MIDDLE EAR TRAUMAS

Dr/ Mai Ghazaly

Lecturer of audio-vestibular medicine
Zagazig university
 MIDDLE EAR TRAUMAS

It take one or more of the following forms

 Tympanic membrane perforation

 Ossicular discontinuity

 Barotraumas

 Fracture base of skull

 MIDDLE EAR TRAUMAS
Tympanic membrane perforation:
common injury, usually due to:

 1. direct trauma from a foreign

body (cotton –bud).
 2. Sudden air or fluid
compression (as it occurs in a
hand-slap to the side of face/ ear,
or ear syringing).
 3. skull-base fracture, when the
fracture line involve tympanic
ring
 MIDDLE EAR TRAUMAS
TYMPANIC MEMBRANE PERFORATION
Sign and symptoms
 Otalgia

 Hearing loss

 ± tinnitus ± dizziness

 ± otorrhoea (bloody initially, purulent if infection

supervenes. Also CSF otorrhoea in temporal bone
fracture).
 Otoscopic examination will reveal a pars tense
perforation with bleeding edges (if recent injury).
 EUSTACHIAN TUBE FUNCTION TEST
INFLATION-DEFLATION TEST
 Idea
Eustachian tube is a potential tube (normally closed). So
tight seal cold be achieved between it and the probe tip
via the perforation with the ability of pressure alternation
between (– ve) and (+ve).
 EUSTACHIAN TUBE FUNCTION TEST
INFLATION-DEFLATION TEST
Steps
 A. put the tip in the ear then detect the seal

If sealing occur if not occur

Decrease pressure
gradually up to -
Eustachian tube
400mm H2o
may be patulous
For clearance of
mucous and debris
 EUSTACHIAN TUBE FUNCTION TEST
INFLATION-DEFLATION TEST
 B. put the pressure to -200 mm H2o
 C. ask the patients to do 4 swallowing

If became between
If the pressure If reach -100 or
- -200 to
not changed less
mm H2o 100

Poor ETF test Good ETF test

Fair ETF test
EUSTACHIAN TUBE FUNCTION TEST
INFLATION-DEFLATION TEST

Good Eustachian tube Poor Eustachian tube function

function test test
 AUDIOLOGICAL ASSESSMENT

Mixed hearing loss in temporal

Conductive hearing loss
bone fracture
 MIDDLE EAR TRAUMAS
TYMPANIC MEMBRANE PERFORATION
 95% of traumatic membrane perforation heal by 6 weeks
after injury.
 Keep the ear dry and treat concurrent infection if present

 If fail to heal within 3 months, consider myringoplasy.

 MIDDLE EAR TRAUMAS
OSSICULAR DISCONTINUITY
Definition:
Loss of normal alignment between the three middle ear ossicules.
Location:
 Most common incudostapedial joint separation/ incudomallelar
joint separation.
 Less common: dislocation of incus, fracture of ossicules

Causes:
 Iatrogenic: middle ear surgery

 Non iatrogenic: blast explosion, fracture temporal bone

 MIDDLE EAR TRAUMAS
OSSICULAR DISCONTINUITY
Clinical picture
 History of trauma

 Hearing loss

 Tinntius

 vertigo

 CT: for documentation and exclude associated ossicules

fractures
 AUDIOLOGICAL ASSESSMENT

Hyper mobile tymapo-ossicular chain Conductive hearing loss ABG>50

mobility )dB HL
 MIDDLE EAR TRAUMAS
OSSICULAR DISCONTINUITY
Management

Hearing aid
Ossiculoplasty
fitting
 BAROTRAUMA
Refers to injury sustained from failure to equalize the
pressure of an air-containing space with that of the
surrounding environment. (Brandon,2002)

The most common examples of barotrauma occur in air

travel and scuba diving
RISK FACTORS:
- Eustachian Tube Obstruction
Temporary: Acute upper respiratory
infection ( Flu )
Intermittent: Allergic rhinitis
Permanent: Cleft palate or orafacial
malformations
External Ear Canal Obstruction-
WHAT ARE OTHER SYMPTOMS OF
BAROTRAUMA?

Hearing Loss
Vertigo) alternobaric vertigo(
Alternobaric Facial Paralysis
HEARING LOSS
-Conductive
-Sensorineural…
due to dysfunction in the inner ear, auditory nerve
or brain.
Mechanism:
- blockage of blood vessels by air bubbles in these
structures.
- leakage of fluid.
- inflammation, or trauma induced degeneration
 .Right Left
0 0
10 10
20 20
30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120
250 500 1000 2000 4000 8000 250 500 1000 2000 4000 8000
Masking
Hz
Intensity Hz
Discrimination SRT Ear

55 65 100% 25 Rt
55 65 100% 25 Lt
 Right Left
2.4 2.4
2.2 2.2
2.0 2.0
1.8 1.8
1.6 1.6
1.4 1.4
1.2 250- 1.2 200-
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
-600 -400 -200 0 +200 -600 -400 -200 0 +200 mmH20
4000 2000 1000 500 Side Ear

NR NR NR NR Contra Right
NR NR NR NR Contra Left
 MIDDLE EAR TRAUMAS
BARORTAUMAS
Management of middle ear barotrauma
 Oral decongestants, short term decongestant nasal spray

 Appropriate antibiotics if secondary infection is present

 Otoinflation with valsalva maneuver

 If fail to resolve, the middle ear effusion is treated with

myringotomy with or without grommet insertion
 If a perforated TM fails to heal within 3 months then
consider myringoplasty.
 MIDDLE EAR TRAUMAS
BARORTAUMAS
Management of inner ear barotrauma
 Bed rest with head elevation, anti-vertiginous
medication, steroids and avoiding coughing, sneezing,
and straining.
 Audiograms should be performed daily. If there is
improvement, continue nonsurgical treatment.
 Most patients recover spontaneously, but if the hearing
loss and vertigo persist or worsen after 5 days, surgical
exploration with repair of the fistula is recommended.
 MIDDLE EAR TRAUMAS
TEMPORAL BONE FRACTURE
According to direction of fracture in relation to long axis of
temporal bone, it can be classified into:
 1. longitudinal (70%)

 2. transverse (20%)

 3. mixed (10%)
 MIDDLE EAR TRAUMAS
TEMPORAL BONE FRACTURE
 Clinical picture
1. Hearing loss can be
 Conducive hearing loss due to middle ear effusion, blood in
the external canal or ossicular damage
 Sensory neural hearing loss more common in transverse
fractures and can be total
2. Dizziness is common but mainly temporary
3. CSF otorrhoea
4. Facial nerve palsy: more common in transverse fracture
 MIDDLE EAR TRAUMAS
TEMPORAL BONE FRACTURE
Investigation
 Pure tone audiometry

 Is CSF leak, collect a sample for analysis

 CT scan of skull base and temporal bone will delineate

fracture line and involved structures.
 MIDDLE EAR TRAUMAS
TEMPORAL BONE FRACTURE
Management
 Manage any associated head injuries

 Facial palsy:

Medical
 high dose steroids (prednisone 1mg/kg)
 Prophylactic antibiotics if CFS leak present > 1 week (high
risk of meningitis)
Surgical
 Consider decompression for patients with immediate
complete paralysis
 If no hearing, perform trans-labyrinthine exploration