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Mair PM, Mayr T, Sprinzl G, Magele A. [An unusual case: fracture of the handle of the malleus due to finger manipulation]. HNO 2024; 72:668-672. [PMID: 39037485 PMCID: PMC11339147 DOI: 10.1007/s00106-024-01503-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 07/23/2024]
Abstract
An isolated fracture of the handle of the malleus is a rare entity in otorhinolaryngology and manifests clinically as acute-onset unilateral hearing loss. Several factors may cause this injury, including acute barotraumatic pressure changes or traumatic events. Various therapeutic approaches such as tympanoplasty, autologous graft, or application of bone cement are discussed. We report the case of a 46-year-old female patient who developed acute hearing loss in her left ear after finger manipulation. Clinical evaluation revealed axial displacement of the handle of the malleus and audiometry indicated conductive hearing loss. After otoscopy, audiometry, and computed tomography, tympanoscopy was indicated due to suspicion of ossicular chain disruption. Intraoperatively, an isolated fracture of the handle of malleus was found, which was treated with glass ionomer cement. Following postoperative examination, there was progressive improvement in the acoustic transmission component, such that a normal hearing threshold was observed 4 months postoperatively. This case report underlines the importance of precise diagnosis and individualized treatment for rare middle ear injuries.
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Affiliation(s)
- Peter M Mair
- Klinische Abteilung für Hals‑, Nasen‑, Ohrenkrankheiten, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich.
- Karl-Landsteiner-Privatuniversität für Gesundheitswissenschaften, Krems, Österreich, Dr. Karl-Dorrek-Straße 30, 3500.
| | - Thomas Mayr
- Klinische Abteilung für Hals‑, Nasen‑, Ohrenkrankheiten, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
- Karl-Landsteiner-Privatuniversität für Gesundheitswissenschaften, Krems, Österreich, Dr. Karl-Dorrek-Straße 30, 3500
| | - Georg Sprinzl
- Klinische Abteilung für Hals‑, Nasen‑, Ohrenkrankheiten, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
- Karl-Landsteiner-Privatuniversität für Gesundheitswissenschaften, Krems, Österreich, Dr. Karl-Dorrek-Straße 30, 3500
| | - Astrid Magele
- Klinische Abteilung für Hals‑, Nasen‑, Ohrenkrankheiten, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Österreich
- Karl-Landsteiner-Privatuniversität für Gesundheitswissenschaften, Krems, Österreich, Dr. Karl-Dorrek-Straße 30, 3500
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2
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Hansen JO, Foghsgaard S. Bone cement repair of malleus handle fractures: Intraoperative video and case report of two patients. Am J Otolaryngol 2024; 45:104256. [PMID: 38492552 DOI: 10.1016/j.amjoto.2024.104256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/18/2024]
Abstract
Isolated malleus fractures are a rare occurrence with few reported cases in the literature. Symptoms include sudden otalgia, hearing loss, tinnitus and aural fullness. Work-up and diagnosis are based on a combination of thorough anamnesis and careful otoscopic evaluation or high-resolution computer tomography. We present two cases of isolated malleus handle fractures who were diagnosed based on a combination of pneumatic otoscopy and tympanometry. Both fractures were surgically repaired using hydroxyapatite bone cement as showcased in the supplemental video material. Post-operative audiometry showed improvement in the pure-tone-average of both patients as well as normalisation of tympanometry. Isolated malleus fracture should be suspected in cases of sudden hearing loss and tinnitus following digital manipulation of the outer ear canal together with a conductive hearing loss with a mostly high-frequent air-bone-gap and hypercompliant tympanometry with hypermobility of the tympanic membrane on pneumatic insufflation. Surgical repair of the fracture using bone cement has good hearing outcomes and leads to improvement in auditory symptoms.
