The bulk of this chapter discusses the adult patient wanting management of an acquired conductive or mixed hearing loss. Often this patient will come directly from an audiologist, or via the patient’s GP who has received a report from an audiologist. The final section of this chapter includes a discussion on the medical treatment of otospongiosis, including the rare patient with otospongiosis with a pure sensorineural hearing loss. It is assumed the patient has already been assessed by the surgeon and has had a complete audiological assessment. It is also assumed the patient is presenting primarily with hearing loss. This chapter describes a systematic approach to patients based around four questions which are what is the cause of the conductive hearing loss, is this patient a suitable candidate for surgery, what types of reconstruction are available and how should special situations be managed.