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Simultaneous Management of Malleus Fixation during Stapedectomy for Otosclerosis
David R Friedmann, MD, Ayaka J Iwata, MS, Anil K Lalwani, MD
Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY.
ABSTRACT
DISCUSSION
FIGURES
Objectives / Hypothesis: Describe a rare entity of simultaneous malleus and stapes fixation, our
approach to its work up and operative management.
Study Design: Case Report.
Methods: A 37 year old patient with presumed otosclerosis underwent left middle ear
exploration for stapedectomy. Pre-operative imaging was normal. Intraoperatively, ligamental
fixation of the malleus was noted in addition to stapes footplate fixation. A single stage
malleostapedotomy was performed.
Results: Postoperative audiogram revealed closure of the left air bone gap to within 10 dB and at
6 months, there is complete closure of the air bone gap.
Conclusions: Preoperative imaging and a methodical intraoperative approach to middle ear
exploration are critical to making an accurate diagnosis. Simultaneous anterior malleolar
fixation stapes fixation can be addressed simultaneously by malleostapedectomy.
INTRODUCTION
• The finding of a simultaneously fixed malleus and stapes is extremely rare, and is reported to
be present in 0.4 to 4% of otosclerosis cases (1-3).
• Preoperatively, the presumed etiology of otosclerosis is isolated stapes fixation, but the
definitive diagnosis is made during surgery.
• Preoperative temporal bone CT scan may be particularly beneficial in cases with an unclear
clinical history.
• Simultaneous malleus and stapes fixation can be managed by a one-step malleostapedectomy
or a two stage operation, but no systematic studies have been done to compare these two
methods.
Figure 1: Preoperative audiogram shows maximal
conductive hearing loss on left and 35 dB air bone
gap on right.
Figure 3: Postoperative audiogram at six weeks
demonstrates closure of the left air bone gap to
within 10 dB, which has since closed completely on
further follow up.
Methods
• Case report and review of the literature.
RESULTS
• We report the case of a 37 year old man who presented with a 10 year history of bilateral
progressive hearing loss.
• He also reported two episodes of vertigo accompanied by hearing loss, fullness, and tinnitus
over the previous five years.
• There was no family history of hearing loss.
• Audiologic evaluation revealed bilateral conductive hearing loss with an air bone gap of 55dB
on the left and 30dB on the right, with good cochlear reserve bilaterally (Figure 1).
• CT of the temporal bone was obtained given the unclear clinical history. It did not reveal foci
of otospongiosis, ossicular fixation, or other abnormality, and the radiology report was read as
normal (Figure 2).
• Upon further independent review intraoperatively, we found some suggestion of fixation in the
area of the left malleus to the anterior epitympanum.
• Patient underwent left middle ear exploration with planned stapedectomy for presumed
otosclerosis.
• Intraoperatively, fixation of both the malleus and stapes footplate was noted.
• The malleus was immobile due to fixation at the anterior malleolar ligament to the
anterosuperior epitympanum.
• A single stage malleostapedotomy was performed with laser lysis of the bony fixation of
malleus and a small fenestra stapedectomy using a 4.5mm Eclipse piston prosthesis.
• There was excellent mobility of the malleus, incus, and the prosthesis within the stapedotomy.
• The postoperative audiogram at six weeks revealed closure of the left air bone gap to within
10 dB (Figure 3).
• On further follow-up at six months, complete air bone gap closure was achieved.
A
B
C
Figure 2: Preoperative computed tomography (CT) of the temporal bone demonstrates area of possible fixation of
the malleus (A). Remainder of temporal bone CT was unremarkable (B, C).
REFERENCES
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• The likelihood of an ossicular chain abnormality is
supported in the setting of a maximal conductive
hearing loss and absent acoustic reflexes.
• Pre-operative imaging in cases with an unclear
clinical history may prevent an unnecessary middle
ear exploration with all the inherent operative
risks.
• While in this particular case, pre-operative imaging
did not help predict all of the intraoperative
findings, having obtained this information assured
us that other possible etiologies that might require
a different surgical approach such as superior
semicircular canal dehiscence (SSCD) were not
present.
• Independent review of the imaging raised
suspicion for left malleus fixation which confirmed
the intraoperative findings (Figure 2).
• Specific palpation of each ossicle is critical to
confirm mobility of the ossicular chain even if
stapes fixation is observed.
• A failure rate of 4 to 37.5% after primary stapes
surgery due to malleus fixation has been reported
by past studies (3, 6-8), but these include cases of
simultaneous malleus-incus ankylosis with stapes
fixation rather than ligamental fixation of the
malleus.
• Otosclerosis may be a predisposing factor to
malleus fixation, related more to the duration of
otosclerosis rather than its severity (4, 5).
• While other groups advocate malleostapedotomy
as the management of choice (8, 9) there are no
systematic studies that compare the results of
specific surgical techniques to address malleus
fixation at the time of stapedectomy for
otosclerosis.
• Of great concern in such cases of ligamental
fixation is the potential for re-fixation of the
malleus, but we are encouraged by our success
over the follow up period to date with complete
closure of the air bone gap.
CONCLUSION
• Consideration for preoperative temporal bone CT
should be given to cases with unclear clinical
history to prepare for surgical exploration.
• Palpation of each bone of the ossicular chain
individually is essential to ensure that no other
bones are fixed.
• While only a single case, the audiometric follow
up in this case supports the safety and efficacy of
simultaneous malleostapedectomy as the primary
management in cases of malleolar ligament
fixation in otosclerosis.