Traumatic Total Incus Dislocation From Ossicular Chain

8/15/2019 Traumatic Total Incus Dislocation From Ossicular Chain

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traumatic total incus dislocation from ossicular chain

C. Mutlu*, M. Ozkiris*, F. Oghan^

*Department of Otolaryngology, Head and Ne k !urgery, "ekden Hospital, #ayseri$ "urkey

^Department of Otolaryngology, Head and Ne k !urgery, Dumlupinar %ni&ersity Medi alFa ulty, #utahya$ "urkey

Abstract

Compli ations of temporal 'one fra tures in lude hearing loss, &esti'ular dysfun tion,ere'rospinal fluid leaks, meningitis, and fa ial ner&e palsy. Ossi ular dislo ation is more

ommonly en ountered after head in(ury. ) higher in iden e has 'een reported in hildhood, possi'ly 'e ause of the greater fle i'ility of the skull in this age group. "his possi'ility should 'e kept in mind +hen e&aluating patients, espe ially hildren, +ho ha&e a persistent ondu ti&edeafness of more than - d +ith an inta t tympani mem'rane follo+ing any form of headin(ury. )n e ploratory tympanotomy +ith appropriate in us re onstru tion, as des ri'ed in this

ase, an yield e ellent results.

#ey+ords/ in us0 head in(ury0 hearing loss

Introduction

"he middle ear and temporal 'one are often in&ol&ed in a idents in&ol&ing trauma to the head."emporal 'one fra tures an ause numerous se1uelae, in luding fa ial ner&e in(ury,ere'rospinal fluid otorrhea, &esti'ular dysfun tion, sensorineural hearing loss, and damage to

the sound ondu ting system 23, 45.

Ossi ular hain dislo ation 2OCD5 is an interruption in the ossi ular hain, or any other disorder+hi h may pre&ent the ossi ular hain from &i'rating effe ti&ely. Ossi ular hain dislo ationmay o ur +ith a temporal 'one fra ture, traumati tympani mem'rane perforation, or

'arotrauma. OCD is seen more fre1uently than ossi ular fra ture 2 , 65. "he most ommon formof ossi ular dis ontinuity after temporal 'one trauma is separation of the (oint onne ting thein us to the stapes. "he se ond most ommon is separation of the (oint onne ting the malleus to

the in us 2 , 75.

"his is a report that present a rare ase of isolated traumati dislo ation of the in us to theantrum and a simple method for ontrolled appli ation of in us to the ossi ular hain.

Case report

) 37$year$old 'oy +as admitted to our department 'e ause of left$sided hearing impairment


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se ondary to motor &ehi le a ident one month after the in(ury. Otos opi e amination andfa ial ner&e fun tion +ere normal. "he tympani mem'ranes +ere normally &isualized. "heotologi tests had sho+n moderate ondu ti&e$type hearing loss 267 d 5 on the left side 2Fig.35.

Fig.1: Unilateral hearing loss as conductive type was determined in audiometric evaluation

) high$resolution Computed tomography s an +ith 3 mm ontiguous se tions of the temporal 'ones dete ted left longitudinal temporal 'one fra tures, dislo ation of the left in us.

"he rest of the ossi ular hain +as found to 'e inta t. "he mastoid air ells and middle ear a&ity+ere +ell aerated 2Fig. 4a, 4'5.


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Fig.2a, 2b Axial 1-mm ! scan through le"t temporal bone at level o" epitympanum showslongitudinal temporal bone "racture. #alleolar head and stapes are visible but not in contactwith body o" incus. $ncus is dislocated and not visible .

)n e ploratory tympanotomy +as performed under general anesthesia &ia a postural approa h."he O!C +as found as dislo ated +hile the in us +as fall to the antrum. "he in us +as remo&edand taken out. 8n us +as re$shaped +ith mi rodrill and pla ed 'et+een malleus and stapes. "hismethod pro&ided an a urate repair of the O!C and resulted in an anatomi ally normalarti ulation as the mass and shape of the ossi le +as preser&ed. Moreo&er, si months after our

patient a hie&ed full air$'one gap losure 2) 9, :3- d H;5 2Fig. 5.


