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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36

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Traumatic ossicular dislocations: etiology and managementB

Sertaç Yetiser4, Yusuf HVdVr, Hakan Birkent, Bqlent Satar, Abdullah Durmaz
Department of ORL & HNS, Gulhane Medical School, Etlik, Ankara, Turkey
Received 21 September 2006; revised 4 January 2007; accepted 7 January 2007

Abstract Objective: This study was conducted to discuss the etiologic factors, clinical-radiologic findings,
and surgical outcomes in patients with traumatic ossicular pathology.
Material and methods: Thirty-two patients with conductive hearing loss due to trauma were
retrospectively analyzed. Their mean age was 24.56 F 7 years. The average delay from injury until
treatment was 5.7 years. Air and bone conduction hearing thresholds were measured by pure tone
audiometry on initial admission, at 1 month postoperatively and during follow-up at 6-month
intervals. Mean follow-up time is 3.2 years. The hearing threshold was calculated as the mean value
of the threshold for 500, 1000, 2000, and 3000 Hertz. All patients were evaluated by high-resolution
computerized tomography of the temporal bone at axial and coronal sections before the surgery.
Results: Traffic accident was the common cause of injury. Seven patients had temporal bone
fracture. Six patients had facial paralysis ranging between House-Brackmann grades II and IV.
Incudostapedial disarticulation was the most common ossicular pathology. Closure of air-bone gap
within 10 and 20 decibels was observed in 37.6% and 71.9% of the patients, respectively. There is an
improvement of 10 decibels or more in the hearing threshold of 27 (84.3%) patients.
Conclusions: Head trauma can be associated with ossicular disruption, which should be suspected in
patients with conductive hearing loss that persists after a healing process of 2 months. The diagnosis
can be best confirmed by tomography. Hearing results after immediate or delayed ossiculoplasty are
apparently satisfying, although late cases are assumed to be associated with adhesion or fibrosis.
D 2008 Published by Elsevier Inc.

1. Introduction resolution of the middle ear aeration and healing of the

tympanic membrane is indicative of ossicular injury. Me-
The ear can be exposed to a trauma. A direct, mechanical
chanical or acoustic effect during blast trauma can be the cause
injury from a foreign body, barotrauma through the ear canal
of sensorineural component in some patients, which is often
or through the Eustachian tube, or indirect injury of the head
neglected. This is especially evident between 2- and
trauma, with or without fracture by transmission of forces
4-kilohertz frequencies ranging between 10 and 30 decibels.
through the skull, are among the frequent causes of ear injury.
Spontaneous recovery is likely over time in some patients [3].
Trauma to the temporal bone is usually associated with
Severe to profound sensorineural hearing loss is usually
conductive, sensorineural, or mixed hearing loss due to
related with the fractures, which involve the otic capsule
ossicular disruption or labyrinthine damage, and rupture of
leading to cochlear hemorrhage, perilymph fistula, and injury
the oval and round windows [1,2]. Conductive hearing loss
to the cochlear nerve and membranous labyrinth [4].
after head trauma is not only due to ossicular lesion, but also
The purpose of this study is to discuss the etiologic factors,
may be due to traumatic hemotympanium, which may subside
clinical findings, and surgical outcomes in 32 patients with
within days to several weeks after the injury. Persistent
conductive hearing loss due to traumatic ossicular pathology.
hearing loss of 30 decibels or more lasting for 2 months after

2. Materials and methods

B
This study was presented as an oral paper at 25th Politzer Society
Meeting, October 5–9, 2005, Seoul, South Korea.
Thirty-two patients with conductive hearing loss due to
4 Corresponding author. Gulhane Medical School, Department of Orl trauma who were operated on between 1994 and 2005 were
& HNS, Etlik 06018, Ankara, Turkey. retrospectively analyzed. Patients with sensorineural hearing
0196-0709/$ – see front matter D 2008 Published by Elsevier Inc.
doi:10.1016/j.amjoto.2007.01.001
32 S. Yetiser et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36