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Affiliation(s)
- Jonathan Olsgård Hansen
- Charlottenlund Private Hospital, Jægersborg Allé 4, DK-2920 Charlottenlund, Denmark; Hearing and Balance Centre, Department of Otorhinolaryngology Head & Neck Surgery and Audiology, Rigshospitalet, Inge Lehmanns Vej 8, DK-2100 Copenhagen Ø, Denmark.
| | - Søren Foghsgaard
- Charlottenlund Private Hospital, Jægersborg Allé 4, DK-2920 Charlottenlund, Denmark; Hearing and Balance Centre, Department of Otorhinolaryngology Head & Neck Surgery and Audiology, Rigshospitalet, Inge Lehmanns Vej 8, DK-2100 Copenhagen Ø, Denmark
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3
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Lovin BD, Page JC, Appelbaum EN, Gorelik D, Lin KF, Vrabec JT. Isolated Fracture of the Malleus: An Overlooked Cause of Conductive Hearing Loss? Laryngoscope 2024; 134:1032-1041. [PMID: 37584374 DOI: 10.1002/lary.30962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE To report the largest case series of isolated malleus fractures with systematic review to characterize the disease's presentation and natural history, and provide suggestions for management. DATA SOURCES PubMed, Embase, Cochrane Library. REVIEW METHODS Retrospective cohort study was performed on 12 patients with isolated malleus fractures. History, physical exam, pre- and post-treatment audiograms, and imaging were obtained. Systematic review of the literature was performed. RESULTS Including the cases herein, 58 isolated malleus fractures were identified, the majority of which were published in the 21st century. Mean time to presentation after injury was 34.4 months. Most common etiology was external auditory canal (EAC) manipulation. Physical exam and imaging did not identify any abnormality at presentation in 16% and 21% of cases, respectively. The majority of fractures involved the manubrium. Air-bone gap (ABG) at initial presentation ranged from 16 to 26 dB, and was greater at higher frequencies. Thirty-six cases underwent surgery. ABG improvement was greater at all frequencies for those who underwent surgery. Final ABG was significantly less than initial ABG at nearly every frequency for those who underwent surgery (p < 0.05), while not at any frequency for those who were observed. CONCLUSIONS Isolated malleus fractures may occur more often than historical data suggests, and are perhaps underdiagnosed. Abrupt removal of a finger from the EAC with pain and hearing loss is nearly pathognomonic. Conductive hearing loss with ABG greater at higher frequencies is most often observed. Observation is unlikely to produce spontaneous improvements in hearing, while surgery demonstrates reliable decreases in ABG. Laryngoscope, 134:1032-1041, 2024.
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Affiliation(s)
- Benjamin D Lovin
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Cody Page
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Kenny F Lin
- Houston Methodist ENT Specialists, Houston, Texas, USA
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Abstract
BACKGROUND AND HYPOTHESIS Isolated malleus shaft fractures are rare cases. A commonly reported cause is a finger pulled out from a wet outer ear canal after a shower or bath. The objective was to investigate experimentally the mechanism and forces needed to establish an isolated malleus shaft fracture. METHODS Ten fresh-frozen human temporal bones were adapted to allow visual inspection of the structures involved while negative pressure trauma was applied. Thirty malleus bones were broken and the required forces were measured. Measurements from 60 adult test subjects were used to create mathematical and physical models to calculate and measure the forces necessary for generating trauma. To calculate the maximum muscle force developed by the tensor tympani muscle, the muscle area and fiber type composition were determined. RESULTS The temporal bone experiments showed that applied negative pressure in a wet ear canal could not fracture the malleus shaft with only passive counterforce from supporting structures, although the forces exceeded what was required for a malleus shaft fracture. When adding calculated counteracting forces from the tensor tympani muscles, which consisted of 87% type II fibers, we estimate that a sufficient force is generated to cause a malleus fracture. CONCLUSION The combination of a negative pressure created by a finger pulling outward in a wet ear canal and a simultaneous counteracting reflexive force by the tensor tympani muscle were found to be sufficient to cause an isolated malleus fracture with an intact tympanic membrane.
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Affiliation(s)
- Anton Rönnblom
- Department of Clinical Science, Otorhinolaryngology/Sunderby Research Unit
| | - Anders Niklasson
- Department of Clinical Science, Otorhinolaryngology/Sunderby Research Unit
| | - Mimmi Werner
- Department of Clinical Science, Otorhinolaryngology
| | - Per Stål
- Department of Integrative Medical Biology, Laboratory of Muscle Biology, Umeå University, Umeå, Sweden
| | - Krister Tano
- Department of Clinical Science, Otorhinolaryngology/Sunderby Research Unit
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Garov EV, Zelenkova VN, Garova EE, Tomilov FA. [Isolated malleus handle fracture: cases report and literature review]. Vestn Otorinolaringol 2021; 86:87-91. [PMID: 34964336 DOI: 10.17116/otorino20218606187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The isolated malleus handle and neck fractures are rare pathology which demands detailed diagnosis and individual treatment plan in every case. Sometimes it could heal without surgery, but in most part of cases surgical treatment is indicated. The short literature review and 2 clinical cases of this pathology are presented in this article. We describe our own variants of surgery repair with autologous cartilage with good results.