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Fig. % #iglioramento nella perdita dell&udito ' stata determinata in valuta(ione audiometrica sei mesi dopo l&opera(ione

Fig.% $mprovement in hearing loss was determined in audiometric evaluation six months a"teroperation.

Discussion

) large part of all head in(uries in&ol&es the ear and the temporal 'one. "he a idents mostfre1uently en ountered are those in&ol&ing motor &ehi les0 ho+e&er, industrial and athletiin(uries may also present potential lesions in the temporal 'one and middle ear. "he features andmanagement of su h in(uries are dis ussed +ith spe ial emphasis on the ne+ on epts ofdamages to the middle and inner ear +hi h sometimes are a essi'le to medi al or surgi altreatment 24, 75.

"he most ommon form of temporal 'one fra ture, o urring from 'lunt trauma, is thelongitudinal fra ture of the temporal 'one. 8t is estimated that -= of temporal 'onefra tures are longitudinal. ;ongitudinal fra tures of the temporal 'one most often ross thetympani ring, ausing a tear in the tympani mem'rane, and a ti&e 'leeding from the middleear may 'e o'ser&ed. Hearing loss asso iated +ith temporal 'one fra tures o urs in ?@A>?= ofin(ured hildren, 'ut persists 'eyond 3 month in only 3 =. "rans&erse temporal 'one fra turesare asso iated +ith sensorineural loss from in(ury to the o hlea or organ of Corti, and


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longitudinal temporal 'one fra tures usually ause ondu ti&e hearing loss 26$?5.

Bhen the otos opi e amination is found to 'e normal, an ossi ular hain lesion must 'esuspe ted. ) high$resolution C"$ s an +ith 3 mm ontiguous se tions is the method of hoi e for

assessing the etiology of a ondu ti&e hearing loss 2>>5 ?7A>@.


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. .D. !+artz, H.E. Harns'erger, !.#. Mukher(i, "he temporal 'one/ ontemporarydiagnosti dilemmas, Eadiol Clin North )m ? 23>>@5 @3>A7 .

6. H. 9larner, M. Meuli, . Hof, . 9allati, D. Nadal, %. Fis h et al, Management of

petrous 'one fra tures in hildren/ analysis of 34< ases, "rauma ? 23>>65 3>@A4-3.

7. !. Ort, #. eus, . 8saa son, Gediatri temporal 'one fra tures in a rural population.Otolaryngol Head Ne k !urg 3 3 24--65 6 $ . ).E. Hozapfel, C.I. Chang, #.D. Gereira, Ossi ular hain dislo ation +ith normalhearing, ar Nose "hroat @6 24--75 73$7 .

3-. . Nikolaidis, "raumati dislo ation of the in udostapedial (oint repaired +ith tissueadhesi&e, ;aryngos ope 343 24-335 7


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la k of anamnesis for any pre&ious ear diseases. "hese su'(e ts 23 patients5 report poorunderstanding of spee h in riti al onditions and ha&e a noise$toleran e le&el of 4.

)roup % / Gatients +ith diseases of the sound$ ondu ting part of the hearing analyzer,a ompanied 'y ondu ti&e or om'ined hearing loss and su'(e ti&e noise. 24 patients, aged 37to 735 )&erage hearing loss/ 64 d 2through air ondu tion for 7--, 3---, 4--- and 6--- Hz.50noise toleran e A patients +ith hroni ailments of general hara ter A high 'lood pressure, dia'etes,artrosis alterations of the spine A a&erage hearing loss/ 6< d 2through air ondu tion for7--, 3---, 4--- and 6--- Hz.5, and a noise toleran e le&el of 6

• 44 patients e posed to hroni noise damage A a&erage hearing loss/ ? d 2through airondu tion for 7--, 3---, 4--- and 6--- Hz.5, and a noise toleran e le&el of .

