We report a case of bilateral conductive hearing loss caused by stapedial suprastructure fixation with normal footplate mobility.

A 50-year-old woman had suffered hearing loss in both ears since childhood. Exploratory tympanotomy revealed immobility of the stapes due to a bony bridge between the stapedial suprastructure and the fallopian canal. The incus was missing, while the malleus handle was minimally deformed. The mobility of the stapes footplate was normal. Post-operatively, the hearing in the right ear improved both subjectively and audiographically, while that in the left ear did not improve because of footplate subluxation during surgery.

This is a rare case of congenital stapedial suprastructure fixation with normal footplate mobility. In this patient, development of the second branchial arch was arrested. When performing exploratory tympanotomy for stapedial fixation, one must keep in mind that normal footplate mobility is possible.

Bone-anchored hearing aid surgery in younger children is a two-stage procedure, with a titanium fixture being allowed to osseointegrate for several months before an abutment is fitted through a skin graft. In the first procedure, it has been usual to place a reserve or sleeper fixture approximately 5 mm from the primary fixture as a backup in case the primary fixture fails to osseointegrate. This ipsilateral sleeper fixture is expensive, is often not used, and is placed in thinner calvarial bone where it is less likely to osseointegrate successfully. The authors have implanted the sleeper fixture on the contralateral side, with the additional objective of reducing the number of procedures for bilateral bone-anchored hearing aid implantation, providing a cost-effective use for the sleeper.

The authors implanted the bone-anchored hearing aid sleeper fixture in the contralateral temporal bone instead of on the ipsilateral side in seven successive paediatric cases with bilateral conductive hearing loss requiring two-stage bone-anchored hearing aids, treated at the Royal Manchester Children's Hospital, UK.

The seven patients ranged in age from five to 15 years, with a mean age of 10 years; in addition, a 20-year-old with learning disability was also treated. In each case, the contralateral sleeper fixture was not needed as a backup fixture, but was used in four patients (57 per cent) as the basis for a second-side bone-anchored hearing aid.

In children with bilateral conductive hearing loss, in whom a bilateral bone-anchored hearing aid is being considered and the second side is to be operated upon at a later date, we recommend placing the sleeper fixture on the contralateral side at the time of primary first-side surgery. Our technique provides a sleeper fixture located in an optimal position, where it also offers the option of use for a second-side bone-anchored hearing aid and reduces the number of procedures needed.

This paper reviews our experience of ossicular chain injuries following head trauma treated at Groote Schuur Hospital, Cape Town, South Africa.

We performed a retrospective chart review of all patients with a history of head trauma and a conductive hearing loss who had undergone exploratory tympanotomy. Sixteen patients were included in the study.

Injury was most common at the incudostapedial joint (63 per cent). Disarticulations of the icudostapedial joint were treated with cartilage interposition in all cases. Audiography showed an improvement in 12 of the patients, with an average improvement of 35 dB.

We discuss the various options available to the otologist to repair ossicular disruptions after trauma. In this series, cartilage autografts were used in most incudostapedial joint injuries, with excellent closure of the air–bone gap.

Cartilage interposition was a very successful method of repairing incudostapedial joint dislocation in this series, at short term follow up.

This study aimed to investigate the outcomes of autologous ossiculoplasty following temporal bone fracture.

We analysed 10 patients who underwent autologous ossiculoplasty following temporal bone fracture from 1993 to 2006. Average results for air conduction, bone conduction and air–bone gap were calculated, using both a three- and a four-frequency average, in order to evaluate the effect of the operation.

The average follow-up time was 24.4 months. Dislocation of the incus was the most common operative finding. The average three- and four-frequency post-operative air–bone gaps were 12.0 dB (standard deviation 8.3) and 13.8 dB (standard deviation 7.7), respectively. The average air–bone gap improvements were 24.5 dB (standard deviation 13.8) and 24.4 dB (standard deviation 12.1), respectively. Eighty per cent (eight of 10) of the patients had socially acceptable hearing in the operated ear. However, only 50 per cent achieved closure of the air–bone gap to within 10 dB.

Methods of maximising the stability of the reconstructed ossicular chain should be further studied.

To describe a series of five patients with isolated fracture of the manubrium of the malleus.

Retrospective case series.

Five patients aged 44–64 years with isolated fracture of the manubrium who presented to our institution over a five-year period (2000–2005).

All patients presented with a history of digitally manipulating the external auditory canal, leading to the manubrial fracture, which we presume was due to a suction-type mechanism. Otomicroscopy often revealed a break in the smooth contour of the manubrium. All patients had air–bone gaps on audiometry, especially at higher frequencies. Tympanometry showed hypermobility of the tympanic membrane in four patients who were tested. Laser-Doppler vibrometry revealed increased umbo velocity in four out of five patients. Four patients were treated conservatively. One patient underwent exploratory tympanotomy with successful ossiculoplasty.

Isolated fracture of the manubrium is a rare condition which may present as sudden-onset hearing loss after digital manipulation of the external auditory canal. The diagnosis can be made on the basis of otomicroscopy, audiometry, tympanometry and laser-Doppler vibrometry. Conservative treatment is often successful.

We report an atypical case of ossicular necrosis affecting the incus, in the absence of any history of chronic serous otitis media. We also discuss the current theories of incus necrosis.

A male patient presented with a history of right unilateral hearing loss and tinnitus. Audiometry confirmed right conductive deafness; tympanometry was normal bilaterally. He underwent a right exploratory tympanotomy, which revealed atypical erosion of the proximal long process of the incus. Middle-ear examination was otherwise normal, with a mobile stapes footplate. The redundant long process of the incus was excised and a partial ossicular replacement prosthesis was inserted, resulting in improved hearing.

Ossicular pathologies most commonly affect the incus. The commonest defect is an absent lenticular and distal long process of the incus, which is most commonly associated with chronic otitis media. This is the first reported case of ossicular necrosis, particularly of the proximal long process of the incus, in the absence of chronic middle-ear pathology.