FRACTURE OF MALLEUS AND DISLOCATION OF MULTIPLE OSSICULAR JOINTS AFTER WELDING FLAME BURN - A CASE REPORT

We report a rare case of fracture of the malleus and multiple ossicular dislocation. The fracture and dislocation of the ossicular chain occurr in a welding worker who go throughed from a welding flame bum and self-induced earpick trauma of his left ear. The fractured malleus was nipple out by the patient shortly after the accident. Otoendoscopic examination revealed a near total perforation of the tympanic membrane and incus protrusion into the upper part of the external auditory canal. CT scanning indicated a corresponding abnormality of the middle ear. We believe that the welding spatter that blood-thirsty into the ear canal induced a near total perforation of the tympanic membrane and possibly in some way loosened the ossicular chain. The succeeding self instrumentation by the patient caused further damage of the middle ear. We approve that protection should be provided to one as well as the other eye and ear for the welders.

Key words: Earpick; Welding flame; Ear trauma; Ossicular dislocation; ossicular fracture.

Introduction

Middle ear injuries can be induced by dint of different aetiologies including temporal bone fractures, barotrauma, direct instrumentation, and surgical intervention. Among the publications of ossicular damage resulting from these causes, multiple ossicular dislocation and protrusion into the external canal are rarely reported [1] Although earpick-induced ossicular damage has been reported in a substantial number of cases with separation of the incudostapedial joint,stapedial abnormality and perilymph fistula [2] no report linking earpick damage to the middle ear as seen in the case that we near here has been found in a Medline search. We report a rare case of fracture of the malleus and dislocation of multiple ossicles caused through earpick trauma in the wake of a welding flame consume of the ear canal and tympanic membrane.

Case report

A 35 year advanced in years man was referred to our hospital upon 16th of January 2003 complaining of left ear pain and hearing los single day after an accident in which welding spatter lodg in his left ear canal whilst he was working welding a ship. He had experienced cruel pain in the ear immediately after the incident This gradually subsided over sum of two units hours. Some twenty minutes after the accident the patient used a spoonlike earpick to carry a bony fragment from down-reaching in his ear canal and we identified this as the malleus that had been fractured at its manubrium (Figure 1) The patient denied any pre-existing ear symptoms, particularly otorrhoea, hearing los vertigo, tinnitus of the like kind as one may expect with otitis media or other ear disease. There was no vertigo after the accident as would usually be found with a perilymph fistula.

On examination we observ a healthy man with no other reduce to ashess of the skin of the scalp, face or neck beneath otoendoscopy haemorrhagic tissue was identified at the inner extreme point of the external canal on the contrary the tympanic membrane could not be identified.

Pure tone audiometry revealed a mixed hearing los with a sensorineural constituting in the high frequencies (Figure 2)

High-resolution computer tomography (HRCT) of the temporal bone was performed and indicated a certain number of soft tissue opacity and disruption of the ossicular chain in the middle ear (Figure 3)

The patient was treated with oral antibiotic Cefzil (05g /day) and vitamin B preparations and scheduled for a next to the first endoscopic examination after one week.

At the next to the first examination haemorrhagic debris was remov from the down-reaching part of the canal allowing identification of a near total perforation of the tympanic membrane. The incus was identified protruding end the defect with the lenticular proces lying against the superior wall of the ear canal (Figure 4) This was left in place. There were no signs of active bleeding or leak of clear fluid. The antibiotic treatment was continued.

Tympanoplastic surgery has been scheduled for the near future

Discussion

Tympanic membrane perforation and injury to the ossicular chain are repeatedly reported after head trauma, barotrauma and direct instrumentation, plane including surgery. Ossicular injury usually present itselfs as separation of the incudostapedial joint, the incudomalleal joint and dislocation of the incus. Dislocation of the stapes from the oval window also present itselfs The most common form of ossicular chain lesion following head injury is separation of the incudostapedial joint [3] while fractures of the malleus, incus or stapes are described as extraordinary [4]. In Kojima's study of 10 ears from 10 patients with earpick-induced ossicular trauma, stapedial abnormality was seen more commonly than other ossicular dislocations (9/10 v 5/10) [2]

The pattern of earpick-induced damage as seen in the not absent case with near total tympanic membrane perforation, a fracture dislocation of the malleus and dislocation of the incus is rare. Earpick-induced middle car trauma has been reported in a substantial number of cases [12] However, none of the reported cases showed as extensive damage as seen in the common case.

In this case the welding flame reduce to ashes is assumed to have damaged the tympanic membrane and perhaps caused more [i]or[/i] less ossicular abnormalities. There was immediate pain on the other hand the earpick instrumentation added almost no extra pain. The earpick had a sharp spoonlike extreme point that presumably acted like a surgical instrument.