loss were excluded. Etiologic factors, physical examination,

and intraoperative findings were noted. Preoperative and
postoperative air and bone conduction hearing thresholds
were measured by pure tone audiometry. Pure tone audio-
grams of the patients were performed on initial admission, at
1 month postoperatively, and during follow-up examinations
at 6-month intervals. Minimum 12 months follow-up range
was required. Mean follow-up time is 3.2 years. The hearing
threshold was calculated as the mean value of the threshold
for 500, 1000, 2000, and 3000 Hertz. Paired-samples t test
was used for comparison of the preoperative and postoper-
ative air and bone conduction hearing thresholds and air-
bone gaps. P b .05 was accepted as statistically significant.
All patients were evaluated by high-resolution comput-
erized tomography (CT) of the temporal bone at axial and
coronal sections before surgery (General Electric Medical
Systems, Milwaukee, WI). Overlapping CT sections of Fig. 2. Longitudinal fracture line and disruption of incudomallear
articulation is shown on the axial section of the right temporal bone.
1.5-mm thickness were obtained. The middle ear and the
Blood in the mastoid air cells is also shown. (Longitudinal fracture line is
continuity of the ossicles were retrospectively reviewed. indicated by a black arrow and disruption of the incudomallear articulation
Preoperative audiometric levels and CT results were is indicated by a white arrow.)
compared with intraoperative findings (Figs. 1-6).
impairment before the surgery, which was on the right
side in 19 patients and on the left side in 13 patients.
3. Results Traffic accident was the common cause of injury (Table 1).
3.1. Clinical findings Trauma was caused by bicycle accidents in 2 patients, a
motorcycle accident in 1 patient, and 14 patients had
There were 31 male and 1 female patients, whose mean accidents inside or outside the vehicle. Two military
age was 24.56 F 7 years (range, 13–45 years). The average personnel were injured by mine explosions. Six patients
delay from injury until treatment was 5.7 years (range, had facial paralysis ranging between House-Brackmann
6 days–18 years). All patients suffered from hearing grades II and IV. All recovered with medical therapy except
1 patient, who had subtotal decompression and ossiculo-
plasty. Only 2 patients had tympanic membrane perforation

Fig. 1. Axial high-resolution CT. Displacement of the incus away from the
malleus is shown on the right temporal bone. (Disruption of incudomallear Fig. 3. Displaced incus (marked by a black arrow) fixed in the attic is
articulation is marked with a circle and fracture at the tegmen is marked by shown on the axial section of the right temporal bone in a patient with a 10-
a black arrow.) year story of head trauma.
 S. Yetiser et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36
Fig. 4. Subluxation of the incus without obvious displacement (marked with
an arrow). Increase in space between the articulation surfaces of the incus
and malleus is seen on axial section of the left temporal bone.
and they also had underlying fascial grafting. Associated
problems are listed in Table 2.
3.2. Radiological findings
Seven patients had temporal bone fracture. Six patients
had longitudinal fracture and 1 patient had a mixed-type
fracture. Incudostapedial disarticulation was the most
common finding (Figs. 1 and 2). In 1 patient with a history
of unilateral conductive hearing loss after a head trauma for
Fig. 5. Axial high-resolution CT. Displacement of the bice cream dipQ is
seen on the right temporal bone (marked with a circle), the head of the
malleus is away from the short process of the incus.
33
more than 10 years, the incus was found to be dislocated
and fixed at the attic, which was also confirmed during the
operation (Fig. 3). Incudomallear disarticulation was noted
as the increase in space between the articulation surfaces of
the bones or displacement of the dip of the ice cream
configuration (Figs. 4 and 5). Disruption of the incudomal-
lear articulation was evident in 2 patients who had CT
evaluations at the posttraumatic 5th and 12th days,
respectively. In 1 patient with unilateral posttraumatic
conductive hearing loss and tympanic membrane perfora-
tion, no incus was evident radiologically and no incus was
seen during surgery (Fig. 6).
3.3. Intraoperative findings
All patients had undergone exploration of the middle ear
under general anesthesia. Incudostapedial disarticulation
was the most common finding (Table 3). Of all the ossicular
fracture cases, the most common fracture was the long
process of the incus. Eight patients had more than 1
ossicular pathology. Intraoperative findings are listed in
Table 3. There was fracture of stapes footplate and
perilymphatic leakage in 2 patients who had partial and
total stapedectomy and total ossicular replacement prosthe-
sis (TORP). One of them was repaired by fat and fibrine
glue and by tutoplast dura graft in another patient. The
ossicles were fixed with bone cement in 2 cases: 1 patient
with the fracture of incus long process and the other patient
with malleus fracture. The ossiculoplasty techniques and the
type of prostheses used are listed on Table 4.
Fig. 6. No incus is visible on axial section of the right temporal bone
(marked with white asterisk).
34 S. Yetiser et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36

