Temporal Bone Fractures and Related Complications in Pediatric and Adult Cranio-Facial Trauma: A Comparison of MDCT Findings in the Acute Emergency Setting.

PURPOSE: The purpose of this study was to analyze the prevalence of and complications resulting from temporal bone fractures in adult and pediatric patients evaluated for cranio-facial trauma in an emergency setting. METHODS: A retrospective blinded analysis of CT scans of a series of 294 consecutive adult and pediatric patients with cranio-facial trauma investigated in the emergency setting was conducted. Findings were compared between the two populations. Preliminary reports made by on-call residents were compared with the retrospective analysis, which was performed in consensus by two experienced readers and served as reference standard. RESULTS: CT revealed 126 fractures in 116/294 (39.5%) patients, although fractures were clinically suspected only in 70/294 (23.8%); p < 0.05. Fractures were longitudinal, transverse and mixed in 69.5%, 10.3% and 19.8% of cases, respectively. Most fractures were otic-sparing fractures (95.2%). Involvement of the external auditory canal, ossicular chain and the osseous structures surrounding the facial nerve was present in 72.2%, 8.7% and 6.3% of cases, respectively. Temporal bone fractures extended into the venous sinuses/jugular foramen and carotid canal in 18.3% and 17.5% of cases, respectively. Vascular injuries (carotid dissection and venous thrombosis) were more common in children than in adults (13.6% versus 5.3%); however, the observed difference did not reach statistical significance. 79.5% of patients with temporal bone fractures had both brain injuries and fractures of the facial bones and cranial vault. Brain injuries were more common in adults (90.4%) than in children (63.6%), p = 0.001. Although on-call residents reliably detected temporal bone fractures (sensitivity = 92.8%), they often missed trauma-associated ossicular dislocation (sensitivity = 27.3%). CONCLUSIONS: Temporal bone fractures and related complications are common in patients with cranio-facial trauma and need to be thoroughly looked for; the pattern of associated injuries is slightly different in children and in adults.

[Diagnosis and treatment of 68 cases of traumatic facial nerve paralysis].

Objective:To summarize the clinical characteristics and therapeutic effect of traumatic facial nerve palsy. Methods:Sixty-eight cases of traumatic facial nerve palsy were retrospectively analyzed from January 2015 to May 2023. Results:The median course of disease was 33 days. The facial nerve function of the patients was grade HB-Ⅱin 2 cases, grade HB-Ⅲ in 4 cases, grade HB-Ⅳin 16 cases, grade HB-Ⅴ in 37 cases（38 ears）, and grade HB-Ⅵ in 9 cases. 42 cases occurred immediately after injury and 26 cases were delayed. CT examination of temporal bone revealed longitudinal fractures in 51 cases（52 ears） , transverse fractures in 6 cases and mixed fractures in 4 cases. No definite temporal bone fracture was found in the remaining 7 cases. The segments of facial nerve injury in 49 cases（50 ears） were geniculate ganglion and adjacent, in 7 cases were vertical segment, in 7 cases were horizontal segment, in 2 cases were horizontal segment and vertical segment; and the other 3 cases could not be evaluated. Conservative treatment with glucocorticoids was used in 23 ears and surgery was used in 46 ears. Patients were followed up 6-24 months after treatment, including 20 cases of grade HB-Ⅰ, 19 cases of grade HB-Ⅱ, 23 cases（24 ears） of grade HB-Ⅲ, 4 cases of grade HB-Ⅳ, and 1 case of grade HB-Ⅴ.One patient was lost to follow-up. After treatment, the facial nerve function of patients was significantly improved（P<0.05）, and there were significant differences between conservative treatment group and surgical treatment group in the course of facial nerve palsy, the ratio of facial palsy immediately after injury, the nerve function before treatment and the nerve function after treatment（P<0.05）. There were no significant differences in age, sex, hearing condition, temporal bone fracture, facial nerve injury segment and rate of favorable neurologic outcomes（P>0.05）. The comparison of patients with neurodegeneration rate>90% and ≤90% showed that the facial nerve function of patients with neurodegeneration rate>90% before treatment was significantly worse（P<0.05）, but there was no significant difference between the facial nerve function after treatment（P>0.05）. There was no significant difference in facial nerve function between middle fossa approach group and mastoid approach group（P>0.05）. Conclusion:Patients with traumatic facial nerve palsy should be evaluated individually. Patients with mild facial nerve palsy, low neurodegeneration rate and short course of disease can be treated conservatively and followed up closely. Patients with severe facial nerve palsy, high neurodegeneration rate and more than 6 weeks of disease can be actively considered surgery. Good prognosis can be obtained by correct evaluation and treatment.

