Goodhill syndrome: a case report.

Conductive hearing loss with a normal tympanic membrane is a common reason for otolaryngology consultation, with otospongiosis being the most frequent cause and House syndrome being extremely rare, requiring systematic investigation. We report the case of a 31-year-old woman who presented with conductive hearing loss with a normal tympanic membrane. A temporal bone computed tomography (CT) scan confirmed a House-Goodhill syndrome due to fixation of the malleus head. Surgical intervention was considered to remove the attic bone synostosis with the malleus head, resulting in a significant clinical improvement. The Goodhill syndrome is a rare condition that causes hearing loss with a normal eardrum. The surgery can highly improve the hearing function.

Audiologic Outcomes After Vestibulotomy in Patients With Congenital Absence of the Oval Window.

OBJECTIVE: To examine the clinical features and surgical outcomes in patients with congenital absence of the oval window (CAOW), and to investigate the potential factors that affect audiologic results. STUDY DESIGN: A retrospective chart review. SETTING: A tertiary academic center. PATIENTS AND INTERVENTION: A total of 17 ears among 16 patients were confirmed to have CAOW. Among them, 13 ears underwent vestibulotomy for hearing reconstruction. Clinical parameters associated with the hearing outcomes were analyzed. MAIN OUTCOME MEASURES: A mean air-bone gap (ABG) after 6-month and long-term follow-up was compared with preoperative measurements. RESULTS: Intraoperative findings showed that anomalies of the malleus or incus were observed in 11 ears (64.7%), stapes anomalies were present in all ears (100%), and facial nerve anomalies were present in 10 ears (58.8%). Because of unfavorable facial nerve anomalies, hearing reconstruction was aborted in four cases (23.5%). In the hearing reconstruction group, the mean ABG at 6 months postoperation was significantly reduced after compared with the preoperative value (44.0 ± 8.4 dB versus 58.8 ± 9.1 dB, p = 0.006). After dividing ears into a success subgroup (ABG ≤ 30 dB, seven ears) and non-success subgroup (ABG > 30 dB, six ears), the use of a drill during vestibulotomy was significantly related to a poor hearing outcome (100% versus 16.7%, p = 0.015). The long-term follow-up result (mean, 60 mo) revealed no deterioration compared with the 6-month postoperative result. Five ears (29.4%) underwent revision surgery, and three of them showed ABG improvements. No serious complications were reported. CONCLUSION: Vestibulotomy is an effective and safe option for hearing restoration in patients with CAOW, particularly when the use of a drill is not required. The long-term audiologic outcome is also reliable.

Exclusive endoscopic management of incus long process major defects: conventional incus interposition versus malleostapediopexy.

PURPOSE: The aim of the current study is to compare the surgical and audiometric results of conventional incus interposition (IP) versus malleostapediopexy (MS) in incus long process large defects. METHODS: A total of 71 patients (incus IP group n = 37, MS group n = 34) were enrolled in this study. All patients enrolled in the current study underwent ossiculoplasty via an exclusive endoscopic transcanal approach. Pre- and postoperative audiometric measurements and air-bone gap (ABG) values were compared, and if the postoperative ABG value was less than 20 dB, ossiculoplasty was considered successful. Graft success rates and complications were also compared. RESULTS: The average auditory gain was 14.7 ± 4.2 dB in the incus IP group and 18.3 ± 5.1 dB in the MS group. The auditory gain was significantly greater in the MS group relative to the incus IP group (p = 0.012). Ossiculoplasty success (postoperative ABG value < 20 dB) rate was 70.3% in the incus IP group patients and 88.2% in the MS group patients (p < 0.001). There was no significant difference in terms of graft success rate between groups (p > 0.05) and the overall graft uptake rate was 91.5% (65/71). CONCLUSION: Malleostapediopexy-bridging of malleus and stapes using bone cement-is an effective, reasonable, and more efficient technique in terms of auditory outcomes relative to the conventional incus interposition in endoscopic transcanal management of incus long process major defects.

Bone cement repair of malleus handle fractures: Intraoperative video and case report of two patients.

