Ossicular Chain Pathology and Reconstruction

Ossicular disease causes conductive hearing loss through fixation, discontinuity or both. Causes: congenital, chronic inflammation, cholesteatoma, trauma or previous surgery. Exclude canal or drum disease and a third-window lesion before attributing an air-bone gap to the chain.

Reconstruction depends on the remaining ossicles, footplate mobility, middle-ear condition and patient goals. PORP couples the drum or malleus to an intact mobile stapes superstructure, TORP to a mobile footplate when the superstructure is absent.

Offer amplification (hearing aid or bone-conduction device) or surgery, and decide whether disease clearance and hearing reconstruction are staged. Control active disease and confirm footplate mobility before reconstruction.

Onset, progression, fluctuation, hearing in each ear, tinnitus, previous audiograms and communication needs; childhood hearing difficulty, chronic discharge, trauma or barotrauma, previous ear surgery or prostheses.

Sudden traumatic loss with vertigo, facial weakness or possible CSF leak: urgent CT temporal bones, facial-nerve assessment and masked air/bone audiometry. Reassess a persistent isolated conductive loss for ossicular discontinuity once haemotympanum or effusion has settled.

Otoscopy/microscopy: wax, canal disease, perforation, retraction, myringosclerosis, effusion, keratin and granulation. A normal drum does not exclude ossicular pathology.

Rinne: fork beside the canal against its base on the mastoid; bone louder than air indicates a conductive component, but cross-hearing in profound unilateral SNHL gives a false-negative result. Weber: fork on the forehead or vertex midline; lateralises to the ear with conductive loss. Confirm with audiometry.

Examine facial function, both ears and craniofacial features: congenital disease may combine canal, ossicular, window and facial-nerve anomalies.