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Pneumolabyrinth following traumatic luxation of the stapes into the vestibule
International Journal of Pediatric Otorhinolaryngology (2006) 70, 159—161
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CASE REPORT
Pneumolabyrinth following traumatic luxation of the stapes into the vestibule Sarp Sarac *, Senem Cengel, Levent Sennaroglu Department of Otolaryngology, Hacettepe University School of Medicine, 06100 Samanpazari, Ankara, Turkey Received 31 March 2005; accepted 11 May 2005
KEYWORDS Stapes luxation; Trauma; Pneumolabyrinth; Vertigo; Nystagmus
Summary Pneumolabyrinth can result from traumatic luxation of stapes into the vestibule. The diagnosis of stapes luxation following a head injury can be delayed especially if the otoscopic examination is within normal limits. Here a 15-year-old girl presenting with vertigo and nystagmus following a blunt head injury was presented, whose computerized tomography revealed air in the vestibule and cochlea (pneumolabyrinth) and stapes was found to be luxated into the vestibule. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Case report A 15-year-old girl was admitted to the outpatient clinic of Department of Otolaryngology of Hacettepe University with the complaint of vertigo after a head trauma. The history revealed that she fell on the floor and hit her occiput. She had vertigo, nausea and vomiting immediately after the injury. She had a spontaneous right beating horizontal nystagmus. Otoscopic examination revealed an intact the tympanic membrane without hemotympanum. No fracture lines were observed in the external ear canal. A pure-tone audiometric examination revealed a profound sensorineural hearing loss in the left. Computerized tomography of the temporal bone showed pneumolabyrinth on the left (Fig. 1). There were no fractures or fluid in the mastoid air cells. No air was observed in the right inner ear (Fig. 2). The explora-
tory tympanotomy could be performed only four days after the day of admission because of the initial refusal of the family. The middle ear mucosa seemed edamatous. Round window was normal. When the ossicles were inspected, no fracture or discontinuity was observed, however the ossicular chain was hypermobile. Intact stapes was depressed down into the vestibule. Upon increasing the intrathoracic pressure, oozing of the perilymph was observed from the oval window. By using a 908 pick, the stapes was gently drawn back from the vestibule and left in its place. Fat, taken from lobule of auricle, was used for sealing the oval window around the footplate. Postoperatively the vestibular symptoms disappeared dramatically the next day. However, no improvement was observed in hearing thresholds of the patient.
2. Discussion * Corresponding author. Tel.: +90 533 4105689; fax: +90 312 3113500. E-mail address: [email protected] (S. Sarac).
Although fracture of the stapes is relatively not so uncommon following an ear injury, luxation of the
0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.05.016
160
S. Sarac et al.
Fig. 1 Axial plane of computerized tomography showed air in the vestibule (white arrow) and cochlea (black arrow) in the left ear.
intact stapes out of the oval window or down in to the vestibule is extremely rare [1—6]. The annular ligament, which firmly attaches the stapes to the oval window, and the housing of the stapes in the deep portion of the tympanic cavity, well protected from external trauma are the two main reasons for this rarity. In the closed head injury without fracture, the effect of concussion and inertia may produce derangement of all movable parts particularly when head strikes a hard immovable structure. Movable ossicular chain tends to stay in motion when the head is stopped, which exerts a strong force upon the ossicles. The diagnosis of stapes luxation following a head injury can be delayed especially if
Fig. 2
the otoscopic examination is within normal limits, where vertigo and nystagmus are misinterpreted as a result of head injury. Index of suspicion for stapes luxation should be kept high when such patients present with vertigo, hearing loss and nystagmus. High-resolution computed tomography with thin overlapping slices is the imaging modality of choice which can show the deeply depressed stapes into the vestibule [6,7]. Disruption of the stapediovestibuler joint often causes a perilymphatic fistula and pneumolabyrinth which can also be demonstrated by CT. In the presented case CT failed to show the depressed intact stapes into the vestibule, however it showed pneumolabyrinth, which is considered as
Axial plane of computerized tomography of the right ear was within normal limits.
