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Temporal Bone Fractures Workup

  • Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Nov 23, 2015
 

Imaging Studies

Most patients with temporal bone fracture have already had a CT scan of the head to rule out or identify intracranial injuries.

High-resolution CT (HRCT) of the temporal bone is useful in assessing injuries complicated by CSF leak, facial paralysis, or suspected vascular injury. Axial and coronal images are usually obtained with 1-mm sections, as are magnified views of the temporal bone. Bone windows are necessary. Axial high-resolution CT of a fractured right temporal bone is seen below.

Axial high-resolution CT of the right temporal bon Axial high-resolution CT of the right temporal bone that represents a longitudinal fracture line that extends from the roof of the external auditory canal to the middle ear cavity.

HRCT of the temporal bone is indicated if surgical intervention for management of otologic complications is required.

If transient or persistent neurologic deficits are present in a patient with basilar skull fracture, HRCT of temporal bone with CT angiography is indicated to evaluate for petrous carotid injury.

Magnetic resonance imaging (MRI) cannot identify temporal bone fracture. MRI has both poor sensitivity and specificity in this respect. MRI is useful in assessment of the intracranial contents and/or a nerve palsy not explained by the HRCT.[2, 19, 20] It also can identify intralabyrinthine hemorrhage, brainstem injury, nerve compression, and herniation of intracranial contents into the mastoid cavity.[2] MRI is also useful prior to neurosurgical intervention for temporal bone fractures, particularly with a middle cranial fossa approach.[19]

Also see the Medscape Reference article Temporal Bone Fracture Imaging.

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Other Tests

Maximum stimulation test

This test is based on the observation of twitch of the facial musculature using the Hilger facial nerve stimulator after the third day of the injury, usually between 3-14 day post injury. It is used only in the case of complete facial nerve paralysis (as determined by the House-Brackmann grading) because of the pain caused by the facial stimulation. Supramaximal stimulation is applied with a maximal tolerated current on the normal side. The affected side is compared with the normal side, using the same stimulating current. An absent or markedly decreased response (barely perceptible movement) indicates a poor and incomplete return of facial nerve function.

Nerve excitability test (minimal nerve excitability test)

This test is similar to the previous test that used the Hilger nerve stimulator after the third day of injury; this test compares the amperage site-to-site necessary to initiate a barely visible response on the affected side. A difference of 3.5 mA or more is significant, carries a poor prognosis, and indicates the need to consider surgical exploration.

Electroneurography

Electroneurography (ENOG) is the technique designed by Fisch. It is used every 2 days between the third and the 21st day after the initial trauma. The results are expressed as a percentage of the amplitude of the action potentials on the paralyzed side as compared with the nonparalyzed side. The results correlate well with the percentage of nerve degeneration. According to Fisch, 90% degeneration of the involved nerve is considered significant and represents the threshold for surgical management.[21]

Fisch has developed accepted indications for surgical management based on the “percentage of nerve degeneration,” advocating exploration and decompression or repair when the ENOG indicates 90% degeneration. In other words, degeneration with 10% or less of nerve function compared with the normal side is considered the critical turning point for surgical management recommendation. Fisch found, histologically, that traumatic injury at the geniculate ganglion induces retrograde degeneration through the labyrinthine and distal meatal segments of the facial nerve. Fisch believes that fibrosis occurs and blocks regenerating fibers and, therefore, advises early surgery in order to avoid this fibrotic complication within the fallopian canal.

Nosan et al believe that ENOG is of paramount importance in determining the need for and the timing of surgery for facial paralysis after trauma. They believe that ENOG has made the determination of the clinical onset of paralysis less necessary and that patients with delayed paralysis can have more severe injuries than those patients with more rapid ENOG degeneration. They believe that the time of paralysis from onset of injury should not confuse the issue.

Electromyography

Normal resting muscle does not produce spontaneous electrical activity. Spontaneous electromyographic activity (fibrillation potentials) found in the muscle indicates complete denervation. Take into consideration that fibrillation potentials take at least 3 weeks to be detected with electromyography. The presence of voluntary motor units (polyphasic action potentials), on the contrary, is a good prognostic factor and the best indicator that regeneration is taking place.

The surgical approach is controversial. Some authorities advocate limited exploration of the facial nerve based on clinical and radiographic information. Fisch, on the other hand, advocates total facial nerve exploration and decompression by a middle fossa and transmastoid approach. In patients who have total sensorineural hearing loss, Fisch suggests a translabyrinthine approach.