Complications After Pediatric Temporal Bone Fractures by Classification System: A Systematic Review and Meta-analysis.

OBJECTIVE: To analyze the rates of complications after pediatric temporal bone fractures (TBF) and the utility of the longitudinal, transverse, and mixed versus the otic capsule sparing (OCS) and otic capsule violating (OCV) classification systems in predicting these complications. DATA SOURCES: PubMed, Scopus, and CINAHL. REVIEW METHODS: Per PRISMA guidelines, studies of children with TBFs were included. Meta-analyses of proportions were performed. RESULTS: A total of 22 studies with 1376 TBFs were included. Children with TBF had higher rates of conductive hearing loss (CHL) than sensorineural hearing loss (SNHL) (31.3% [95% confidence interval [CI] 23.2-40.1] vs 12.9% [95% CI 8.9-17.5]). No differences in both CHL and SNHL were seen between longitudinal and transverse TBFs; however, OCV TBFs had higher rates of SNHL than OCS TBFs (59.3% [95% CI 27.8-87.0] vs 4.9% [95% CI 1.5-10.1]). Of all patients, 9.9% [95% CI 7.2-13.1] experienced facial nerve (FN) paresis/paralysis, and 13.4% [95% CI 5.9-23.2] experienced cerebrospinal fluid otorrhea. Transverse TBFs had higher rates of FN paresis/paralysis than longitudinal (27.7% [95% CI 17.4-40.0] vs 8.6% [95% CI 5.2-12.8]), but rates were similar between OCS and OCV TBFs. CONCLUSION: CHL was the most common complication after TBF in children; however, neither classification system was superior in identifying CHL. The traditional system was more effective at identifying FN injuries, and the new system was more robust at identifying SNHL. While these results suggest that both classification systems might have utility in evaluating pediatric TBFs, these analyses were limited by sample size. Future research on outcomes of pediatric TBFs stratified by type of fracture, mainly focusing on long-term outcomes, is needed.

Imaging Patterns of Temporal Bone Fracture among Patients with Head Injury at Tikur Anbessa Specialized Hospital, Ethiopia.

Background: Temporal bone fracture is usually a sequel of significant blunt head injury. Fracture of the temporal bone is mainly classified according to the orientation of the fracture plane and whether there is involvement of the otic capsule. Despite its frequent occurrence, there is limited research on the frequency and pattern of temporal bone fractures in our setup. Methods: Retrospective cross-sectional hospital - based study of 60 patients who underwent computed tomography of the head for head trauma at Tikur Anbessa Specialized Hospital during the study period from October 2020 - October 2022. Results: Among the 60 patients enrolled in the study, the mean age of presentation was 31.1 years with a male-to-female ratio of 4:1. There were 69 temporal bone fractures, 9(15%) were bilateral and 51(85%) unilateral The longitudinal fracture pattern was the most common fracture pattern, occurring in 40(78.4%) of unilateral cases, 15(83.3%) of bilateral cases. Otic capsule sparing fractures accounted for 49(96.07%) of unilateral fracture cases, and all patients with bilateral involvement had an otic capsule sparing fracture. Among the 42 patients for whom data regarding post-traumatic hearing outcome was available, 4 patients had post-traumatic hearing impairment. Anatomically, the squamous portion of the temporal bone was involved in 30(43.5%) of cases. Conclusions: Fractures affecting the squamous portion of the temporal bone, longitudinal fracture patterns, and otic capsule sparing were the most frequent forms. The majority of temporal bone fractures were associated with other bone fractures and intracranial injuries.

Utility of Temporal Bone Computed Tomography in Pediatric Emergency Medicine.

