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Malleus fracture: experimental and clinical aspects
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Otorhinolaryngology.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Patients with malleus fractures are described as rare in the literature. The cause of these fractures are most commonly trauma and digital manipulation of the ear canal, while in some cases the causes are unknown. At our clinic we record one new case every year, which leads to an incidence of approximately 40-50 new cases every year in Sweden. Different treatments have been proposed for this condition. However, since the condition is rare, no consensus has been reached regarding the best treatment. Additionally, it remains unclear whether malleus fractures can heal.

Aim: To get a deeper understanding of how malleus fractures occur, how they should be treated surgically, and if the malleus shows any sign of bone healing.

Materials and methods: Paper I. We carried out both a retrospective study of the medical records of nine Swedish patients with isolated malleus fractures, and a literature review of this condition. Symptoms, clinical findings and patients’ history were collected.Paper II. Ossiculoplasty on human temporal bones was performed in the presence of a malleus fracture. We developed a surgical model from freshly frozen human temporal bones, and we performed Laser Doppler vibrometry (LDV) measurements on this model both before and after ossiculoplasty.Paper III. We performed ossiculoplasties with different types of partial ossicular replacement prostheses (PORP) on human temporal bones and we measured the results with LDV.Paper IV. We performed an in vivo animal study on Merino sheep, in which we produced isolated malleus fractures. We then compared the bone healing of these fractures with that of the nasal bone and the mandible. Bone healing was detected with micro-CT.

Results: Paper I. The most common cause of isolated malleus fractures was found to be a so-called “digital” trauma, which occurred when the patients had removed a finger from the wet ear canal after bath. The hearing loss was occasionally accompanied by tinnitus and transient pain. Pneumatic otoscopy and tympanometry showed a hypermobile tympanic membrane, while audiometry showed a conductive hearing loss that increased towards higher frequencies.Paper II. Our LDV measurements indicated that fixation of an isolated malleus with bone cement may give the best results after surgery.Paper III. The best LDV measurements were obtained when ossiculoplasty was done using a PORP in lateral contact with both the tympanic membrane and the malleus handle.Paper IV. In our animal study we found no signs of bone healing at micro-CT four weeks after producing the malleus fractures. In contrast, both the nasal bone and the mandible showed bone healing. This indicates that the bone healing properties of the ossicles probably differ from those of other bones in the body.

Conclusion: Digital trauma is the major cause of isolated malleus fractures. Pneumatic otoscopy and tympanometry showed a hypermobile tympanic membrane, while audiometry showed a conductive hearing loss increasing towards the higher frequencies. We developed a method to employ freshly frozen human temporal bones and we used LDV for detecting optimal results. This method allows to evaluate and develop otosurgery, aimed to restore hearing after an interrupted ossicular chain. The animal study indicates that malleus fractures will not heal spontaneously.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 52
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2013
Keywords [en]
malleus fracture middle ear human temporal bone laser doppler vibrometry
National Category
Otorhinolaryngology
Research subject
Oto-Rhino-Laryngology
Identifiers
URN: urn:nbn:se:umu:diva-156847ISBN: 978-91-7855-021-0 (print)OAI: oai:DiVA.org:umu-156847DiVA, id: diva2:1292833
Public defence
2019-03-29, Aulan, Sunderby sjukhus, Luleå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-03-08 Created: 2019-03-01 Last updated: 2019-03-21Bibliographically approved
List of papers
1. Self-inflicted negative pressure of the external ear canal: a common cause of isolated malleus fractures
Open this publication in new window or tab >>Self-inflicted negative pressure of the external ear canal: a common cause of isolated malleus fractures
2010 (English)In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 130, no 3, p. 410-416Article in journal (Refereed) Published
Abstract [en]

We report the investigation of the cause of isolated malleus fractures based on four recent patients at our clinic and five patients reported to us by Swedish otosurgeons. In recent years we have treated four patients with isolated malleus fractures. Colleagues in the Swedish Society of Otosurgeons were encouraged to send us reports on patients with diagnosed isolated malleus fractures, resulting in five more cases. A literature review focusing on the cause and management of this injury was also conducted. Eight of nine patients in the Swedish material had the same history. The patients had inserted a finger into the external auditory canal (most often after a bath) and then pulled it out. Immediately afterwards they experienced a short pain and a hearing loss. An audiogram revealed a conductive hearing loss. After exploration of the middle ear, the most common operation performed was ossiculoplasty. In the present material the most common cause of isolated malleus fractures was a sudden negative pressure in the external auditory canal created by a quick outward movement of a finger in the external ear canal. Since this fracture appears to be infrequent, it can easily be missed at otomicroscopic examination. Tympanometry and pneumatic otomicroscopy are helpful diagnostic tools.