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Affiliation(s)
- E V Garov
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - V N Zelenkova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - E E Garova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - F A Tomilov
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
Isolated malleus fractures are an infrequent cause of hearing loss. Even more unusual is a fracture secondary to a sneeze. Here, we review the case of a 32-year-old man with the first surgically confirmed malleus fracture due to a suppressed sneeze, which was then successfully repaired with hydroxyapatite bone cement. We discuss the presentation, diagnosis, and management of this patient and review the literature on isolated malleus injuries.
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Affiliation(s)
- Nina W Zhao
- Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, USA
| | - Philip Perez
- Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, USA
| | - Jeffrey D Sharon
- Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, USA
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Gilberto N, Santos R, Sousa P, O'Neill A, Escada P, Pais D. Pars tensa and tympanicomalleal joint: proposal for a new anatomic classification. Eur Arch Otorhinolaryngol 2019; 276:2141-2148. [PMID: 31004197 DOI: 10.1007/s00405-019-05434-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/15/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The tympanic membrane (TM) belongs to the ear. Despite its place in the ear anatomy, can we give it also a different anatomic classification? The main objective is to clarify the nature of TM, tympanic bone and malleus to propose a new anatomic classification. METHODS This cadaveric study was performed in two human heads and six fresh temporal bones. A study of the temporomandibular joint, external acoustic meatus (EAM), TM and middle ear structures was conducted. A medical literature review englobing anatomy, embryology, histology and phylogeny of the ear was performed and the results were compared with the results of the dissection. RESULTS The external ear is constituted by the auricle and the EAM. This last segment is made by a cartilaginous and an osseous portion. The osseous portion of the EAM is constituted mainly by tympanic bone. The external ear is separated from the middle ear by the TM. Inside the middle ear, there are three ossicles: malleus, incus and stapes, which allow the conduction of sound to the cochlea. Based on the anatomic dissection and medical literature review of the tympanic bone, malleus and TM, we propose that these structures are interconnected like a joint, and named it "Tympanicomalleal joint". CONCLUSIONS It seems that the TM can be part of a joint that evolved to improve sound transmission and middle ear protection. Thinking TM has part of a joint may help in the development of more efficient reconstructive surgical techniques.
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Affiliation(s)
- Nelson Gilberto
- Department of Otorhinolaryngology, Centro Hospitalar de Lisboa Ocidental EPE, Nova Medical School, Egas Moniz Hospital, New University of Lisbon, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal.
- Department of Anatomy, Nova Medical School, New University of Lisbon, Lisbon, Portugal.
- Emergency Department, Hospital das Forças Armadas, Lisbon, Portugal.
