Temporal bone fracture is a common variant of traumatic brain injury, in which linear, depressed or comminuted damage to bone structures in the temple and ear area occurs. The condition occurs when the temporal zone is mechanically affected as a result of an accident, domestic, sports and professional injuries. Clinically, the fracture is manifested by unilateral hearing loss, posterior hematoma, bleeding and / or cerebrospinal fluid from the auditory canal. For diagnosis, a CT scan of the temporal bone, audiometry, neurological examination and electroneurography are performed. Treatment involves conservative or surgical methods, after which the patient is shown long-term rehabilitation.
Meaning
Fractures of the temporal bone are a common variant of damage to the base of the skull in various types of injuries. The condition occurs more often in young and middle-aged people. Men are more prone to injury due to a tendency to engage in dangerous sports and hard physical work. Taking into account the close location of all anatomical parts of the skull, 50% of patients have a combination of a temporal bone fracture with damage to other bone and intracranial structures. In 9% of cases, simultaneous injury of the temporal zone and the cervical spine is diagnosed.
Causes
Injury to the temporal bones requires the impact of mechanical force. Up to 30% of fractures occur in road accidents, which are accompanied by sudden acceleration and braking, which often leads to damage to the skull and brain structures. Typical causes also include blows to the temple that occur during contact sports, physical violence, as a result of a fall or accidental impact on a solid object.
Pathogenesis
According to the nature of the application of mechanical action on the temporal bone, there are 2 variants of fractures: longitudinal and transverse. Up to 80% of injuries are longitudinal injuries, in which the impact force is directed along the scales or mastoid process of the temporal bone. In this case, a linear fracture is formed, located in front of the auditory capsule. With transverse fractures, the auditory bones and structures of the inner ear suffer.
A separate group includes depressed fractures that have a special mechanism of development. They are formed in the area of the scales of the temporal bone, which is its thinnest part, or in the area of the natural buttresses of the skull – at the point of departure of the temporal pyramid. For the formation of this type of fracture, direct contact of the traumatic object with the surface of the head is necessary.
Symptoms
The clinical picture of a temporal bone fracture is determined by the severity of the patient’s condition and the presence of combined injuries. The pathognomonic symptom of this injury is a sign of a Battle – subcutaneous hemorrhage behind the ear, in the area of the projection of the mastoid process. The second characteristic manifestation is bleeding from the ear, in which blood can flow through a ruptured eardrum or directly from the fracture line in the external auditory canal.
If the structures of the temporal bone and the meninges are damaged, otoliquorrhea is possible — the outflow of cerebrospinal fluid from the auditory canal. Since the cerebrospinal fluid is a clear, odorless liquid, this symptom often goes unnoticed against the background of bleeding. It is possible to confirm the presence of basal liquorrhea by the symptom of a “double spot”: when a drop of bloody discharge from the ear is applied to a napkin, a light rim appears around the blood.
The victims have different degrees of hearing loss. The longitudinal type of fractures is characterized by conductive hearing loss, which is associated with damage to the auditory ossicles. It is often accompanied by cyanotic staining of the eardrum caused by blood accumulations in the middle ear cavity. For a transverse fracture of the temporal bone, sensorineural hearing loss is typical, accompanied by dizziness and balance disorders.
An important sign of involvement in the process of temporal bone is facial nerve paralysis, which is observed in 20% of patients with longitudinal fractures and 40% of patients with transverse bone damage. The condition is manifested by the expansion of the eye slit and the inability to completely close the eye, the immobility of one half of the face, an asymmetric smile. Patients are concerned about dryness and burning in the eye, a decrease in taste sensations.
According to the rate of development of symptoms, it is possible to assume the nature of nerve damage. If paralysis occurs suddenly and is accompanied by vivid clinical manifestations, a mechanical injury or compression of a nerve fiber by displaced bone structures is diagnosed. With gradual and delayed onset of symptoms, swelling of the facial nerve without tearing or compression of the fibers is more likely.
Complications
The most dangerous are combined traumatic brain injuries (TBI), in which fractures of the pyramid of the temporal bone are supplemented by damage to the articular process of the occipital bone, the orbital surface of the frontal bone, the lattice plate of the sphenoid bone. Numerous injuries are accompanied by damage to the sinuses of the dura mater and the actual medulla. In such a situation, there is a high risk of coma and death in the acute period.
The fracture is occasionally complicated by a perilymphatic fistula, in which there is a pathological communication of the tympanic cavity with semicircular channels. This condition is characterized by deafness, ringing in the ears, attacks of vestibular disorders. Dizziness and other symptoms increase when listening to loud music, sneezing and coughing. With damage to the sinuses of the dura mater and the presence of otoliquorrhea, there is a risk of infection and the development of meningitis.
