Home Ahead of print Instructions Contacts
About us Current issue Submit article Advertise  
Editorial board Archives Subscribe Login   


 
 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 20  |  Issue : 2  |  Page : 89-91

A case of posttraumatic incudomalleolar disruption


Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla, Kerala, India

Date of Web Publication3-May-2014

Correspondence Address:
Vivek Sasindran
Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla - 689 101, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.131877

Rights and Permissions
  Abstract 

Hearing loss following head trauma or head injury is a major medical problem. Trauma related conductive hearing loss can be due to injury to the ossicular chain, hemotympanum or laceration to the tympanic membrane. Sensorineural hearing loss is caused due to injury to the cochlea or organ of Corti. Head trauma associated with ossicular disruption should be suspected in patients with conductive hearing loss that persists after a healing process of 2 months. High-resolution computed tomography is the investigation of choice. Here, we present a case of traumatic isolated incudomalleolar disruption in a 46-year-old male following a road traffic accident. He presented with a persistent conductive hearing loss for 4 months following the incident.

Keywords: Incudomalleolar disruption, Posttraumatic hearing loss, Posttraumatic ossicular disruption


How to cite this article:
Sasindran V, Joseph A, Babu B, George P. A case of posttraumatic incudomalleolar disruption. Indian J Otol 2014;20:89-91

How to cite this URL:
Sasindran V, Joseph A, Babu B, George P. A case of posttraumatic incudomalleolar disruption. Indian J Otol [serial online] 2014 [cited 2019 Aug 24];20:89-91. Available from: http://www.indianjotol.org/text.asp?2014/20/2/89/131877


  Introduction Top


Hearing loss following head trauma or head injury is a major medical problem. [1] Posttraumatic hearing loss is documented in 24-66% of individuals suffering from temporal bone fractures. [2]

One of the common causes of conductive hearing loss, following head injury is ossicular dislocation. Ossicular disruption should be suspected in patients with conductive hearing loss that persists after a healing process of 2 months. The most common ossicular dislocation is separation of the incudostapedial joint with or without dislocation of the body of the incus from the articulation with the malleus head. The second most common injury of the ossicular chain is fracture of the stapes crura. In our case, there was an isolated dislocation of the incudomalleolar joint which is not common.


  Case Report Top


A 46-year-old male patient presented to us with a persistent decreased hearing in his left ear following a road traffic accident 4 months back. Otoscopic examination was found to be normal. Audiogram showed a conductive hearing loss of 50 dB with mixed component at 2 KHz and 4 KHz and an air-bone gap of 43.4 dB across speech frequencies. Impedance audiometry revealed a type A curve with reflexes absent.

A high-resolution computed tomography (HRCT) scan of the temporal bones revealed an oblique fracture involving the left mastoid temporal bone extending superiorly to involve the squamous temporal bone and disruption of the left incudomalleolar joint. Integrity of the ossicles was found to be maintained [Figure 1].
Figure 1: High-resolution computed tomography of the temporal bone, axial section at the level of the epitympanum, showing the normal "ice-cream cone configuration" on the right side and the distorted configuration on the left side where the "ice-cream" appears to have fallen of the "cone." The red circle encloses the incudo-malleolar joint

Click here to view


An exploratory tympanotomy was carried out under general anesthesia. Intra operative findings revealed the malleus to be fixed initially. On exposing the attic, the head of the malleus was found to be dislocated from the incudomalleolar joint and displaced medially, under the body of the incus, thus restricting its mobility. The incudostapedial joint was intact, and the stapes were found to be mobile. A myringostapediopexy assembly with an incus autograft was achieved.

Air-bone gap was brought to 20 dB and a pure-tone average of 26.6 dB was obtained 6 months following surgery.


  Discussion Top


Head injuries are often associated with fracture of the temporal bone. The common serious consequences of the temporal bone fractures are hearing loss and/or facial nerve paralysis. [3] The most common type of fracture of the temporal bone, from blunt trauma, is the longitudinal fracture. It comprises about 70-90% of temporal bone fracture. Longitudinal fractures involve the tympanic ring and are associated with conductive hearing loss. Transverse fractures of the temporal bone are associated with sensorineural hearing loss due to injury to the cochlea or organ of Corti. [4],[5],[6]

In a study of 820 temporal bone fracture patients, hearing loss was conductive in 21%, mixed in 22% and sensorineural in 57%. Most conductive hearing losses dissipated with time or were lost to follow-up and 5 patients underwent ossicular chain reconstruction for sustained loss. [7] High-frequency hearing loss, as seen in our patient, may be caused by concussion and intense acoustic stimulation, concussion being reversible. The peak loss is usually at 4000 Hz. Griffiths study (M.V. Griffiths) in 1979 showed a residual hearing loss in 14% of patients even after 6 months in cases of head injury with concussion without fracture. [8]

The most common surgically treatable complication of temporal bone fracture is ossicular chain disruption. [9] The most common ossicular dislocation is separation of the incudostapedial joint with or without dislocation of the body of the incus from the articulation with the malleus head. The second most common injury of the ossicular chain is fracture of the stapes crura. [10] Other varieties of ossicular chain disruption include incudomalleolar joint separation, dislocation of the incus, dislocation of the malleoincudal complex, and stapediovestibular dislocation. [11]

When a patient presents with conductive hearing loss that persists after a healing process of 2 months, following head trauma, with a normal otoscopic finding, ossicular chain pathology should be suspected. A HRCT-scan with 1 mm contiguous sections is the method of choice for assessing the etiology of a conductive hearing loss. [10],[12]

The incudomalleolar joint is a saddle-shaped diarthrodial joint, which is seen as an "ice-cream cone" on axial computed tomography planes. Head of the malleus resembles the scoop and the body and short process of the incus resembles the cone. [11] In incudomalleolar disruption, the "ice-cream" appears to have fallen off the "cone."