| | - Ricardo Santos
- Department of Otorhinolaryngology, Centro Hospitalar de Lisboa Ocidental EPE, Nova Medical School, Egas Moniz Hospital, New University of Lisbon, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal
| | - Pedro Sousa
- Department of Otorhinolaryngology, Centro Hospitalar de Lisboa Ocidental EPE, Nova Medical School, Egas Moniz Hospital, New University of Lisbon, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal
| | - Assunção O'Neill
- Department of Otorhinolaryngology, Centro Hospitalar de Lisboa Ocidental EPE, Nova Medical School, Egas Moniz Hospital, New University of Lisbon, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal
- Department of Anatomy, Nova Medical School, New University of Lisbon, Lisbon, Portugal
| | - Pedro Escada
- Department of Otorhinolaryngology, Centro Hospitalar de Lisboa Ocidental EPE, Nova Medical School, Egas Moniz Hospital, New University of Lisbon, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal
| | - Diogo Pais
- Department of Anatomy, Nova Medical School, New University of Lisbon, Lisbon, Portugal
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Abstract
INTRODUCTION Handle of malleus fracture is a rare condition with <100 cases having been reported. The clinical presentation is conductive hearing loss following a history of trauma, typically, during manipulation of the external auditory canal. The diagnosis of the condition is clinical and radiological. The options for treatment are either a hearing aid or ossiculoplasty. We describe an isolated case of malleus handle fracture after trauma associated with manipulation of the external auditory canal. CASE REPORT A 56-year-old female, reported a right ear trauma. She suffered immediate otalgia, hearing loss and nonpulsatile tinnitus. An indistinct umbo was identified on endoscopic inspection and a hypermobile right tympanic membrane during Valsalva. Clinical testing of hearing revealed a mild-to-moderate conductive hearing loss. Computed Tomography scan revealed a fracture of the right malleus handle. A decision for surgical treatment was made based on continuing symptomatology as well as audiology and CT findings. A tragal composite cartilage graft was harvested and placed over the remaining superior part of the malleus and under the inferior fragment of the malleus attached to the tympanic membrane. The patient had immediate improvement of fluctuating hearing loss and tinnitus in the postoperative period. CONCLUSION A fracture of the malleus handle should be included in the etiologies of conductive hearing loss after trauma. A careful history, thorough otology examination, and a meticulous analysis of the CT will usually confirm this rare condition and exclude other ossicular abnormalities.
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Fracture of the Incus Caused by Digital Manipulation of the Ear Canal and its Diagnosis Using Wideband Acoustic Immittance. Otol Neurotol 2019; 40:e115-e118. [DOI: 10.1097/mao.0000000000002103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Sepulveda I, Ulloa JP, Santamaría A, Rivas-Rodriguez F. Bilateral Fracture of the Handle Malleus: A Case Report and Review of the Literature. J Clin Imaging Sci 2018; 8:49. [PMID: 30546933 PMCID: PMC6251240 DOI: 10.4103/jcis.jcis_44_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/10/2018] [Indexed: 11/04/2022] Open
Abstract
Malleus fracture is a rare condition. Usually, the handle of the malleus is involved, and we do not find reports in the literature of this condition in the bilateral presentation. It is present as sudden conductive hearing loss commonly after digital manipulation of the external auditory canal. The diagnosis is based principally on clinical examination by otomicroscopy and audiometry. Cone-beam computed tomography emerging as a powerful tool in the field of otolaryngology, especially for explorations of paranasal sinuses and temporal bone, due to imaging with a high resolution and few artifacts with lower dose radiation in comparison with multislice computed tomography.
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Affiliation(s)
- Ilson Sepulveda
- Finis Terrae University School of Dentistry, Radiology Department, ENT-Head and Neck Surgery Service, General Hospital of Concepcion, Concepción, Chile
| | - J Patricio Ulloa
- ENT-Head and Neck Surgery Service, General Hospital of Concepcion, University of Concepción, School of Medicine, Concepción, Chile
| | - Alfredo Santamaría
- ENT-Head and Neck Surgery Service, General Hospital of Concepcion, University of Concepción, School of Medicine, Concepción, Chile
| | - Francisco Rivas-Rodriguez
- Department of Radiology, Division of Neuroradiology, University of Michigan Health System. Ann Arbor, Michigan, USA
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11
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Imagen de la hipoacusia postraumática. RADIOLOGIA 2018; 60:119-127. [DOI: 10.1016/j.rx.2017.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022]
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Mazón M, Pont E, Albertz N, Carreres-Polo J, Más-Estellés F. Imaging of post-traumatic hearing loss. RADIOLOGIA 2018. [DOI: 10.1016/j.rxeng.2018.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sarmento KMA, Sampaio ALL, Santos TGT, de Oliveira CACP. High-frequency conductive hearing loss as a diagnostic test for incomplete ossicular discontinuity in non-cholesteatomatous chronic suppurative otitis media. PLoS One 2017; 12:e0189997. [PMID: 29267386 PMCID: PMC5739461 DOI: 10.1371/journal.pone.0189997] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/06/2017] [Indexed: 11/19/2022] Open
Abstract
Chronic suppurative otitis media, with or without cholesteatoma, may lead to erosion of the ossicles and discontinuity of the ossicular chain. In incomplete ossicular discontinuity (IOD), partial erosion of the ossicles occurs, but some sound transmission is noted throughout the ossicular chain. High-frequency conductive hearing loss (HfCHL) has been considered a hallmark of incomplete ossicular discontinuity. This study aims to evaluate the use of HfCHL as a preoperative predictor of IOD in patients with non-cholesteatomatous chronic suppurative otitis media. The HfCHL test was defined as the preoperative air-bone gap (ABG) at 4 kHz minus the average of the ABG at 0.25 and 0.5 kHz. The test was applied in 328 patients before surgery and compared to intraoperative findings as the gold standard. At surgery, 201 (61.3%) patients had an intact ossicular chain, 44 (13.4%) had a complete ossicular discontinuity, and 83 (25.3%) exhibited an IOD. The best cutoff level was calculated as 10 dB. The HfCHL test to diagnose IOD had a sensitivity of 83% and a specificity of 92% with a post-test probability of 78% and a likelihood ratio of 10.2. We concluded that the HfCHL test is highly effective in predicting IOD in patients with non-cholesteatomatous chronic suppurative otitis media and that it should be used routinely as a screening test prior to surgery.
