Volume 32, Issue 1 , Pages 77-79, January 2011
Isolated malleus-handle fracture surgical repair using tragal cartilage
Article Outline
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 [1] 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 [2], [3]. 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 [2], [4], [5], 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. 1A). 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.
Fig. 1.
(A) Preoperative audiogram shows conductive hearing loss in the left ear. (B) Postoperative audiogram shows significant closure of the air-bone gap across the frequency range of 250 to 1000 Hz in the left ear.
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.
Fig. 2.
A malleus-handle fracture was seen at the middle of the manubrium (arrow) via a transcanal approach with an ear speculum.
Fig. 3.
Illustration of an autologous cartilaginous graft inserted into the gap created by fracture injury.
The postoperative course was uneventful. The Gelfoam packing was removed 10 days later. The pure tone audiometry performed at 6 and 12 months postoperatively revealed significant improvement in the left-sided air-bone gap and satisfactory hearing outcome without deterioration (Fig. 1B).
3. Discussion
There is surgical difficulty in restoring the fractured malleus to its original shape and maintaining good sound transmission, especially when the fracture is through the neck. Reconstruction will require removal of the incus and a columella strut to bridge the gap between the stapes head and the manubrium or TM [1]. This type of surgical repair is extensive and involves disarticulating the intact portion of the ossicular chain. Applebaum and Goldin [6] suggested wedging a cortical bone strut in place between the malleus neck at the fracture site and the incus long process. Their surgical outcome was successful. However, this technique may involve more exact estimation of the strut dimension to avoid displacing the fracture site more laterally.
In isolated malleus handle fractures, most cases reported in the literature have been treated conservatively or referred for amplification with a hearing aid if severe hearing loss is not present and the surgical treatment is only partially successful [2], [3], [7]. Harris and Butler [7] have illustrated several forms of isolated malleus-handle fractures and performed surgical repair in one of them using a bone chip wedged into the fracture site. Initially, complete closure of the air-bone gap was achieved. However, the patient's hearing deteriorated over time. Pedersen [8] used bone chips and placed them on either side of the fracture, followed by Gelfoam packing in the inner and outer surface of the TM to hold the chips in position. Because this reconstruction depends on callus formation, sustained TM vibration and movement of the malleus during sound transmission may impair the bony reunion [3], [6]. Recently, a malleus-handle fracture repair using calcium phosphate bone cement has been reported [9]. This bone cement application is superior to fibrin glue because the glue is unable to maintain the shape of the malleus handle with sufficient adhesive power. Because calcium phosphate bone cement is an artificial material, product safety and long-term reliability must be considered regarding its application in repairing an ossicular fracture.
Our presented technique for repairing the isolated malleus-handle fracture does not rely on callus formation or using xenograft implantation materials. We used an autologous tragal cartilage to reconnect the 2 fractured ends by placing it between these 2 fractured fragments using a cross-linking relation. This cross-linking interposition of cartilage helps to restore the fractured manubrium function not by direct union of the fractured ends, but by an indirect union, like a seesaw action, to link the 2 portions. Despite concerns about the weakness of cartilage graft as compared to bone graft, which may be responsible for a limited improvement in closing high-tone air-bone gap, the curvature, flexibility, and adjustable slicing thickness make the tragal cartilage a good material to be wedged perfectly into the gap between the TM and malleus handle. Because the TM was attached to the malleus handle, this intact attachment is able to provide durable strength and limited space to hold the inserted cartilaginous graft in place. Unlike the other techniques mentioned above, our technique does not require any Gelfoam or other efforts to maintain the graft's shape. Hearing improvement can be checked immediately after the surgical procedure and long-term reliability can be expected. Most importantly, the lever action for sound amplification can be restored physiologically and can be easily compared to the other techniques reported in the literature.
4. Conclusion
We present a technique to successfully repair an isolated malleus-handle fracture using an autologous cartilaginous graft. Our approach offers an easy and reliable choice to restore continuity of the ossicular chain and produce a satisfying, subjective hearing ability in this uncommon fracture situation.
Acknowledgments
The authors would like to thank Ms Li-Mei Hsiao of Tri-Service General Hospital for providing the surgical procedure illustration. This work was supported in part by grants from the Research Fund of Tri-Service General Hospital (TSGH-C98-32 and C98-33) and Chen-Han Foundation for Education, Taipei, Taiwan.
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PII: S0196-0709(09)00210-5
doi:10.1016/j.amjoto.2009.09.005
© 2011 Elsevier Inc. All rights reserved.
Volume 32, Issue 1 , Pages 77-79, January 2011
