hearing pattern** | Conductive/mixed | Sensorineural | Conductive | Sensorineural | | **Tinnitus** | Common | Common | Rare | Prominent | | **Vertigo** | Mild, positional | Absent | Absent | Severe, episodic | | **Otoscopy** | Normal | Normal | Perforation/discharge | Normal | | **Schwartze sign** | Present (active) | Absent | Absent | Absent | ## Management **Tip:** Early diagnosis allows: - Hearing aids for symptomatic relief - Stapes surgery (stapedectomy/stapedotomy) for definitive treatment — >90% success rate - Sodium fluoride therapy (controversial, limited evidence) to slow bone remodelling [cite:Scott-Brown's Otolaryngology Ch 3.7]