With a direct blow to the temporal region and a duration of exposure of more than 0.2 seconds, damage to the soft tissues of the head occurs. Since the thickness of the hypodermis in the skull area is only 2 mm, the injury causes extensive areas of skin necrosis. The situation is aggravated by ruptures of large vessels that supply blood to the scalp, as a result of which necrotic zones reach large sizes and are difficult to treat.
Diagnostics
The initial examination and emergency care for a patient with signs of a skull fracture is carried out by a doctor of the SMP team, after which the victim enters the traumatology department. With extensive and combined injuries, diagnostic procedures are accompanied by therapeutic measures to stabilize vital functions. The survey program includes the following methods:
- CT skull. The most informative and accurate visualization method that allows a traumatologist to determine the presence of a fracture, assess its nature, the degree of damage to the temporal bone and surrounding structures. If brain damage is suspected, the examination is supplemented with an MRI of the brain.
- Audiometry. The study is shown to determine hearing disorders on the affected side and assess the degree of hearing loss. If the victim is conscious and responds adequately to the doctor’s instructions, tuning fork tests of Weber and Rinne are performed. They are necessary for the differential diagnosis between conductive and sensorineural deafness.
- Neurological examination. Physical examination reveals paresis of facial muscles, lacrimation disorders and taste sensations, which are typical for facial nerve injury. To confirm damage to the VII pair of cranial nerves, an electroneurography is performed.
- Laboratory methods. To confirm otoliquorrhea, an immunological study of the beta fraction of transferrin, a specific protein that is present in the cerebrospinal fluid and perilymph, is necessary. To assess the general condition of the victim, clinical and biochemical blood tests, a study of the gas composition of the blood, a coagulogram are performed.
Differential diagnosis
With open fractures or with a posterior hematoma, the diagnosis leaves no doubt. Differential diagnosis is carried out in difficult cases when neurological complications and vestibular syndrome come to the fore. It is necessary to exclude:
- acute cerebrovascular accident (ischemic or hemorrhagic stroke);
- rupture of a cerebral artery aneurysm;
- neuroinfection.
Diagnosis in patients in an unconscious state is particularly difficult.
Treatment
Conservative therapy
Drug treatment is prescribed to patients with a satisfactory state of health and delayed development of neurological symptoms. To stop the pathology of the facial nerve, therapy with systemic glucocorticosteroids, antihypoxants and vasodilators is carried out. With liquorrhea, strict bed rest with an elevated head position is indicated, which is accompanied by dehydration therapy and spinal punctures (according to indications).
Surgical treatment
The help of a neurosurgeon is required for patients with multiple, comminuted and complicated fractures, especially when they are combined with injuries to the meninges and nervous tissue. The timing of the start of surgery varies from several hours to several months after the injury, which depends on the nature of the injury and the clinical picture. Emergency operations are required for acute compression of the facial nerve, hemorrhage in the medulla.
To restore hearing in conductive hearing loss, delayed interventions are performed to reconstruct the auditory ossicles in the tympanic cavity. With vestibular disorders associated with perilymphatic fistula, surgical closure of the fistula is indicated, which allows you to get rid of dizziness and restore the normal operation of the vestibular apparatus.
Rehabilitation
Like other types of TBI, fractures of the temporal bone require complex rehabilitation measures that begin 4-5 weeks after the injury and last for several months. The program includes therapeutic gymnastics, breathing exercises, massage and manual therapy. Physiotherapy methods are widely used: electrophoresis, phonophoresis, magnetotherapy and laser therapy.
Prognosis and prevention
The outcome depends on the severity of the injury to the bone structures, the degree of hearing loss and the reversibility of neurological disorders caused by facial nerve compression. The prognosis is determined individually for each patient, and may change during therapy, taking into account the response to treatment and the dynamics of the disease. In order to prevent fractures of the temporal bone, preventive measures are being taken to reduce the level of domestic, professional and road traffic injuries.
Literature
- Johnson F, Semaan MT, Megerian CA. Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin North Am. 2008 Jun;41(3):597-618, x. – link
- Cannon CR, Jahrsdoerfer RA. Temporal bone fractures. Review of 90 cases. Arch Otolaryngol. 1983 May;109(5):285-8. – link
- Travis LW, Stalnaker RL, Melvin JW. Impact trauma of the human temporal bone. J Trauma. 1977 Oct;17(10):761-6. – link
- Diaz RC, Cervenka B, Brodie HA. Treatment of Temporal Bone Fractures. J Neurol Surg B Skull Base. 2016 Oct;77(5):419-29. link
- Jones RM, Rothman MI, Gray WC, Zoarski GH, Mattox DE. Temporal lobe injury in temporal bone fractures. Arch Otolaryngol Head Neck Surg. 2000 Feb;126(2):131-5. – link
