Aim: To examine if a Gelfoam V R plug in combination with surgical removal of the perforation edges could be an alternative to the widely accepted fat plug treatment for smaller ear drum perforations.Materials and Methods: A prospective study of 17 consecutive patients with persistent small ear drum perforations considered for myringoplasty. The perforations were central perforations 2 to 4 mm in diameter. Patient ages ranged from 6 to 83 years, and the operation was performed under general anesthesia with mask ventilation in children and under topical local anesthesia in adults. A Gelfoam V R plug was inserted into the perforation after surgical removal of the perforation edges. The follow-up time was more than 3 months.Results: The closure rate of the ear drum was 83% (15/18). Pure tone average (PTA) was 19 dB preoperatively and 16 dB postoperatively.Conclusions: We show for the first time in humans that a Gelfoam V R plug in combination with surgical removal of the perforation edges seems to result in about the same closure rate as the fat plug technique in persistent small ear drum perforations. Moreover, the method using Gelfoam V R is simpler and faster than the fat plug technique. We suggest that randomized studies comparing the Gelfoam V R plug technique with the fat plug technique should be performed.

We report the investigation of the cause of isolated malleus fractures based on four recent patients at our clinic and five patients reported to us by Swedish otosurgeons. In recent years we have treated four patients with isolated malleus fractures. Colleagues in the Swedish Society of Otosurgeons were encouraged to send us reports on patients with diagnosed isolated malleus fractures, resulting in five more cases. A literature review focusing on the cause and management of this injury was also conducted. Eight of nine patients in the Swedish material had the same history. The patients had inserted a finger into the external auditory canal (most often after a bath) and then pulled it out. Immediately afterwards they experienced a short pain and a hearing loss. An audiogram revealed a conductive hearing loss. After exploration of the middle ear, the most common operation performed was ossiculoplasty. In the present material the most common cause of isolated malleus fractures was a sudden negative pressure in the external auditory canal created by a quick outward movement of a finger in the external ear canal. Since this fracture appears to be infrequent, it can easily be missed at otomicroscopic examination. Tympanometry and pneumatic otomicroscopy are helpful diagnostic tools.

The best sound transmission might be achieved by placing a PORP in contact with both the tympanic membrane and the handle of the malleus.

All three surgical methods gave good results, but when the distal end of the fractured malleus can be attached close to the proximal end, the technique using only cement tends to be the best option. If the parts are too far apart, a malleus prosthesis or a PORP would be good options.