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Affiliation(s)
- Krishnamurti M. A. Sarmento
- Department of Otolaryngology, Brasilia Military Police Hospital, Brasilia, DF, Brazil
- Affiliated Center of the Fisch International Microsurgery Foundation (FIMF), Brasilia, DF, Brazil
- * E-mail:
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Ossiculoplasty on Isolated Malleus Fractures: A Human Temporal Bone Study Using Laser Doppler Vibrometry. Otol Neurotol 2017; 37:895-901. [PMID: 27253075 DOI: 10.1097/mao.0000000000001086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS In the literature several surgical methods have been reported that aim to improve hearing in patients with isolated malleus fractures; however, it is still not clear which method gives the best results. BACKGROUND In this study, laser Doppler vibrometry (LDV) was used to compare the outcome of different surgical methods on malleus fractures in fresh frozen human temporal bones. METHODS Fractured malleus shafts of defrosted human temporal bones were repaired with bone cement, with a malleus prosthesis from cortical bone, or with a partial ossicular replacement prosthesis (PORP) from cortical bone, and LDV measurements were obtained for analysis. RESULTS The best result was achieved with the bone cement only, applied directly at the site of the fracture. The malleus prosthesis and the PORP gave similar results. CONCLUSION All three surgical methods gave good results, but when the distal end of the fractured malleus can be attached close to the proximal end, the technique using only cement tends to be the best option. If the parts are too far apart, a malleus prosthesis or a PORP would be good options.
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Eine seltene Ursache für Schallleitungsschwerhörigkeit. HNO 2017; 65:251-255. [DOI: 10.1007/s00106-016-0154-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
OBJECTIVES Ossicular discontinuity may be complete, with no contact between the disconnected ends, or partial, where normal contact at an ossicular joint or along a continuous bony segment of an ossicle is replaced by soft tissue or simply by contact of opposing bones. Complete ossicular discontinuity typically results in an audiometric pattern of a large, flat conductive hearing loss. In contrast, in cases where otomicroscopy reveals a normal external ear canal and tympanic membrane, high-frequency conductive hearing loss has been proposed as an indicator of partial ossicular discontinuity. Nevertheless, the diagnostic utility of high-frequency conductive hearing loss has been limited due to gaps in previous research on the subject, and clinicians often assume that an audiogram showing high-frequency conductive hearing loss is flawed. This study aims to improve the diagnostic utility of high-frequency conductive hearing loss in cases of partial ossicular discontinuity by (1) making use of a control population against which to compare the audiometry of partial ossicular discontinuity patients and (2) examining the correlation between high-frequency conductive hearing loss and partial ossicular discontinuity under controlled experimental conditions on fresh cadaveric temporal bones. Furthermore, ear-canal measurements of umbo velocity and wideband acoustic immittance measurements were investigated to determine the usefulness regarding diagnosis of ossicular discontinuity. DESIGN The authors analyzed audiograms from 66 patients with either form of surgically confirmed ossicular discontinuity and no confounding pathologies. The authors also analyzed umbo velocity (n = 29) and power reflectance (n = 12) measurements from a subset of these patients. Finally, the authors performed experiments on six fresh temporal bone specimens to study the differing mechanical effects of complete and partial discontinuity. The mechanical effects of these lesions were assessed via laser Doppler measurements of stapes velocity. In a subset of the specimen (n = 4), wideband acoustic immittance measurements were also collected. RESULTS (1) Calculations comparing the air-bone gap (ABG) at high and low frequencies show that when high-frequency ABGs are larger than low-frequency ABGs, the surgeon usually reported soft-tissue bands at the point of discontinuity. However, in cases with larger low-frequency ABGs and flat ABGs across frequencies, some partial discontinuities as well as complete discontinuities were reported. (2) Analysis of umbo velocity and power reflectance (calculated from wideband acoustic immittance) in patients reveal no significant difference across frequencies between the two types of ossicular discontinuities. (3) Temporal bone experiments reveal that partial discontinuity results in a greater loss in stapes velocity at high frequencies when compared with low frequencies, whereas with complete discontinuity, large losses in stapes velocity occur at all frequencies. CONCLUSION The clinical and experimental findings suggest that when encountering larger ABGs at high frequencies when compared with low frequencies, partial ossicular discontinuity should be considered in the differential diagnosis.
