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Currently, there is no consensus on the treatment protocol for ossicular chain trauma. This study aims to investigate the classification and treatment strategies for traumatic ossicular chain dislocation. We retrospectively analyzed 15 patients. Traumatic ossicular chain dislocations were categorized based on the location of trauma identified during surgery: Type I-ossicular trauma without stapediovestibular dislocation; Type II-stapediovestibular dislocation (with or without associated incus dislocation). Of the 10 patients with Type I trauma, 9 experienced head trauma, and 1 had a penetrating injury to the external auditory canal. Among these, 2 cases involved incudomalleolar dislocation, 2 cases incus dislocation, 5 cases incudostapedial dislocation, and 1 case a fracture of the anterior and posterior arches of the stapes. Seven patients exhibited conductive hearing loss, while 3 presented with mixed hearing loss. Ossiculoplasty was performed using partial ossicular replacement prostheses (PORP) in 8 patients and total ossicular replacement prostheses (TORP) in 2 patients. Postoperative air conduction thresholds significantly improved in all 10 patients. In Type II trauma, all 5 patients had a penetrating injury to the external auditory canal, resulting in varying degrees of hearing loss. Postoperatively, 3 patients experienced improvement in hearing, while 2 showed no significant change. All patients developed vertigo and tinnitus following the trauma, with vertigo resolving after surgery. Pneumolabyrinth was detected in 2 patients. We propose a novel classification system for traumatic ossicular chain dislocation. Treatment strategies should be tailored according to the specific trauma type., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: As tympanotomy using the transcanal approach was a routine surgical technique for traumatic ossicular disruption, the efficacy of the posterior tympanum approach was rarely explored., Aim: This study aimed to investigate whether the hearing outcomes improved after simultaneous ossiculoplasty and facial nerve decompression using the posterior tympanum approach compared with the transcanal approach., Material and Methods: The data of 11 patients who underwent ossiculoplasty and facial nerve decompression using the posterior tympanum approach and 21 patients who underwent ossiculoplasty via transcannal approach were analyzed., Results: The average air-bone gap (ABG) of patients undergoing posterior tympanotomy showed a statistically significant improvement. Postoperative ABG within 20 dB was observed in 81.8% of patients in the posterior tympanum group and 76.2% of patients in the transcanal group. However, the ABG closure in the two groups was not statistically different., Conclusions and Significance: Simultaneous ossiculoplasty using the posterior tympanum approach was practical, and the hearing outcomes were promising for the patients with traumatic facial nerve paralysis and ossicular disruption.

Background: The ossicular chain status is directly associated with the severity of conductive hearing loss (CHL) when the tympanic membrane (TM) is intact., Aims/objectives: To analyze the relationship between intraoperative findings and audiological data in patients with unilateral CHL and an intact TM., Material and Methods: Forty-three patients who underwent surgery at Xinhua hospital from January 1, 2012, to December 31, 2019, were included and categorized based on their intraoperative findings. Demographic data, intraoperative findings, and preoperative and postoperative audiological results of these patients were analyzed., Results: Patients with ossicular chain disruption had significantly better outcomes than those with ossicular chain fixation (air conduction threshold [ACT]: 26.51 ± 8.82 vs. 44.08 ± 14.41 dB, p  < .01; air-bone gap [ABG]: 10.66 ± 6.47 vs. 18.91 ± 9.32 dB, p  = .04). Patients with ossicular chain deformities had a higher ACT (56.95 ± 13.81 vs. 44.56 ± 15.44 dB, p  = .048) and a larger ABG (43.17 ± 9.94 vs. 33.02 ± 13.41 dB, p  = .047) preoperatively than those with cholesteatoma; however, the postoperative outcomes between both patient groups were similar., Conclusions: Congenital ossicular chain anomalies had similar surgical outcome regardless of the pathology. In acquired cases, ossicular chain disruption had better audiological outcomes than ossicular chain fixation., Significance: Ossicular chain reconstruction can significantly improve the hearing in patients with UCHL with intact TM.

Objectives: To assess the feasibility of radiologic measurements and find out whether hearing outcome could be predicted based on computer tomography (CT) scan evaluation in patients with temporal bone fractures and suspected ossicular joint dislocation., Methods: We assessed 4002 temporal bone CT scans and identified 34 patients with reported ossicular joint dislocation due to trauma. We excluded those with no proven traumatic ossicular dislocation in CT scan and patients with bilateral temporal bone fractures. We measured four parameters such as malleus-incus axis distance, malleus-incus angle at midpoints, malleus- incus axis angle and ossicular joint space. The contralateral healthy side served as its own control. Hearing outcome 1-3 months after the index visit was analyzed. We assessed diagnostic accuracy and performed a logistic regression using radiologic measurement parameters for outcome prediction of conductive hearing loss (defined as >20dB air-bone gap)., Results: We found excellent inter-rater agreement on the measurement of axis deviation between incus and malleus in CT scans (interclass correlation coefficient 0.81). The larger the deviation of incus and malleus axis, the higher probability of poor hearing outcome (odds ratio (OR) 2.67 per 0.1mm, p = .006). A cut-off value for the axis deviation of 0.25mm showed a sensitivity of 0.778 and a specificity of 0.94 (p < .001) for discrimination between poor and good hearing outcome in terms of conductive hearing loss., Conclusion: Adequate assessment of high resolution CT scans of temporal bone in which ossicular chain dislocation had occurred after trauma was feasible. Axis deviations of the incus and the malleus were strongly predictive for poor hearing outcome in terms of air conduction 1-3 months after trauma. We propose a 3-level classification system for hearing outcome prediction based on radiologic measures., Competing Interests: The authors have declared that no competing interests exist.