OBJECTIVE: Temporal bone computed tomography (CT) requires a relatively high radiation dose to produce high-resolution images required to define surgical anatomy. In the acute setting, the need for this detailed evaluation of temporal bone pathology may not be required for nonsurgical management and clinical decision-making. We performed a retrospective review of the clinical characteristics and subsequent management of children who underwent CT of the temporal bone with the goal of optimizing clinical decision-making and mitigating the risks of radiation exposure in children. METHODS: We included pediatric patients (<18 years of age) with International Classification of Diseases (9th or 10th revision) diagnoses consistent with otitis externa, otitis media, mastoiditis, head trauma, temporal bone fracture, and otalgia who were treated in the emergency department and underwent temporal bone CT from January 1, 2012-December 31, 2016. We collected data regarding the patients' presenting symptoms, physical exam findings, indications for imaging, radiographic findings, disposition, and operative intervention within 30 days of imaging. Features of the suspected mastoiditis group were compared between operative and non-operative patients. RESULTS: Over the four-year study period there were 96 temporal bone CTs. Most studies (70%) were associated with a subsequent inpatient admission. Common indications for imaging included evaluation of acute mastoiditis (55%) or trauma (41%). Of the 53 patients with concern for mastoiditis, 27 (51%) required otologic surgery. Two patients in the trauma group required surgical intervention, both for facial nerve decompression. In patients with suspected mastoiditis, mental status changes (P = 0.02), auricular proptosis (P = 0.05), and fluctuance (P = 0.02) were significantly more prevalent in the operative group; however, no other findings were significantly associated with operative intervention. CONCLUSION: Temporal bone CT is beneficial in guiding diagnosis and management of acute mastoiditis. We found that a majority of patients with suspected mastoiditis who underwent temporal bone CT ultimately required surgery or hospital admission. However, the potential for reduction in the use of CT still exists in this population. Fractures of the temporal bone typically do not require urgent operative intervention in the absence of complete facial nerve paralysis; thus, the utility of temporal bone CT in trauma evaluation may be limited.

Effectiveness of Surgical Treatment in Traumatic Facial Paralysis.

INTRODUCTION: In the etiology of facial nerve palsy, trauma is the most important. Our aim was to present our experience gained by evaluating the surgical approaches we have used in extratemporal and intratemporal facial nerve injuries and their long-term results, also to contribute to the consensus that will be formed on this subject. MATERIALS AND METHODS: Thirteen patients among 24 patients who underwent surgery with a diagnosis of traumatic facial paralysis were evaluated in this study. The clinical response of these patients to treatment was examined by classifying them according to the House-Brackmann classification in the preoperative and postoperative periods. RESULTS: Of the 13 patients, 9 had fractures due to temporal bone trauma, and 4 had nerve damage in the extratemporal part of the facial nerve. in the treatment, facial nerve decompression was performed using the middle fossa approach in 9 patients with temporal bone fractures. in the 4 patients with extratemporal facial nerve injury, graft repair or primary suturing was performed. in the postoperative period, the stages of the patients were III or below in 12 patients (92%), and only 1 (8%) patient remained in stage IV. DISCUSSION: When the postop conditions of the patients were examined according to House-Brackmann staging, it was observed that surgical treatment caused a significant improvement in the functions of the facial nerve. CONCLUSIONS: Our results showed that surgery was an effective treatment method in patients with indications for traumatic facial paralysis.

Pintail Comb Injury as a Rare Cause of Penetrating Temporal Bone Trauma With Facial Paralysis.

We present a case of novel penetrating temporal bone trauma with a pintail comb causing facial paralysis. We describe a 42-year-old woman with acute facial paralysis, hearing loss, and dizziness following accidental tympanic membrane puncture. The patient underwent middle ear exploration with tympanoplasty and was found to have an intact but severely edematous facial nerve. The patient demonstrated less than 90% degeneration under electroneuronography and was treated medically without decompression, and by 6 months had exhibited complete resolution of facial nerve dysfunction with normal hearing. This case report highlights a unique cause of penetrating temporal bone trauma and supports the utility of electroneuronography in predicting the likelihood of recovery and need for decompression in patients where the facial nerve has obvious signs of trauma but remains grossly intact.

Tympanal bone fracture in forensic practice.

A tympanal bone fracture is an uncommon complication of head trauma and is mostly associated with a mandibular or petrous bone fracture. Upon reviewing the medicolegal literature, we could not find any publications on this topic. Tympanal bone fracture may lead to chronic complications (including external auditory canal stenosis and conductive hearing loss), with an important impact in both the medical and judiciary fields (e.g., chronic disabilities with loss of income). We decided to investigate the prevalence and mechanisms of tympanal bone fractures by means of a retrospective observational study on living victims who underwent head computed tomography after blunt head trauma and clinical forensic investigation at our center. We selected 159 cases of living victims with blunt head trauma (following an assault, traffic accident, or work accident) between January 2016 and December 2020. Re-examination of head imaging revealed 12 cases of tympanal bone fracture. Seven individuals showed cranial fractures involving the petrous bone (on the same side as the tympanal bone fracture). Three individuals had a temporomandibular fracture after a fall with chin impact. Only two victims exhibited an isolated tympanal bone fracture.

The dynamic impact behavior of the human neurocranium.

