Visualization of a transtympanic ossicular prosthesis.

A 53-year-old woman presented to us with disequilibrium and oscillopsia. Her history was significant for bilateral stapedectomies performed by other otolaryngologists. Her most recent operation had been a revision right stapedectomy 1 year prior to her first visit to our office. Since that time, she had experienced a persistent sensation of being off-balance, and she complained of objects "bouncing" around her while she walked. She had undergone vestibular testing, which suggested a right-sided weakness. She had tried vestibular rehabilitation without success. She denied rotary vertigo, but her disequilibrium prevented her from doing her job as a warehouse supervisor. She denied any recent hearing change. Her medical history was otherwise significant for migraine.

Otoscopic evaluation revealed a retracted right tympanic membrane and a prosthesis visible through the eardrum. The left tympanic membrane appeared to be normal. Hennebert's test was positive in the right ear. Audiography revealed a mild-to-severe mixed hearing loss, but excellent speech discrimination bilaterally. Electronystagmography (ENG) demonstrated a 65% caloric weakness on the right; findings on optokinetic testing were also abnormal. ENG was negative for fistuale, but the results were interpreted with caution because of the caloric weakness. Findings on auditory brainstem response testing and radiologic evaluations were negative.

The patient was taken to the operating room for an exploratory tympanotomy, which showed that a Teflon loop attached to the prosthesis encircled the malleus (figure). The distal end of the loop protruded into the vestibule. A perilymph fistula was identified. This was repaired with a promontory mucosal flap, and ossicular chain continuity was restored with a Sheehy incus replacement prosthesis. The patient tolerated the procedure well, and her hearing and disequilibrium improved.

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