Tympanoplasty is often a necessary part of middle-ear surgery, the most common defect being that between an intact, mobile stapes and the malleus handle. The most readily available tissue is the patient's incus, reshaped to bridge the space between an intact stapes and the malleus. When the incus cannot be used, the hydroxyapatite Wehrs incus prosthesis® can be used as an alternative.

Twenty-six patients had an autograft incus ossiculoplasty and 20 patients underwent modified Wehrs incus prosthesis ossiculoplasty. The average post-operative air–bone gaps (ABGs) were 16.2 dB hearing loss (dBHL) and 17.2 dBHL, respectively. Air–bone gap closure to within 15 dBHL was achieved for 48 per cent of incus autografts and for 57 per cent of Wehrs prostheses, and to within 20 dBHL for 77 per cent and 62 per cent, respectively. Over four years follow up, the reconstruction was stable for each group, the ABGs being 17.7 dBHL and 17.1 dBHL, respectively.

Congenital conductive hearing loss due to ossicular deformities can be treated by either rehabilitation with a hearing aid or surgical reconstruction. We present the results of exploratory tympanotomy performed in a large paediatric otolaryngology centre in 67 patients with non-serous congenital conductive hearing loss. Forty-two children had malformation of one or more ossicles without fixation of the stapes, and 19 had fixed stapes.

In 26 cases, the surgeon decided not to perform surgical correction. Seven operated patients were lost to follow-up. As a group, 47 per cent of the patients who underwent reconstruction showed no significant benefit from surgery, with post-operative air-bone gaps (ABG) greater than 30 dB. Assessment of the results by pathology showed that 64 per cent of the patients with mobile stapes had an air-bone gap within 30 dB compared to only 33 per cent of the patients with fixed stapes. One patient sustained severe sensorineural loss after the procedure. Considering that exploratory tympanotomy is a relatively minimal, benign procedure but that findings during exploration may exclude the option of reconstruction (in 39 per cent of our patients), we suggest exploring the ear, but in a more realistic, informed way.

Both hydroxyapatite (Ha) and titanium (Ti) are well-accepted alloplastic materials for ossicular prostheses. Many different designs of Ha and Ti prostheses are presently available. Fourteen surgeons of different seniority and surgical experience were asked to ‘test-drive’ four different types of ossicular prostheses in cadaveric temporal bones to investigate the user-friendliness of these protheses. The Goldenberg design Ha incus prosthesis and the Dusseldorf design Bell Ti prosthesis were used as partial ossicular replacement prostheses (PORP). The Richards design Ha incus-stapes prosthesis and the Dusseldorf design Aerial Ti prosthesis were used as a total ossicular replacement prostheses (TORP). Nine out of 14 surgeons found the Ha PORP to be more user-friendly because of the notch design in the head. The Ti prosthesis was found to be more difficult to manipulate because it was too light. Half of the surgeons preferred the Ti TORP because of the open design of the top-plate. The Ha TORP was thought to be too top-heavy and to have a tendency to fall over.

An ossicular prosthesis produced by making a mould from a cadaveric incus and injecting ionomeric cement into it (incus replica prosthesis, IRP) has been cemented to the malleus head and stapes head and evaluated in fresh human temporal bones using a laser vibrometer. Stapes velocity was recorded under acoustic stimulation and foot plate displacements were derived. Fourteen frequencies between 125 Hz and 8000 Hz have been used. Measurements were made with the ossicular chain intact, following removal of the incus, with the prosthesis cemented to the malleus, but not the stapes, and with the incudo-stapedial joint cemented. In a second series of experiments the performance of the IRP was compared with that of a Causse partial ossicular replacement prosthesis, using the same experimental set-up. The results indicate that the prosthesis performs almost as well as the intact ossicular chain and that cementing the incudostapedial joint gives better sound transmission than leaving it uncemented. In addition the IRP outperforms the conventional partial ossicular replacement prosthesis.