Isolated malleus fractures are a rare occurrence with few reported cases in the literature. Symptoms include sudden otalgia, hearing loss, tinnitus and aural fullness. Work-up and diagnosis are based on a combination of thorough anamnesis and careful otoscopic evaluation or high-resolution computer tomography. We present two cases of isolated malleus handle fractures who were diagnosed based on a combination of pneumatic otoscopy and tympanometry. Both fractures were surgically repaired using hydroxyapatite bone cement as showcased in the supplemental video material. Post-operative audiometry showed improvement in the pure-tone-average of both patients as well as normalisation of tympanometry. Isolated malleus fracture should be suspected in cases of sudden hearing loss and tinnitus following digital manipulation of the outer ear canal together with a conductive hearing loss with a mostly high-frequent air-bone-gap and hypercompliant tympanometry with hypermobility of the tympanic membrane on pneumatic insufflation. Surgical repair of the fracture using bone cement has good hearing outcomes and leads to improvement in auditory symptoms.

Linear transmission between malleus and stapes in cases with incus necrosis.

OBJECTIVE: The outcome of cartilage interposition ossiculoplasty was assessed in cases of incus necrosis after posterior malleus repositioning in the plane of the stapes, in terms of hearing gain after ossicular reconstruction. METHODS: A retrospective observational study was conducted of 30 patients admitted to an Ain Shams University hospital from March 2021 to September 2021. All patients with ossicular disruption due to chronic suppurative otitis media and hearing loss of more than 40 dB were included in the study. Pure tone audiometry was conducted for each patient after three months, six months and one year post operation. RESULTS: The audiogram showed a post-operative air-bone gap of 20 dB or less in 83.33 per cent of patients (n = 25) at three months post-operatively and in 80 per cent of patients after six months; after one year, the results remained the same. CONCLUSION: The use of cartilage interposition after malleus posterior mobilisation represents an excellent partial ossicular replacement technique.

Registration of preoperative temporal bone CT-scan to otoendoscopic video for augmented-reality based on convolutional neural networks.

PURPOSE: Patient-to-image registration is a preliminary step required in surgical navigation based on preoperative images. Human intervention and fiducial markers hamper this task as they are time-consuming and introduce potential errors. We aimed to develop a fully automatic 2D registration system for augmented reality in ear surgery. METHODS: CT-scans and corresponding oto-endoscopic videos were collected from 41 patients (58 ears) undergoing ear examination (vestibular schwannoma before surgery, profound hearing loss requiring cochlear implant, suspicion of perilymphatic fistula, contralateral ears in cases of unilateral chronic otitis media). Two to four images were selected from each case. For the training phase, data from patients (75% of the dataset) and 11 cadaveric specimens were used. Tympanic membranes and malleus handles were contoured on both video images and CT-scans by expert surgeons. The algorithm used a U-Net network for detecting the contours of the tympanic membrane and the malleus on both preoperative CT-scans and endoscopic video frames. Then, contours were processed and registered through an iterative closest point algorithm. Validation was performed on 4 cases and testing on 6 cases. Registration error was measured by overlaying both images and measuring the average and Hausdorff distances. RESULTS: The proposed registration method yielded a precision compatible with ear surgery with a 2D mean overlay error of 0.65 ± 0.60 mm for the incus and 0.48 ± 0.32 mm for the round window. The average Hausdorff distance for these 2 targets was 0.98 ± 0.60 mm and 0.78 ± 0.34 mm respectively. An outlier case with higher errors (2.3 mm and 1.5 mm average Hausdorff distance for incus and round window respectively) was observed in relation to a high discrepancy between the projection angle of the reconstructed CT-scan and the video image. The maximum duration for the overall process was 18 s. CONCLUSIONS: A fully automatic 2D registration method based on a convolutional neural network and applied to ear surgery was developed. The method did not rely on any external fiducial markers nor human intervention for landmark recognition. The method was fast and its precision was compatible with ear surgery.

An Endoscopic Procedure for the Simultaneous Treatment of both Otosclerosis and Malleus Fixation.

To report the case of the simultaneous treatment of otosclerosis and malleus fixation through an entirely endoscopic transcanal approach. A targeted transcanalar epitympanotomy with annular bony ridge conservation was planned preoperatively, with 3D CT localization of the fixed part of the malleus head. The upper part of the malleus head and the superior ossified ligament of the malleus were drilled. A 0.6 mm stapedotomy was performed and a piston inserted. The patient's recovery was uneventful, with closure of the air-bone gap on her postoperative audiogram, associated with an overclosure in 500Hz, 1kHz, 2 kHz and 4 kHz. Laryngoscope, 134:2411-2414, 2024.