Background: Transcanal endoscopic ear surgery (TEES) for traumatic ossicular injuries (TOI) is not well studied. Objectives: To analyze the treatment outcomes of TEES for TOI. Material and methods: Retrospective case review of fifteen patients (15 ears) with TOI was performed. The patients underwent an either ossiculoplasty or stapes surgery according to status of the ossicular chain using ear endoscopes. Postoperative audiometric results and complications were analyzed. Results: All subjects demonstrated improvement in their air conduction threshold and air-bone gap (ABG). The mean preoperative air conduction threshold and ABG were 55.3 dB (SD: 12.8) and 33.0 dB (SD: 9.5), respectively. Postoperatively, the air conduction threshold and ABG significantly improved to 28.1 dB (SD: 16.0) and 8.1 dB (SD: 4.5), respectively. Separation of the incudomalleolar joint accompanied by defect of the tegmen, which was not discernible on preoperative imaging, could be identified without additional incision or mastoidectomy. No patients experienced complications or a sensorineural hearing loss. Conversion to open approach was not necessary for any of the 15 procedures performed. Conclusion and significance: TEES for TOI yielded favorable audiometric results without any complication. TEES can provide an alternative method to manage TOI with the advantage of avoidance of skin incisions and mastoidectomy.

Although human bone conduction (BC) hearing is well investigated, there is a lack of information about BC hearing in most other species. In humans, the amount of conductive loss is estimated as the difference between the air conduction (AC) and BC thresholds. Similar estimations for animals are difficult since in most species, the normal BC hearing thresholds have not been established. In the current study, the normal BC thresholds in the frequency range between 2 kHz and 20 kHz are investigated for the Guinea pig. Also, the effect of a middle ear lesion, here modelled by severing the ossicles (ossicular discontinuity) and gluing the ossicles to the bone (otosclerosis), is investigated for both AC and BC. The hearing thresholds in the Guinea pigs were estimated by a regression of the amplitude of the compound action potential (CAP) with stimulation level and was found robust and gave a high resolution of the threshold level. The reference for the BC thresholds was the cochlear promontory bone velocity. This reference enables comparison of BC hearing in animals, both intra and inter species, which is independent on the vibrator and stimulation position. The vibration was measured in three orthogonal directions where the dominating vibration directions was in line with the stimulation direction, here the ventral direction. The BC thresholds lay between -10 and 3 dB re 1 μm/s. The slopes of CAP growth function were similar for AC and BC at low and high frequencies, but slightly lower for BC than AC at frequencies between 8 and 16 kHz. This was attributed to differences in the stimulus levels used for the slope estimation and not a real difference in CAP slopes between the stimulation modalities. Two kinds of middle ear lesions, ossicular discontinuity and stapes glued to the surrounding bone, gave threshold shifts of between 23 and 53 dB for AC while it was below 16 dB when the stimulation was by BC. Statistically different threshold shifts between the two types of lesions were found where the AC threshold shifts for a glued stapes at 2 and 4 kHz were 9-18 dB greater than for a severed ossicular chain, and the BC threshold shifts for a glued stapes at 4 and 12 kHz were 8-9 dB greater than for a severed ossicular chain., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Fractures of the petrous part of the temporal bone are a common lesion of the base of the skull; most of these fractures result from high-energy trauma. In patients with multiple trauma, these injuries can be detected on CT scans of the head and neck, where the direct and indirect signs are usually sufficient to establish the diagnosis. It is important to these fractures because the temporal bone has critical structures and the complexity of this region increases the risk of error unless special care is taken. This article reviews the key anatomical points, the systematization of the imaging findings, and the classifications used for temporal bone fracture. We emphasize the usefulness of identifying and describing the findings in relation to important structures in this region, of looking for unseen fractures suspected through indirect signs, and of identifying anatomical structures that can simulate fractures. We point out that the classical classifications of these fractures are less useful, although they continue to be used for treatment decisions., (Copyright © 2019 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.)

Traumatic head injuries can be associated with ossicular chain disruption. Especially in the setting of temporal bone fractures, proper alignment of the ossicular chain has to be insured. Loss of normal ossicular alignment is associated with conductive hearing loss. Treatment of ossicular chain disruption, so called ossiculoplasty, aims to restore proper anatomic alignment of the ossicles with osseous or cartilaginous autograft and/or prosthetic devices., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Conductive hearing loss (CHL) commonly results from middle ear fluid and inflammation (otitis media). Less commonly in patients with CHL, the middle ear cleft is well aerated or 'dry' with absence of soft tissue or fluid clinically and on imaging. There are numerous causes for this but they can be clinically challenging to diagnose. This pictorial review aims to illustrate and discuss the CT features of both common and less common causes of CHL in patients with a "dry middle ear cavity"., (Crown Copyright © 2018. Published by Elsevier B.V. All rights reserved.)

