To report an extremely rare case of malleoincudal osteoma that led to conductive hearing loss despite an unusually normal otomicroscopic appearance, and to highlight the usefulness of costal cartilage for ossicular chain reconstruction after tumour removal.

A 37-year-old woman presented with a 2-year history of progressive, right-sided hearing loss. Physical examination revealed a normal tympanic membrane. Pure tone audiometry showed a right-sided conductive hearing loss. High-resolution computed tomography revealed a right-sided epitympanic mass arising from the malleus head and contiguous with the incus. The patient underwent a closed mastoido-epitympanectomy. The malleus head and the incus with associated malleoincudal osteoma were removed. Ossicular chain reconstruction using costal cartilage was performed at the time of tumour removal.

The possibility of a middle-ear osteoma must be considered in cases of unilateral and progressive conductive hearing loss with a normal otomicroscopic appearance in patients with no history of ear infection, trauma or prior surgery, and with no family history of hearing loss. Surgical treatment is indicated in cases of significant conductive hearing loss. To our knowledge, this is the first case report of malleoincudal osteoma in which the ossicular chain was reconstructed using costal cartilage.

This study was undertaken to determine the accuracy of the surgeon's assessment in detecting epithelial remnants over the malleus after de-epithelisation in tympanoplasty.

Intra-operatively, the umbo was assessed for epithelial remnants with the microscope. The umbo was then resected and sent for histopathological examination to detect epithelial remnants.

Out of 42 cases, microscopic examination findings for epithelium were positive in 16 cases and negative in 26 cases. Histopathology findings were positive in 13 cases. The surgeons’ assessment was accurate only in two cases.

Residents, with their limited experience, are more likely to leave residual epithelium. When the chance of residual epithelium over the umbo is significant, the surgeon has two choices: to place the graft medial to the umbo or to resect the umbo. It is our opinion that the malleus exteriorisation should be incorporated into tympanoplasty training, with the aim of preventing epithelial entrapment in the middle ear.

To compare post-operative audiometric outcomes for the two prevailing surgical approaches for isolated malleus and/or incus fixation: ossicular mobilisation with preservation of the ossicular chain, and disruption and reconstruction of the ossicular chain.

A search was conducted, in December 2016, of PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature articles written in English. Papers presenting original data regarding post-operative audiometric outcomes in patients who underwent surgical treatment for malleus and/or incus fixation with a mobile and intact stapes were included. A risk of bias assessment was performed on the 14 selected papers and a tier system was developed. Meta-analysis was accomplished by comparing pooled rates of surgical success by chi-square test and calculating odds ratios by logistical regression. Analysis was performed using Revman5 and R software.

Analysis of the literature revealed no differences in audiometric outcomes between ossicular chain mobilisation and ossicular chain reconstruction in patients with isolated malleus and/or incus fixation. A large, prospective study comparing both short- and long-term hearing results for ossicular chain mobilisation and ossicular chain reconstruction in this population may identify whether a difference in outcomes exists between the two approaches.

Tympanic middle ears have evolved multiple times independently among vertebrates, and share common features. We review flexibility within tympanic middle ears and consider its physiological and clinical implications.

The chain of conducting elements is flexible: even the ‘single ossicle’ ears of most non-mammalian tetrapods are functionally ‘double ossicle’ ears due to mobile articulations between the stapes and extrastapes; there may also be bending within individual elements.

Simple models suggest that flexibility will generally reduce the transmission of sound energy through the middle ear, although in certain theoretical situations flexibility within or between conducting elements might improve transmission. The most obvious role of middle-ear flexibility is to protect the inner ear from high-amplitude displacements.

Inter-ossicular joint dysfunction is associated with a number of pathologies in humans. We examine attempts to improve prosthesis design by incorporating flexible components.

To assess results of malleostapedotomy using a Fisch Storz titanium piston with at least 10 months’ follow up.

Using a prospective database, the indications, surgical technique, and pre- and post-operative audiometric data for 60 patients undergoing malleostapedotomy between 2002 and 2010 were evaluated. Diagnoses and primary and revision surgeries were compared with reference to the literature.

