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Table of Contents
ORIGINAL ARTICLE
Year : 2001  |  Volume : 3  |  Issue : 1  |  Page : 1-5

Otological complications of temporal bone fractures


1 Consultant ENT Surgeon, Department of Otolaryngology, Assir Central Hospital, Abha, Saudi Arabia
2 Associate Professor, King Khalid University, Abha, Saudi Arabia
3 Assistant Professor of Otolaryngology, King Khalid University, Abha, Saudi Arabia

Date of Web Publication9-Jul-2020

Correspondence Address:
FRCS (Ed) Yinka Fawehinmi
Department of Otolaryngology, Assir Central Hospital, P.O. Box 34, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.289349

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  Abstract 


Objective: The purpose of this study was to find out the percentage of patients who had clinical and radiological evidence of temporal bone involvement in basal skull facture.The study also looked at the incidence of otological symptoms and signs reported in the case files during admission and review subsequent patients management.
Methods: The case files of 400 patients admitted to Assir Central Hospital with basal skull fractures were retrospectively reviewed. Only 40 met our selection criteria of a clear evidence of basal skull fracture with temporal bone involvement using plain x-ray and computerized axial tomographic scan.
Results: The result showed that the parietal area was the commonest site of impact,[40%], followed by the frontal area [12%], the temporal site [12%], and the occipital [4%]. About three-quarters of the patients were bleeding from the external auditory meatus when first seen and 12% had cerebrospinal fluid otorrhoea. All the patients were referred to ear, nose, and throat specialist within 24hours of admission.
Conclusion: We propose that all patients with head injuries with one or more symptoms and signs characteristics of temporal bone fracture should automatically have otological assessment at the time of presentation. We also advocate thorough history, physical examination, computerized axial tomographic scan and audiogram for all these patients as early as practicable.

Keywords: Basal skull fracture, Temporal bone involvement, otological assessment


How to cite this article:
Fawehinmi Y, Al-Ghamdi S, Fageeh N. Otological complications of temporal bone fractures. Saudi J Otorhinolaryngol Head Neck Surg 2001;3:1-5

How to cite this URL:
Fawehinmi Y, Al-Ghamdi S, Fageeh N. Otological complications of temporal bone fractures. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2001 [cited 2021 May 5];3:1-5. Available from: https://www.sjohns.org/text.asp?2001/3/1/1/289349




  Introduction Top


Assir region has a temperate climate with an influx of tourists to the region during summer, which markedly increases the accident rate at this period. Many of these patients would have sustained other life threatening injuries which usually take priority in the initial treatment. In the striously ill patient it is important not to overlook the management of non-life threatening injuries in an attempt to try and improve their subsequent quality of life.[l] Unrecognized otological complications are one of such injuries, which if left uncorrected may add to the difficulties in rehabilitation and adversely affect the overall quality of life. Head injuries can cause temporal bone fracture especially if the impact of the trauma is mainly on the parietotemporal part of the skull. Temporal bone fracture can be either longitudinal, transverse of mixed depending on the relationship of the fracture line to the long axis of the petrous temporal bone. [Figure 1] Eighty percent of temporal bone fractures are longitudinal and this usually results from trauma to the temporal or parietal areas.[2] Twenty percent of temporal bone fractures are transverse and this is as a result of trauma to the occipital or frontal areas.[2] The purpose of this study was to look at the incidence of temporal bone involvement in patients with basal skull fracture and to review the otological complications and subsequent patient management.
Figure 1: Shows transverse fracture of right temporal bone and longitudinal fracture of left temporal bone.

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Figure 2: Shows longitudinal fracture of right temporal bone in another patient.

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Figure 3: Documented Otological Symptoms and Signs [n=40]

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  Materials and Methods Top


The case files of 400 patients admitted to our busy tertiary referral center (which is also the regional center for neurosurgery) from 1991 to 1998 were reviewed. All these patients had been diagnosed as having basal skull fracture on either clinical or radiological grounds. Information was gathered by careful retrospective review of the histories. From these cases only 40 patients fulfilled our selection criteria of a clear history of evidence of a basal skull fracture with one or more of the following findings: computerized tomographic scan (CT scan) evidence of a temporal bone fracture, cerebrospinal fluid (CSF) otorrhoea, otoheamatorrhea, and clinical evidence of a heamotympanum. Patients with facial nerve paralysis had elec- tromyography, measurement of taste, stapedial reflex and Iacrimation to determine activities of residual motor units and anatomical level of the lesion.


