eMedicine Specialties > Radiology > Head/Neck

Temporal Bone, Fractures: Imaging

Author: Richard J Woodcock Jr, MD, Consulting Radiologist, Atlanta Radiology Consultants, LLC; Consulting Radiologist and MRI Director, St Joseph's Hospital
Contributor Information and Disclosures

Updated: Jun 10, 2009

Radiography

Findings

Plain film radiographs of the skull may show opacified mastoid air cells, intracranial air, or, rarely, a lucency (fracture line).

Degree of Confidence

Generally, diagnosis of temporal bone fracture by plain film radiographs is difficult and requires confirmation by CT scanning.

False Positives/Negatives

The false-negative rate with plain film radiographs is high.

Computed Tomography


Axial noncontrast CT scan with bone windows revea...

Axial noncontrast CT scan with bone windows reveals a longitudinal temporal bone fracture (arrows).

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Axial noncontrast CT scan with bone windows revea...

Axial noncontrast CT scan with bone windows reveals a longitudinal temporal bone fracture (arrows).



Axial noncontrast CT scan with bone windows revea...

Axial noncontrast CT scan with bone windows reveals a transverse temporal bone fracture (arrow).

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Axial noncontrast CT scan with bone windows revea...

Axial noncontrast CT scan with bone windows reveals a transverse temporal bone fracture (arrow).



Axial noncontrast CT scan with bone windows demon...

Axial noncontrast CT scan with bone windows demonstrates a complex fracture with a transverse component (arrow) and an oblique component (arrowhead).

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Axial noncontrast CT scan with bone windows demon...

Axial noncontrast CT scan with bone windows demonstrates a complex fracture with a transverse component (arrow) and an oblique component (arrowhead).


Findings

  • A thin-section (1 mm) CT scan can demonstrate a lucency through the temporal bone. Involvement of the middle ear, petrous bone, otic capsule, and facial nerve canal are the primary determinants of prognosis.
  • A longitudinal fracture roughly parallels the petrous bone long axis. Involvement of the middle ear, carotid canal, bony labyrinth, and external auditory canal should be noted.
  • A transverse fracture is perpendicular to the petrous bone long axis. Involvement of the inner ear structures and facial nerve course should be noted.
  • An oblique fracture has both transverse and longitudinal elements.

Dempewolf et al evaluated the sensitivity and specificity of temporal bone CT versus maxillofacial CT for identifying carotid canal fractures and noted that a combination of helical CT and physical exam findings can allow for judicious use of temporal bone CTs when no maxillofacial CT is indicated. Although temporal bone CTs rarely change acute management, when they do, it is in regard to the need for further workup of possible vascular injury.8

Degree of Confidence

If adequate CT scanning technique is used, fractures can be diagnosed with a high degree of confidence.

False Positives/Negatives

False-positives may result when normal sutures are misdiagnosed as fracture lines. False-negatives may occur with subtle fractures or when suboptimal technique is utilized (as when the study is performed using section thickness >1.25 mm collimation or without employing a bone algorithm).

Magnetic Resonance Imaging

Findings

MRI may demonstrate fluid (high signal on T2-weighted images) in the middle ear and mastoid air cells. T1-weighted images may reveal a bright signal in the labyrinth or middle ear, consistent with hemorrhage.

Degree of Confidence

With regard to depicting temporal bone fractures, MRI has both poor sensitivity and specificity.

Nuclear Imaging

Findings

Nuclear medicine studies are not a factor in the diagnosis of acute trauma; however, nuclear cisternography may be used as an adjunct to CT scanning in the diagnosis of a persistent, trauma-related CSF leak. In this setting, nuclear cisternography is a sensitive means of confirming the CSF leak but is not accurate in depicting the location.

Angiography

Findings

Angiography typically is not a factor in the diagnosis or management of temporal bone fracture; however, when the fracture involves the internal carotid artery canal, damage to the carotid artery may occur. Angiography may reveal a filling defect in the lumen, resulting from intimal flap dissection (linear defect) or thrombosis (irregular or round defect). Alternatively, pseudoaneurysm may be present.

