Correlación clínico-radiológica de las fracturas de hueso temporal

IntroductionThe diagnosis of temporal bone fractures (TBF) is based on radiological imaging. The most widely used classification divides fractures into longitudinal, transverse, and mixed. In recent years, other classifications have emerged to better predict clinical manifestations.ObjectivesTo review computed tomography (CT) images of TBF, define their radiological pattern, and study the concordance of the observed findings with those described in the radiological report. To analyse the association between fracture types and clinical findings. To study the impact of mastoid pneumatization on fracture characteristics.MethodsRetrospective study of 110 TBF diagnosed with CT between January 2016 and May 2019.ResultsFifty-two transverse (47%), 34 longitudinal (30%), and 19 mixed fractures (17%) were identified with good interobserver agreement (k = .637). Longitudinal fractures were associated with conductive hearing loss (p < .001) and transverse fractures with sensorineural hearing loss (p = .005). Of the fractures, 8.2% showed involvement of the otic capsule, and were associated with sensorineural hearing loss (p < .001), facial paralysis (p = .019) and vertigo (p = .035). Fractures were more frequent in cases of greater pneumatization, and the involvement of the otic capsule in cases of very good pneumatization (p = .024).ConclusionsThe traditional classification of TBF is reproducible. Its association with clinical findings improves when the involvement of the otic capsule is also analysed. Mastoid pneumatization is not a protective factor for TBF or for involvement of the otic capsule.     

Comparison of the clinical relevance of traditional and new classification systems of temporal bone fractures

Temporal bone fractures are traditionally classified as transverse, longitudinal or mixed. Since these categories have shown little association with clinical symptoms, new classifications have been introduced, including those related to the involvement of the petrous bone and otic capsule. We have formulated a new classification based on the involvement of four parts of the temporal bone (squama, tympanic, mastoid, and petrous) and assessed which of these classification systems is the most rational using a retrospective chart review in hospital settings (KyungHee Medical Center, Seoul, Korea and Samsung Changwon Hospital, Changwon, Korea). The association between each classification and clinical symptoms was examined by analyzing temporal bone computed tomography scans of 129 patients diagnosed as temporal bone fractures over the past 7?years. Using the traditional classification, there was a significant correlation between transverse fractures and the incidence of sensorineural hearing loss. Patients with petrous bone fractures had significantly higher incidence rates of sensorineural hearing loss, vertigo, and eardrum perforation than patients without petrous bone involvement. Involvement of the otic capsule was significantly associated with sensorineural hearing loss and the severity of hearing loss. The associations of the traditional classification and the classification according to the involvement of the otic capsule, four parts of temporal bone with clinical symptoms were not high. Petrous bone fractures were significantly associated with sensorineural hearing loss, vertigo, and eardrum perforation, suggesting that this classification may be optimally associated with clinical symptoms including hearing and the results of otological examination.     

Pediatric Temporal Bone Fractures

Objective: To examine the etiology, presentation, and management of temporal bone fractures in children. Study Design: Case control. Method: Retrospective review of a level I pediatric trauma center from July 1, 1990 to November 1, 1996 identified 680 patients. Inclusion criteria of age less than 14 years and only blunt temporal bone trauma identified 122 patients, with 97 charts available for review. The criteria for temporal bone fracture consisted of both clinical and radiologic information. Only patients with temporal bone fractures confirmed by computed tomography, a complete otolaryngology examination, and audiometric evaluations were included in the study. The data were analyzed with the Kruskal-Wallis analysis of variance (ANOVA) for examining the three separate age groups of fractures. Chi-squared analysis was used to compare these data with previously published adult and pediatric temporal bone fracture series and to examine the three separate age groups of fractures. Results: The review identified 72 children with 79 temporal bone fractures: 47 boys and 25 girls. The patients ranged from 6 months to 14 years of age, with a bimodal distribution of patients with peaks at 3 years and 12 years of age. The most common causes of fractures were motor vehicle accidents (47%), falls (40%), biking accidents (8%), and blows to the head (7%). Common presenting signs and symptoms included hearing loss (82%), hemotympanum (81%), loss of consciousness (63%), intracranial injuries (58%), bloody otorrhea (58%), extremity fractures (8%), and facial nerve weakness (3%). The most common causes of temporal bone fractures were falls and motor vehicle accidents. Forty-two patients were noted to have bloody otorrhea and possible cerebrospinal fluid leak. Twenty-four received intravenous antibiotics. No patient developed prolonged otorrhea or meningitis during hospitalization and the follow-up period. The classification of fracture patterns was longitudinal, 54%; transverse, 6%; oblique, 10%; squamous, 27%; and other, 3%. Hearing loss was found in 59 patients, with conductive hearing loss being the most common finding in 56% of the patients, followed by sensorineural hearing loss in 17% and mixed hearing loss in 10%. Conclusions: Pediatric temporal bone fractures are associated with falls and motor vehicle accidents. There is a high incidence of associated intracranial injuries and hearing loss, but facial nerve injuries are uncommon. Timely management minimizes complications.     

