Restoration, Not Bypass: Otoferlin Gene Therapy and a New Era in Hearing Loss Treatment

The FDA approval of Otarmeni, an AAV‐based gene therapy for biallelic OTOF‐associated sensorineural hearing loss, represents a conceptual shift in otology: from bypassing defective auditory physiology to restoring it. Unlike cochlear implantation, which circumvents damaged sensory structures, OTOF gene replacement targets a synaptic deficit in a structurally intact cochlea. Early clinical trial data are encouraging, with 75% of evaluable participants—children with molecularly confirmed biallelic OTOF variants enrolled in early‐phase trials—achieving the primary hearing endpoint at 24 weeks. However, critical questions remain regarding long‐term durability, the feasibility of redosing, and the surgical and logistical infrastructure required for intracochlear delivery. This commentary argues that otoferlin gene therapy initiates a new treatment hierarchy rather than rendering cochlear implantation obsolete: restore when biology permits, bypass when it does not. Realizing this potential will require advances in newborn genetic screening, workforce training, and equitable access to gene delivery.