Penetrating Injury Ear

Hi,

I have a 14 yr Male, who sustained penetrating injury right ear by a small needlefish, while 

swimming,  He could feel 'something tearing deep in the ear' when he tried to dislodge it, when most part of the fish broke off, leaving its beak inside. 

When I saw him in the ER (about half hour later), he was fully conscious but vertigenous and vomiting with a Gr III horizontal nystagmus to Left (Injury in R ear). No facial palsy. Could bring him to ENT OP on a wheel chair and I instilled a few drops of 2% Xylocaine into his bloody right ear canal. After a couple of minutes with Welch Allyn Lumiview to see, eased  out the FB using a ear microforceps.

 It was the beak of the fish, about 3 cm long.

<(Left: The two pieces of FB from Ext Ear Canal

Right:The beak opened, mirco-forceps kept alongside                      )>

 

A peak inside revealed tramatic large perforation of the TM, with the HOM lying in a deeper plane, as if leaning back on the promontary. I wondered if it were really the HOM or another FB, like a broken piece of the beak. 

Took him to OT and under GA, examined the ear under microscope. No sign suggesting perilymph fistula. Cleaned the site with light suchtion. TM was found to be torn off in front and behind the HOM, the malleus subluxated to a deeper and anterior location. Also, could see another FB, a greenish-black, irregular, bony-hard bar in the middle ear, deep to the malleus, and at right angles to it. Incus couldn't be seen, head and neck of the stapes were visible. With some difficulty (as the long axis of the FB was at right angles to the handle of malleus) FB was removed which was found to be part of the broken tip of the lower beak. 

In the picture, near the thumb is the new piece retrieved from the middle ear, cleaned of the greenish black skin; and that near the micro-cup forceps is the earlier one from external canal )>

                     After lavage with lukewarm saline, instilled Ciprofloxacin and Dexamethasone drops and the ear was plugged and patient sent to the ward on systemic antibiotics. Also Inj. Dexa-methasone 4mg is being given OD parenterally.

After two nights, today, he is doing much better. Vertigo is episodic. Nystagmus is Gr I. TM is healing well, and Seigelisation doesn't provoke any vertigo. Weber's (512Hz) was lateralized to the same side, with BC > AC there. In Left ear AC>BC. Pure Tone Audiogram shows Mixed loss (Audiologist: me)

Freq	250	500	1K	2K	3k	4k	6k	8k
RAC	55	50	55	65	90	85	85	80
RAC(mskd)	55	65	65	65	90	100	90	NA
RBC (mskd)	15	20	30	45	55	35?	50?	NA
LAC	25	30	20	30	35	35	35	35

Since patient is doing well, I am planning to do a Temporal Bone CT tomorrow and then decide.

What do you think should be the course of action?

Thanking you in advance,

Thomas Antony

Aden, Yemen

Here are the CT images. Incidentally you can also see "Pneumosinus dilatans multiplex" as well as the "Korner's septum:"