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For bilateral cases surgical intervention is appropriate, with the principal aim being to improve hearing. Minor malformations associated with a normal or near-normal ear canal can be approached according to the principles of tympanoplastic surgery described in Chapter 15 (tympanoplasty). In major cases, the principles of surgery include creation of a new ear canal and exploration of the malformed middle ear and mastoid (along the lines described for mastoid surgery, Chapter 15) with a view to fashioning a new and working middle ear. Homograft tympanic membranes and ossicles from deceased donors offer the best chance of an effective reconstruction, but the surgery is fraught with risk. Inner ear damage and injury to the facial nerve, because of the distorted anatomy, are real possibilities. An appropriate age for surgery is 6-12 years. Further discussion of these highly-specialised surgical techniques is beyond the scope of this book.