Detection of pneumolabyrinth after temporal bone trauma using computed tomography

Conclusion: Pneumolabyrinth is a very rare condition, even in otic capsule disrupting (OCD) fracture. Hearing was not always impaired, even in cases with OCD fracture. The co-existence of pneumocochlea, regarded as a risk factor for total hearing loss, was extremely rare in cases of pneumolabyrinth. Objectives: The purposes of this study were to analyze the radiological and clinical features in patients with pneumolabyrinth and to overcome the diagnostic pitfalls encountered during pneumocochlea detection. Materials and methods: The temporal bone computed tomographies (TBCT) of 402 patients diagnosed with temporal bone fracture along with their clinical records were retrospectively reviewed. Results: Only six patients (7% of those with OCD fractures or 1.5% of those with temporal bone fracture) were found to have pneumolabyrinth. Locations of the pneumolabyrinth were in the vestibule in all six cases and three of them showed air densities both in the cochlea and semicircular canal. The size of the air density in the vestibule was 5.38?±?4.56?mm² at the axial view and 6.57?±?5.67?mm² at the coronal view. The mean minimal Hounsfield unit (HU) of air density area in the vestibule was ?968.1?±?22.94 at the axial view and ?941?±?16.88 at the coronal view. Patients with pneumocochlea eventually developed total hearing loss.     

A comparison of temporal bone fracture classification systems

Objectives: To compare the traditional and otic capsule classification system of temporal bone fractures for clinical relevance. Design: A retrospective review of all patients with a radiological diagnosis of a skull‐base fracture over a 5‐year period. Setting: All patients were seen at Beaumont Hospital, the national tertiary referral centre for Neuro‐otology. Participants: Patients with a clinical diagnosis of skull fracture were identified from the hospitals in patient enquiry (HIPE) database. Of 338 patients, 31 (9%) were identified as having a temporal bone fracture on high‐resolution CT scanning. Main outcome measures: The rate and distribution of each major clinical complications within each classification system to establish if either one was more clinically useful. Results: Fractures were classified as mixed in 14 (45%), longitudinal in 9 (29%) and horizontal in 8 (26%). Alternatively, 2 (7%) were otic capsule violating and 29 (93%) were otic capsule sparing. Seventeen patients (54.8%) sustained a hearing loss. Seven patients (23%) sustained a facial nerve injury. Four (13%) developed a cerebrospinal fluid (CSF) leak. Of all clinical findings only sensorineural hearing loss occurred significantly more often in the horizontal as opposed to the longitudinal group (P = 0.029) and in the otic violating as opposed to the otic sparing group (P = 0.013). Conclusions: We acknowledge that the relatively small size of our cohort diminishes the statistical power of our conclusions. However, we found that the otic capsule‐based classification system was not significantly better than the traditional system in predicting the likelihood of sustaining specific injuries from fractures of the temporal bone.     

