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.
1
Introduction
Isolated malleus fracture is a rare condition in ear injury and may present with fracture of the manubrium or the malleus neck. The most common cause of self-inflicted injury is the cotton-tipped applicator or ear-pick used to clean the ear, as shown in our case. Head trauma, barotraumas, or a large negative pressure created by rapidly removing a finger from the ear canal may also result in this uncommon fracture . This injury tends to be overlooked because the tympanic membrane (TM) often naturally heals and appears intact during the physical inspection. When conductive hearing loss is associated with a history of trauma, abnormal malleus motion on the pneumatic otoscopy, and high compliance at tympanometry, this evidence helps to support a diagnosis of ossicular chain disruption.
As only sporadic cases have been reported in the English literature over the past years , surgical intervention may be challenging because of the lack of a consistent approach to ensure preservation of the physiological coupling between TM vibration and the fractured ossicular chain. Although various surgical attempts have been made to correct this fracture, these techniques either largely relied on xenograft implantation materials or were more complicated and extensive to involve disarticulation of the remaining normal ossicular chain. 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. This technique provides a successful hearing outcome and also offers a less costly approach to restore the coupling between TM vibration and the forces exerted on the oval window of the inner ear using a physiologic lever action.
2
Case report
A 48-year-old woman noted progressive hearing loss in her left ear after an ear-pick penetration injury 5 years earlier. Otoscopic examination revealed an intact TM with an atrophic area about 10% in size, lying anterior-inferiorly to the malleus handle. The Weber tuning fork test showed a lateralization in the left ear; the Rinne test showed bone conduction was greater than air conduction. The pure tone audiometry revealed conductive hearing loss on the left side, with a 25- to 40-dB air-bone gap across the frequency range of 250 to 1000 Hz ( Fig. 1 A ). Tympanometry showed a high compliance type Ad tympanogram on the left ear. These findings enabled us to make a diagnosis of conductive hearing loss resulting from traumatic ossicular chain disruption. The patient was advised to receive surgical intervention.
With the patient under local anesthesia, a transcanal exploratory tympanotomy was performed. The tympanomeatal flap was elevated to access the tympanic cavity, and the chorda tympani nerve was preserved. By dissecting and reflecting the TM anteriorly to the level of the umbo, a malleus-handle fracture was seen at the middle of the manubrium ( Fig. 2 ). The remainder of the ossicular chain was intact, with normal mobility. We harvested a small cartilaginous graft from the tragus, which was shaped into dimensions of 3 × 2.5 × 0.5 mm using a no. 15 scalpel blade. The previous traumatic gap between the TM and fractured manubrium was increased to facilitate cartilaginous graft insertion by incising the malleus handle periosteum 1 mm above the upper fractured end. The cartilaginous graft was interposed just between the 2 malleolar fragments by positioning it over the upper fractured malleolar fragment but beneath the lower fractured one ( Fig. 3 ). Satisfactory motility of the ossicular chain was attained using this procedure, and the tympanomeatal flap was replaced. At that moment, the patient reported a great improvement in hearing acuity. The tympanomeatal flap was held in position by Gelfoam packing in the external auditory canal.
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