Comment “Techniques for Repairing Tegmen Defects When the Ossicles Protrude Above the Floor of the Middle Fossa”

We read with great interest the study by Kosarchuk et al. examining surgical strategies for tegmen defect repair in cases where the ossicles protrude above the middle fossa floor.[1] The pragmatic intent to preserve ossicular integrity without compromising defect closure is commendable, and the described “manhole cover” and “bony igloo” methods reflect thoughtful adaptations to a challenging anatomical context.

However, several aspects of the manuscript merit further scrutiny, particularly in relation to the audiological outcomes and their attribution. While none of the patients required intraoperative ossicular manipulation, two of the three experienced a measurable decline in hearing, including one with sensorineural hearing loss and the other with mixed hearing loss and radiographic pneumolabyrinth. The study's conclusion implies that avoiding ossicular chain disarticulation contributed to hearing preservation; however, the data suggest that ossicular preservation alone may not confer audiologic protection.[2] Without preoperative vestibular or cochlear imaging to exclude preexisting labyrinthine pathology and given the presence of superior semicircular canal dehiscence in multiple cases, the causative link between the surgical method and hearing loss remains speculative.[3] This limits the generalizability of the claimed benefit to hearing outcomes.

Furthermore, the authors did not clarify the intraoperative criteria for verifying ossicular mobility during the combined approach. While ossicular chain continuity was confirmed, the absence of quantifiable intraoperative auditory monitoring (e.g., electrocochleography or auditory brainstem response) raises the question of whether ossicular integrity is equated with functional preservation. This distinction is particularly relevant in case 3, where ossicular mobility was confirmed, yet the patient experienced postoperative hearing decline, suggesting a potential dissociation between mechanical continuity and auditory function.

Finally, although the authors reported a 67% incidence of postoperative cholesteatoma, the proposed relationship with eustachian tube dysfunction is presented as hypothesis-generating rather than evidence-based. This observation, although intriguing, should be interpreted with caution in the absence of a matched cohort or longer-term follow-up data.

In summary, the authors present a creative surgical solution for a rare anatomical challenge and contribute meaningfully to the discourse on tegmen repair. However, the reported audiologic outcomes highlight the need for further investigation into whether ossicular preservation alone ensures hearing stability and underscore the importance of integrating objective intraoperative auditory assessment into future protocols.

 

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Conflict of Interest

The Authors Declare That They Have No Conflict Of Interest.

Declaration of GenAI Use

Generative Artificial Intelligence tools, including Paperpal and ChatGPT-4o, were utilized solely for language refinement, grammar enhancement, and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented.

Data Availability Statement

Not applicable as no data were generated or analyzed in this study.

Contributors' Statement

P.S. contributed to conceptualization, methodology, drafting the original manuscript, and reviewing and editing. R.M. was involved in drafting the original manuscript as well as reviewing and editing. R.S. contributed to validation, supervision, project administration, drafting the original manuscript, and reviewing and editing.

• References

• 1 Kosarchuk J, Majid M, Ho S, Noonan K, Sillman J, Heilman C. Techniques for repairing tegmen defects when the ossicles protrude above the floor of the middle fossa. J Neurol Surg Rep 2025; 86 (03) e158-e163
• 2 O'Connell BP, Dedmon MM, Haynes DS. Hearing preservation cochlear implantation: a review of audiologic benefits, surgical success rates, and variables that impact success. Curr Otorhinolaryngol Rep 2017; 5 (04) 286-294
• 3 Tiano BN, Mecham JC, Kingsbury S, Bendok BR, Weisskopf PA, Deep NL. Surgical management of superior semicircular canal dehiscence syndrome. Contemp Neurosurg 2025; 47 (01) 1-7

Publication History

Received: 04 August 2025

Accepted: 11 August 2025

Article published online:
29 August 2025