Purpose: After a trauma, the conductive ossicular chain may be disrupted by ossicular luxation or fracture. Recent developments in 3D-CT allow a better understanding of ossicular injuries. In this retrospective study, we compared patients with post-traumatic conductive hearing loss (CHL) with those referred without CHL to evaluate the relationship between ossicular injuries and CHL. We also assessed the added value of 3D reconstructions on 2D-CT scan to detect ossicular lesions in patients surgically managed., Methods: The CT scans were performed using a 40-section spiral CT scanner in 49 patients with post-traumatic CHL (n=29) and without CHL (n=20). Three radiologists performed independent blind evaluations of 2D-CT and 3D reconstructions to detect ossicular chain injury. We used the t-test to explore differences regarding the number of subjects with ossicular injury in the two groups. We also estimated the diagnostic accuracy and the inter-rater agreement of the 3D-CT reconstructions associated to 2D-CT scan., Results: We identified ossicular abnormality in 14 patients out of 29 and in one patient out of 20 in the CHL and non-CHL groups respectively. There was a significant difference regarding the number of subjects with ossicular lesions between the two groups (P≤0.01). The diagnostic sensitivity of 3D-CT reconstructions associated with 2D-CT ranged from 66% to 100% and the inter-reader agreement ranged from 0.85 to 1, depending of the type of lesion., Conclusion: The relationship between ossicular lesion and the presence of CHL tightly correlated. 3D-CT reconstructions of the temporal bone are useful to assess patients in a post-traumatic context., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Hypothesis: Drilling on the incus produces intracochlear pressure changes comparable to pressures created by high-intensity acoustic stimuli., Background: New-onset sensorineural hearing loss (SNHL) following mastoid surgery can occur secondary to inadvertent drilling on the ossicular chain. To investigate this, we test the hypothesis that high sound pressure levels are generated when a high-speed drill contacts the incus., Methods: Human cadaveric heads underwent mastoidectomy, and fiber-optic sensors were placed in scala tympani and vestibuli to measure intracochlear pressures (PIC). Stapes velocities (Vstap) were measured using single-axis laser Doppler vibrometry. PIC and Vstap were measured while drilling on the incus. Four-millimeter diamond and cutting burrs were used at drill speeds of 20k, 50k, and 80k Hz., Results: No differences in peak equivalent ear canal noise exposures (134-165 dB SPL) were seen between drill speeds or burr types. Root-mean-square PIC amplitude calculated in third-octave bandwidths around 0.5, 1, 2, 4, and 8 kHz revealed equivalent ear canal (EAC) pressures up to 110 to 112 dB SPL. A statistically significant trend toward increasing noise exposure with decreasing drill speed was seen. No significant differences were noted between burr types. Calculations of equivalent EAC pressure from Vstap were significantly higher at 101 to 116 dB SPL., Conclusion: Our results suggest that incidental drilling on the ossicular chain can generate PIC comparable to high-intensity acoustic stimulation. Drill speed, but not burr type, significantly affected the magnitude of PIC. Inadvertent drilling on the ossicular chain produces intense cochlear stimulation that could cause SNHL.

Objective: The purpose of this study was to investigate etiological, clinical, and pathological characteristics of traumatic injuries of the middle ear ossicular chain and to evaluate hearing outcome after surgery., Material and Methods: Thirty consecutive patients (31 ears) with traumatic ossicular injuries operated on between 2004 and 2015 in two tertiary referral otologic centers were retrospectively analyzed. Traumatic events, clinical features, ossicular lesions, treatment procedures, and audiometric results were evaluated. Air conduction (AC), bone conduction (BC), and air-bone gap (ABG) were analyzed preoperatively and postoperatively. Amsterdam Hearing Evaluation Plots (AHEPs) were used to visualize the individual hearing results., Results: The mean age at the moment of trauma was 27.9±17.1 years (range, 2-75 years) and the mean age at surgery was 33.2±16.3 years (range, 5-75 years). In 10 cases (32.3%), the injury occurred by a fall on the head and in 9 (29.0%) by a traffic accident. Isolated luxation of the incus was observed in 8 cases (25.8%). Dislocation of the stapes footplate was seen in 4 cases (12.9%). The postoperative ABG closure to within 10 and 20 dB was 30% and 76.7%, respectively., Conclusion: Ossicular chain injury by direct or indirect trauma can provoke hearing loss, tinnitus, and vertigo. As injuries are heterogeneous, they require a tailored surgical approach. In this study, the overall hearing outcome after surgical repair was favorable.