Place, publisher, year, edition, pages
Taylor & Francis, 2010
Keywords
Conductive hearing loss, ossiculoplasty
National Category
Otorhinolaryngology
Identifiers
urn:nbn:se:umu:diva-90921 (URN)10.1080/00016480903177521 (DOI)000274884500017 ()19707905 (PubMedID)
Available from: 2014-07-03 Created: 2014-07-03 Last updated: 2019-03-01Bibliographically approved
2. Ossiculoplasty on Isolated Malleus Fractures: A Human Temporal Bone Study Using Laser Doppler Vibrometry
Open this publication in new window or tab >>Ossiculoplasty on Isolated Malleus Fractures: A Human Temporal Bone Study Using Laser Doppler Vibrometry
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2016 (English)In: Otology and Neurotology, ISSN 1531-7129, E-ISSN 1537-4505, Vol. 37, no 7, p. 895-901Article in journal (Refereed) Published
Abstract [en]

Hypothesis: In the literature several surgical methods have been reported that aim to improve hearing in patients with isolated malleus fractures; however, it is still not clear which method gives the best results.

Background: In this study, laser Doppler vibrometry (LDV) was used to compare the outcome of different surgical methods on malleus fractures in fresh frozen human temporal bones.

Methods: Fractured malleus shafts of defrosted human temporal bones were repaired with bone cement, with a malleus prosthesis from cortical bone, or with a partial ossicular replacement prosthesis (PORP) from cortical bone, and LDV measurements were obtained for analysis.

Results: The best result was achieved with the bone cement only, applied directly at the site of the fracture. The malleus prosthesis and the PORP gave similar results.

Conclusion: All three surgical methods gave good results, but when the distal end of the fractured malleus can be attached close to the proximal end, the technique using only cement tends to be the best option. If the parts are too far apart, a malleus prosthesis or a PORP would be good options.

Keywords
Bone cement, Human temporal bone, Laser Doppler vibrometry (LDV), Malleus fracture, siculoplasty, Conductive hearing loss, ossiculoplasty
National Category
Otorhinolaryngology
Identifiers
urn:nbn:se:umu:diva-125585 (URN)10.1097/MAO.0000000000001086 (DOI)000380621200028 ()27253075 (PubMedID)
Available from: 2016-09-23 Created: 2016-09-13 Last updated: 2019-05-06Bibliographically approved
3. An optimal partial ossicular prosthesis should connect both to the tympanic membrane and malleus: a temporal bone study using laser doppler vibrometry
Open this publication in new window or tab >>An optimal partial ossicular prosthesis should connect both to the tympanic membrane and malleus: a temporal bone study using laser doppler vibrometry
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2018 (English)In: Otology and Neurotology, ISSN 1531-7129, E-ISSN 1537-4505, Vol. 39, no 3, p. 333-339Article in journal (Refereed) Published
Abstract [en]

Objective: To compare stapes vibrations in different partial ossicular replacement prosthesis (PORP) applications.

Methods: Stapedial vibrations were measured on fresh frozen human temporal bones with laser Doppler vibrometry. Eight different types of common ossiculoplasty methods were compared regarding recovery of stapes vibrations in relation with the normal ossicular chain. The PORPs were divided into three groups: 1) PORPs with the lateral contact only with the tympanic membrane, 2) PORPs with lateral contact only to the malleus handle, and 3) PORPs with lateral contact with both the malleus handle and the tympanic membrane.

Results: The PORPs with lateral contact only to the malleus handle performed better than the PORPs with lateral contact to the tympanic membrane only at 2 kHZ, but the best recovery was found in the group with contact both to the malleus handle and the tympanic membrane.

Conclusion: The best sound transmission might be achieved by placing a PORP in contact with both the tympanic membrane and the handle of the malleus.

National Category
Otorhinolaryngology
Research subject
Oto-Rhino-Laryngology
Identifiers
urn:nbn:se:umu:diva-156845 (URN)10.1097/MAO.0000000000001699 (DOI)000457772600021 ()
Available from: 2019-03-01 Created: 2019-03-01 Last updated: 2019-03-06Bibliographically approved
4. Malleus fracture healing studied in a new sheep model
Open this publication in new window or tab >>Malleus fracture healing studied in a new sheep model
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(English)Manuscript (preprint) (Other academic)
Keywords
malleus fracture bone remodeling sheep
National Category
Otorhinolaryngology
Research subject
Oto-Rhino-Laryngology
Identifiers
urn:nbn:se:umu:diva-156850 (URN)
Available from: 2019-03-01 Created: 2019-03-01 Last updated: 2019-03-19

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