Isolated Traumatic Fracture of the Malleus Handle Causing Hearing

Home , Malleus

Ear — of reverse 8 Conductive hearing loss was made based on continuing ology and CT findings. A tragal — postoperative period. CASE REPORT e244–e247, 2019. 40: Bone fractures A fracture of the malleus handle should be Malleus. Nirmal Patel — yz The procedure was performed endoscopically under A 56-year-old female, with no previous otologic his- On examination, she had an indistinct umbo on endo- An audiogram (Fig. 2A) and a CT (Fig. 1B)After informed were discussion with the patient, a decision Department of Otolaryngology and Head and Neck Surgery, rare condition andKey exclude Words: otherossicules ossicular abnormalities. Otol Neurotol decision for surgicalsymptomatology treatment as well ascomposite audi cartilage graftremaining superior was part harvestedfragment of and of the the placedThe malleus malleus over patient and attached had the underloss immediate to and the improvement the tinnitus of inferior in tympanicConclusion: fluctuating the membrane. hearing included in thetrauma. A etiologies careful history, ofa thorough conductive meticulous otology examination, hearing analysis and loss of after the CT will usually confirm this to operate was madeogy based as on well continuing as symptomatol- audiology and CTgeneral findings. anesthesia with the patient in 10 tory, reported a rightappointment. ear She trauma was one scratchingbud month her prior when ear to using the aimmediate a otalgia, hearing cotton friend loss and bumpedFor nonpulsatile the tinnitus. subsequent her weeks prior elbow.included to surgery, persisting She her tinnitus symptoms suffered andwhich fluctuating caused hearing the loss patient significant distress. scopic inspection (Fig. 1A). Duringhad Valsalva a testing, she hypermobiletesting right of tympanic hearing membrane. revealedtive Clinical hearing a loss. mild-to-moderate The conduc- was rest unremarkable. of her otological examination performed. The audiogram confirmedconductive a hearing loss mild-to-moderate and the CTof scan the revealed a right fracture malleus handle without any other abnormality. y e244 100 < Kolling Deafness Research Centre, Macquarie University and z University of Sydney, NSW, Australia Imaging Case of the Month Marina Neves Cavada and Causing Hearing Fluctuation A 56-year-old female, reported a right ear Handle of malleus fracture is a rare condition Isolated Traumatic Fracture of the Malleus Handle 2019, Otology & Neurotology, Inc. Royal North Shore Hospital, Sydney; and ß 100 cases having been reported. The clinical presenta- < Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this Handle of malleus fracture is a rare condition with The options for treatment are either a hearing aid or The diagnosis of the condition is clinical and radio- Address correspondence and reprint requests toThe authors Marina disclose Neves noDOI: conflicts 10.1097/MAO.0000000000002111 of interest. :e244–e247 Faculty of Medicine and Health Sciences, Macquarie University; Cavada, M.D., 3Australia; Technology E-mail: PI, [email protected]. Macquarie University, NSW 2109 Otology & Neurotology 40 of malleus handle fracturemanipulation after of trauma the external associated auditory with canal. findings are conductivelarger hearing loss at withtympanometry high air-bone (5). gap frequencies Adetect computed and these tomography fractures provided hypermobility (CT) thererotation may is in of a displacement the the or fractured fragment (1). ossiculoplasty (3). This paper describes an isolated case canal (1,3). Symptoms include sudden otalgia,ing mild hear- loss, hearingclicking sensation. loss High-frequency tinnitus fluctuation, mayent, be either ear pres- intermittently or fullness, continuously (3,4). and a logical. The clinical diagnosisscopy, is audiometry, based and on tympanometry. history, The oto- audiogram cases having been reported (1,2). The clinicalis presentation conductive hearing loss followingtypically, a during history of manipulation trauma, of the external auditory raphy scan revealed a fracture of the right malleus handle. A trauma associated withcanal. manipulation of theCase external auditory report: trauma. Shenonpulsatile suffered tinnitus. immediateendoscopic An otalgia, inspection indistinct hearingmembrane and loss umbo during Valsalva. and a was Clinicala testing mild-to-moderate identified hypermobile of conductive hearing on hearing right revealed loss. Computed tympanic Tomog- Introduction: with tion is conductive hearingtypically, loss during following manipulation a ofThe history diagnosis the of of external the trauma, options condition auditory is for canal. treatment clinical are and either radiological.We The a describe hearing an aid isolated or ossiculoplasty. case of malleus handle fracture after

Downloaded from http://journals.lww.com/otology-neurotology by IJFFeEaHn1eeltApCfg9c7yVI2fguJ9PASBuFPPrq0O0PZN57Rz0eAv4YUUourz8+RIudBMJChCQDGllp3smZUOaQ90rAwYbGjJxfkIrI4yH884AvBPhiC2FCIBFobYq on 02/13/2019 Downloaded from http://journals.lww.com/otology-neurotology by IJFFeEaHn1eeltApCfg9c7yVI2fguJ9PASBuFPPrq0O0PZN57Rz0eAv4YUUourz8+RIudBMJChCQDGllp3smZUOaQ90rAwYbGjJxfkIrI4yH884AvBPhiC2FCIBFobYq on 02/13/2019 FRACTURED HANDLE OF MALLEUS e245

FIG. 1. (A) Preoperative image of the right external auditory canal revealing an indistinct fragment of the malleus handle; (B) Malleus handle fracture. Coronal CT scan of the right temporal bone demonstrates the right malleus handle fracture. CT indicates computed tomography.

trendelenburg. The external right auditory canal and A tragal composite cartilage graft was tragus were infiltrated with 1% ropivicaine and harvested leaving the thin posterior perichondrium 1:50000 adrenaline. A tympanomeatal flap was raised adherent to the cartilage. The graft was shaped as and the distal fragment of the malleus handle was identi- required and placed over the remaining superior fied (Fig. 3A). The fragment of the malleus handle and part of the malleus and under the inferior fragment of umbo were scored on its medial aspect with a sharp hook the malleus attached to the tympanic membrane to allow a graft to adhere. (Fig. 3B).

