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Isolated Traumatic Fracture of the Malleus Handle Causing Hearing

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Isolated Traumatic Fracture of the Malleus Handle Causing Hearing Otology & Neurotology 40:e244–e247 ß 2019, Otology & Neurotology, Inc. Imaging Case of the Month Isolated Traumatic Fracture of the Malleus Handle Causing Hearing Fluctuation ÃMarina Neves Cavada and ÃyzNirmal Patel ÃFaculty of Medicine and Health Sciences, Macquarie University; yDepartment of Otolaryngology and Head and Neck Surgery, Royal North Shore Hospital, Sydney; and zKolling Deafness Research Centre, Macquarie University and 02/13/2019 on IJFFeEaHn1eeltApCfg9c7yVI2fguJ9PASBuFPPrq0O0PZN57Rz0eAv4YUUourz8+RIudBMJChCQDGllp3smZUOaQ90rAwYbGjJxfkIrI4yH884AvBPhiC2FCIBFobYq by http://journals.lww.com/otology-neurotology from Downloaded Downloaded University of Sydney, NSW, Australia from http://journals.lww.com/otology-neurotology Introduction: Handle of malleus fracture is a rare condition decision for surgical treatment was made based on continuing with <100 cases having been reported. The clinical presenta- symptomatology as well as audiology and CT findings. A tragal tion is conductive hearing loss following a history of trauma, composite cartilage graft was harvested and placed over the typically, during manipulation of the external auditory canal. remaining superior part of the malleus and under the inferior The diagnosis of the condition is clinical and radiological. The fragment of the malleus attached to the tympanic membrane. options for treatment are either a hearing aid or ossiculoplasty. The patient had immediate improvement of fluctuating hearing We describe an isolated case of malleus handle fracture after loss and tinnitus in the postoperative period. by trauma associated with manipulation of the external auditory Conclusion: A fracture of the malleus handle should be IJFFeEaHn1eeltApCfg9c7yVI2fguJ9PASBuFPPrq0O0PZN57Rz0eAv4YUUourz8+RIudBMJChCQDGllp3smZUOaQ90rAwYbGjJxfkIrI4yH884AvBPhiC2FCIBFobYq canal. included in the etiologies of conductive hearing loss after Case report: A 56-year-old female, reported a right ear trauma. A careful history, thorough otology examination, and trauma. She suffered immediate otalgia, hearing loss and a meticulous analysis of the CT will usually confirm this nonpulsatile tinnitus. An indistinct umbo was identified on rare condition and exclude other ossicular abnormalities. endoscopic inspection and a hypermobile right tympanic Key Words: Bone fractures—Conductive hearing loss—Ear membrane during Valsalva. Clinical testing of hearing revealed ossicules—Malleus. a mild-to-moderate conductive hearing loss. Computed Tomog- raphy scan revealed a fracture of the right malleus handle. A Otol Neurotol 40:e244–e247, 2019. Handle of malleus fracture is a rare condition with <100 CASE REPORT cases having been reported (1,2). The clinical presentation is conductive hearing loss following a history of trauma, A 56-year-old female, with no previous otologic his- typically, during manipulation of the external auditory tory, reported a right ear trauma one month prior to the canal (1,3). Symptoms include sudden otalgia, mild hear- appointment. She was scratching her ear using a cotton ing loss, hearing loss fluctuation, ear fullness, and a bud when a friend bumped her elbow. She suffered clicking sensation. High-frequency tinnitus may be pres- immediate otalgia, hearing loss and nonpulsatile tinnitus. ent, either intermittently or continuously (3,4). For the subsequent weeks prior to surgery, her symptoms The diagnosis of the condition is clinical and radio- included persisting tinnitus and fluctuating hearing loss logical. The clinical diagnosis is based on history, oto- which caused the patient significant distress. scopy, audiometry, and tympanometry. The audiogram On examination, she had an indistinct umbo on endo- findings are conductive hearing loss with air-bone gap scopic inspection (Fig. 1A). During Valsalva testing, she larger at high frequencies and hypermobility in the had a hypermobile right tympanic membrane. Clinical tympanometry (5). A computed tomography (CT) may testing of hearing revealed a mild-to-moderate conduc- detect these fractures provided there is a displacement or tive hearing loss. The rest of her otological examination rotation of the fractured fragment (1). was unremarkable. on The options for treatment are either a hearing aid or An audiogram (Fig. 2A) and a CT (Fig. 1B) were 02/13/2019 ossiculoplasty (3). This paper describes an isolated case performed. The audiogram confirmed a mild-to-moderate of malleus handle fracture after trauma associated with conductive hearing loss and the CT scan revealed a fracture manipulation of the external auditory canal. of the right malleus handle without any other abnormality. After informed discussion with the patient, a decision Address correspondence and reprint requests to Marina Neves to operate was made based on continuing symptomatol- Cavada, M.D., 3 Technology PI, Macquarie University, NSW 2109 Australia; E-mail: [email protected]. ogy as well as audiology and CT findings. The authors disclose no conflicts of interest. The procedure was performed endoscopically under DOI: 10.1097/MAO.0000000000002111 general anesthesia with the patient in 108 of reverse e244 Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited. e246 M. N. CAVADA AND N. PATEL 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
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