Realistic biomechanical models of the human head should accurately reflect the mechanical properties of all neurocranial bones. Previous studies predominantly focused on static testing setups, males, restricted age ranges and scarcely investigated the temporal area. This given study determined the biomechanical properties of 64 human neurocranial samples (age range of 3 weeks to 94 years) using testing velocities of 2.5, 3.0 and 3.5 m/s in a three-point bending setup. Maximum forces were higher with increasing testing velocities (p ≤ 0.031) but bending strengths only revealed insignificant increases (p ≥ 0.052). The maximum force positively correlated with the sample thickness (p ≤ 0.012 at 2.0 m/s and 3.0 m/s) and bending strength negatively correlated with both age (p ≤ 0.041) and sample thickness (p ≤ 0.036). All parameters were independent of sex (p ≥ 0.120) apart from a higher bending strength of females (p = 0.040) for the 3.5 -m/s group. All parameters were independent of the post mortem interval (p ≥ 0.061). This study provides novel insights into the dynamic mechanical properties of distinct neurocranial bones over an age range spanning almost one century. It is concluded that the former are age-, site- and thickness-dependent, whereas sex dependence needs further investigation.

Insertion trauma of a new cochlear implant electrode: evaluated by histology in fresh human temporal bone specimens.

BACKGROUND: Combining acoustic and electrical stimulation has been successfully used in patients with low-frequency residual hearing. Electrode insertion trauma, such as electrode translocation could result in loss of residual hearing. OBJECTIVES: The aim of the study is to evaluate the LCI-20PI electrode array insertion trauma to the intra-cochlear structures in fresh human temporal bone specimens. MATERIALS AND METHODS: The LCI-20PI electrode arrays were inserted into scalae tympani through round window membrane in 10 cochleae from ten fresh human cadavers. The intracochlear trauma was evaluated histologically by a scale of 0-4: 0 - no observable trauma, 1 - elevation of basilar membrane, 2 - rupture of basilar membrane or spiral ligament, 3-dislocation into scala vestibuli and 4 - fracture of modiolus or osseous spiral lamina. The insertion depth was measured by radiography. RESULTS: Histological results revealed no observable trauma in seven specimens; basal membrane elevation and rupture in two specimens; the electrode array misled into scala vestibuli in one specimen. The insertion depth varied from 228° to 288°. CONCLUSIONS AND SIGNIFICANCE: The insertion of the LCI-20PI electrode arrays caused no trauma in the majority of the fresh temporal bone specimens. No translocation of the electrode arrays from the scala tympani to the scala vestibuli was observed.

Utilization of Computed Tomography in Temporal Bone Fractures at a Large Level I Trauma Center.

OBJECTIVES/HYPOTHESIS: To identify which patients with temporal bone fractures who have already undergone trauma pan-scan computed tomography (CT) do not require an additional dedicated temporal bone CT. To determine the added cost of dedicated temporal bone CT in a lower-risk group of patients. STUDY DESIGN: Retrospective chart review. METHODS: A chart review was conducted of adult patients at a large level I trauma center with temporal bone fractures who underwent both trauma pan-scan CT and dedicated temporal bone CT. Patients were risk stratified into lower- and higher-risk groups based on imaging and physical exam findings. Imaging findings regarding five critical anatomic structures were compared between the two types of CT scans. RESULTS: There were 180 patients who met inclusion criteria, with 120 patients stratified to the lower-risk group. The negative predictive values of trauma pan-scan CT within the lower-risk group for fracture involvement with the five critical anatomic structures were as follows: otic capsule (1.000), carotid canal (0.960), facial nerve canal (1.000), ossicular chain (0.992), and tegmen (0.856). The annual out-of-pocket cost to patients for dedicated temporal bone CT imaging in the lower-risk group was estimated to be approximately $34,000, for a total of $190,000 during the complete study period. CONCLUSIONS: Trauma pan-scan CT may be sufficient in lower-risk patients to identify temporal bone fracture involvement with critical anatomic structures of the temporal bone. Reductions in dedicated temporal bone imaging will decrease both radiation exposure to trauma patients and strain on radiology departments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E278-E282, 2021.

Temporal Bone Fractures Caused by Ballistic Projectiles: A Systematic Review.

OBJECTIVE: Ballistic injuries to the temporal bone are uncommon but devastating injuries that damage critical neurovascular structures. This review describes outcomes after ballistic injuries to the temporal bone and offers initiatives for standardized high-quality future research. DATA SOURCES: A systematic search of PubMed, Embase, and Cochrane. REVIEW METHODS: Studies in the review included adults who experienced temporal bone fractures due to gunshot wounds and survived longer than 48 hours. Individual case reports were excluded. The various searches returned 139 results, of which 6 met inclusion criteria. RESULTS: Most of the included studies are case series with low-level evidence that report a wide range of outcomes and follow-up. Outcomes include demographic patient information, audiologic outcomes, vascular injuries, intracranial complications, facial nerve function, and surgical indications. CONCLUSION: This review is the first to characterize the nature and progression of patients who experienced gunshot wounds to the temporal bone. Although all patients share an etiology of injury, they often have vastly different hospital courses and outcomes. This review provides a basis for future studies to guide care for these injuries, as most of the existing literature includes small dated case series.

