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 aimed to evaluate hearing outcomes and device safety in a large, single-surgeon experience with the totally implantable active middle-ear implants.

This was a retrospective case series review of 116 patients with moderate-to-severe sensorineural hearing loss undergoing implantation of active middle-ear implants.

Mean baseline unaided pure tone average improved from 57.6 dB before surgery to 34.1 dB post-operatively, signifying a mean gain in pure tone average of 23.5 dB (p = 0.0002). Phonetically balanced maximum word recognition score improved slightly from 70.5 per cent to 75.8 per cent (p = 0.416), and word recognition score at a hearing level of 50 dB values increased substantially from 14.4 per cent to 70.4 per cent (p < 0.0001). Both revision and explant rates were low and dropped with increasing surgeon experience over time.

This study showed excellent post-operative hearing results with active middle-ear implants with regard to pure tone average and word recognition score at a hearing level of 50 db. Complication rates in this case series were significantly lower with increasing experience of the surgeon. Active middle-ear implants should be considered in appropriate patients with moderate-to-severe sensorineural hearing loss who have struggled with conventional amplification and are good surgical candidates.

This study aimed to evaluate the long-term results of ossiculoplasty using bone cement.

Forty patients (24 females and 16 males; mean age: 34.1 ± 11.8 years; range, 9–54 years) with chronic otitis media with perforation but without cholesteatoma who had undergone incudostapedial rebridging ossiculoplasty using bone cement were evaluated retrospectively. Pre-operative and post-operative audiograms were evaluated. Bone conduction, air conduction and air–bone gaps were calculated according to international guidelines.

There was a mean reduction in pre-operative and post-operative air conduction (12.30 ± 11.98 dB), and this result was significant (p = 0.0001). There was a mean reduction in pre-operative and post-operative bone conduction (4.30 ± 6.69 dB), and this result was significant (p < 0.0001). The pre-operative air–bone gap was 27.65 dB and decreased to 19.65 dB during follow-up (p = 0.0001). No adverse reactions or complications were observed.

Bone cement is reliable for the repair of incudostapedial-joint defects.

Manubrio-incudo-stapedioplasty functional outcomes were compared to those of other methods for reconstructing Austin–Kartush type B ossicular defects.

Forty-two patients underwent Austin–Kartush type B ossicular defect reconstruction using: manubrio-incudo-stapedioplasty (13 patients), an autologous incus (19 patients) or a titanium ossicular replacement prosthesis (10 patients). For manubrio-incudo-stapedioplasty reconstruction, the malleus head was removed, the manubrium was relocated posteriorly and the incus short process was placed on the mobile footplate. The manubrium was placed on the incus body groove and bone cement was applied to stabilise the manubrium–incus junction. Pre- and post-operative hearing thresholds were assessed.

The air–bone gap decreased from 25.9 ± 6.0 dB to 12.3 ± 5.0 dB (p < 0.05) in the manubrio-incudo-stapedioplasty group. The hearing gain was 13.6 ± 5.2 dB for manubrio-incudo-stapedioplasty, 3.4 ± 14.2 dB with the autologous incus, and 3.3 ± 11.07 dB with the titanium ossicular replacement prosthesis. Hearing improvement was greater for manubrio-incudo-stapedioplasty compared to the other reconstruction methods (p < 0.05).

Manubrio-incudo-stapedioplasty resulted in satisfactory hearing outcomes in patients with Austin–Kartush type B ossicular defects. This technique can be considered a stable, inexpensive and effective method to reconstruct Austin–Kartush type B ossicular defects.

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.

This study aimed to compare the functional and anatomical outcomes of ossiculoplasty using an autograft incus or a titanium partial ossicular replacement prosthesis for reconstructing Austin type A ossicular defects.

Patients with Austin A ossicular defects were randomly divided into two groups: one group underwent ossiculoplasty with an autologous incus (the autologous incus group) and the other underwent ossiculoplasty with a titanium partial ossicular replacement prosthesis (the titanium prosthesis group). Otoscopic examination and audiological assessment was done pre-operatively and at 3, 6 and 12 months post-operatively.

A post-operative average air–bone gap closure of less than 20 dB was seen in 13 patients (65 per cent) in the autologous incus group and 7 (35 per cent) in the titanium prosthesis group. There were fewer post-operative complications in the autologous incus group (20 per cent) than in the titanium prosthesis group (45 per cent).

Hearing outcomes and graft take up after ossiculoplasty were significantly better when an autologous incus rather than a titanium partial ossicular replacement prosthesis was used to reconstruct Austin type A ossicular defects. The major disadvantages of the titanium prosthesis were unpredictable results and more post-operative complications.

The Vibrant Soundbridge is an active middle-ear implant for hearing rehabilitation that is usually placed in the long process of the incus or round window. This study reports on the unusual implant attachment to the short process of the incus in a patient with ear malformation, and describes their audiological and clinical outcomes.

