In Response to How I Do It: A Stepwise Surgical Technique for Fisch Class B Glomus Tympanicum

We thank Prof. Piazza for his thoughtful comments on our article “How I Do It: A Stepwise Surgical Technique for Fisch Class B Glomus Tympanicum” 1. His letter raises several pertinent points that we are pleased to address. Regarding postoperative air-bone gaps following the remove-and-replace maneuver of the malleus (Point 1), we do not have comparative data between malleus-repositioned and malleus-preserved cases, and to our knowledge, no published series has specifically addressed this comparison. Available series consistently report favorable hearing outcomes after tympanic paraganglioma surgery when ossicular reconstruction is performed, and in our experience, the air-bone gap is closed in the vast majority of cases 2. We believe that temporary mobilization of the malleus does not inherently compromise the outcome, but acknowledge that dedicated comparative studies would be needed to confirm this. On the subject of canal stenosis and blunting (Point 2), the risk of cicatricial complications is expected to be lower in paragangliomas, where the tympanic membrane and middle ear mucosa are relatively healthy, compared to extensive cholesteatoma with inflammatory tissue. Furthermore, as classically demonstrated by Farrior, canaloplasty converting the acute anterior tympanomeatal angle into a more obtuse configuration is in itself protective against blunting, as it reduces the risk of fibrosis and stenosis at this critical location 3. We routinely apply this principle in our workflow. We agree that adequate hemostasis is mandatory (Point 3). Surgicel is a useful adjunct, and we would add that it can be placed around a ball of bone wax (Horsley wax) for more effective mechanical tamponade, particularly when bleeding originates from the jugular bulb. We also thank Prof. Piazza for highlighting ossicular chain reconstruction alternatives (Point 4), which may be considered when autologous ossicles are unavailable. Regarding tumors eroding the carotid canal (Point 5), we agree that dissection around the carotid artery should be the final surgical step. Such cases represent a more advanced subset of Fisch class B disease in which management differs substantially from our standardized workflow, which focuses on lesions without major vascular involvement. Wider exposure and vascular control are required, potentially involving subtotal petrosectomy, as described by Sanna et al. 2. In conclusion, we are grateful to Prof. Piazza for enriching the discussion. His complementary observations are valuable additions, and we believe this exchange will benefit the readership of The Laryngoscope. The authors have nothing to report. The authors declare no conflicts of interest.