Predicting complications of pediatric temporal bone fractures.

OBJECTIVE: Our aim is to characterize complications of pediatric temporal bone fractures and identify predictive risk factors associated with fracture complications. METHODS: A retrospective review was conducted of all temporal bone fractures diagnosed in children (age less than or equal to 18 years) from a single academic institution between 2003 and 2017. Demographics, mechanism of injury, fracture characteristics, computed tomography evaluation and follow-up duration were recorded on each patient. Outcomes measured include facial nerve injury (FNI), cerebrospinal fluid (CSF) leak, sensorineural hearing loss (SNHL), and conductive hearing loss (CHL). RESULTS: One-hundred-seventeen patients with 129 temporal bone fractures were included in the study. Most fractures were otic capsule sparing (OCS) (96%, n = 124) and longitudinal (71%, n = 91). Otic capsule violating (OCV) fractures were associated with higher CSF leak rates (20% versus 2%, p = 0.14) and FNI rates (60% versus 5%, p = 0.002) compared to OCS fractures. Audiograms were available in 37 patients (34%). Patients with Glasgow coma scale (GCS) consistent with a mild traumatic brain injury (TBI) (GCS > 13) had significantly fewer complications (FNI and CSF leaks) compared to the group with moderate and severe TBI (GCS < 13), 5% versus 23% (p = 0.03). CONCLUSIONS: Higher complication rates are seen with OCV fractures and transverse fractures. Moderate and severe TBI as measured by GCS is predictive of FNI and CSF complications in pediatric temporal bone fractures.

Growing skull fracture with an atypical mechanism: a case report.

Growing skull fractures (GSFs) are well-known but rare causes of pediatric head trauma. They generally occur several months after a head injury, and the main lesion is located under the periosteum. We herein report a case involving a 3-month-old boy with GSF that developed by a different mechanism than previously considered. It developed 18 days after the head injury. A large mass containing cerebrospinal fluid and brain tissue was present within the periosteum. A good outcome was obtained with early strategic surgery. Injury to the inner layer of the periosteum and sudden increase in intracranial pressure might be related to GSF in this case.

Temporal Bone Trauma: Typical CT and MRI Appearances and Important Points for Evaluation.

Temporal bone trauma is frequently encountered in the emergency department. Technologic advances have enabled timely acquisition of thin-section images and multiplanar reconstructions such that temporal bone anatomy can be evaluated in great detail, with excellent delineation of fractures. The temporal bone is composed of a myriad of tiny structures, including many fissures and canals, that must be distinguished from true fractures. In addition, injury to important structures may result in serious complications such as hearing loss, dizziness, imbalance, perilymphatic fistula, cerebrospinal fluid leakage, facial nerve paralysis, and vascular injury. Structures that should be examined include the tympanic cavity and tegmen, the ossicular chain, the bony labyrinth, the facial canal, the internal carotid artery, the jugular foramen and venous sinuses, and the intracranial contents. Radiologists should be familiar with the anatomy of the temporal bone and be able to describe any pathologic findings and make suggestions to referring clinicians to guide management and determine the prognosis. The authors describe the typical CT and MRI appearances of temporal bone trauma, entities that mimic this injury and thus must be differentiated, and compulsory points for evaluating clinically relevant associated complications. Instruction is provided for acquiring the diagnostic skills necessary to report suggested injury status, complications, and likely sequelae to clinicians.©RSNA, 2020.

A large case series of temporal bone fractures at a UK major trauma centre with an evidence-based management protocol.

OBJECTIVE: To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol. METHODS: A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention. RESULTS: Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients. CONCLUSION: Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Post-traumatic bilateral longitudinal temporal bone fracture with bilateral facial nerve palsy: a rare case.

Facial paralysis is a potentially disabling complication of temporal bone fractures. Although unilateral palsy is commonly encountered, bilateral facial nerve palsy is rare, especially in post-traumatic situations. Other recognised causes of bilateral facial palsy are neurologic, infectious, neoplastic, idiopathic or metabolic disorders. A 25-year-old male patient presented with difficulty in talking, eating and closing eyes for 15 days since a post-vehicular accident. CT of skull showed bilateral longitudinal temporal bone fractures. Bilateral facial palsy was confirmed by clinical and topodiagnostic tests. Patient was given a course of steroids which led to an early improvement on left side followed by a delayed right-sided improvement at 6 months.