Finally, an ossiculoplasty may be performed in the newly cleaned space; the techniques for this are discussed elsewhere in the literature. The malleus is lateralized by visualizing it endoscopically or microscopically, or feeling for it with the incudostapedial joint knife; then the tensor tympani tendon is severed. When the stapes is stabilized, the handle of the malleus can be lateralized 1 or 2 mm to allow for a larger middle ear space, but lateralization must be carefully balanced with pressure on the stapedial joint to avoid subluxation of the incudostapedial or the incudomalleal joint. Then silicone sheeting (Silastic 0.005 to 0.13 mm thick) is custom cut to cover the mucosa of the promontory and the opening of the eustachian tube, taking care to keep it outside the eustachian tube and not touching the stapedial crura. The ossicles are assessed for the need for partial or total reconstruction. It is preferable to insert any prosthesis for partial ossiculoplasty under the handle of the malleus for better connection and reduced risk of extrusion. The prosthesis would then be surrounded by Gelfoam soaked in a combined solution of sulfa, steroids, and antibiotics.
Myringotomy is performed in the anteroinferior tympanic remnant or any remnant available. A small (type 1) Paparella ventilation tube with internal diameter of 1.1 mm is inserted, avoiding insertion through fascial grafts of temporalis muscle, if possible. However, it may not be possible to avoid it with a severely dysfunctional eustachian tube and ossiculoplasty, and putting the tube in the graft may then be necessary to prevent postoperative effusion, retraction, or rejection of the implant. In most patients who receive tubes in the fascial graft, it may be in position permanently.
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