Radiographic classification of temporal bone fractures: clinical predictability using a new system

OBJECTIVE: To compare the traditional system of radiographic classification of temporal bone fractures (transverse vs longitudinal vs oblique) with a newer system (otic capsule violating vs otic capsule sparing) with respect to their ability to predict sequelae of temporal bone trauma. DESIGN: Retrospective chart and radiology review. SETTING: University trauma center and Department of Otolaryngology-Head and Neck Surgery. PATIENTS: Patients with temporal bone fractures. INTERVENTIONS: Clinic records and computed tomographic scans were reviewed to evaluate the clinical predictability of complications of temporal bone fractures. MAIN OUTCOME MEASURES: Complications of temporal bone fractures (ie, sensorineural hearing loss, conductive hearing loss, cerebrospinal fluid leakage, and facial nerve weakness) were recorded. Two classification schemes for temporal bone fractures were statistically analyzed and compared as to their ability to predict each complication. RESULTS: A total of 234 temporal bone fractures were identified; 30 cases met our strict criteria for inclusion. The traditional classification system of temporal bone fractures did not significantly predict temporal bone complications (P = .71). On the other hand, the otic capsule-based system did demonstrate statistically significant predictive ability (P < .001). Patients with otic capsule-violating fractures were 5 times more likely to have facial nerve injury, 25 times more likely to have sensorineural hearing loss, and 8 times more likely to have cerebrospinal fluid otorrhea than those with otic capsule-sparing fractures. CONCLUSIONS: The traditional radiographic classification system failed to demonstrate clinical predictability in our series. Furthermore, the newer system of classification (otic capsule sparing vs otic capsule violating) demonstrated statistically significant predictive ability for serious clinical outcomes associated with temporal bone fractures.     

Vertigo, dizziness, and tinnitus after otobasal fractures

Some 15% of temporal bone fractures are produced by blows to the occiput. The fracture line begins in the posterior fossa, at or near the foramen magnum, and crosses the petrous ridge through the internal auditory canal or the otic capsule. Thus, it is called a transverse fracture. In cases of transverse fractures of the temporal bone, due to automobile accidents or other causes of head injury, the labyrinth is involved more frequently than in longitudinal fractures. Severe vertigo with severe or total hearing loss is not uncommon in such injuries. In milder injuries, labyrinthine "concussion" may occur, with transitory auditory-vestibular symptoms. The force that causes the fracture is so great that it not only fractures the base of the skull but may cause a lesion of the brainstem, resulting in a combined peripheral and central lesion. We evaluated 61 patients (50 [81.97%] male, 11 [18.03%] female) with neurootological complaints of sequelae of otobasal fractures. Of these, 40.98% complained of tinnitus and 52.82% of hearing loss. Reviewing our experimental neurootometric investigations, we identified pathological processes on 75.41% of the butterfly calorigrams and 72.13% of the stepping craniocorpograms, as well as in 32.79% and 39.34% of subjects on right- and left-ear bone-conduction audiometry, respectively.     

Pediatric temporal bone fractures

Temporal bone trauma are more common nowadays related to sports. We report 2 cases with temporal bone fractures in patients younger than 14 years. They were two male, 9 and 12-year-old respectively, that presented traumatism after accidental falls from lowe height. The first case had a longitudinal temporal bone fracture without hypoacusia or vertigo, whereas the second one had an oblique fracture involving the otic capsule, provoking permanent neurosensorial hearing loss, as well as vertigo and unsteadiness that resolved later, related to a vestibular hyporreflexia. Neither case had facial paresia or paralysis. CT scanning was essential to determine the importance of the trauma. Despite the otic capsule rupture, hearing loss in the second case was only significant over 2 KHz, suggesting a selective cochlear trauma. We present clinical and imaging findings, as well as correlation of audiological and vestibular alterations, reviewing the clinical presentation of temporal bone trauma in children.     

Histopathology of temporal bone fractures: Implications for cochlear implantation

Temporal bone fractures often cause loss of audiovestibular function. Those patients with bilateral profound sensorineural hearing losses secondary to temporal bone fractures become candidates for cochlear implantation. The authors present the histopathology of five temporal bone fractures in three patients, evaluating specifically the traumatic effects on the neural elements of the inner ear. Transverse fractures of the temporal bone result in severe loss of hair cells, ganglion cells, and other supporting cells in the inner ear. Occasionally labyrinthitis ossificans may occur as a consequence of trauma or infection. While longitudinal fractures do not violate the otic capsule, these same neural elements may be damaged by concussion.     

Bilateral cochlear implantation in a patient with bilateral temporal bone fractures

With the emphasis on bilateral hearing nowadays, bilateral cochlear implantation has been tried out for bilateral aural rehabilitation. Bilateral sensorineural hearing loss caused by head trauma can get help from cochlear implantation. We present the case of a 44-year-old man with bilateral otic capsule violating temporal bone fractures due to head trauma. The patient demonstrated much improved audiometric and psychoacoustic performance after bilateral cochlear implantation. We believe bilateral cochlear implantation in such patient can be a very effective tool for rehabilitation.     

