An assessment is made of the oval window region; any dehiscence over the seventh nerve is noted and stapes fixation is checked. Subtle fixation may be detected by palpating the footplate while observing the annular ligament for change in color or width. The footplate is also examined for the most appro
priate site for perforation. The ideal site is a thin, blue area in the center. A thick white or an obliterated footplate may require drilling or other efforts.
Occasionally, a case with no apparent fixation will be encountered. When this happens, it is incumbent upon the surgeon to determine if there are any other causes of a conductive hearing loss. Malleus and incus fixation, or the presence of a serous otitis, are three obvious conditions to exclude.
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