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Juliano AF, Ginat DT, Moonis G. Imaging Review of the Temporal Bone: Part II. Traumatic, Postoperative, and Noninflammatory Nonneoplastic Conditions. Radiology 2015; 276:655-72. [PMID: 26302389 DOI: 10.1148/radiol.2015140800] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The first part of this review of the temporal bone discussed anatomy of the temporal bone as well as inflammatory and neoplastic processes in the temporal bone region (1). This second part will first discuss trauma to the temporal bone and posttraumatic complications. The indications for common surgical procedures performed in the temporal bone and their postoperative imaging appearance are then presented. Finally, a few noninflammatory nonneoplastic entities involving the temporal bone are reviewed. They are relatively uncommon diagnoses compared with infectious or inflammatory diseases. However, because patients present with symptoms that are either common (hearing loss) or distinctive (sensorineural hearing loss in a child), they are important for the radiologist to be aware of and recognize.
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Affiliation(s)
- Amy F Juliano
- From the Department of Radiology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (A.F.J.); Department of Radiology, The University of Chicago Medicine, Chicago, Ill (D.T.G.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (G.M.)
| | - Daniel T Ginat
- From the Department of Radiology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (A.F.J.); Department of Radiology, The University of Chicago Medicine, Chicago, Ill (D.T.G.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (G.M.)
| | - Gul Moonis
- From the Department of Radiology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (A.F.J.); Department of Radiology, The University of Chicago Medicine, Chicago, Ill (D.T.G.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (G.M.)
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Delrue S, De Foer B, van Dinther J, Zarowski A, Somers T, Casselman J, Offeciers E. Handling an Isolated Malleus Handle Fracture. Ann Otol Rhinol Laryngol 2014; 124:244-9. [PMID: 25228668 DOI: 10.1177/0003489414550240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: An isolated malleus handle fracture is rare and presents with vague otological symptoms. Diagnosis depends on careful history taking and otoscopic examination. Different treatment options are available. Reconstruction with hydroxyapatite bone cement is a relatively new technique. Objective: The aim of this article is to review the current diagnostic work-up and treatment options and to demonstrate our method of treatment with hydroxyapatite bone cement. Methods: Three cases, repaired with hydroxyapatite bone cement in a tertiary referral otologic center, were retrospectively analyzed. A review of the literature on diagnosis and treatment procedures was performed. Results: One fracture occurred by withdrawing a finger from the external auditory canal and 2 occurred without clear prior trauma. Our 3 cases were successfully repaired with hydroxyapatite bone cement. Conclusion: Diagnosis of an isolated malleus handle fracture still depends on careful clinical examination. In addition to pure tone audiometry, both low and higher frequency tympanometry may be useful. High resolution computed tomography with reformatting through the malleus handle is the most accurate imaging modality. Reconstruction with hydroxyapatite bone cement is reliable by restoring the original situation with only minimal manipulation and without additional ossicular interruption.
