A negative middle ear exploration for otosclerosis is disappointing for the patient and surgeon alike. Perhaps worse is finding a pathology that the team is not prepared to manage or for which surgery is contraindicated. Accordingly, this panel presentation will equip clinicians to successfully distinguish and manage the range of “can’t miss” diagnoses that mimic otosclerosis. Experienced panelists will present clinical cases united by a chief complaint of conductive hearing loss. Cases will include acquired and congenital pathologies (e.g., ossicular fixation, discontinuities, x-linked stapes gusher), occult chronic otitis media, third window lesions (e.g., canal dehiscence and enlarged vestibular aqueduct), and pseudo-conductive hearing loss. Panelists will discuss, debate, and illustrate key elements of the history, physical exam, and audiometric test battery that point to specific diagnostic possibilities. They will detail their approaches to imaging acquisition and interpretation and will discuss a systematic approach to middle ear exploration when the diagnosis remains ambiguous. Evidence-based surgical and non-surgical management strategies for conductive hearing loss will be presented for each case, along with expected outcomes and potential complications.