TEMPORAL BONE FRACTURES

BY: NUR AINI JUSOH

INTRODUCTION
The temporal bone is the most complex bone

in the human body. It houses many vital structures, including the cochlear and vestibular end organs, the facial nerve, the carotid artery, and the jugular vein. Motor vehicle accidents are the cause of 31% of temporal bone fractures.

Divided into 5 components: Squamous portion Tympanic portion Styloid process Mastoid portion Petrous portion

General symptoms
Hearing loss: conductive or sensorineural

Dizziness and dysequilibrium

Facial weakness or paralysis Otorrhea Rhinorrhea More rare: facial numbness and diplopia

Physical Examination
Hemotympanum Laceration and

hematoma of the auricle Battles sign: postauricular ecchymosis Raccoon sign: periorbital ecchymosis

CLASSIFICATION
Ulrichs Classification (1926) Longitudinal fractures Transverse fractures

LONGITUDINAL FRACTURES
The commonest type accounting 80% of all

the temporal bone fractures. Caused by lateral blows like temporal or parietal type. The fracture line parallels the long axis of the petrous pyramid. It starts in the pars squamosa extends through the posterosuperior bony external canal, continues across the roof of the middle ear space anterior to the labyrinth, and ends anteromedially in the middle cranial fossa in close proximity to the foramen lacerum and

Longitudinal Fractures

Clinical features
1. Bleeding from external canal due to laceration of skin and ear drum 2. Haemotympanum (conductive deafness) 3. Fractures involving the bony portion of external canal 4. Ossicular chain disruption causing conductive deafness. 5. Facial palsy (rare) 6. CSF otorrhoea (usually temporary) 7. Sensorineural hearing loss can occur due to concussion

TRANSVERSE FRACTURES
Comprises about 20% of all temporal bone

fractures. Usually caused by frontal or parietal blow, rarely by occipital blow. The fracture line runs at a right angle to the long axis of the petrous pyramid and starts in the middle cranial fossa close to the foramen lacerum and spinosum). It then crosses the petrous pyramid transversely and ends at the foramen magnum

Transverse Fractures

Clinical features
1. Sensorineural hearing loss due to damage to

8th cranial nerve 2. Facial palsy due to damage of facial nerve 3. Vertigo

Difference of longitudinal vs transverse

FEATURE
Incidence Mechanism CSF otorrhea Tympanic membrane perforation Facial nerve damage

LONGITUDINAL
Approximately 80% Temporal or parietal trauma Common Common 20% (most often temporary and frequently delayed in onset)

TRANSVERSE
Approximately 20% Frontal or occipital trauma Occasional Rare 50% (severe, usually permanent, and immediate in onset)

Hearing loss

Common (conductive type and Common (severe possibly high tone sensorineural or mixed) neurosensorial) Common (associated with otorrhagia) Common (spontaneous, less intense) Common Common (less intense) Possible (not associated with otorrhagia) Common (spontaneous, intense) Rare Common (intense)

Hemotympanum Nystagmus Otorrhagia Vertigo

New Classification (Kelly and Tami)

FEATURE OTIC CAPSULE SPARING OTIC CAPSULE DISRUPTING

Incidence Mechanism Line of fracture Pathway

Approximately 95% Temporal or parietal trauma Anterolateral to the otic capsule Squamosa portion of temporal bone Posterosuperior wall of the external auditory canal and tympanic membrane commonly involved. Also, mastoid air cells and middle ear. Middle cranial fossa Common

Approximately 5% Occipital trauma Through the otic capsule Foramen magnum, petrous pyramid and otic capsule Also jugular foramen, internal auditory canal and foramen lacerum Tympanic membrane and external auditory canal not usually affected Posterior cranial fossa Rare

CSF leak Ossicular chain involvement

Hearing loss
Facial paralysis

Conductive or mixed
Less common

Sensorineural
Common

IMAGING
HRCT (High Resolution CT)

Useful in assessing injuries complicated with

CSF leak, facial palsy or suspected vascular injury. Also indicated when surgical intervention for otologic complications following temporal bone fracture becomes necessary Indicated in patients with persistent cranial nerve injuries following skull base fracture.

CT angiography Indicated in evaluation of petrous carotid artery MRI Helps in identification of intralabyrinthine haemorrhage, brain stem injury and nerve compression

Management
Management;
ABC, AMPLE history Primary survey Head and neck exam Cranial nerve exam

Medical treatment:
Stabilize the patient condition Patient with delayed facial paralysis is managed

conservatively with 10-14 days of systemic corticosteroids unless medically contraindicated.

Surgical treatment
Indicated in facial nerve injury, hearing loss and CSF

leak persisting > 14 days

Common sequelae
Facial nerve palsy Damaged to chochleo vestibular apparatus causing

sensorineural hearing loss Conductive hearing loss due to ossicular disruption Balance disruption Tinnitus/vertigo CSF leak Perilymph fistula Post traumatic endolymphatics hydrops Otogenic meningitis Injuries to cranial nerves VI, IX, XI Vascular injuries eg: internal carotid artery and sigmoid sinus

Delayed sequelae
Meningocele/encephalocele

Can manifest as a late onset CSF otorrhea,

unilateral clear middle ear effusion, or recurrent meningitis. The delay can range from 1-20 years. Cholesteatoma Could be due to traumatic implantation of epithelial elements during injury into the middle ear cavity.