Preoperative audiogram is essential to assess the type and degree of hearing loss, for planning further management and explaining the possible postoperative hearing outcomes to the patient.

In patients where the ossicular injury is the cause of unresolved hearing loss, surgical intervention may be required. Reconstruction of the ossicular chain is considered if a patient has a conductive hearing loss of more than 30 dB. [13]

The surgical treatment of choice where ossicular disruption is confirmed or suspected is exploratory tympanotomy with subsequent ossicular chain reconstruction when required. Ossiculoplasty can be carried out with autografts (cartilage, ossicle) or other prosthesis, which include high-density polyethylene sponge (Plasti-Pore), aluminum oxide, ceramic, and hydroxyapatite. Many of the preferred methods attempt to utilize the patient's own tissue, but when this is not available prosthetic devices can be used depending on the type and extent of injury to the ossicular chain. [5],[6],[14] Prosthetic devices include incus prostheses, incus-stapes prostheses, partial ossicular replacement prostheses and total ossicular replacement prostheses.

Posttraumatic hearing loss is not an uncommon entity, especially following a road traffic accident. A conductive hearing loss persisting for more than 2 months following the incident should raise the possibility of ossicular discontinuity. A HRCT scan will aid in diagnosis and surgery with ossicular reconstruction is the definitive treatment.

 
  References Top

1.Bergemalm PO, Borg E. Long-term objective and subjective audiologic consequences of closed head injury. Acta Otolaryngol 2001;121:724-34.  Back to cited text no. 1
    
2.Kahn JB, Stewart MG, Diaz-Marchan PJ. Acute temporal bone trauma: Utility of high-resolution computed tomography. Am J Otol 2000;21:743-52.  Back to cited text no. 2
    
3.Johnson DW, Hasso AN, Stewart CE 3 rd , Thompson JR, Hinshaw DB Jr. Temporal bone trauma: High-resolution computed tomographic evaluation. Radiology 1984;151:411-5.  Back to cited text no. 3
    
4.Glarner H, Meuli M, Hof E, Gallati V, Nadal D, Fisch U, et al. Management of petrous bone fractures in children: Analysis of 127 cases. J Trauma 1994;36:198-201.  Back to cited text no. 4
    
5.Ort S, Beus K, Isaacson J. Pediatric temporal bone fractures in a rural population. Otolaryngol Head Neck Surg 2004;131:433-7.  Back to cited text no. 5
    
6.Amadasun JE. An observational study of the management of traumatic tympanic membrane perforations. J Laryngol Otol 2002;116:181-4.  Back to cited text no. 6
    
7.Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997;18:188-97.  Back to cited text no. 7
    
8.Emerson LP. In: Naz S, editor. Hearing Loss in Minor Head Injury, Hearing Loss. InTech Europe Janeza Trdine 9 51000 Rijeka, Croatia: InTech; 2012. ISBN: 978-953-51-0366-0.Available from: http://www.intechopen.com/books/hearing-loss/hearingloss-in-minor-head-injury. [Last accessed on 2012 Mar 28].  Back to cited text no. 8
    
9.Schubiger O, Valavanis A, Stuckmann G, Antonucci F. Temporal bone fractures and their complications. Examination with high resolution CT. Neuroradiology 1986;28:93-9.  Back to cited text no. 9
    
10.Yetiser S, Hidir Y, Birkent H, Satar B, Durmaz A. Traumatic ossicular dislocations: Etiology and management. Am J Otolaryngol 2008;29:31-6.  Back to cited text no. 10
    
11.Meriot P, Veillon F, Garcia JF, Nonent M, Jezequel J, Bourjat P, et al. CT appearances of ossicular injuries. Radiographics 1997;17:1445-54.  Back to cited text no. 11
    
12.Offiah CE, Ramsden RT, Gillespie JE. Imaging appearances of unusual conditions of the middle and inner ear. Br J Radiol 2008;81:504-14.  Back to cited text no. 12
    
13.Nikolaidis V. Traumatic dislocation of the incudostapedial joint repaired with fibrin tissue adhesive. Laryngoscope 2011;121:577-9.  Back to cited text no. 13
    
14.14. Chole RA, Skarada DJ. Middle ear reconstructive techniques. Otolaryngol Clin North Am 1999;32:489-503.  Back to cited text no. 14
    


    Figures

  [Figure 1]


This article has been cited by
1 Sports-related head injury as a cause of ossicular trauma
Lilian Felipe
Journal of Otolaryngology-ENT Research. 2018; 10(5)
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed2382    
    Printed41    
    Emailed0    
    PDF Downloaded202    
    Comments [Add]    
    Cited by others 1    

Recommend this journal