Table 1 of patients with fracture [8,9]. Brodie and Thompson [10]

Causes of the ossicular trauma in patients with conductive hearing loss reported that 21% of patients with documented hearing loss
Ethiology No. of patients (%) after temporal bone fracture had conductive hearing loss.
Traffic accident 17 (53.1) However, the incidence of conductive hearing loss is much
Falling down from high places 7 (21.8) lower after blast injury. Wolf et al [11] reported 12 (5.7%)
Head trauma 2 (6.2)
ossicular lesions in 210 ears exposed to blast trauma. In this
Mine explosion 2 (6.2)
Direct ear trauma (fist, slam, etc) 3 (9.3) study, closed head trauma due to traffic accident and falling
Injury due to foreign body insertion 1 (3.1) down are the main causes of ossicular injury.
Total 32 (100) Various types of ossicular injury may occur: incudosta-
pedial or incudomalleolar joint separation, dislocation of the
3.4. Audiologic findings incus, dislocation of the malleoincudal complex, stapedio-
vestibular dislocation, or fractures of the ossicles. Disloca-
Audiograms were performed at 1 month postoperatively
tion is the most common type of injury and occurs more
and during the follow-up examinations at 6-month intervals.
Preoperative air-conduction thresholds ranged between 22 often than fracture [1]. Incudostapedial joint separation is
the most common form of traumatic ossicular dislocation,
and 85 decibels, whereas preoperative bone-conduction
as shown in the present study [7,12]. Ossicular fracture is
thresholds ranged between 7 and 35 decibels. Postoperative
less common and incus is frequently exposed to luxation or
air-conduction thresholds ranged between 17 and 65
fracture [6]. Vulnerability of the incus is reasonable because
decibels, whereas postoperative bone-conduction thresholds
the malleus is well stabilized by the tympanic membrane
ranged between 5 and 42 decibels. Pre- and postoperative
and the tensor tympani tendon. On the other hand, the
mean hearing thresholds and air-bone gaps of the patients
stapes is firmly secured by the annular ligament and the
are shown in Table 5. The improvement in air-conduction
threshold and closure of the air-bone gap was statistically stapedial tendon. Absence of the incus after trauma in a
patient with tympanic membrane perforation in the present
significant. Closure of air-bone gap within 10 decibels was
study is an interesting finding. Saito et al [13] proposed that
observed in 37.6% of patients and closure of air-bone gap
the incus may rotate posteriorly along the long process and
within 20 decibels was observed in 71.9% of patients
is pushed to the external auditory canal, or it may protrude
(Table 6). There is an improvement of 10 decibels or more
through the fracture line of the posterior canal wall, which
in the hearing threshold of 27 (84.3%) patients. None of the
must be opened widely enough for dislocation. Implosive
patients showed a decrease in bone-conduction threshold.
force may produce fixation of malleus head in the attic and
malleus fracture or dislocation, which is rare and is usually
4. Discussion found with other ossicular injuries [14]. Isolated malleus
injury is mostly associated with small conductive hearing
Injury of the ossicular chain has various etiologies. The
loss. Stapedial damage is usually associated with balance
main causes of ossicular injury are as follows: insertion of a
problems. There were 5 stapedial lesions in this study. On
foreign body to the external ear canal, particularly in the
the other hand, there seems to be a time delay leading to
pediatric age group; skull trauma, which is frequently due to
surgery unless patients have vestibular problems. This is
a traffic accident; and blows to the temporal, parietal, or
probably due to posttrauma period of unconsciousness or
occipital region with or without fracture of the temporal
bone [5,6]. Ossicular lesions are much more related to head Table 3
trauma with or without fracture rather than blast-type injury. Ossicular lesions observed during surgery
Hasso and Ledington [7] reported that up to 50% of Ossicular pathology No. of patients (%)
temporal bone fractures are associated with ossicular injury. Incudostapedial dislocation and rotation 10 (25)
Tos [8] found 67% of patients with hearing loss immediately of incus with maintaining IM articulation
after head trauma, of which 59% had conductive deafness. Fracture of the long process of incus 6 (15)
Erosion of the long process of incus 5 (12.5)
Persistent conductive hearing loss is found in 15% to 20% Incus dislocation 3 (7.5)
Absence of incus 3 (7.5)
Table 2 Fracture of the anterior crus of stapes 3 (7.5)
Associated problems in patients with hearing loss Stapes footplate fracture 2 (5)
Erosion of the anterior crus of stapes 1 (2.5)
Clinical findings No. of patients (%) Erosion of stapes 1 (2.5)
Facial paralysis 6 (20.7) Fracture of the processus brevis of incus 1 (2.5)
Temporal bone fracture 7 [6 longitudinal + 1 mixed] (24.1) Incus fixation 1 (2.5)
Sudden hearing loss 2 (7) Incudomallear joint dislocation 1 (2.5)
Tympanic membrane perforation 2 (7) Absence of malleus 1 (2.5)
Seconder membrane formation 2 (7) Malleus fixation 1 (2.5)
Osteoma of the external 2 (7) Malleus fracture 1 (2.5)
auditory canal Total 40 (100)
Total 21 (100) IM, incudomallear.
 S. Yetiser et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36 35