Objective: We analyzed audiologic and surgical findings in patients with conductive hearing loss (CHL) with an intact tympanic membrane (TM) that was of a non-inflammatory origin., Methods: We reviewed data from patients who underwent exploratory tympanotomy for CHL with intact TM from January 1995 to November 2012. Patients with diseases of non-inflammatory origin were enrolled (69 patients; 79 ears). Patients were categorized into two groups: non-trauma (50 ears) and trauma (29 ears). Demographic data, intraoperative findings, and audiologic results were obtained and analyzed., Results: Overall, the second decade was the most common age of diagnosis in both the non-trauma and trauma groups. Operative findings showed that ossicular dislocation was more prevalent than ossicular fixation; all trauma group subjects had ossicular dislocation. Short columellization or partial ossicular replacement was the most frequently adopted surgical procedures in both groups. Overall, audiologically, air-conduction thresholds (ACs) and air-bone gaps were significantly improved over the short- and long-term period in both groups. However, the non-trauma group had significantly higher preoperative ACs than the trauma group, especially at low frequencies., Conclusion: This study provides clinicians with useful information regarding the clinical characteristics of CHL with intact TM of non-inflammatory origin., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Importance: Physicians should ideally be able to provide patients with chronic otitis media and/or cholesteatoma specific information about postoperative hearing outcome, based on their level of preoperative ossicular chain damage (OCD)., Objective: To identify the influence of preoperative OCD on hearing outcomes in patients after chronic otitis media and/or cholesteatoma surgery., Data Sources: PubMed, EMBASE, and the Cochrane Library databases were systematically searched for available evidence, without any constraints, on December 13, 2014, for articles published between January 1, 1975, and December 13, 2014., Study Selection: We reviewed the literature for articles assessing the prognostic value of OCD on postoperative hearing outcome (air-bone gap [ABG] in decibels), using Austin-Kartush criteria or independent OCD classification systems. We assessed relevance and validity using a self-designed critical appraisal tool based on the Cochrane Collaboration's risk of bias tool., Data Extraction: Characteristics of study populations and postoperative ABGs in decibels were extracted from all included studies by 4 authors (E.F.B., M.N.G., N.J.K., A.S.H.J.L.)., Results: The tested hypothesis was formulated before data collection. Primary study outcome was defined as postoperative adult hearing outcomes after COM and/or cholesteatoma surgery defined as mean postoperative ABG. Our search yielded 5661 articles. Nine articles with high relevance were included. Pooled results of studies using the Austin-Kartush criteria showed a significant (P < .001) difference in mean ABG in favor of group B, when comparing group B (patients with malleus present, stapes absent; 11.1 [95% CI, 10.3-11.8] dB) to group C (patients with malleus absent, stapes present; 15.7 [95% CI, 14.6-16.7] dB) and group B to group D (patients with malleus absent, stapes absent; 16.5 [95% CI, 15.2-17.9] dB). Three studies using independent OCD classification criteria found no influence of stapes structure (intact stapes suprastructure, 13.5 [95% CI, 10.3-16.7], 15.1 [95% CI, 11.8-18.3], and 21.9 [95% CI, 15.0-28.8] dB vs absent stapes structure, 12.8 [95% CI, 9.5-16.1], 19.5 [95% CI, 14.9-24.1], and 30.2 [95% CI, 24.7-35.8] dB) on postoperative ABG. One study reported a significant (P = .04) difference in mean ABG between patients with present (18.9 [95% CI, 15.7-22.1] dB) and absent (24.4 [95% CI, 20.2-28.6] dB) malleus., Conclusions and Relevance: Pooled results of Austin-Kartush studies showed that in patients with COM, with or without cholesteatoma, the malleus status is a significant predictor of postoperative hearing outcome, independent of the stapes condition. Studies reporting on individual ossicle status supported this finding by showing that only malleus condition influenced postoperative hearing outcome. These findings are based on level IV evidence, which indicates the need for future high-level evidence studies.

Stapediovestibular dislocation is an unusual form of ossicular trauma. In this article, a case of medial stapediovestibular dislocation and pneumolabyrinth due to penetrating injury with a stick diagnosed on temporal bone CT is described. In particular, 3D CT renderings can aid in the evaluation of the displaced ossicles., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Conclusion: More severe high frequency hearing loss, especially at 8 kHz, occurs with fracture of the stapes suprastructure (SSF) compared with isolated incudostapedial joint dislocation (ISD). Successful hearing gain can be achieved in the speech range with appropriate ossicular reconstruction., Objectives: Traumatic SSF is a rare consequence of head trauma. This study aimed to demonstrate the characteristic features of SSF compared with traumatic ISD., Methods: Eighteen patients who suffered from conductive hearing loss after head trauma and were operated from 2000 to 2012 were enrolled. Eight and 10 patients were confirmed to have a traumatic SSF (SSF group) and ISD (ISD group), respectively. The etiology of ossicular disruption, preoperative CT scan of the temporal bone, and intraoperative findings were retrospectively reviewed. Pre- and postoperative hearing was analyzed by both pure tone averages and thresholds at each frequency (0.5-8 kHz)., Results: The most common etiologies in the SSF group were fall (n = 3) and direct ear trauma (n = 3), and for those in the ISD group, the most common etiology was traffic accident (n = 6). CT scan showed no evidence of fracture in the SSF group, whereas findings of ossicular dislocation were found in 70% of patients in the ISD group. Hearing outcomes according to the frequencies demonstrated that pre- and postoperative hearing loss at 8 kHz was more severe in the SSF group than in the ISD group. In a comparison of hearing outcomes at each frequency, the postoperative hearing threshold at 8 kHz was higher than for other frequencies. Postoperatively, 63% of the SSF group and 70% of the ISD group obtained an air-bone gap of within 15 dB.

Background: Up to 53% of individuals suffering from traumatic brain injuries develop tinnitus., Objective: To review the current literature on trauma-associated tinnitus in order to provide orientation for the clinical management of patients with trauma-associated tinnitus., Materials: A systematic literature search has been conducted in PubMed database applying the search terms posttraumatic tinnitus and trauma-associated tinnitus. Results have been complemented by related studies, book chapters, and the authors' clinical experience., Results: Not only mechanical, pressure-related, or noise-related head traumata but also neck injuries and emotional trauma can cause tinnitus. Exact diagnosis is essential. Disorders such as ossicular chain disruption, traumatic eardrum perforation, or perilymphatic fistula can be surgically treated. It should also be considered that pulsatile tinnitus can be a sign of life-threatening disorders such as carotid cavernous fistulas, arteriovenous malformations, and carotid dissections. Also, posttraumatic stress disorder should be taken into consideration as a potential contributing factor., Conclusions: There is an evident mismatch between the high incidence of trauma-associated tinnitus and scarce literature on the topic. A consistent and-at best-standardized assessment of tinnitus- and hearing-related sequelae of trauma is recommended both for the improvement of clinical care and for a deeper understanding of the various pathophysiological mechanisms of trauma-associated tinnitus.