Isolated Fracture of the Malleus: An Overlooked Cause of Conductive Hearing Loss?

OBJECTIVE: To report the largest case series of isolated malleus fractures with systematic review to characterize the disease's presentation and natural history, and provide suggestions for management. DATA SOURCES: PubMed, Embase, Cochrane Library. REVIEW METHODS: Retrospective cohort study was performed on 12 patients with isolated malleus fractures. History, physical exam, pre- and post-treatment audiograms, and imaging were obtained. Systematic review of the literature was performed. RESULTS: Including the cases herein, 58 isolated malleus fractures were identified, the majority of which were published in the 21st century. Mean time to presentation after injury was 34.4 months. Most common etiology was external auditory canal (EAC) manipulation. Physical exam and imaging did not identify any abnormality at presentation in 16% and 21% of cases, respectively. The majority of fractures involved the manubrium. Air-bone gap (ABG) at initial presentation ranged from 16 to 26 dB, and was greater at higher frequencies. Thirty-six cases underwent surgery. ABG improvement was greater at all frequencies for those who underwent surgery. Final ABG was significantly less than initial ABG at nearly every frequency for those who underwent surgery (p < 0.05), while not at any frequency for those who were observed. CONCLUSIONS: Isolated malleus fractures may occur more often than historical data suggests, and are perhaps underdiagnosed. Abrupt removal of a finger from the EAC with pain and hearing loss is nearly pathognomonic. Conductive hearing loss with ABG greater at higher frequencies is most often observed. Observation is unlikely to produce spontaneous improvements in hearing, while surgery demonstrates reliable decreases in ABG. Laryngoscope, 134:1032-1041, 2024.

[Analysis of medium and long term efficacy of ossicle chain bypass technique in treatment of tympanosclerosis].

Objective:For tympanosclerosis patients with ossicular chain fixation, we use ossicular chain bypass technique and evaluate its long-term effects. Methods:From June 2017 to June 2019, 147 patients with tympanosclerosis who underwent middle ear surgery with otoscopy in Yinchuan First People's Hospital were reviewed. The subjects were divided into three groups according to the implemented operation plan, 51 cases in the ossicular chain mobilization group（OCM）, 56 cases in the ossicular chain bypass reconstruction group（OCB）, and 40 cases in the malleus-incus complex resection reconstruction group（MICR）. Through a three-year follow-up, the medium and long-term effects of different operation plans were compared and analyzed. Results:There was no significant difference among the three groups in the incidence of tympanic membrane perforation, delayed facial nerve palsy, and the dispatch and displacement of PORP. The incidence of tympanic membrane retraction pocket or cholesteatoma after operation in OCB group（0） was significantly lower than that in OCM group（11.76%） and MICR group（7.5%）（P<0.05）. At 12 months after operation, ΔABG of OCB group and MICR group were better than that in the OCM group（P<0.05）. At 36 months after operation, ΔABG of OCB group was better than that in the OCM group（P<0.05）, and there was no significant difference between OCB group and MICR group. The audiological performance of patients with epitympanic sclerosis（ETS） at 12, 24 and 36 months after operation was better than that of patients with posterior tympanosclerosis（PTS） and total tympanosclerosis（TTS）（P<0.05）. Conclusion:Compared with patients undergoing ossicular chain mobilization and malleus-incus complex resection for ossicular chain reconstruction, patients with tympanosclerosis undergoing bypass technique have better and stable hearing prognosis in medium and long term. This technique can effectively prevent the formation of retracted pocket and cholesteatoma in patients with tympanosclerosis after operation.

A novel technique in treatment of advanced tympanosclerosis: results of malleus replacement and loop prostheses combination; pure endoscopic transcanal approach.

