Acute high frequency conductive hearing loss

History: after swimming at the seaside the 35years old male felt left sided aural fulness like the water stayed in the ear canal. At that time he didn't have any upper airway infection, no problems at airplain on the way back and no fluctuation of hearing except when perform Valsalva maneuver he noticed better hearing. He didn't complain having tinnitus.

Otomycroscopy showed normal TM.
Tympanograms:

Audiometry showed very strange conductive hearing loss, the most pronounced at high frequencies:

Ipsilateral acoustic reflex is absent at the left side what is in accordance with audiogram which shows conductive hearing loss.

When perform the Valsalva maneuver the tympanogram at left side changes:

And the audiogram shows much better hearing:

History of acute drop of hearing, type A tympanograms and down-slope air-conduction audiogram give rise to suspect acute sensorineural hearing loss. But bone conduction and lack of acoustic reflex at the affected side definitely suggest middle ear pathology.

The only middle ear pathology which can explain acute onset of hearing loss and air-bone gap most pronounced at high frequencies is - malleus fracture.

The most frequent mechanisam of this type of injury is a sudden negative pressure applied to the external auditory canal, most often seen after rapid withdrawal of the finger from the EAC after a bath or a shower.
It happened to our patient after swimming, what makes very possible that he tried at some moment to remove water out of ear canal by the finger.

Malleus handle fracture is often seen at otomicroscopy, but maleus neck fracture isn't.

Better look at the tympanograms reveals hypermobility of the left TM, which is caracteristic of all malleus fractures.

Air-Bone gap vary for maleus fractures. But shape of audiogram which shows most pronounced conductive hearing loss at high frequencies is dificult to connect to any other middle ear pathology except malleus fractures.

CT scan can reveal malleus fracture when there is dislocation of the fragments. This is unusally seen with malleus handle fracture, but not so often with malleus neck fracture. CT scans of the patient ear didn't reveal fracture line.

Patients with malleus fracture are indicated for surgical repair. Our patient refused the operation, probably because of moderate hearing loss.

Literature:
1985. Harris JP, Butler D. Recognition of malleus handle fracture in the differential diagnosis of otologic trauma

1989. Pedersen CB Traumatic middle ear lesions. Fracture of the malleus handle, aetiology, diagnosis and treatment

1999. Iurato S, Quaranta A Malleus-handle fracture: historical review and three new cases

2000. Applebaum EL, Goldin AD Surgical management of isolated malleus handle fractures

2003. Ayache D., Williams MT Malleus handle fracture

2005. Bajiens L., Manni J. Isolated Malleus Handle Fracture: Case Report

2006. Punke C, Pau HW Isolated fracture of the handle of malleus. A rare differential diagnosis in cases of conductive hearing loss

2006. Orabi AA Isolated malleus neck fracture

2006. Abo-Khatwa Malleus- Handle Fracture: Literature Review and A New Surgical Approach

2007. Hato N Repair of a malleus-handle fracture using calcium phosphate bone cement
2008. W Chien, 5 slucajeva Isolated fracture of the manubrium of the malleus
2010. Niklasson A., 9 slucajeva Self-inflicted negative pressure of the external ear canal: a common cause of isolated malleus fractures
2010. Casale M Isolated fracture of the malleus handle: a video clip

2011. Blanchard M Isolated malleus-handle fracture

2011. Chang YN Isolated malleus-handle fracture surgical repair using tragal cartilage