Objective: The "Mushroom technique" is introduced in this paper as an alternative technique to reconstruct the total ossicular chain by using autologous grafts where it is not possible to use the patient's ossicles, and to seal a peri-lymphatic fistula (PLF) if present., Materials and Methods: This non randomized retrospective study covers 18 patients aged between 26 and 72 years, operated between January 2006 and March 2012 by the same surgeon using a retro-auricular approach. There were 13 males and 5 females, 12 right ears and 6 left ears. The three ossicles were damaged in 18 patients, a PLF was associated in 3 cases, and a tympanum perforation was present in 2 ears. Postoperative follow-up period was a minimum of 6 months and up to 6.5 years. The origin of 18 patient's disease was; post traumatic in 11 patients and post removal cholesteatoma in 7 patients. The "mushroom technique" was performed for all patients. The average Air Bone Gap (ABG) of each patient was calculated (frequencies 500, 1000, 2000 and 4000 Hz) both pre and 6 months postoperatively., Results: There were no extrusion of the composite graft. In the three cases of PLF; the leak was sealed. And in the two ears with tympanum perforation; the perforation was closed. The average post-operative ABG is 25 dB while it was 45 dB before surgery. Average gain is 20 dB. Non sensorineural hearing loss ocurred., Conclusion: This technique has several advantages: The mounting footplate-fascia-connective tissue-bone-cartilage-perichondrium-tympanum is solid and long lasting, the rate of leak closure in case of PLF is improved; This technique closes the leak, the hearing results are satisfactory, the cost of autograft is null and the tolerance is excellent. On the other hand, it might be time consuming since it is a delicate looking procedure.

Although endoscopic ear surgery (EES) has been used to perform middle ear surgery since 1993, it has not become as common in otologic surgery as it is in endoscopic sinus surgery. This report discusses the problems and the indications for EES in traumatic ossicular disruptions in two cases. Case 1 was a 33-year-old man with a left longitudinal temporal bone fracture who presented with mixed hearing loss, with an average hearing level of 45.0 dB in the left ear. He underwent EES, which revealed incudostapedial joint disrutption. Repositioning of the incus resulted in an improvement in hearing to 18.3 dB postoperatively. Case 2 was a 30-year-old man with a right mixed hearing loss of 56.7 dB. Computed tomography showed a right longitudinal temporal bone fracture and dislocation of the incus. EES revealed dislocation of the incus and fracture of the anterior crus of the stapes. A type IV tympanoplasty was performed, interpositioning the autologous incus between the footplate and the malleus handle. Postoperatively, the average hearing level was 18.3 dB, with a 1.7-dB air-bone gap. Traumatic ossicular disruptions are considered to be a good indication for EES.

Introduction: Syringing of the ear is one of the most common procedures performed for cleaning cerumen from the external auditory canal. Common complications following syringing are pain, external auditory canal trauma and otitis externa. Hearing and vestibular loss have also been reported as complications. However, we are unaware of any report of facial nerve palsy as a complication of ear syringing. Such a case is reported., Case Presentation: We describe a case of facial nerve palsy as a complication of syringing, which demonstrates the dramatic presentation of this condition and emphasises the need for great care while syringing the ears., Conclusion: It is important to be aware of this unusual complication with its distinctive presentation. Surgical intervention should be undertaken at the earliest opportunity, for favourable results. A risk-minimising strategy for ear syringing is recommended.

Objective: To investigate the diagnose therapy and the postoperative curative effect of traumatic ossicular chain disruption and dislocation., Method: Eight cases (8 ears) with traumatic ossicular chain disruption. Six cases of unilateral conductivity deafness, 2 of mixed deafness still with conductive primarily. Eight ears all were performed tympanic exploration and ossicular replacement prosthesis, 1 ear with TORP (total ossicular replacement prosthesis). 4 ears with PORP (partial ossicular replacement prosthesis), 2 with ossicular chain reset, 1 with artificial incus reconstruction. The treatment effect was compared by the preoperative and postoperative ABG (air bone gap)., Result: Preoperative average ABG was 42. 9 dB, the average ABG 3 weeks after operation was 22.3 dB, which reduced 20.6 dB compared to the preoperative, having a statistically significant difference (t = 22.10, P < 0.01). The average ABG was 18.6 dB 6-8 months after operation, which reduced 24.3 dB compared to the preoperative, having a statistically significant difference (t = 12.813, P < 0.01)., Conclusion: The conductivity hearing loss after traumatic ossicular chain disruption or dislocation is preferred operation treatment, and replacement should use different ways according to the operation in case, and the hearing improvement was obvious.

Objectives: To describe the pattern of ear injuries sustained by all British servicemen serving in Iraq and Afghanistan between 2006 and 2009; to identify all servicemen evacuated to the Royal Centre for Defence Medicine following blast injury; to ascertain how many underwent otological assessment; and to calculate the incidence of hearing loss., Design and Setting: A retrospective analysis of data obtained from the Joint Theatre Trauma Registry and the Defence Analytical and Statistics Agency, together with audiometry records from the University Hospitals Birmingham National Health Service Trust., Results: Ear damage was present in 5 per cent of all British servicemen sustaining battle injuries. Tympanic membrane rupture occurred in 8 per cent of personnel evacuated with blast injuries. In 2006, 1 per cent of servicemen sustaining blast injury underwent audiography; this figure rose to 13 per cent in 2009. Fifty-three per cent of these audiograms were abnormal., Conclusion: The incidence of tympanic membrane rupture was higher than that found in previous conflicts. Otological assessment prior to and following military deployment is required to determine the incidence of ear injury amongst British servicemen following blast trauma.