Fibrous dysplasia: rare manifestation in the temporal bone

IntroductionFibrous dysplasia is a benign disorder, in which normal bone is replaced by fibrosis and immature bone trabeculae, showing a similar distribution between the genders, and being more prevalent in the earlier decades of life. Fibrous dysplasia of the temporal bone is a rare condition, and there is no consensus as to whether it is more common in monostotic or polyostotic forms. External auditory meatus stenosis and conductive dysacusis are the most common manifestations, with cholesteatoma being a common complication, whereas the involvement of the otic capsule is an unusual one. Surgical treatment is indicated to control pain or dysacusis, otorrhea, cholesteatoma, and deformity.ObjectivesTo describe the clinical experience of a tertiary referral hospital with cases of fibrous dysplasia of the temporal bone.MethodsSampling of patients diagnosed with fibrous dysplasia of the temporal bone, confirmed by tomography, treated at the pediatric otology and otorhinolaryngology outpatient clinics, between 2015 and 2018. The assessed variables were age, gender, laterality, external auditory meatus stenosis, deformity, hearing loss, presence of secondary cholesteatoma of the external auditory meatus, lesion extension and management.ResultsFive patients were included, four females and one male, with age ranging from 13 to 34 years. Three had the polyostotic form and two the monostotic form of fibrous dysplasia of the temporal bone. Four patients had local deformity and external auditory meatus stenosis, two of which progressed to cholesteatoma. All patients showed some degree of hearing impairment. All had preserved otic capsule at the tomography. Two patients are currently undergoing clinical observation; two were submitted to tympanomastoidectomy due to secondary cholesteatoma; one was submitted to lesion resection, aiming to control the dysacusis progression.ConclusionFive cases of fibrous dysplasia of the temporal bone were described, a rare disorder of which the otologist should be aware.     

Prognostic indicators for sensorineural hearing loss in temporal bone histiocytosis

Objective

Our review aims: (1) to highlight the suspicion of sensorineural hearing loss (SNHL) in temporal bone Langerhans’ cell histiocytosis (LCH); (2) to assess the evolution of SNHL in this pathology; (3) to identify radiologic findings of the otic capsule invasion by LCH; (4) to determine prognostic factors for SNHL in temporal bone LCH.

Methods

We performed a literature review through MEDLINE for SNHL in temporal bone LCH related articles that were published between 1954 and 2008. We identified 12 related studies of which 18 patients were noted. We also added our case to this series. The information from the reports was analyzed to characterize the clinical and demographic data and to focus on the sensorineural hearing aspect of the disease and on the damage of the semicircular canals (SCC) and the cochlea.

Results

Ten percent of patients with temporal bone LCH presented SNHL. The mean age of patients is 3.5 years among children and 35.5 years among adults. Male to female ratio is 1:1.14. There were 13 unilateral cases, 6 bilateral cases and 1 case of multisystemic histiocytosis. Cochlea and SSCs were involved in 4 and 20 temporal bones, respectively. The lateral SCC is the most frequently eroded canal. In 23 ears hearing level was reported: 15 ears had a SNHL and the remaining was a mixed or a conductive hearing loss type. 10 ears suffered from a profound hearing loss and none of them improved after treatment regardless otic capsule affected structures. In all cases of normal hearing, moderate hearing loss and severe hearing loss before treatment cochlea have not been affected. However a single or two semicircular canals invasions have been noted. Where it is reported (15 out of 25 temporal bone) there was a radiological healing of the otic capsule lesion after treatment. Remineralization occurs 6 months after treatment.

Conclusion

In LCH, hearing loss level before treatment can be considered as a prognostic indicator for hearing in response to treatment. Even though bone mineralization is essential for a hearing improvement, radiological healing is not a prognostic factor for better hearing level after treatment.     

Appropriate hearing screening in the pediatric patient with head trauma

Purpose

To develop an algorithm for the appropriate audiologic screening of in children with head trauma.