Pneumolabyrinth following traumatic luxation of the stapes
an important evidence of stapes luxation. Exploratory tympanotomy helps both for the exact diagnosis and the treatment. Unfortunately, there is no settled treatment protocol for these cases due to the limited number of the cases. The condition of the stapes is the key factor for the determining how the surgery should be done. If the stapes is slightly depressed into vestibule, reconstruction with or without removal of the stapes yielded fairly good postoperative hearing results [1,5]. On the other hand, when the stapes is deeply depressed into the vestibule, the risk of additional inner ear damage increases, resulting in unfavorable postoperative hearing results. However, leaving a deeply depressed stapes in the vestibule can cause scarring which may occupy vestibular spaces and may cause late inner ear damage. Such a case was reported by Herman et al. [4], who developed severe sensorineural hearing loss and disabling vertigo 3 years after the trauma. So it seems to be wise to remove the depressed stapes from the vestibule at all costs. This should be performed as soon as possible before the fibrotic bands develop so that additional inner
161
ear damage can be minimized. It is also important to seal the oval window to prevent the perilymph fistula.
References [1] F.G. Arrag, M.M. Paparella, Traumatic fracture of the stapes, Laryngoscope 74 (1964) 1329—1332. [2] Y. Nomura, Effective photography in otolaryngology—head and neck surgery: endoscopic photography of the middle ear, Otolaryngol. Head Neck Surg. 90 (1982) 395—398. [3] L. Vanderstock, H. Vermeersch, E. DeVel, Traumatic luxation of the stapes, J. Laryngol. Otol. 97 (1983) 533—537. [4] P. Herman, J.P. Guichard, T. Van den Abbeele, et al. Traumatic luxation of the stapes evidenced by high-resolution CT, Am. J. Neuroradiol. 17 (1996) 1242—1244. [5] K. Ogawa, J. Kanzaki, S. Ogawa, et al. Traumatic perilymphatic fistulas by earpick, Otol. Jpn. 4 (1994) 189—195 (in Japanese). [6] T. Yamasoba, N. Amagai, S. Karino, Traumatic luxation of the stapes into the vestibule, Otolaryngol. Head Neck Surg. 129 (2003) 287—290. [7] H.R. Harnsberger, R.H. Wiggins, J.D. Swartz, P.A. Hudgins, Pocket Radiologist.TMTemporal Bone Top 100 Diagnoses, Amirsys Press, Utah, 2003, pp. 245—246.
www.elsevier.com/locate/ijporl
CASE REPORT
Pneumolabyrinth following traumatic luxation of the stapes into the vestibule Sarp Sarac *, Senem Cengel, Levent Sennaroglu Department of Otolaryngology, Hacettepe University School of Medicine, 06100 Samanpazari, Ankara, Turkey Received 31 March 2005; accepted 11 May 2005
KEYWORDS Stapes luxation; Trauma; Pneumolabyrinth; Vertigo; Nystagmus
Summary Pneumolabyrinth can result from traumatic luxation of stapes into the vestibule. The diagnosis of stapes luxation following a head injury can be delayed especially if the otoscopic examination is within normal limits. Here a 15-year-old girl presenting with vertigo and nystagmus following a blunt head injury was presented, whose computerized tomography revealed air in the vestibule and cochlea (pneumolabyrinth) and stapes was found to be luxated into the vestibule. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Case report A 15-year-old girl was admitted to the outpatient clinic of Department of Otolaryngology of Hacettepe University with the complaint of vertigo after a head trauma. The history revealed that she fell on the floor and hit her occiput. She had vertigo, nausea and vomiting immediately after the injury. She had a spontaneous right beating horizontal nystagmus. Otoscopic examination revealed an intact the tympanic membrane without hemotympanum. No fracture lines were observed in the external ear canal. A pure-tone audiometric examination revealed a profound sensorineural hearing loss in the left. Computerized tomography of the temporal bone showed pneumolabyrinth on the left (Fig. 1). There were no fractures or fluid in the mastoid air cells. No air was observed in the right inner ear (Fig. 2). The explora-
tory tympanotomy could be performed only four days after the day of admission because of the initial refusal of the family. The middle ear mucosa seemed edamatous. Round window was normal. When the ossicles were inspected, no fracture or discontinuity was observed, however the ossicular chain was hypermobile. Intact stapes was depressed down into the vestibule. Upon increasing the intrathoracic pressure, oozing of the perilymph was observed from the oval window. By using a 908 pick, the stapes was gently drawn back from the vestibule and left in its place. Fat, taken from lobule of auricle, was used for sealing the oval window around the footplate. Postoperatively the vestibular symptoms disappeared dramatically the next day. However, no improvement was observed in hearing thresholds of the patient.
