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Fracture of the Incus Caused by Digital Manipulation of the Ear Canal and its Diagnosis Using Wideband Acoustic Immittance

Masud, Salwa F.*; Knudson, Inge M.; Stankovic, Konstantina M.; Nakajima, Hideko Heidi

doi: 10.1097/MAO.0000000000002103

Objective: To describe the first reported case of a fracture of the long process of the incus due to digital manipulation of the ear canal and to discuss diagnostic markers for ossicular fractures.

Patient: A 46-year-old woman with incessant clicking and crunching in her left ear, and hearing loss after digital manipulation of the ear canal.

Intervention: Diagnostic evaluation and therapeutic ossiculoplasty.

Main Outcome Measure(s): Audiometric and wideband acoustic immittance (WAI) measurements were made before surgery to investigate the cause of clicking sounds and mild conductive hearing loss (CHL).

Results: The clinical suspicion of a loose ossicular chain was confirmed by a large narrow-band decrease in power reflectance (calculated from WAI) at frequencies between 600 and 700 Hz, and a mid- to high-frequency air-bone gap. Exploratory tympanotomy revealed an ossicular fracture of the distal aspect of the long process of the incus. Ossiculoplasty with bone cement resolved bothersome clicking sounds.

Conclusion: A finger inserted into the ear canal can produce an air seal, and subsequent quick removal of the finger can result in the fracture of an ossicle. Clinicians should be cognizant of this form of trauma because insertion of a finger, ear plug, and earphone into the ear canal are common. Ossicular fractures can result in high-frequency CHL, and can be misdiagnosed as sensorineural loss because bone conduction thresholds are not measured above 4 kHz. As in this case, an ossicular fracture may be misdiagnosed and result in inappropriate treatment. Here, WAI, a non-invasive measure of ear mechanics, diagnosed a loose ossicular chain.

*Program in Speech and Hearing Bioscience and Technology, Harvard University, Cambridge

Eaton-Peabody Laboratory

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts

Address correspondence and reprint requests to Salwa F. Masud, M.S., 243 Charles Street, Boston, MA 02114; E-mail:

H.H.N. and K.M.S. have jointly contributed as senior authors.

Funding received for this work from National Institutes of Health NIH/NIDCD R01 DC013303, NIH/NIDCD F31 DC016761, and the Speech and Hearing Bioscience and Technology NIH training grant.

These data have not been published in another journal or presented at a professional meeting.

The authors disclose no conflicts of interest.

Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company