Tympanosclerosis is a scarring process with a remarkable variability in its localization within the middle ear. It can lead to conductive hearing loss in many cases. It is usually caused by recurrent chronic inflammation of the middle ear. It is generally accepted that functionally relevant tympanosclerotic findings of the middle ear structures should be treated by surgery. Depending on the extent of the surgical resection, the tympanic membrane and the ossicular chain must be reconstructed individually. In cases of isolated myringosclerosis with no hearing loss, no surgery is required. When the ossicular chain is affected by the sclerosis, sound conduction can often be restored only by interposition of grafts. Stapes footplate fixation can be treated by a stapesplasty. Tympanosclerosis of the oval window combined with other chronic inflammation usually requires two-stage surgery. Tympanosclerotic findings without any clinical symptoms should not be removed. The fitting of conventional or implantable hearing aids is the only treatment if chain reconstruction fails or is impossible.