  Results Top


The patients selected were between the ages of 1 to 75 years with a male to female ratio of 10:1. The age distribution and percentage of patients with otological complications is shown in [Table 1]. The site of impact of the head injury was the parietal region 40%, frontoparietal region 25%, frontal region 20%, temporal region 12%, and occipital region 4%. On admission, 75% of patients were noticed to be bleeding from the external auditory meatus while 12% were suspected to have cerebrospinal fluid otorrhea. Documented examination of 30% of patients revealed a haemotympanum. In total, 65% required respiratory support in the form of mechanical ventilation, and they were subsequently transferred to an intensive care unit. On hospital admission, 36 patients had a cranial computerized tomography scan; 20 (50%) patients were reported as having a temporal bone fracture, and a further 10 (25%) more specifically as having a petrous bone fracture. All the 40 (100%) patients had otological opinion from the Department of Otolaryngology. The range and frequency of otological symptoms and signs reported are shown Table II. Pure tone audiometry was performed in30 (75%) patients, the remaining 10 (25%) patients were too unwell for such an investigation. Fourteen patients had conductive hearing loss, 6 (15%) had mixed deafness while 4 (10%) had pure sensorineural deafness. Patients were reviewed with audiogram atl, 3, and 6 months intervals; only 25 (62.5 %) patients came for review after three months while the rest were lost to review, either from failure to attend, or because of transfer to higher center or to the original referral source for convalescence.
Table 1: Age distribution of patients with otological complications[n=40]

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Four patients had a documented facial palsy. Two of them were documented lower motor neurone lesion of the facial nerve. Both of them were assessed as being grade six on the House-Brackman classification. They both underwent facial nerve decompression in another center. The palsy in one of them subsequently improved to grade two whilst the second one improved only to grade three. The remaining two patients had delayed facial palsy and were managed conservatively.


  Discussion Top


Complications after temporal bone fracture are rel-atively common.The majority of these complication are not life threatening.[3] Hearing loss is the commonest and this can be classified as being conductive, sensori-neural or mixed. Conductive hearing loss is characterized by an air bone gap on the pure tone audiogram which implies that the cochlea and intracranial pathways for audition are intact. The conducting pathways for sound, which include the external auditory canal, tympanic membrane, and middle ear ossicles, are in some way dysfunctional. Hence, pure tone audiometry demonstrates a difference between the inner ear hearing potential, measured by the bone conduction, and the actual hearing level to air conducted sound, resulting in air-bone gap. This is usually due to haemotympanum or tympanic membrane perforation, both of which usually resolve spontaneously over six to ten weeks. In patients, haemotympanum can be a sign of a temporal bone fracture. Postmortem endoscopy in forensic autopsy cases also revealed haemotympanum findings without any fracture. [4] In our study there was an average of improvement in the air bone gap of 15 dB over a 6 month period of follow up. If the air- bone gap fails to close after a period of sixteen weeks then one should consider an ossicular discontinuity. If ossicular discontinuity is suspected, it is advisable to wait for a period of 6 to 12 months to allow transient defects to correct themselves spontaneously before corrective ossiculoplasty.[5] Ossicular discontinuity is considered to be the commonest surgically correctable complication of temporal bone fracture. This occurred in 3 out of 14 patients in our series. Schubiger et al. in 1986 found its incidence to be 25.8% in a series of 89 temporal bone fractures. [6] most discontinuity occur at the incudo-stapedial joint. Other injuries are displacement of incus and fracture of the stapedial arch.[7] An alternative to surgery in a conductive hearing loss is provision of a hearing aids.