Background: Temporary sensorineural hearing losses after CO(2) assisted stapes surgery have been described in literature. Whether thermal effects are the reason for this side effect is still unclear. The specific aim of this research is to demonstrate the thermal spread during CO(2) laser stapedotomy using a high-speed infrared camera., Material and Methods: Thermal depth effects in physiological saline solutions were examined in cochlea models (glass capillary tube, crystal cuvette and temporal bone preparation). Temperature changes and exchange processes after CO(2) laser application were measured using a high-speed infrared camera. Visualization of gas bubbles triggered by vaporisation underneath the stapes footplate after CO(2) shot was achieved with a high-speed camera. The footplate perforations were performed with a scanner system using a micromanipulator (laser power 20 W, 0.6 mm diameter, continuous wave, duration of 40 ms)., Results: Homogenous temperature increases of more than 100°C were measured on the surface of the footplate and 0.25 mm within the capillary tube after single shot CO(2) laser stapedotomy. Gas bubbles may cause isolated temperature increases of up to 65 K. These effects were found in depths of up to 2 mm underneath the stapes footplate. CO(2) shots on the saline solutions with parameter used for initial laser application may lead to temperature increases between 20-65 K in depths of 3-6 mm., Conclusions: CO(2) applications to an opened inner ear with the same laser parameter used for initial shot on the stapes footplate should be avoided., (© Georg Thieme Verlag KG Stuttgart · New York.)

This article presents a review of diseases of the temporal bone which are relevant for radiologists in routine clinical practice. First the most prominent imaging methods will be briefly summarized with respect to the current state of the art and the most important aspects of cross-sectional anatomy of the temporal bone will be presented. This is followed by the presentation of various inflammatory diseases. Fractures (longitudinal, transverse and mixed fractures), auditory ossicle lesions and contusions of the labyrinth will be discussed in connection with injuries of the temporal bone. Tumors and tumor-like lesions and the clinical symptoms of otosclerosis and malformations will also be discussed. Finally the postoperative use of imaging methods will be presented. Special importance is given to the position of imaging techniques in the diagnostic chain and their evidential value. This is supplemented by special morphological imaging characteristics and aspects of differential diagnostics.

This retrospective study examined the etiology and treatment results for traumatic, conductive hearing loss in 22 patients who underwent surgery between 1998 and 2008 at Osaka Red Cross Hospital. All patients underwent computed tomography (CT) of the temporal bone preoperatively. The ear surgery comprised closure of the ruptured tympanic membranes and restoration of the sound-transmitting function of the ossicular chain. Their mean age was 30.3 years, and the average delay from injury until treatment was 6.0 years. Of the injuries due to foreign-body insertion, the most common cause was ear-pick injury. Incudostapedial disarticulation was the most common finding, which was diagnosed preoperatively using CT in seven cases and identified at surgery in 15 cases. Closure of the air-bone gap to within 10 and 20 dB was observed in 50.0 and 68.2% of the patients, respectively. The hearing threshold improved by 10 dB or more in 16 (72.7%) patients. If no improvement in hearing loss follows the absorption of hemotympanium or closure of an eardrum perforation, dislocation of the ossicular bones should be suspected. Ossicular reconstruction following trauma produces more stable and better hearing results, even after delayed treatment.

Introduction: Despite advances in imaging and other diagnostic tests, it is often impossible to establish with confidence a pre-operative diagnosis in a patient with a conductive hearing loss., Methods: We studied a series of 340 exploratory tympanotomies for conductive hearing loss carried out by a single surgeon., Results: The most common operative diagnosis was otosclerosis (n = 164, 48.2 per cent). Ossicular discontinuity was found more commonly than previously reported (n = 103, 30.3 per cent). A small but significant number of patients were found to have cholesteatoma (n = 7.2 per cent)., Conclusions: This information is of value when discussing potential findings at surgery for conductive hearing loss. While otosclerosis is the commonest finding in such cases, a significant number of patients have defects of the ossicular chain.

Introduction: This paper reviews our experience of ossicular chain injuries following head trauma treated at Groote Schuur Hospital, Cape Town, South Africa., Materials and Methods: We performed a retrospective chart review of all patients with a history of head trauma and a conductive hearing loss who had undergone exploratory tympanotomy. Sixteen patients were included in the study., Results: Injury was most common at the incudostapedial joint (63 per cent). Disarticulations of the icudostapedial joint were treated with cartilage interposition in all cases. Audiography showed an improvement in 12 of the patients, with an average improvement of 35 dB., Discussion: We discuss the various options available to the otologist to repair ossicular disruptions after trauma. In this series, cartilage autografts were used in most incudostapedial joint injuries, with excellent closure of the air-bone gap., Conclusion: Cartilage interposition was a very successful method of repairing incudostapedial joint dislocation in this series, at short term follow up.

As the auditory ossicles are difficult to display without harming them in conventional autopsies, lesions of these minute bones and the ossicular chain are regularly missed. In this study, the method of choice in clinical medicine for the examination of such lesions, namely multislice computed tomography, was applied to 100 corpses. The hereby obtained results regarding ossicle luxation and petrous bone fracture indicated that the lesions were not dependant on the amount, but rather on the type of energy inflicted to the head.