Ahmed et al conducted a retrospective study of the use of angiography for evaluation of temporal bone fractures and found that mortality was significantly higher in patients with an abnormal CT and no angiogram than it was in patients with an abnormal CT and an abnormal angiogram. The authors concluded that current guidelines for angiography may need to be expanded to include all patients who have CT evidence of neurocranial injury, so as to detect vascular injuries that need aggressive management and thus lower overall mortality.9

More on Temporal Bone, Fractures

Overview: Temporal Bone, Fractures
Imaging: Temporal Bone, Fractures
Follow-up: Temporal Bone, Fractures
Multimedia: Temporal Bone, Fractures
References
Further Reading
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References

  1. Saraiya PV, Aygun N. Temporal bone fractures. Emerg Radiol. Nov 4 2008;[Medline].

  2. Johnson F, Semaan MT, Megerian CA. Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin North Am. Jun 2008;41(3):597-618, x. [Medline].

  3. Gladwell M, Viozzi C. Temporal bone fractures: a review for the oral and maxillofacial surgeon. J Oral Maxillofac Surg. Mar 2008;66(3):513-22. [Medline].

  4. Swartz JD. Temporal bone trauma. Semin Ultrasound CT MR. Jun 2001;22(3):219-28. [Medline].

  5. Nishiike S, Miyao Y, Gouda S, et al. Brain herniation into the middle ear following temporal bone fracture. Acta Otolaryngol. Aug 2005;125(8):902-5.

  6. Yetiser S, Hidir Y, Gonul E. Facial nerve problems and hearing loss in patients with temporal bone fractures: demographic data. J Trauma. Dec 2008;65(6):1314-20. [Medline].

  7. Khan Y, Laurencin CT. Fracture repair with ultrasound: clinical and cell-based evaluation. J Bone Joint Surg Am. Feb 2008;90 Suppl 1:138-44. [Medline].

  8. Dempewolf R, Gubbels S, Hansen MR. Acute radiographic workup of blunt temporal bone trauma: maxillofacial versus temporal bone CT. Laryngoscope. Mar 2009;119(3):442-8. [Medline].

  9. Ahmed KA, Alison D, Whatley WS, Chandra RK. The role of angiography in managing patients with temporal bone fractures: a retrospective study of 64 cases. Ear Nose Throat J. May 2009;88(5):922-5. [Medline].

  10. Aguilar EA 3rd, Yeakley JW, Ghorayeb BY, et al. High resolution CT scan of temporal bone fractures: association of facial nerve paralysis with temporal bone fractures. Head Neck Surg. Jan-Feb 1987;9(3):162-6. [Medline].

  11. Cannon CR, Jahrsdoerfer RA. Temporal bone fractures. Review of 90 cases. Arch Otolaryngol. May 1983;109(5):285-8. [Medline].

  12. Goodwin WJ Jr. Temporal bone fractures. Otolaryngol Clin North Am. Aug 1983;16(3):651-9. [Medline].

  13. Holland BA, Brant-Zawadzki M. High-resolution CT of temporal bone trauma. AJR Am J Roentgenol. Aug 1984;143(2):391-5. [Medline].

  14. Ishman SL, Friedland DR. Temporal bone fractures: traditional classification and clinical relevance. Laryngoscope. Oct 2004;114(10):1734-41. [Medline].

  15. Lipkin AF, Bryan RN, Jenkins HA. Pneumolabyrinth after temporal bone fracture: documentation by high- resolution CT. AJNR Am J Neuroradiol. Mar-Apr 1985;6(2):294-5. [Medline].

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Keywords

temporal bone fracture, temporal bone fracture diagnosis, petrous temporal bone fracture, mixed temporal bone fracture, oblique temporal bone fracture, horizontal temporal bone fracture, longitudinal temporal bone fracture

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Contributor Information and Disclosures

Author

Richard J Woodcock Jr, MD, Consulting Radiologist, Atlanta Radiology Consultants, LLC; Consulting Radiologist and MRI Director, St Joseph's Hospital
Richard J Woodcock Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Phi Beta Kappa, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Barton F Branstetter IV, MD, Associate Professor of Radiology, Otolaryngology, and Biomedical Informatics, University of Pittsburgh; Director of Head and Neck Imaging, Clinical Director of Neuroradiology, Department of Radiology, Division of Neuroradiology, University of Pittsburgh Medical Center
Barton F Branstetter IV, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Pennsylvania Medical Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

C Douglas Phillips, MD, Director of Head and Neck Imaging, Division of Neuroradiology, Weill Medical College of Cornell University/New York Presbyterian Hospital
C Douglas Phillips, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

James G Smirniotopoulos, MD, Professor of Radiology, Neurology, and Biomedical Informatics, Chairman, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Head and Neck Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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