FIG. 2. (A) Preoperative audiogram. Mild-to moderate conductive hearing loss; (B) Postoperative audiogram. Audiogram at 4 weeks after surgery demonstrating improvement of conductive hearing loss at low frequencies.

Otology & Neurotology, Vol. 40, No. 3, 2019

FIG. 3. (A) Intraoperative image. Endoscopic image of the malleus handle fracture with the fragment of malleus handle attached to umbo; (B) Intraoperative image. Endoscopic image displaying the composite cartilage graft being placed onlay the remaining part of the malleus handle.

The patient had immediate improvement of fluctuating In cases where conductive hearing loss, hearing hearing loss and tinnitus in the postoperative period. loss fluctuation and aural fullness are troubling, a Audiogram at 4 weeks after surgery demonstrated sig- hearing aid as well as surgery are options to be nificant early closure of the air bone gap at low frequen- discussed with the patient (5). Even though many tech- cies (Fig. 2B). niques have been performed to improve hearing threshold, there is no standard procedure that is recom- DISCUSSION mended. Spontaneous improvement of hearing can be observed An isolated malleus handle fracture can be easily in a patient who choses conservative management (5); misdiagnosed and overlooked due to its subtle appear- however, patients with persistent symptoms may benefit ance upon physical examination, as well as similarities to from surgical repair (3). Ossicular reconstruction may be symptoms and clinical findings with other ossicular chain performed with an autologous incus, partial ossicular fractures (2,5). The tympanic membrane often naturally replacement prosthesis (PORP) or a total ossicular heals and is intact during physical inspection (4). The replacement prosthesis (TORP) depending on the ossic- most commonly reported cause of the condition is a quick ular configuration (3). Some surgeons opt to stabilize the removal of a finger from the external auditory canal, fracture interpositioning with bone chips or cartilage, especially when the ear canal is wet. The rapid movement others choose to reconstruct the malleus handle with provokes a sudden negative pressure in the external ear hydroxyapatite (3,4). Tan et al (1) reported a case in canal, causing a fracture (4,5). which the fractured malleus was stabilized with hydroxy- Otomicroscopy may reveal a fracture line, with pneu- apatite bone cement. There was closure of the air-bone matic otoscopy helping to demonstrate hypermobility of gap, except beyond 4000 Hz, in the postoperative audio- the distal fragment of the malleus (2). A Valsalva maneu- gram. Hydroxyapatite bone cement has shown positive ver may reveal the dis-conjugated movement between the results in other cases with improvement of postoperative two parts of the malleus (2,3,4). Another helpful diag- audiometry (2). nostic tool is a laser-Doppler vibrometry, which reveals A unique repair using containment of the fracture with an increased umbo velocity (3,5). a small piece of titanium mesh filled with bone fragments CT plays an important role in diagnosis, as it may not and fixed with Tissucol (Baxter Healthcare, Deerfield, only confirm the separate malleus fragment, but it also IL) has also been described. Symptoms and hearing fully excludes other associated ossicular injury. However, the recovered postoperatively (4). Another surgeon repaired CT findings can easily be overlooked. Usually, the the malleus fracture by removing the incus and placing a longitudinal axis of the malleus demonstrates the dis- PORP between the stapes head and the tympanic mem- placement of proximal and distal fragment of the malleus brane. Postoperatively, patient reported resolutions of her handle with lateralization of the inferior segment and symptoms and significant improvement of the air-bone medialization of the superior segment (2). gap in the audiogram (5). In the case presented, due to the

Otology & Neurotology, Vol. 40, No. 3, 2019

Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. FRACTURED HANDLE OF MALLEUS e247 relatively long intact proximal handle of the malleus still REFERENCES available, a composite cartilage graft was interposed between the malleus and the TM. 1. Tan M, Ullman N, Pearl MS, et al. Fracture of the manubrium of the malleus. Otol Neurotol 2016;37:e254–255. 2. Blanchard M, Abergel A, Verillaud B, et al. Isolated malleus-handle CONCLUSION fracture. Auris Nasus Larynx 2011;38:439–43. 3. Niklasson A, Ronnblom A, Muyshondt P, et al. Ossiculoplasty on A fracture of the malleus handle should be included isolated malleus fractures: a human temporal bone study using laser in the etiologies of conductive hearing loss after Doppler vibrometry. Otol Neurotol 2016;37:895–901. trauma. A careful history, thorough otology examination, 4. Delrue S, De Foer B, van Dinther J, et al. Handling an isolated and a meticulous analysis of the CT will usually malleus handle fracture: current diagnostic work-up and treatment options. Ann Otol Rhinol Laryngol 2015;124:244–9. confirm this rare condition and exclude other ossicular 5. Chien W, McKenna MJ, Rosowski JJ, et al. Isolated fracture of the abnormalities. manubrium of the malleus. J Laryngol Otol 2008;122:898–904.

Otology & Neurotology, Vol. 40, No. 3, 2019