HOUSE SYNDROME (FIXED MALLEUS HEAD): A DIAGNOSTIC PITFALL TO CONSIDER BEFORE STAPES SURGERY

Background: Conductive or mixed hearing loss with a normal tympanic membrane is most often attributed to otosclerosis. However, primary malleus fixation also known as House or Goodhill syndrome is a rare differential diagnosis that can mimic stapes fixation and fundamentally alters surgical management [1 4].

Case presentation: A 67-year-old man presented with long-standing, bilateral hypoacusis, more pronounced on the right side. Otoscopy was normal. Audiometry showed bilateral mixed hearing loss with a mean air bone gap (ABG) of about 30 dB, without a Carhart notch. The initial high-resolution temporal bone CT (HRCT) appeared normal. Endoscopic middle-ear exploration was undertaken for presumed otosclerosis. Intraoperatively, the handle of the malleus was immobile, and stapes palpation did not show the typical fixity of otosclerosis. The procedure was halted for diagnostic reassessment. Re-evaluation of the HRCT revealed ossification of the malleus suspensory ligament, confirming House syndrome [2,5]. A revision transcanal endoscopic ossiculoplasty was then performed, including uncudo-stapedial disarticulation, section of the incus long process, and insertion of a partial ossicular replacement prosthesis (PORP) between the malleus and stapes head. Postoperative recovery was uneventful, with partial ABG closure and significant functional improvement.