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Affiliation(s)
- Stefan Delrue
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Bert De Foer
- Department of Radiology, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Joost van Dinther
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Andrzej Zarowski
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Thomas Somers
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Jan Casselman
- Department of Radiology, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
| | - Erwin Offeciers
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Antwerp, Belgium
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Can an incomplete ossicular discontinuity be predicted by audiometric and clinical findings? Otol Neurotol 2013; 34:699-704. [PMID: 23640088 DOI: 10.1097/mao.0b013e31828864a7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate a pathology of conductive hearing loss caused by an incomplete ossicular discontinuity. It can manifest as a triad of the following: 1) conductive hearing loss most prominent in the high frequencies (hfCHL), defined as [ABG for 4 kHz] > [mean ABG for 0.25-0.5 kHz] + 10 dB or more; 2) fluctuating hearing loss; and 3) short-lasting improvement of hearing after Valsalva maneuver. STUDY DESIGN Retrospective clinical trial. SETTING Tertiary referral center. PATIENTS Fourteen patients with an incomplete ossicular discontinuity who underwent incus interposition were included. INTERVENTION Incus interposition, mathematical model. MAIN OUTCOME MEASURES First, the prevalence of the triad was documented. Second, the hypothesis that mechanical ossicular compliance was responsible for the triad of symptoms was evaluated and simulated in a mathematical model. Finally, the postoperative hearing results with a follow-up of 12 months were analyzed and compared with those reported in the literature. RESULTS The presence of the triad of symptoms is a strong indicator for detecting patients with an incomplete ossicular discontinuity. High frequency conductive hearing loss was present in 93% (13/14 patients). Ten (71%) of the 14 patients presented with fluctuating hearing loss and improvement of hearing after Valsalva maneuver. The hfCHL could be simulated adequately in the mathematical model. Success rate for surgical intervention (ABG < 20 dB; 0.5, 1, 2, and 3 kHz) was 93% and was comparable to the results reported in the literature. CONCLUSION Patients with hfCHL, fluctuating hearing loss, and improvement of hearing after Valsalva maneuver are likely to have an incomplete ossicular discontinuity. A favorable postoperative hearing recovery by incus interposition can be expected.
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Blanchard M, Abergel A, Vérillaud B, Williams MT, Ayache D. Isolated malleus-handle fracture. Auris Nasus Larynx 2011; 38:439-43. [PMID: 21216115 DOI: 10.1016/j.anl.2010.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 11/17/2010] [Accepted: 11/18/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Marion Blanchard
- Department of Otolaryngology-Head and Neck Surgery, Fondation Adolphe de Rothschild, Paris, France
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Chang YN, Hung CC, Lee JC, Wang CH. Isolated malleus-handle fracture surgical repair using tragal cartilage. Am J Otolaryngol 2011; 32:77-9. [PMID: 20015811 DOI: 10.1016/j.amjoto.2009.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Accepted: 09/06/2009] [Indexed: 11/25/2022]
Abstract
The isolated malleus-handle fracture is a rare ossicular injury and tends to be overlooked when the tympanic membrane appears normal. Various surgical attempts have been made to correct this fracture; however, these techniques largely relied on xenograft implantation materials; the autologous cartilaginous graft application has never been reported. Herein we describe a simple, rapid, and effective method that uses available tragal cartilaginous graft to repair an isolated malleus-handle fracture. Our approach offers a reliable choice to restore continuity of the ossicular chain and produce a more satisfying, subjective hearing ability in this uncommon fracture situation.
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Casale M, De Franco A, Rinaldi V, Zini C, Salvinelli F. Isolated fracture of the malleus handle: A video clip. Laryngoscope 2010; 120:813-4. [DOI: 10.1002/lary.20783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Niklasson A, Tano K. Self-inflicted negative pressure of the external ear canal: a common cause of isolated malleus fractures. Acta Otolaryngol 2010. [DOI: 10.3109/00016480903177521] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Öztürk Ö, Üneri C. Isolated fracture of the malleus handle. Otolaryngol Head Neck Surg 2009; 141:653-4. [DOI: 10.1016/j.otohns.2009.06.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/26/2009] [Accepted: 06/16/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Özmen Öztürk
- Department of Otorhinolaryngology, Head and Neck Surgery, Acibadem Kozyatagi Oncology and Neurological Sciences Hospital, Istanbul, Turkey
| | - Cüneyd Üneri
- Department of Otorhinolaryngology, Head and Neck Surgery, Acibadem Kozyatagi Oncology and Neurological Sciences Hospital, Istanbul, Turkey
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