Systematic preservation of the ossicular chain in cholesteatoma surgery using a fiber-guided laser. 
1.  To investigate whether systematic preservation of the intact ossicular chain in cholesteatoma surgery provides better hearing than dismantling the chain and reconstructing it.  2.  To determine whether systematic preservation of the ossicular chain in cholesteatoma surgery can be performed safely.  Longitudinal parallel group study.  District general hospital and private hospital.  Adults and children who underwent primary intact canal wall cholesteatoma surgery.  Group A: Laser-assisted cholesteatoma surgery resulting in an intact ossicular chain.  Group B: Laser-assisted cholesteatoma surgery resulting in a disrupted chain and an ossiculoplasty onto an intact stapes superstructure.  1a.  Conductive hearing loss (four frequency air-bone gap).  1b.  Patient-orientated outcome (Belfast Rules of Thumb).  2a.  Change in bone conduction threshold (four frequencies).  2b.  Residual cholesteatoma rate.  2c.  Rate of facial palsy.  There were eighty ears in Group A and sixty-nine in group B.The median hearing loss for Group A is 11.44 dB HL.The median hearing loss for Group B is 15.63 dB HL. ( p = 0.001).  Seventy out of eighty ears in Group A and forty-six out of sixty-nine ears in Group B fulfilled the Belfast Rule of Thumb. ( p = 0.002).  The null hypothesis is rejected for both of the hearing outcome measures. The two groups did not significantly differ in respect of any of the risk assessment measures.  The fibre-guided laser allows the cholesteatoma surgeon to preserve the ossicular chain in a systematic manner which is both safe and of benefit to the patient.