Clinical diagnosing

For pulsing noise is parti ularly diffi ult, and re1uires a 'road spe trum of ommon medi al andaudiologi al e aminations, to define and o'(e ti&ely determine the kind of tinnitus +ithma imum a ura y, as +ell as its duration and in some ases, the origin of the su'(e ti&e noise."he ne essary e aminations in lude/

• anamnesis0

• otolaringologi al status he k0

• general medi al e aminations A to &erify the ardio&as ular, kidney, endo hrynologi al,meta'oli , ollagen diseases and others0

• audiometri e aminations A tonal and spee h audiometry, tympanometry andimpedan emetry, O) , rainstem &oked Eesponse )udiometry,ele tronystagmography. Be reated our o+n self$assessment s ale for su'(e ti&e noise,for noise toleran e le&els 2- A 3-50


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• 'lood riteria/ Full 'lood test, and an e amination of the thyroid hormone le&els0

• imaging e amination/ C)"$s an and ME8.

8n this +ay, +e an determine the kind and degree of hearing loss, the topi of the lesion, and +ean e lude retro$ o hlear damage, Mor'us Meniere, se ondary hydrops of the la'yrinth, as

+ell as intera tion +ith other diseases.

Results

Be applied different treatment to the patients in the groups des ri'ed a'o&e, a ording to theetiology of their onditions, as +ell as non$medi al therapy, +ith different time spans.

). "he patients +ith a ute a ousti trauma +ere treated +ith orti al steroids in de reasingdoses, &essel$e panders, de$s+elling su'stan es, and &itamins of the group. "he treatment+as ondu ted for 3- days, on an inter$&ein 'asis, and 37 days per os. 8n the he k e aminationon the tenth day, +e noted an impro&ement in the hearing, from < d to 4 d , and aninfluen e in the noise from le&el < to le&el 3-.

. 8n treating the patients of the se ond group, +e used the follo+ing medi aments/

De ametazone0 enzodiazephines and a silen ing of the noise 'y listening to pleasant musi2analogi al to tinnitus retraining therapy5. "he results after 3- days of training +ere/ a positi&einfluen e on the stress le&els, 'ut +ith the noise persisting, +ith an intensity le&el of @. "he

ontinuation of the treatment for a further 4- days did not lead to any su'stantial hanges.

C. "he patients in this group +ere treated etiologi ally, a ording to their 'asi disease, 'yadditional therapy of orti al steroids and &itamins. )s a result of this treatment, +e o'ser&ed

orrelation 'et+een the dynami s of the main inflammatory disease of the middle ear and thedegree of the hearing and noise damage. "he hanges on the tenth day +ere/ an impro&ement in

hearing, from 64 to 43 d , and a de rease in noise to le&el >.

D. 8n treating the patients of this group, the first su'$di&ision +as treated +ith medi aments,su h as &essel$e panding su'stan es and &itamins, and non$medi ament therapy, +ith tinnitus$masker or the use of hearing aids for permanent hearing loss. "he result is a hange in o'(e ti&enoise from 6 to ?, for the patients +ithhearing aids, +hi h e perien e 'etter so ial intera tion


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+ith the impro&ement in their hearing, and therefore, 'etter toleran e of their o+n noise. "he patients of the se ond su'$di&ision +ere treated intensi&ely +ith orti osteroides in de reasingdoses, &essel$e panders, de$s+elling su'stan es, and group &itamins. "en days later, thetherapy +as ontinued +ith 'enzodiazepines and tinnitus masker. Be registered an

unsatisfa tory hange in relati&ely fe+ of the patients.

Treatment

+ith a mild e""ect / ;ido aine, enzodiazepines, )ntidepressants, le tri al stimulations,no aparine

+ith a moderate e""ect / Car'amazepine, 9inko$ ilo'a, 9a'apentine, essel$e panders,itamins, Minerals, De ametazone

on-medicament therapy applied / tinnitus$masker, hearing aids, tinnitus retraining therapy andothers.

Be re ommend, if there is a persisting su'(e ti&e noise in the ear/

• a&oid loud sound, noise and &i'ration0

• a&oid ner&ous stimulants, su h as affeine and ni otine, e&en in small 1uantities0

• a&oid ototo i drugs, lengthy dosage of aspirin, nonsteroid antiflamatory, 1uinine and itsderi&ati&es, and ototo i anti'ioti s, some diureti s, hemotherapy +ith is$platinum0

• patients +ith su'(e ti&e ear noise should keep to ertain physi al regimes and dieting.

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Traumatic Total Incus Dislocation From Ossicular Chain