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Otology/Neurotology

(298) Malleus Head Fixation: Clinical Exam Demonstration and Systematic Management Approach

Monday, October 2, 2023
2:45 PM – 3:45 PM East Coast USA Time

    Presenting Author(s)

  • Douglas Josiah Totten, MD, MBA

    Resident Physician
    Indiana University School of Medicine, Department of Otolaryngology -- Head and Neck Surgery
    Indianapolis, Indiana, United States

    • Senior Author(s)

  • Rick F. Nelson, MD, PhD

    Professor
    Indiana University
    Zionsville, Indiana, United States

    • Co-Author(s)

  • Evan C. Cumpston, MD

    Neurotology Fellow
    Indiana University School of Medicine , Department of Otolaryngology -- Head and Neck Surgery
    Indianapolis, Indiana, United States

Disclosure(s):
Douglas Josiah Totten, MD, MBA: No relevant relationships to disclose.
Rick F. Nelson, MD, PhD: No relevant relationships to disclose.
Evan C. Cumpston, MD: No relevant relationships to disclose.


Introduction: Malleus head fixation results in conductive hearing loss (CHL) that has overlapping audiologic finding to otosclerosis making it difficult to diagnose. To our knowledge, no prior research has documented a systematic approach to the workup of patients with suspected malleus head fixation. This study describes five cases of malleus head fixation, postoperative outcomes, and proposes a systematic approach to patient workup and management.

Methods: Patients diagnosed with malleus head fixation from 2018-2023 were included in this study. Presenting symptoms, past surgical and otologic history, radiographic findings, operative records, and pre- and post-operative pure tone average (PTA) of 0.5, 1, 2 and 3 kHz were recorded.

Results: Five patients diagnosed with malleus head fixation underwent ossicular chain reconstruction. Four were female. Average age was 53 (standard deviation: 6) years. All patients presented with a prolonged history of hearing loss and had absent acoustic reflexes pre-operatively. Four patients had documented malleus head immobility on pneumatic otoscopy and pre-operative imaging demonstrating malleus head fixation in all cases. One patient with suspected otosclerosis had malleus head fixation noted intraoperatively. All patients were treated with endaural atticotomy with laser for mobilization. Four patients experienced subjective hearing improvement while one patient’s outcome was complicated by additional middle ear pathology. The pre-operative PTA air-bone gap (ABG) improved from 22.5 dB to 9.4 dB post-operatively with a with mean improvement in ABG of 13.1 dB (p=0.008).

Conclusions: While rare, CHL from malleus head fixation presents with absent acoustic reflexes and may be reliably detected with pre-operative pneumatic otoscopy. We present videos showing malleus immobility with pneumatic otoscopy. Malleus immobility should prompt imaging to confirm malleus head fixation pre-operatively. Endaural atticotomy may be easily converted to from a standard transcanal tympanoplasty approach.