PURPOSE: The objectives of the present clinical trial are to describe our surgical technique for advanced tympanosclerosis (TS) and to present the comparison of pre-and postoperative audiometric results. METHODS: 21 patients suffering from advanced TS (Only type III and IV patients according to Wielinga-Kerr classification) were enrolled in this prospective study. A pure transcanal endoscopic approach was preferred for all patients included in the study. Titanium malleus replacement prosthesis (MRP) and polytetrafluoroethylene (PTFE) loop prosthesis combination were used to bypass fixed ossicles to achieve sound transmission to the inner ear. Pre-and postoperative pure tone audiometry (PTA) measurements and air-bone gap (ABG) results compared, and surgical technique was considered successful if postoperative ABG was less than 20 dB. RESULTS: Six of the 21 patients had been operated on before and the tympanic membrane (TM) was intact. The remaining 15 of the 21 patients were the primary cases, and TM perforation repair and ossiculoplasty using combination of the MRP and PTFE loop prosthesis were performed at single-staged operation. The average preoperative ABG values significantly improved from 37.1 ± 6.2 to 14.5 ± 1.2 dB postoperatively (p < 0.001). The mean preoperative air conduction threshold (ACT) significantly decreased from 51.7 ± 11.4 to 28.5 ± 9.1 dB (p < 0.001). CONCLUSION: TS surgery is still a controversial issue particularly in stapes footplate fixation. However, our surgical and audiological results in this study are quite promising. The combination of titanium MRP and PTFE loop prosthesis for restoring sound transmission in advanced TS cases is reliable, effective and novel treatment option via endoscopic transcanal approach.

Isolated Traumatic Dislocation of the Malleus into the External Auditory Canal.

We report a rare case of isolated malleus dislocation into the external auditory canal with lateralized intact tympanic membrane following a head trauma. The patient was a 63-year-old woman who presented at the outpatient department of our institute with hearing loss of 10 years' duration after a bicycle accident. During physical examination of the patient, total dislocation of the malleus-like bony structure into the external auditory canal on the right side was observed. In the computed tomography scan, an isolated malleus dislocation with intact incus-stapes articulation was identified. The patient was successfully treated with endoscopic exploratory tympanotomy and partial ossicular replacement prosthesis. The isolated malleus dislocation can rarely occur after trauma. A careful diagnostic step through history, physical examination, and temporal bone computed tomography scan are needed to confirm this rare condition.

Analysis of medium and long term efficacy of ossicle chain bypass technique in treatment of tympanosclerosis / 临床耳鼻咽喉头颈外科杂志

Objective:For tympanosclerosis patients with ossicular chain fixation, we use ossicular chain bypass technique and evaluate its long-term effects. Methods:From June 2017 to June 2019, 147 patients with tympanosclerosis who underwent middle ear surgery with otoscopy in Yinchuan First People's Hospital were reviewed. The subjects were divided into three groups according to the implemented operation plan, 51 cases in the ossicular chain mobilization group（OCM）, 56 cases in the ossicular chain bypass reconstruction group（OCB）, and 40 cases in the malleus-incus complex resection reconstruction group（MICR）. Through a three-year follow-up, the medium and long-term effects of different operation plans were compared and analyzed. Results:There was no significant difference among the three groups in the incidence of tympanic membrane perforation, delayed facial nerve palsy, and the dispatch and displacement of PORP. The incidence of tympanic membrane retraction pocket or cholesteatoma after operation in OCB group（0） was significantly lower than that in OCM group（11.76%） and MICR group（7.5%）（P<0.05）. At 12 months after operation, ΔABG of OCB group and MICR group were better than that in the OCM group（P<0.05）. At 36 months after operation, ΔABG of OCB group was better than that in the OCM group（P<0.05）, and there was no significant difference between OCB group and MICR group. The audiological performance of patients with epitympanic sclerosis（ETS） at 12, 24 and 36 months after operation was better than that of patients with posterior tympanosclerosis（PTS） and total tympanosclerosis（TTS）（P<0.05）. Conclusion:Compared with patients undergoing ossicular chain mobilization and malleus-incus complex resection for ossicular chain reconstruction, patients with tympanosclerosis undergoing bypass technique have better and stable hearing prognosis in medium and long term. This technique can effectively prevent the formation of retracted pocket and cholesteatoma in patients with tympanosclerosis after operation.

