Endoscopic Malleostapedotomy as a Primary Intervention in a 17-year-old

Malleostapedotomy (MS) is an advanced surgical approach that involves the attachment of a piston prosthesis to connect the malleus with the oval window, instead of the standard stapedotomy of which connects the long process of incus to the oval window. MS is used when the incus is not suitable for attachment. In our case, we operated MS on an 17-year-old female patient who presented with a 5-year history of bilateral progressive conductive hearing loss due to otosclerosis. A Carhart’s notch of up to 30 dB was noted on the right ear, with severe right-sided hearing loss and air-bone gap (ABG) of 48.75 dB. During her endoscopic stapes surgery, mobility test showed significant pan-ossicular fixation, necessitating removal of malleus head, incus, and stapes suprastructure. The stapedotomy was then sealed with a perichondrium graft. A 0.6 mm × 5 mm teflon piston prosthesis was placed between the malleus handle and the sealed oval window. At 2 month postoperative follow up, pure tone audiometry showed a mild right side conductive hearing loss and ABG of 25 dB. To date, the experience with MS is still evolving. As such, different surgical approaches and techniques utilizing variable prosthesis for a range of indications are being reported. Many otologists still prefer not to perform MS due to its surgical complexity, especially when using an endoscopic technique. We believe that every surgeon performing stapes surgery should be familiar with MS as an intraoperative option for cases involving incus pathology, fixation, or iatrogenic incudostapedial subluxation.