Kartush added three more classes to Austin classifications for intact ossicular chain but with ossicular fixation:

• Group E for ossicular head fixation with intact ossicles.
• Group F for stapes fixation with presence of all ossicles.

Candidates for Ossiculoplasty:

1. The clinical presentation of patients who would benefit from ossiculoplasty is quite variable.
2. The goal of ossicular chain reconstruction is better-hearing, most typically for conversational speech.
3. The aim of ossiculoplasty is not only to close the air-bone gap but to improve the patient’s overall hearing (improve the air conduction score).
4. A patient’s perceived hearing improvement is best when the hearing level of the poorer-hearing ear is raised to a level close to that of the better-hearing ear.
5. Small improvements in hearing are more likely to be appreciated by patients with bilateral hearing loss.
6. In most cases, the worst ear is selected for surgery, but unless the surgery can restore symmetrical or nearly symmetrical hearing, or convert the operated ear into the better ear, the patient is unlikely to experience a reduction in disability.
7. The conductive hearing loss may be the result of ossicular erosion or fixation from chronic ear disease, blunt or penetrating trauma, or congenital or neoplastic causes.
8. It may also be associated with inner ear causes. These inner ear causes include superior semicircular canal dehiscence and an enlarged vestibular aqueduct. In these conditions ossiculoplasty is not useful.

Contraindications for Ossiculoplasty:

1. Active infection in the ear is the only true contraindication.
2. Relative contraindications include persistent middle ear mucosal disease, sensorineural hearing loss and repeated unsuccessful use of the same or similar prosthesis.

Prerequisites for Ossiculoplasty:

1. The presence of normal or minimally hypertrophied middle ear mucosa.
2. Patent eustachian tube orifice.
3. Mobile stapes footplate.

Materials used for Ossiculoplasty:

1. The materials used in ossiculoplasty can be autografts or homografts or of synthetic materials.
2. Autografts:a) It includes refashioned ossicles, cortical bone and cartilage.

   b) They have the advantage low extrusion rates.

   c) The most commonly used autograft material has been the incus body, which is often reshaped to fit between the manubrium of the malleus and the stapes capitulum.

   d) Autograft materials are not always available, or as in patients with cholesteatoma, an ossicle may have microscopic squamous epithelium infiltration that precludes such use.

   e) Autografts have several disadvantages it includes

   • • Lack of availability in chronically diseased ears.
     • Prolonged operative time to obtain and shape the material.
     • Resorption and/or loss of rigidity (especially with cartilage).
     • Possible fixation to the walls of the middle ear.
     • Osteitis may exist within the ossicles, and the risk of residual cholesteatoma may be increased in patients with cholesteatoma.
3. The Grafts processed from cadavers like cadaver ossicles, cadaver knee cartilage can be called as homografts.
4. Because of the disadvantages of autograft materials and the potential risk of infection from homograft implants, alloplastic materials are the most commonly used materials for ossicular reconstruction.