The malleus is the largest of the three middle ear ossicles, resembling a hammer (Latin: malleus). Its handle (manubrium) is embedded in the fibrous layer of the tympanic membrane, and its head articulates with the incus at the incudomalleolar joint. The lateral process and anterior process attach to the tympanic annulus. The malleus transmits vibrations from the tympanic membrane to the incus and then the stapes, amplifying sound by mechanical advantage.
The lateral process and handle of the malleus are visible otoscopically through the tympanic membrane as the cone of light reflex landmark. Otosclerosis initially fixes the stapes footplate but can secondarily fix the malleus. Tympanoplasty and ossiculoplasty procedures reconstruct the ossicular chain when the malleus, incus, or stapes are disrupted by trauma, cholesteatoma, or chronic otitis media. The malleus handle is used as the attachment point for type I tympanoplasty grafts.
Temporal bone fracture, barotrauma, or blast injury can disrupt the malleus-incus or incudomalleolar joint, producing conductive hearing loss of up to 60 dB that requires ossiculoplasty to restore the mechanical sound transmission chain.
Cholesteatoma eroding the ossicular chain characteristically begins with the incus long process but can involve the malleus head and neck, requiring careful surgical removal with ossicular chain reconstruction using prostheses.
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