Reparación de fractura aislada del mango del martillo con cemento ionomérico vidrioso autocurado / Repair of a malleus handle fracture using glass ionomer luting cement

Resumen La fractura aislada del mango del martillo es una entidad clínica poco habitual, pero frecuentemente subdiagnosticada. Lo fundamental es la sospecha clínica. El diagnóstico se confirma con la otoscopia neumática o la otomicroscopia con maniobra de Valsalva, en la cual se observa una movilidad anormal del mango del martillo. El rasgo de fractura se puede demostrar con tomografía computada de alta resolución o cone beam. Existen diferentes opciones de tratamiento como interposición de cartílago o uso de prótesis de reemplazo osicular así como cemento óseo. El cemento ionomérico vidrioso autocurado, muy utilizado en odontología, se ha usado en distintas cirugías otológicas con buenos resultados y biocompatibilidad. A nuestro saber no se ha usado en esta patología por lo que presentamos esta serie de tres casos en los cuales se ha usado esta novedosa técnica con buenos resultados clínicos.

Abstract Isolated fracture of the manubrium of the malleus is a rare clinical entity. Clinical suspicion is paramount. The usual clinical presentation is acute otalgia followed by tinnitus and fluctuating hearing loss after a brisk introduction and withdrawal of a finger into the external auditory canal. On physical examination, the eardrum looks normal on otoscopy. Only in pneumatic otoscopy or otomicroscopy with Valsalva an abnormal motility of the manubrium could bee seen. High-resolution computed tomography (CT) or cone beam CT is able to show the fracture line. Several treatment options have been proposed, such as interposition of bone or cartilage between the manubrium and the incus, total or partial ossicular replacement prosthesis; and the use of bone cement. Glass ionomer luting cement, with wide use in dentistry, has been used in several otological procedures with good biocompatibility and results, however, to our best knowledge, it has not been used to repair this type of fractures, so we present this novel material in three cases.

Short-term hearing outcome of malleus removal for surgery: An observational cohort study.

OBJECTIVES: The main goal of the present study was to assess hearing outcome for malleus removal in cholesteatoma surgery compared to a group with malleus conservation. The secondary aim was to compare the auditory involvement of the stapes between the two groups. MATERIAL AND METHODS: A single-center observational study included adult patients operated on by ossiculoplasty for acquired cholesteatoma between 2015 and 2019. Endpoints comprised improvement in pure-tone average air-bone gap (PTA-ABG) and air-bone gap (ABG) at conversational frequencies and, independently, per frequency. 136 patients were included: 95 with conserved malleus (M+) and 41 with malleus removal (M(). Mean time to audiometric follow-up was 9 months in both groups. RESULTS: The PTA-ABG improvement was 4.4±12.6dB for the M+ group and 3.8±13.4dB for the M- group, with no significant significance (P=0.8). Better results (not exceeding 7.5dB) were found for the M+ group at 2 and 8kHz (P=0.3 and P=0.052 respectively). Presence or absence of the stapes did not affect the results in either group. CONCLUSION: Those results suggest a negligible role of the malleus in early hearing outcome of tympanoplasty for cholesteatoma. A slight improvement was observed in the M+ group at 2 and 8kHz, but its interpretation remains uncertain.

[Isolated malleus handle fracture: cases report and literature review]. / Izolirovannyi perelom rukoyatki molotochka. Obzor literatury i klinicheskie sluchai.

The isolated malleus handle and neck fractures are rare pathology which demands detailed diagnosis and individual treatment plan in every case. Sometimes it could heal without surgery, but in most part of cases surgical treatment is indicated. The short literature review and 2 clinical cases of this pathology are presented in this article. We describe our own variants of surgery repair with autologous cartilage with good results.

[Postoperative hearing in tympanoplasty preserving the manubrium of malleus and tensor tympani muscle tendon].

Objective:To study the effect of retaining the manubrium of malleus and tensor tympani muscle tendon （TT） on postoperative hearing reconstruction in tympanoplasty. Methods:Ninety-seven patients underwent tympanoplasty and ossiculoplasty in Peking University Third Hospital from January 2012 to December 2017, their postoperative results of audiometry were analyzed and compared with the preoperative results. The patients were divided into two groups according to retaining the manubrium of malleus and TT or not during the operation. Retention group include the cases with the manubrium of malleus and TT retained, resection group include the cases with TT resected with the manubrium retained or resected. T test was used to analyze and compare the differences of air conduction threshold air-bone gap （ABG） and the postoperative improvement between the two groups. Results:One year after operation, the air conduction thresholds and ABG were lower in retention group （n= 44） than those in resection group （n= 53） at each frequency, and there were differences with statistically significant at 0.25, 0.5 and 1.0 kHz （P<0.05）; the postoperative improvement of hearing thresholds and ABG at above frequencies in retention group was better than that in resection group. In cases with canal-wall-up operations or partial ossicular prostheses implanted, the above differences still existed between the two groups with statistical significance （P<0.05）; while in cases with canal-wall-down operations or total ossicular prostheses implanted, there were no significant differences between the two groups （P>0.05）. Conclusion:The preservation of the manubrium of malleus and TT is significant for postoperative hearing improvement in tympanoplasty, especially in the canal-wall-up operation with partial ossicular prostheses.

