Congenital anomaly: Middle ear malformation.

This is the otoscopic view of the right ear of a patient with conductive hearing loss bilaterally. The tympanic membrane is intact, but it shows evidence of previous infection and healing of a perforation with a two-layered neo-membrane. A triangle-shaped part of the normal-appearing pars tensa extends from the umbo to the anterior annulus. The obvious abnormality is the short, thick, vertically placed manubrium of the malleus and the inferiorly placed chorda tympani nerve. The chorda tympani nerve is seen through the tympanic membrane crossing the tympanum at the widest diameter of the tympanic ring. A small mass of gold-colored cerumen overlies the exit of the chorda tympani nerve from the posterior canaliculus. The caliber of the nerve is larger than normal. Treatment is tympanoplasty with ossicular reconstruction.

From Gap, France (Dr. Deguine), and the Pulee Ear Clinic, Los Angeles (Dr. Pulec).