Objectives: To retrospectively determine, by using multislice computed tomography (MSCT), whether additional interpretation of sliding-thin-slab maximum-intensity projection (MIP) reformation images improve diagnostic accuracy when compared with the diagnostic interpretation of conventional sliding-thin-slab multiplanar reformation (MPR) CT images for traumatic ossicular chain separation., Materials and Methods: Twenty-nine patients with pathologically or clinically confirmed unilateral traumatic ossicular chain separation who underwent temporal bone MSCT were retrospectively identified from electronic medical records. An additional 29 control subjects, who underwent temporal bone MSCT for other reasons, were retrospectively selected from the same period. Two neuroradiologists independently reviewed the 116 temporal bones twice. One review was restricted to MPR ("MPR only") images. The other review used MIP images and MPR ("all reformations") images. The observers were blinded to clinical history, and the 2 reviews took place 8 weeks apart to avoid recall bias. The chi2 test was performed for diagnostic accuracy between MPR images and all reformation images. Cohen kappa statistics was used to evaluate interobserver variability., Results: With "all reformations" images, observer 1 diagnosed traumatic ossicular chain separation in 28 (24.1%) of 116 temporal bones, which is significantly higher than that with MPR (16.4%, 19/116 temporal bones, P < 0.05); Observer 2 diagnosed traumatic ossicular chain separation in 27 (23.3%) of 116 temporal bones, which is also significantly higher than that with MPR (17.2.0%, 20/116 bones, P < 0.05). The kappa values were 0.89 and 0.96, respectively, on the basis of MPR and "all reformations" images that revealed high interobserver agreement, independent of the imaging modality (MPR or "all reformations" images)., Conclusions: Additional interpreting MIP images provided more accurate diagnoses than interpreting MPR images alone for diagnosis of traumatic ossicular chain separation.

Objective: To evaluate the therapeutic effects of epitympanum approach tympanotomy in treating traumatic ossicular chain disruption., Method: Ten patients with temporal bone fracture and trauma of ear, whose CT scan of temporal bone showed that Malleoincudal joint irregular shape in the axial view and incudostapedial joint dislocation in the coronal view, were included in this study, Virtual endoscopy showed Malleoincudal joint separation, incudostapedial joint dislocation and interruption, ossicular chain disruption in all patients. The surgical approach was opening the atticus via temporal line, remaining the intact posterior and superior wall of external acoustic meatus, exposing the atticus and posterior tympanic cavity sufficiently, and treating the lesions of ossicular chain., Result: One patient with the long process of the incus fracture, adopted the fitted incus prosthesis between the handle of the malleus and the head of the stapes. Six patients with Malleoincudal joint separation or incudostapedial joint dislocation, 3 patients with incus body dislocation completely, adopted incus positioning two articulation decis. The air-conducting hearing levels had an enhancement of 25-50dB in average after surgery., Conclusion: The effect of intact canal wall epitympanum approach ossicular reposition in treating traumatic ossicular chain disruption is satisfying.

We report an indirect temporal bone fracture with ossicular chain injury occurring only on the side opposite a facial bone fracture caused by a direct blow. A 45-year-old female was referred to our clinic complaining of right hearing loss. She had suffered a left facial bone fracture in a traffic accident 6 months earlier. Her right hearing impairment was conductive. Exploration of her right middle ear revealed a temporal bone fracture, with ossicular chain separation and a dislocated stapes with a perilymphatic fistula. These injuries were considered to be caused by an indirect force following a blow to the face on the opposite side. Well-developed mastoid cells are composed of sparse, light bone in contrast to the compact bone of the bony canal, ossicles, and otic capsule, and therefore their mechanical compliance may differ.

Objective: To evaluate the clinical use of virtual endoscopy in the traumatic ossicular chain disruption with intact tympanum pre- and post-operation., Methods: The series consisted of 17 cases with temporal bone fracture and 4 cases with tympanum contusion. All were examinated with a high resolution spiral CT by axial and oblique coronal planes of the temporal bone. Three-dimensional reconstruction was processed using the virtual endoscopy software. Ten cases of traumatic ossicular chain disruption were performed with intact canal wall epitympanum approach Ossicular reposition. Eleven patients with facial paralysis were performed ossiculoplasty and facial nerve decompression. Nine cases re-examinated virtual endoscopy after operation., Results: Seventeen cases with temporal bone fractures and traumatic ossicular chain disruption, including 3 cases with the long process of the incus fracture, 9 cases with incus bone dislocation, and 5 cases with incus shedding. In the 4 cases of tympanum contusion, 2 cases with incus bone dislocation, 2 cases with incus bone shedding. The axial plane of temporal bone CT could only showed the fracture line and the hammer and incus bone irregular shape. Perioperatively virtual endoscopy showed hammer incus joint separation, incus stirrup dislocation and joint deformation. Surgery confirmed that the incus body was torn off below the hammer following bone displacement, soft tissue wrapped articular surface, incus and stapes just connected with soft tissue. During the tympanum contusion operation could see incus bone-shedding was valgus. Three to six months after surgery, re-examinated virtual endoscopy showed incus bone dislocation ossicular chain was restored to normal, temporal bone shedding ossicular chain connecting almost intact Hearing increased significantly to the level of practical hearing. The coincidence of traumatic disruption of the ossicular chain by virtual endoscopy and surgery was 100%., Conclusion: Virtual endoscopy was valuable for providing accurate assessment and individual program for treating and following-up the traumatic ossicular chain disruption.