The role of malleostapedotomy in intra-operative incus injury: A review of 2 cases.

Malleostapedotomy (MS) is an evolving otology procedure that involves attaching prosthesis to the malleus on one end and the stapes footplate on the other end. It has multiple indications and requires skills and experience. We present 2 cases operated in our center (King Abdullah Ear Specialist Center, Riyadh, Saudi Arabia) in which intraoperative incus injury occurred, and MS was used to reconstruct the ossicular chain with good postoperative outcomes and patient satisfaction. As the procedure was surgically difficult and time consuming, many otologists prefer not to do it. Nevertheless, we believe that all surgeons dealing with stapes surgery should be familiar and gain confidence in performing MS considering that intraoperative incus dislocation is a complication that can happen even with great caution.

Endaural Over-Underlay Cartilage Tympanoplasty for Repair of Dry Subtotal Perforations.

OBJECTIVES: We explored the auditory and anatomical success of grafting when the cartilage perichondrium (CP) was prepared using two different methods. METHODS: Patients with subtotal or total perforation underwent tympanoplasty with a CP graft. A V-shaped groove for the handle of the malleus was prepared for CP grafts in patients in group 1. Patients in group 2 did not have a groove on the graft. The anatomical success of the graft was evaluated as success, partial success, or failure. Results of auditory evaluations were compared between the two groups. RESULTS: A total of 195 patients were included in the study. The total CP graft integration rate was 96% for both groups. Significant changes were detected in all hearing criteria evaluated 12 months after surgery compared to the preoperative period (P < .05). There were no significant differences between the groups in terms of the relationship between graft technique and postoperative hearing results. However, rates of partial success were significantly higher for group 1 than group 2 (P = .033). CONCLUSION: Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation. Partial failures are rare, but when they occur, they most often involved anterior graft medialization. When a piece of cartilage is removed at the malleus interface there may be a higher rate of partial failure.

Fibrous dysplasia limited to an ossicle.

Fibrous dysplasia is an unusual pathologic condition caused by abnormal bone metabolism. Temporal bone involvement is often seen, but it is uncommon to find fibrous dysplasia limited to the middle ear, especially originating in and confined to a single ossicle. Here we report a case of osteofibrous dysplasia limited exclusively to an ossicle (malleus) causing gradual conductive hearing loss, which recovered after eventual complete removal of the dysplastic area. The lesion showed firm attachment to adjacent structures and initial removal was not possible. This report provides information to help other otologic surgeons facing similar conditions.

The effect of using a PORP to reconstruct the ossicular chain under otoendoscopy with and without a malleus handle.

BACKGROUND: There are many reports on the role of the malleus handle in ossicular chain reconstruction (OCR). However, the effect of the presence of the malleus handle is not clear. AIM/OBJECTIVES: To compare the hearing outcomes of using a partial ossicular replacement prosthesis (PORP) to reconstruct the ossicular chain under otoendoscopy with and without a malleus handle. METHODS: Records of 57 patients requiring OCR were retrospectively analyzed. They were divided into the malleus handle-present group (group 1) and the malleus handle-absent group (group 2). The audiometric results were analyzed pre- and postoperatively. A postoperative air-bone gap (ABG)≤20 dB was considered successful. RESULTS: The mean improvement in air conduction hearing thresholds was 19.80 dB in group 1 and 16.70 dB in group 2. The mean ABG improvement was 18.09 ± 12.79 dB for group 1 and 17.20 ± 16.44 dB for group 2. The malleus handle-present group achieved higher success (65.63%) than the malleus handle-absent group (52%; p> .05). CONCLUSIONS AND SIGNIFICANCE: Improvements in hearing outcomes were similar for the two groups. However, the malleus handle-present group showed a better reconstruction success rate. Our results suggest that if there is no lesion in the malleus handle, it is recommended to be retained.