2. Discussion * Corresponding author. Tel.: +90 533 4105689; fax: +90 312 3113500. E-mail address: [email protected] (S. Sarac).
Although fracture of the stapes is relatively not so uncommon following an ear injury, luxation of the
0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.05.016
160
S. Sarac et al.
Fig. 1 Axial plane of computerized tomography showed air in the vestibule (white arrow) and cochlea (black arrow) in the left ear.
intact stapes out of the oval window or down in to the vestibule is extremely rare [1—6]. The annular ligament, which firmly attaches the stapes to the oval window, and the housing of the stapes in the deep portion of the tympanic cavity, well protected from external trauma are the two main reasons for this rarity. In the closed head injury without fracture, the effect of concussion and inertia may produce derangement of all movable parts particularly when head strikes a hard immovable structure. Movable ossicular chain tends to stay in motion when the head is stopped, which exerts a strong force upon the ossicles. The diagnosis of stapes luxation following a head injury can be delayed especially if
Fig. 2
the otoscopic examination is within normal limits, where vertigo and nystagmus are misinterpreted as a result of head injury. Index of suspicion for stapes luxation should be kept high when such patients present with vertigo, hearing loss and nystagmus. High-resolution computed tomography with thin overlapping slices is the imaging modality of choice which can show the deeply depressed stapes into the vestibule [6,7]. Disruption of the stapediovestibuler joint often causes a perilymphatic fistula and pneumolabyrinth which can also be demonstrated by CT. In the presented case CT failed to show the depressed intact stapes into the vestibule, however it showed pneumolabyrinth, which is considered as
Axial plane of computerized tomography of the right ear was within normal limits.
Pneumolabyrinth following traumatic luxation of the stapes
an important evidence of stapes luxation. Exploratory tympanotomy helps both for the exact diagnosis and the treatment. Unfortunately, there is no settled treatment protocol for these cases due to the limited number of the cases. The condition of the stapes is the key factor for the determining how the surgery should be done. If the stapes is slightly depressed into vestibule, reconstruction with or without removal of the stapes yielded fairly good postoperative hearing results [1,5]. On the other hand, when the stapes is deeply depressed into the vestibule, the risk of additional inner ear damage increases, resulting in unfavorable postoperative hearing results. However, leaving a deeply depressed stapes in the vestibule can cause scarring which may occupy vestibular spaces and may cause late inner ear damage. Such a case was reported by Herman et al. [4], who developed severe sensorineural hearing loss and disabling vertigo 3 years after the trauma. So it seems to be wise to remove the depressed stapes from the vestibule at all costs. This should be performed as soon as possible before the fibrotic bands develop so that additional inner
161
ear damage can be minimized. It is also important to seal the oval window to prevent the perilymph fistula.
References [1] F.G. Arrag, M.M. Paparella, Traumatic fracture of the stapes, Laryngoscope 74 (1964) 1329—1332. [2] Y. Nomura, Effective photography in otolaryngology—head and neck surgery: endoscopic photography of the middle ear, Otolaryngol. Head Neck Surg. 90 (1982) 395—398. [3] L. Vanderstock, H. Vermeersch, E. DeVel, Traumatic luxation of the stapes, J. Laryngol. Otol. 97 (1983) 533—537. [4] P. Herman, J.P. Guichard, T. Van den Abbeele, et al. Traumatic luxation of the stapes evidenced by high-resolution CT, Am. J. Neuroradiol. 17 (1996) 1242—1244. [5] K. Ogawa, J. Kanzaki, S. Ogawa, et al. Traumatic perilymphatic fistulas by earpick, Otol. Jpn. 4 (1994) 189—195 (in Japanese). [6] T. Yamasoba, N. Amagai, S. Karino, Traumatic luxation of the stapes into the vestibule, Otolaryngol. Head Neck Surg. 129 (2003) 287—290. [7] H.R. Harnsberger, R.H. Wiggins, J.D. Swartz, P.A. Hudgins, Pocket Radiologist.TMTemporal Bone Top 100 Diagnoses, Amirsys Press, Utah, 2003, pp. 245—246.