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 +/- 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.

Objective: Surgical treatment of dislocation and fracture of the middle ear ossicles is recommended to be carried out within months of the initial injury. Here we present 6 patients with traumatic ossicular injury whose surgery was delayed over 1 year. We evaluated the clinical and pathological changes that occurred over time and assessed the surgical outcomes in delayed cases., Methodology: Histories of the causative traumas, computerized tomography (CT) and tympanometry findings, pre- and postoperative hearing thresholds, and ossicular damages assessed at the tympanotomies were evaluated., Results: The time lapse between the trauma and the surgery varied from 1 to 6 years. The resultant hearing losses were moderate or moderately severe, conductive, mixed or sensorineural type. Tympanometry and CT revealed ossicular discontinuity in only two cases. In operations, various types of ossicular abnormalities in the form of absence, displacement, fracture and/or fixation were identified. Continuity and mobility of the ossicular chains were restored with various techniques. Air-bone conduction gap was brought to within 20 dBHL in all cases, and within 10 dB in 3 (50%) of the cases. Gains in the bone conduction were also notable., Conclusion: Trauma to the middle ear may result in an elevation in the air and/or bone conduction thresholds due to ossicular disruption and fixation. Our findings confirmed that tympanotomy is superior to methods such as CT and tympanometry in delineating the type and extent of the traumatic ossicular damage, and usually gives favorable results even in delayed cases.

Due to the unusual anatomical situation in the middle ear, there are a variety of possible complications that may occur during tympanoplasty. Dislocation of the ossicular chain with and without opening of the labyrinth, injuries to the facial nerve and hemorrhage from large arteries and veins may occur. Adequate management of these complications is necessary in order to avoid further damage for the patient. The first question in case of an acute complication is always whether it is possible to stop the operation. It is also important to determine the time to react, e.g. if an injury of the facial nerve is assumed, when a revision needs to be performed. It also should be considered to refer the patient to a colleague who is not as emotionally involved in the case as the primary surgeon.

We report a unique case of an ossicular chain injury in a young man. Despite the fact that the patient's incus was dislocated into the external auditory canal while remaining attached to the stapes, his hearing was not affected and remained nearly normal. We discuss the patient's presenting features and our diagnostic and management strategy in this case.

Penetrating middle ear injury can result in hearing loss, vertigo, and facial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disruption; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a perforation in the posterosuperior quadrant of the tympanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other. Both children underwent middle ear exploration and reduction of a subluxed stapes. We discuss the diagnosis, causes, and management of penetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeons should act promptly and be versatile in choosing methods of repairing ossicular chain injuries.

Auricular foreign bodies are usually presented to the emergency department in an easily recognizable fashion. We report the case of a 16-year-old male who presented to the emergency department with complaints of unilateral tinnitus and dysgeusia. He denied any history of injury except for falling from his bike in the woods earlier that day. On examination, a wooden foreign body was found in the external auditory canal. A computed tomography scan revealed a 3-cm-long twig that pierced the middle ear disrupting the ossicles. He was taken to the operating room for removal and microscopic evaluation. On evaluation, the chorda tympani nerve was found to be severed along with disruption of the ossicles. This is an unusual presentation for an aural foreign body, and the resulting injury of the chorda tympani is not well published. One should consider the possibility of injury to the middle and inner ear and perform the necessary clinical evaluation before and after removal of aural foreign bodies.

Post-processing of CT-data allows non-invasive 3D-Visualisation of the middle ear for diagnosis and surgical planning. In this study different post-processing techniques and the clinical application of a 3D-postprocessing algorithm in a large number of patients are presented. 20 normal patients, 6 dissected temporal bones and 213 patients with suspected middle ear pathology were examined using a low-dosage Multi-Slice CT protocol. Virtual endoscopic views of the middle ear and 3D-images of the ossicles were generated using a standardised algorithm. Evaluation of the image quality was performed. The virtual views of the dissected temporal bones were compared to real views. In 32 patients high-quality 3D-models of the individual anatomical structures were generated and displayed using different visualisation techniques. The standardised and evaluated method enabled visualisation of the normal middle ear anatomy. Assessment of different pathologies, especially malformation, trauma, implants and postoperative alterations, was facilitated. The high-quality 3D-models allowed precise imaging of the anatomical structures. 3D-Visualisation of the middle ear using CT-data is beneficial for radiological diagnosis and surgical planning in cases of complex middle ear pathology as a complementary examination technique.

Objective: To investigate the importance of the high resolution computerized tomography of temporal bone in evaluation of traumatic lesions, particularly of the ossicular disruption., Method: Ten patients with traumatic ossicles dislocation underwent preoperative CT scanning followed by surgical exploration of the middle ear., Result: The radiographic finding was consistent with the operative demonstration for malleoincudal disarticulation (3 ears), incudostapedial dislocation (7 ears), and the fracture of temporal bone (8 ears)., Conclusion: The incus was the most vulnerable ossicle in the trauma to the middle ear. CT scans can diagnose exactly the damage position in middle ear.

Tissue adhesives have been available and in use for more than 40 years. They have, however, never been popular for ossiculoplasty because of the reported excessive inflammatory reaction and ototoxicity. The authors present a case of ossicular disruption successfully repaired with tissue adhesive and review the literature.