The second type of hearing loss which is sensori-neural, is caused by trauma to the cochlear auditory nerve, or auditory intracranial pathways. This may be transient or permanent. Even minor head injuries without temporal bone fracture can produce sensori-neural hearing loss. In Griffiths study of 84 patients admitted with concussion but no skull fracture following head injury, a total of 66 ears exhibited a sensori-neural pattern of hearing loss.[8] Lyos et al [9]found that transverse fracture often violate the otic capsule and commonly, although not invariably, result in immediate and profound sensori-neural hearing loss. In our series we found that after 12 months, 80% patients with low type sensori-neural loss have recovered while only 25% of those with high frequency type hearing loss had recovered.

We also found that cerebrospinal fluid otorrhoea was documented in 5(12%) patients, all of who were managed conservatively with the use of Pro- phylactic antibiotics.

We found that vertigo was documented in 10 (25%) of patients.lt has been reported in the literature, that temporal bone fracture in which the fissure happens to extend through the vestibular aqueduct, causing fibro-osseous blockage of the endolymphatic duct resulting in endolymphatic hydrops that may be delayed in onset and is usually persis- tcnt.[10] Most of our patients, (90%) with tinnitus and vertigo had resolution of these complications with conservative management after 6-12 months. Our series revealed the incidence of facial palsy to be 10%. It is not within the scope of this paper to discuss the complex neuro-otological management of post-traumatic facial palsies, and it still remains a topic of debate amongst otolaryngologists. We stress the importance of the involvement of an otolaryngologist in all posttraumatic facial, palsies at the earliest opportunity.[ll]


  Conclsuions: Top


A large number of patients admitted with basal skull fracture had clinical or radiological evidence of temporal bone involvement. We found that most of these patients with temporal bone fracture, had one or more otological complications, which may warrant surgical interventions. In some cases these operations can be performed as soon as the patient is fit enough for the procedure, however in most, a period of observation is necessary for evaluation. We identified the significant shortcomings in the initial evaluation and monitoring of patients with temporal bone fracture. Specific and thorough facial nerve examinations were not initially conducted on temporal bone fracture patients. This article reminds the emergency physicians of the importance of initial diagnosis of otological complications and temporal bone fractures.



 
  References Top

1.
Jennett EM. Head injuries in Scottish hospitals. Lancetl977; 2:696-698.  Back to cited text no. 1
    
2.
Proctor B, Guardian ES, Webster JE. The ear in head trauma. Laryngoscope 1956; 66: 16.  Back to cited text no. 2
    
3.
Pollanen MS, Deck JHN, Blenkinsop B, Farkas EM. Fracture of temporal bone with exsanguinations: pathology and mechanism. Can J Neurol Sci 1992; 19:196-200.  Back to cited text no. 3
    
4.
Amberg R, Strurtz J. Differential diagnosis of haemotympanum in forensic autopsy. Laryngorhinologie 1995; 74(5): 312-316.  Back to cited text no. 4
    
5.
Tos M. Prognosis of hearing loss in temporal bone fracture. J Laryng Otol 1971; 85 (1): 147-159.  Back to cited text no. 5
    
6.
Schuwbiger VA, Stickman G. Fractured temporal bone and their complications. Neuro-Radiol 1986; 28: 93-99.  Back to cited text no. 6
    
7.
Hough JVD. Fractures of the temporal bone and associated middle & inner ear trauma. Proc R Soc Med 1970;63:245-252.  Back to cited text no. 7
    
8.
Podoshin L, Fradis M. Hearing loss after head injury. Arch Otolaryngol 1975; 101: 15-18.  Back to cited text no. 8
    
9.
Lyos AT, Marsh MA, Jenkins HA, Coker NJ. Progressive hearing loss after transverse temporal bone fracture. Arch Otolaryngol Head & Neck Surg 1995;121(7): 795-799.  Back to cited text no. 9
    
10.
Driscoll CL, Facer CW. Temporal bone fractures. Am J Otol 1995; 16 (2): 235-240.  Back to cited text no. 10
    
11.
Lancaster JI, Alderson DJ, Curley JWA. Otological complications following basal skull fractures. J R Coll Surg Edinb 1999; 44: 87-90.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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