Case report and literature review.

Audiological evaluation with the Vibrant Soundbridge implant showed a pure tone average of 31 dB. The speech test, at 65 dB HL, revealed correct recognition of 92 per cent of disyllabic words. The Glasgow Hearing Aid Benefit Profile showed high levels of satisfaction, hearing aid use and benefit.

Fixation of the Vibrant Soundbridge implant on the short process of the incus is a feasible option, with good clinical and audiological outcomes. Coupling the floating mass transducer to the short process of the incus is a good surgical option, especially when the long process and the oval or round window are inaccessible.

To study the biomechanical properties of glass ionomer cement used for incudostapedial rebridging.

Two groups were established based on the size of the gap between the incus and stapes (1.0 mm in group 1 and 2.0 mm in group 2). Glass ionomer cement was applied to the gaps, and compression tests were performed. Maximum force was measured at the fracture point, and was divided by the cross-sectional area to obtain the maximum compressive strength.

No significant difference was found in the maximum force for the two groups (p = 0.312). The glass ionomer cement diameter was significantly higher in group 2 than in group 1 (p = 0.006). The maximum compressive strength was significantly higher in group 1 than in group 2 (p = 0.042).

The fragility of bone cement used in this study was 25.5 per cent higher for a 2 mm gap than for a 1 mm gap. We speculate that the use of bone cement may be safer for the repair of smaller incudostapedial defects.

To determine the effectiveness of biocements in rebridging isolated incudostapedial erosion.

A review of the use of biocements for isolated incudostapedial joint erosion was performed on publications from 1998 to 2012 available from Medline, Embase and Pubmed. Inclusion criteria were papers published in English, case series or comparative studies with more than 10 patients, isolated incudostapedial erosion through chronic ear disease, minimal air-bone gap less than 20 dB (or air-bone gap less than 10 dB) and follow up for at least one year.

In 108 patients, rebridging ossiculoplasty was performed using hydroxyapatite cement. Closure of air-bone gaps less than 20 dB and less than 10 dB was achieved in 80–94.4 per cent and 29–75 per cent, respectively. Glass ionomer cement was used in 318 patients. Closure of air-bone gaps less than 20 dB and less than 10 dB was achieved in 74–94 per cent and 40–76 per cent, respectively.

Biocements can be successfully used to close isolated incudostapedial erosions. Larger comparative prospective studies documenting the length of eroded incus and types of reformation of the incudostapedial joint, with standardised reporting, are needed in the future.

This study aimed to compare the hearing results of incus interposition and bone cement ossiculoplasty in patients with incus long process defects.

Ninety-nine patients with incus long process defects were included. Incus interposition was performed in 49 patients (group 1) and bone cement ossiculoplasty was performed in 50 patients (group 2). Group 1 included 29 female and 20 male patients, with a mean age ± standard deviation of 29.43 ± 12.5 years (range, 8–58 years). Group 2 comprised 32 female and 18 male patients, with a mean age ± standard deviation of 29.1 ± 14.89 years (range, 8–67 years).

The mean hearing gain ± standard deviation was 15.2 ± 9.01 dB in group 1 and 19.36 ± 9.08 dB in group 2. Hearing gain was significantly greater in the bone cement group than in the incus interposition group (p = 0.0186). Successful hearing results (i.e. air–bone gap < 20 dB) were achieved by 63.2 per cent of group 1 patients and 78 per cent of group 2 patients.

Incus interposition and bone cement ossiculoplasty are safe and reliable methods with which to manage incus long process defects. Bone cement ossiculoplasty gives a greater hearing gain in appropriate cases.

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 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.

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 compare hearing results in patients undergoing myringostapediopexy or myringolenticulopexy in canal wall down mastoidectomy.

Case series of one surgeon. A retrospective review of 83 consecutive mastoid cavity operations for primary cholesteatoma. Only those patients who had undergone either myringostapediopexy or myringolenticulopexy were included.

District general hospital.

Forty-two procedures were performed in 40 patients. The mean age was 42 years old. The average follow up was 5.9 years.

Seventeen patients underwent myringolenticulopexy (the incus head was excised, leaving the lenticular process attached to the stapes prior to graft placement) and 25 underwent myringostapediopexy (type III tympanoplasty).

Audiometry three to six months after surgery, and status of mastoid cavity after a minimum follow up of one year.

Comparison of post-operative hearing results for the two groups showed a statistically significant hearing advantage for myringolenticulopexy (p = 0.029). In the myringolenticulopexy group, 92 per cent achieved a post-operative air–bone gap of less than 30 dB, compared with 62 per cent in the myringostapediopexy group. The mean post-operative air–bone gaps in the two groups were 17.5 and 24.7 dB, respectively.

When surgically feasible, the technique of myringolenticulopexy is a useful method of preserving serviceable hearing in single-stage mastoid cavity surgery.

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.