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Contributor Information and Disclosures
Author

Antonio Riera March, MD, FACS Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine

Antonio Riera March, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, Society for Ear, Nose and Throat Advances in Children, American Cleft Palate-Craniofacial Association, American College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Peter C Belafsky, MD, MPH, PhD Assistant Professor, Department of Otolaryngology, University of California at Davis

Peter C Belafsky, MD, MPH, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Sarah Connell, MD Fellow, Department of Otolaryngology, Head and Neck Surgery, University of Miami, Jackson Memorial Hospital

Sarah Connell, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, Triological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Auditory Society, The Triological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Jack A Shohet, MD President, Shohet Ear Associates Medical Group, Inc; Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, School of Medicine

Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American Medical Association, California Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Envoy Medical <br/>Received consulting fee from Envoy Medical for medical advisory board member. for: Envoy Medical .

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Mark L Belafsky, MD, FACS, to the development and writing of this article.

The author wishes to acknowledge Joan Flaherty, RN, for her editorial assistance.

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Internal aspect of the skull base: arcuate eminence (AE), cochlea (C), foramen magnum (FM), internal auditory canal (IAC), foramen lacerum (L), foramen ovale (O), foramen rotundum (R), foramen spinosum (SP), sigmoid sinus (SS), transverse sinus (TS), vestibular system (V).
External aspect of the skull base: carotid canal (C), condyle (CO), foramen magnum (FM), jugular foramen (J), foramen lacerum (L), foramen ovale (O), pterygoid plates (P), styloid foramen (S), foramen spinosum (SP).
Internal aspect of the skull base that represents, in black and blue colors, the pathway of the longitudinal temporal bone fracture lines.
Internal aspect of the skull base that represents, in black and red colors, the pathways of the transverse temporal bone fracture lines.
Axial high-resolution CT of the right temporal bone that represents a longitudinal fracture line that extends from the roof of the external auditory canal to the middle ear cavity.
Right temporal bone transverse fracture with severe spontaneous nystagmus (third degree) manifesting immediately after trauma. The fast component beats away from the fracture site in all directions of the gaze; the intensity of the spontaneous nystagmus is represented by the different lengths of black arrows. This type of nystagmus is usually seen by the naked eye. According to Alexander's law, the nystagmus increases when the eyes are turned in the direction of the quick component and decreases when the eyes are turned in the direction of the slow component.
Internal aspect of the skull base depicting, in green color, a mixed temporal bone fracture line with both a longitudinal pattern (circle) and a transverse pattern (rectangle).
Left temporal bone fracture line crossing the mastoid process and into Henle's spine and the external auditory canal (surgeon's view).
Table 1. Longitudinal and Transverse Fractures
Feature Longitudinal Fractures Transverse Fractures
Incidence Approximately 80% Approximately 20%
Mechanism Temporal or parietal trauma Frontal or occipital trauma
CSF otorrhea Common Occasional
Tympanic membrane perforation Common Rare
Facial nerve damage 20% (most often temporary and frequently delayed in onset) 50% (severe, usually permanent, and immediate in onset)
Hearing loss Common (conductive type and possibly high tone neurosensorial secondary to concomitant inner ear concussion) Common (severe sensorineural or mixed)
Hemotympanum Common (associated with otorrhagia) Possible (not associated with otorrhagia)
Nystagmus Common (usually spontaneous, usually less intense [first or second degree] or positional; nystagmus absence also possible) Common (intense [third degree], spontaneous, fast component beating to the opposite ear, long lasting; positional nystagmus also possible before and after compensation period)
Otorrhagia Common Rare
Vertigo Common (less intense, and/or positional; absence is also possible) Common (intense, usually associated in the acute phase with nausea and possibly vomiting)
Table 2. Otic Capsule–Sparing and Otic Capsule–Disrupting Fractures
Feature Otic Capsule Sparing Otic Capsule Disrupting
Incidence Approximately 95% Approximately 5%
Mechanism Temporal or parietal trauma Occipital trauma
Line of fracture Anterolateral to the otic capsule Through the otic capsule
Pathway
  • Squamosa portion of temporal bone
  • Posterosuperior wall of the external auditory canal and tympanic membrane commonly involved
  • Also, mastoid air cells and middle ear
  • 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
CSF leak Middle cranial fossa (tegmen mastoideum, tegmen tympani, middle ear, and external auditory canal or eustachian tube) Posterior cranial fossa (middle ear, eustachian tube)
Ossicular chain involvement Common Rare
Hearing loss Conductive or mixed Sensorineural
Facial paralysis Less common Common
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