Table 4 Table 6
Types of ossiculoplasty Pre- and postoperative gap distribution of 32 patients
Ossiculoplasty No. of patients Gap interval (dB) Preoperative (%) Postoperative (%)
PORP-HA 8 0–10 0 (0) 12 (37.6)
PORP-Flouroplastic 4 10–20 4 (12.5) 11 (34.3)
Incus repositioning 4 20–30 4 (12.5) 7 (21.9)
Incus interpositioning 3 30–40 12 (37.6) 1 (3.1)
Flouroplastic piston prosthesis 2 40–50 8 (25) 1 (3.1)
PORP-Plastipore 2 50–60 2 (6.2) 0 (0)
Incus prosthesis-HA 2 60–70 2 (6.2) 0 (0)
Kruz prosthesis-gold 1
TORP-HA 2
TORP-titanium 1 the disruption of both incudomallear and incudostapedial
No ossiculoplasty 3 articulations, which may be termed as subluxation of the
Total 32 incus maintaining a fibrotic bridge contact at both surfaces
PORP indicates partial ossicular replacement prosthesis; HA, hydoxyapatite. without obvious displacement. This should be suspected
radiologically if the space between the articulation surfaces
priority of other life-threatening injuries depending on the of the incus and malleus has increased, as shown in Fig. 4.
general condition of the patients. Timing of the ossicular This conclusion is important from a surgical point of view.
repair is elective for those patients. Sometimes, hearing One should consider inspecting the incus from both sides if
impairment is neglected or often underestimated, especially the evaluation of the incudostapedial articulation through a
in younger age groups. Wennmo and Spandow [15] transcanal approach is not informative.
reported that the duration of onset of trauma to surgery There are many types of reconstruction methods for
ranged from 9 days to 27 years. The longest span for ossicular pathologies depending on the type and location of
surgery in the present study is 18 years and the average the ossicular injury. Repositioning or interpositioning of the
delay to surgery is 5.7 years. autogenous or homogenous ossicular tissue, cortical bone
Traumatic ossicular lesion is usually associated with grafts, bone cement, and other types of partial or total
longitudinal fractures of the temporal bone extending into prostheses are used for ossicular reconstruction. A cartilage
the middle ear along the tegmen tympani and is present in graft, cortical bone, temporalis fascia, or tissue adhesive
almost 20% of cases with head trauma [1,16]. Injury to the may be used to connect the stapes to the incus if
ossicular chain can be best visualized by high-resolution CT reapproximation is not satisfactory [15,21,22]. Mundada
[2,17-19]. However, diagnosis of ossicular dislocation is et al [21] reported air-bone gap closure within 10 decibels in
sometimes difficult in the presence of hemotympanium or 80.3% of patients with fascial arthroplastic ossiculoplasty in
opacification of middle ear cavity in the case of acute injury. cases of incus dislocation. Mills et al [23] reported their
Magnetic resonance imaging is more useful in evaluating results on physiologic repositioning of dislocated incus with
the membranous labyrinth. Pneumolabyrinth is a significant stabilization of the incudustapedial joint by silicone splint in
radiologic finding that should lead one to suspect the 6 patients with traumatic injury. They found a mean residual