Sixty endaural malleostapedotomies were performed, 28 as a primary intervention and 32 as revision surgery. In 68 per cent, the underlying pathology was otosclerosis. The most common reason for revision surgery (i.e. in 59 per cent) was prosthesis dysfunction. Overall, the mean air–bone gap (0.5–3 kHz) for the primary intervention and revision surgery groups was 9.4 and 11.3 dB, respectively; an air–bone gap of less than 20 dB was obtained in 100 and 81 per cent of patients, respectively. There was no significant audiological difference between the primary and revision surgeries groups, and no deafness.

Malleostapedotomy shows comparable results to standard incus-stapedotomy and may be preferable in the presented situations.

To report a rare case of a symptomatic malleo-incudal osteoma, and to highlight the difficulties in making the clinical diagnosis.

Case report and literature review.

Malleo-incudal osteoma is a rare cause of unilateral conductive hearing loss. Its symptoms may mimic those of other otological causes of conductive hearing loss, such as otosclerosis.

This case report highlights the challenges involved in establishing a clinical diagnosis of malleo-incudal osteoma. It also emphasises the importance of assessing the mobility of the divided ossicular chain during a planned stapedectomy.

This study aimed to use a new otological technique, malleus relocation, to solve the problems of ossicular reconstruction undertaken during revision stapes surgery for incus necrosis.

Prospective study of 12 patients undergoing revision stapedectomy for incus necrosis, in the otolaryngology department of Mansoura University, Egypt.

Twelve patients underwent ossiculoplasty between June 2004 and June 2007, as part of revision surgery for otosclerosis with incus necrosis. All patients underwent ossiculoplasty using the malleus relocation technique. Ossiculoplasty used the patient's own, necrosed incus between the relocated malleus and the footplate.

Post-operative air–bone gap closure to within 10 dB was achieved in seven patients (58.3 per cent). An air–bone gap of less than 20 dB was obtained in 10 patients (83.3 per cent). Deterioration of bone conduction by 10 dB occurred in one case. No patients were left with a ‘dead ear’. Patients’ hearing was stable throughout the follow-up period (range six to 40 months; mean ± standard deviation 23.5 ± 12.8 months).

These findings indicate that malleus relocation, performed during revision stapes surgery, is a safe and efficient technique for the treatment of incus necrosis.

Upon direct inspection of surgically removed ossicles from the ears of patients with long-term post-mastoidectomy cavity problems, the extent of malleus destruction often appears greater in patients with a longer duration of cavity problems, whereas the extent of incus destruction does not appear to correlate with the duration of cavity problems. This study aimed to investigate this impression.

As a result of total middle-ear reconstruction, 41 ossicles (21 malleus and 20 incus bones) were obtained from 31 patients with post-mastoidectomy cavity problems. The ossicles were examined histopathologically, and the proportion of lamellar bone area to total bone area (expressed as percentage lamellar bone) was measured. We also calculated the inter-operation time, i.e. the time period between the previous mastoidectomy and the recent total middle-ear reconstruction; this parameter was used as an approximate measure of the duration of the patient's cavity problem. Correlations between percentage lamellar bone and inter-operation time were calculated for the two ossicles.

The range of inter-operation times was seven to 65 years. We observed a correlation between percentage lamellar bone and inter-operation time for malleus bones (r = −0.512, p < 0.05), but not for incus bones.

These results were in agreement with our pre-study impressions.

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.

The relationship of pars flaccida retraction with epitympanic aeration and mastoid size is ill-defined. Both pars flaccida retraction and small mastoid size are traits of nearly all clinical entities of otitis media.

To determine, in clinically normal specimens, the relationship of pars flaccida retraction with mastoid pneumatisation and epitympanic aeration.

Post-mortem anatomical dissection of 41 bequeathed adult crania without clinical otitis.

Pars flaccida retractions were viewed with an operating microscope and judged using Sade's classification. Mastoid sizes were determined radiographically (by plain Law lateral images). Ten crania, five with the largest mastoids and five with the smallest mastoids, were studied by computed tomography.

No specimen had a retraction worse than Sade grade two (i.e. retracted onto the neck of the malleus). Retractions were unrelated to the extent of mastoid pneumatisation. All epitympani were found to be normal on both anatomical dissection and computed tomography imaging.

Pars flaccida retraction is probably related to prior, presumably transient, non-aeration of Prussak's space.