In the first instance, you need to know the cause of the conductive deafness.  Impedance testing will be able to pinpoint the site of lesion.

Thank you for your response. Actually you are right because there is 50 dB hearing loss and impedance audiometry is useful in checking the state of the ossicles.

Rt. Ear

       The ext. aud. canal is tortuous for bulging of its posterior wall. It needs correction to get natural expulsion of wax.

      C.T should precisely view mastoid cell structure, ossicular chain and their alignment and tympanum – epi. Meso. and hypo. Then only middle ear surgery may be planed.          

Dear Sudhakar Pattanaik,

Thank you for your valuable response.

Best regards

Raid

Are you looking for surgical suggestions or rehabilitative suggestions? If rehabilitative, I can share your question with a national US audiology site? 

"impedance audiometry is useful in checking the state of the ossicles."

    and also for...

     If his main initial complaint was just deafness, I would suspect that the hearing or middle ear pressure in the left ear was not 100% normal.

Dear Kym Meyer,

   Thank you for your reply and I appreciate your help. I need the best way to treat such a patient whether  surgical or rehabilitative ways or both.

Best regards

Raid

Dear Anthony G Gordon

Thank you for your response. The patient is healthy and wealthy before 2 years. There is no history of previous ear discharge, also there is no previous ear trauma or surgery. The main complaint of the patient is right sided deafness and inability in localization of the side  of the sound.

Best regards

Raid

Interesting case. Doing nothing is an option but denies the patient of any possible relief even if is for a limited period. A hearing aid for unilateral deafness is unlikely to be acceptable to a 17 year old. Surgery to enlarge the canal should be feasible, a post aural incision and partial division of the meatus should make life easier. If the soft tissue of the meatus was left intact the healing would more certain. If a spiral CT scan is available the exact extent of the pathology would more clear. Good luck.

Dear Ranjit Kumar Mal,

Thank you so much for your valuable participation.

Best regards

Raid

If you feel that wax impaction is going to be an ongoing concern, I would think a behind the ear hearing aid would be a good option.  If not, a completely in the ear hearing aid would offer a good rehabilitation option as well as being cosmetically.  A unilateral hearing loss has been shown to have a significant impact on education and interactions.  That hearing aids are not acceptable to 17 year old boys is very old school thinking and can be due to the bias of that way of thinking.  Modern communication devices are often seen in people's ears and we are finding very good acceptance.  Hearing aids are microprocessors that can be used as handsfree telephone devices and to stream music and podcasts. Very relevant to today's 17 year old.

Dear Lisa Seerup,

Thank you so much for your valuable rehabilitative option of this patient. I appreciate your cooperation.

Best regards

Raid  

"A unilateral hearing loss has been shown to have a significant impact on education and interactions."

   I think the brain compensates well for a stable unilateral loss, even if a total loss.  Slight losses, especially if fluctuating and present in infancy, do I think have serious long-term effects on language development.   Whenever I saw someone in the ENT with a unilateral loss, I always carefully quizzed them about any problems this had caused.  Many denied any problems with hearing or education, and those that did had slight defects of the opposite supposedly normal ear which I thought were by far the crucial factor.  For that reason I find the published data on effects of unilateral deafness quite uninterpretable since minor defects in the normal ear have not been taken into account.

Thank you Anthony G Gordon for your valuable explanation. 

Surgical treatment of fibrous dysplasia of the temporal bone (TBFD) revealed relatively good outcomes. Also, active surgical intervention is necessary to prevent the formation of secondary cholesteatoma or other complications. In particular, FD involving the inner ear may require greater caution when deciding on the resection area and timing of surgery. Surgery, particularly in such a challenging region as the skull base, should be reserved for patients with functional impairment or a cosmetic deformity. Because of the benign nature of the condition, the surgery itself should be relatively conservative, with the primary goal being preservation of existing function.

"the surgery itself should be relatively conservative, with the primary goal being preservation of existing function."

  The cause of the conductive deafness is probably quite straightforward and therefore surgically fixable, ending up with improved function.

I agree professor and surgery may have some hazards as facial paresis and or palsy.

Dear Liza, Please don`t tell us you are a saint and have no bias. Your thinking is through  your own bias, we are all biased.How many 17 year old with unilateral hearing loss with meatal stenosis is wearing an in the ear or a post aural hearing aid under your care now?

"unilateral hearing loss with meatal stenosis"

   I doubt that the hearing loss in anything to do with the meatal stenosis or with the wax.   Hearing is only impaired if the blockage is complete.  A residual pinhole passage can easily be found by tympanometry.

A solution had been given earlier. please have a good  CT (or magnetic) scan identifying  the status of ossicles, tympanum (epi, meso and hypo) and tympanic membrane. The ground glass appearance may be cholesteotoma mass or infected granulation tissue. An efficient and clear scanning is most required. That will clearly indicate the approach for an effective management.         

"An efficient and clear scanning is most required."

    ...but impedance testing is a much cheaper and more convenient way to determine the cause of the conductive deafness.

A soft band bone conduction hearing aid on the affected side would improve hearing ability. If there are no other surgical  options, a bone anchored hearing ( Cochlear Corp- BAHA Attract) would be the best option with no abutment through the skin.

Options

1. nil

2. Transcanal bore-out, preserving skin if possible, fine split skin if not

3. Bonebridge (I find the Contour Attract a bit clunky)

"Transcanal bore-out"

   Is this intended to improve the hearing?   If so, by what mechanism?

Option 1 - nil - if the middle ear is obliterated, often not the case in fibrous dyplsasia.If clear (I can't see the middle ear well on the image above) the chain may be normal.

Opton 2. The drum and chain may be intact but the EAC skin unsalvageable. Removing a ca. 1 cm cylinder of soft tissue and bone down to the drum, then grafting, restores hearing. A fine axillary graft is best, totally covering bare bone, cipro ointment. Pack 3/52, clean by suction only at 5/52.Needs cleaning each 6-12/12.

Option 3 Bonebridge if the middle ,ext ear hopeless

The main problem here is the wax impaction. Conductive hearing loss is best addressed by a bone anchored hearing solution if there is a communication problem. Some sort of canalplasty may be required with the possibility of free STSG if there is a shortage of skin. Otherwise no action is required. Rarely progressive compression of the facial nerve or narrowing of IAM could require decompressive surgery but this is uncommon in non syndromic patients

Thank you dear colleagues for your valuable advices  to handle such a rare and problematic case.

Kind regards Raid

We still do not know why the patient was deaf.   Incidentally, any deafness from wax is usually sudden, as when a drop of water seals off the only pinhole passage through the wax.

Stenosed canal is the main cause of his deafness which prevents the normal clearance of the wax.

My present research on PIL (pauciballary indeterminate leprosy indicates that F.D. may be one manifestation. Pl. get a detail investigation & needful before progress of deafness. Thanks.

"Stenosed canal is the main cause of his deafness which prevents the normal clearance of the wax."

I do not see how this has been diagnosed given the difficulty in visualization. The cause of deafness can only be diagnosed by acoustic impedance testing. I do not expect this to show a small rigid cavity.