fracture of the stapes footplate [20]. The presence of the bYQ hearing loss of less than 30 decibels at 1 year with some
sign on the coronal high-resolution CT sections of the deterioration over time, which was attributed to the
temporal bones shows lateral displacement of the incus adhesions at the joint. Biomaterials used for ossicular chain
[2,18]. However, coronal projections may be difficult to reconstruction have changed in time with improvement in
obtain in an acutely injured patient. Incudomallear articu- biocompability. Polyethylene and Teflon prostheses had
lation is well visualized on axial CT scans, and the high extrusion rate as compared to hydroxyapatite and
configuration of the articulation is described as bice cream titanium prostheses [24,25]. Pedersen [6] reported a 78%
coneQ [18]. Displacement of the bice cream dip,Q which success in ossiculoplasty in patients with traumatic lesions.
corresponds to the head of the malleus away from the bconeQ Spector et al [26] analyzed the outcome of delayed
( which resembles the body) and the short process of the reconstruction in ossicular fractures in 28 patients and
incus, is indicative of disarticulation. We have also noticed reported air-bone gap closure within 10 decibels in 66% and
within 20 decibels in 82% of patients having more stable
Table 5
Average pre- and postoperative air-bone gap, and air- and bone-conduction
audiologic results in incus replacement prosthesis and type
threshold of 30 patients III tympanoplasty. Meriot et al [19] reported an air-bone gap
Hearing Preoperative (dB) Postoperative (dB) P
of 20 decibels or less in 89% of patients and 10 decibels or
less in 67% of patients. Gap closure of 10 decibels or more
Mean ABG 39.24 F 11.6 17.55 F 10.6 .0004
Mean AC threshold 57.79 F 14.7 35 F 17.6 .0004 was achieved in 84.3% of patients who had undergone
Mean BC threshold 18.3 F 9.2 19.9 F 9 .324 ossiculoplasty. Closure of air-bone gap within 10 decibels
AC indicates air conduction; BC, bone conduction; ABG, air-bone gap. was observed in 37.6% of patients and closure of air-bone
4 Statistically significant, P b .05). gap within 20 decibels was observed in 71.9% of patients.
36 S. Yetiser et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 29 (2008) 31 – 36
The most typical traumatic defect for ossicular reconstruc-
tion seems to be the dislocation of incudostapedial joint in
which incus reposition, interposition, or partial prosthesis
can provide considerable air-bone gap closure. An average
closure of 10 decibels is slightly low in the present study.
This may be due to some blate casesQ with fibrosis or
sclerosis of the ossicles, or may be due to more specific
problems because 8 patients in this series have more than
1 ossicular pathology, of which 2 had total prosthesis with
stapedectomy after stapes footplate fracture.
In conclusion, head trauma can be associated with
ossicular disruption, which should be suspected in patients
with conductive hearing loss that persists after a healing
process of 2 months. However, the diagnosis can be best
confirmed by CT. Hearing results after immediate or
delayed ossiculoplasty is satisfying even though late cases
are usually associated with adhesion and fibrosis.
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