Epitympanic malleus fixation: correction without disrupting the ossicular chain

The preoperative diagnosis of malleus fixation can be made consistently with a pneumatic otoscope. Nontympanosclerotic epitympanic malleus fixation, for the most part, has been corrected by disrupting the ossicular chain and then reconstructing the sound-conducting mechanism. Once the diagnosis of malleus fixation is established, the surgical approach should be modified to cope with the fixed malleus. A wide, inferiorly based tympanotomy flap affords ample access to the epitympanum and permits definitive resolution of the associated conductive hearing loss. Atticotomy and discreet osteotomy can free the fixed malleus and preserve continuity of the osscular chain in over 90 percent of the patients with this syndrome. Experience for 46 patients having bony epitympanic malleus fixation, both congenital and acquired, was examined in concluding that the anatomical continuity of the ossicular chain can and should be maintained in most patients. The residual air-bone gap is less with an intact, though modified, ossicular chain than it is with a chain that has been reconstructed.