Journal Reading

Traumatic ossicle extrusion into the external

auditory canal

By Manish Gupta, MS(ENT); Sunder Singh, MS(ENT); and Monica

Gupta, MD(Med)

REVIEWED BY:
ADRIAN PRASETYA SUDJONO
 Introduction

 Head trauma can cause injury to ear and temporal

bone:
 Tympanic membrane perforation
 Hemotympanum injury
 Injury to the ossicular chain and facial nerve
 Perilymphatic fistula-> hearing loss
Ossicular chain
 Case Report

 The case described in this article occurred at Gian

Sagar Medical College and Hospital

 Male, 35 years old > surgical emergency unit

 Headache, vertigo, vomitting
 Traffic accident and sustain head injury
 Loss conciousness for 1 hour
 Right ear bleeding
 No history of seizures
 ENT Examination

1. Otoscope:
 Bony structure and blood clot in right auditory canal
2. CT Scan:
 Longitudinal fracture of right temporal bone that
transversed the mastoid cavity, middle ear, and
pestrous apex
 Left frontotempoparietal hematoma
 Left frontoremporal contusion
Longitudinal fracture of
the right temporal bone
with disruption of the
ossicular chain
Normal CT-Scan
 The ossicular chain of the right ear was disrupted,
and an incus-like bony image was seen in the
external auditory canal along with the blood clot
 Neurosurgical intervention in the form of a
craniotomy with evacuation of the subdural
hematoma was done.
 Postoperative examination

 After 1 month
 Persistent hearing loss in right ear
 Otoscopy:
The incus, with all its processes intact, was attached to
the posterosuperior portion of the external canal The
long process was projecting laterally, and there was
normal epithelium cover in continuity with the
adjacent canal skin
 Audiometry: Hearing loss of 50 dB on right side
 Intact incus fixed in
the posterosuperior
portion of the
external auditory
canal, tympanic
membrane is intact
and normal medially
 Discussion

Cause of hearing loss:

 Hemotympanum: Resolves within weeks without
intervention
 Tympanic membrane perforation: Also heals
spontaneously
 Ossicular chain disruption
 (Vestibular sign and symptoms & sensorineural
hearing loss)
Surgical management is needed: damage to the stapes
footplate/perilymphatic fistula
 Ossicular chain disruption

 Suspected in cases if nonresolving conductive

hearing loss with posterosuperior quadrant
perforation without vestibular symptoms Hearing
loss of 30dB or more, lasting 2 months after
tympanic membrane healing
 Usually occurs as discoloration, there are 5 types:
 Incudostapedal joint separation
 Incudomalleolar joint separation
 Dislocation of incus (most common)
 Dislocation of incudomalleolar complex
 Stapediovestibular dislocation
 Incus is most vulnerable (no muscular attachment)
 Incus is the heaviest of the ossicles (25 mg)
 High-resolution CT-scan is modality of choice:
 Axial: Joint separation and fracture of stapes

 Axial & Coronal: Dislocation of malleus and incus

 A traumatic ossicular is associated most by

longitudinal fracture of temporal bone -> extends to
middle ear
 Tympanic membrane perforation-> incus replaced
by fibrous band that joned malleus and stapes
 Other Cases

 Saito et al: incus dislocation to the external auditory

canal, the incus have rotated approx 1800on the axis
of chorda tympani and protruded through the
fracture line of the posterior canal wall
 Hough and Stuart: Incus is trapped within a breach
in the wall of the posterosuperior bony canal,
fracture line was opened widely enough to force
dislocation of the ossicles and then closed during
dislocation process, therefore trapping the incus