Methods

Participants were the first consecutive 50 children admitted to a children's hospital trauma service after October 1, 2005, whose injuries resulted in a Glasgow Coma Scale (GCS) score ≤13 and/or loss of consciousness (LOC) but no history of hearing loss. Screening tympanometry, otoacoustic emissions testing, and/or routine audiometric evaluation were performed as soon as possible after admission. Age, GCS score, Pediatric Trauma Score, Injury Severity Score, presence of head and neck soft tissue injury, temporal bone fracture, skull fracture not involving the temporal bone, midface/mandible fractures, intracranial abnormality on computed tomography, and cervical fracture were analyzed as risk factors for hearing loss.

Results

Seventeen (34%) of the 50 children had abnormal hearing test results. Fischer's exact test showed abnormal test results were most strongly related to temporal bone fracture (p = 0.0041), non-temporal bone skull fracture (p = 0.0211) and younger age (p = 0.0638).

Conclusions

Any child with head trauma and clinical or radiologic evidence of temporal bone fracture should have early hearing evaluation. Using the proposed algorithm to test children with head trauma and GCS ≤13 and/or LOC and age <3 years or any type of skull fracture may help identify children with hearing loss in a more cost effective manner.     

Vascular injury arising from lateral skull base fractures

PurposeAlthough uncommon, vascular injury can be seen in patients with lateral skull base fractures (LSBF). However, little is known about this potentially life-threatening comorbidity. The objective of this study is to better characterize the vascular injuries associated with temporal and lateral sphenoid bone fractures.Basic proceduresRetrospective review of all patients with computed tomography angiography (CTA) performed specifically to evaluate for vascular injury following LSBF. In addition to patient demographics (age, gender, race), the mechanism of injury, the location of fracture(s), and the nature of vascular injury diagnosed by CTA was recorded. Two-way ANOVA was performed to determine if any variables were predictive of vascular injury.Main findingsFrom 2011 to 2021, 143 patients with 333 subsite fractures met inclusion criteria. Of all patients, 46 (32.2 %) had CTA evidence of at least one vascular injury, the most common type being venous thrombosis/filling defect (41.7 %). Evidence of vascular injury was unclear in 14 patients (9.8 %). Fractures most associated with vascular injury ranged from 0.7 % (otic capsule fractures) to 26.7 % (mastoid, lateral sphenoid fractures). Risk of vascular injury was no different between patients with single vs multiple fractures. There were no fracture locations that could reliably predict specific vascular injury.ConclusionsOver 40 % of all CTAs ordered following LSBF identified were suspicious for associated vascular injury. Yet fracture location and number cannot reliably predict vascular injury. Until such determinants can be better identified, clinicians should have a low threshold to obtain CTA to rule out associated vascular injury.     

Cranial base fracture and rhino cerebrospinmal fluid leakage. A case report

Oto cerebrospinal fluid leakage occurs frequently in skull base fractures but it is not always recognized which may produce potentially serious consequences on the prognosis. The aim of this study is to present a case of an extended skull base fracture with bad defined symptoms. A male in coma was admitted to our hospital following a road accident. Imaging revealed a fracture that transversally crossed the squamous occipital bone and petrous portions of temporal bone on the right, the sphenoid bone, and the left zygomatic bone. Ten days later the patient regained consciousness presenting symptoms of right complete hearing loss, cephalalgia and fever. Lumbar puncture showed a Gram negative germ growth. After specific antibiotic treatment he underwent surgery with exclusion of the middle ear and the mastoid from outside by obliterating the Eustachian tube, sealing the surgical cavity (subtotal petrosectomy) with abdominal fat and closing the external auditory canal as a blind sac. At the same time, nasal fibroendoscopy was also performed to close the fistulas in the sphenoid region. Since the cephalalgia persisted further CT examination was performed and revealed another fracture rima in the ethmoid bone. Nasal fibroendoscopy was performed again to close this fistula. The symptoms thus disappeared and the patient has continued to be symptom-free during the two years follow-up. Skull base fractures may involve various bone structure (petrous portion of temporal bone, ethmoid, sphenoid, parietal bone). As a result of the complex anatomy of the skull base, the fracture may damage numerous vital structures (cranial nerves, internal carotid artery, cavernous sinus, jugular vein etc) and the dura mater, causing cerebrospinal fluid leak. When the fracture in the petrous bone is transversal, it is highly important not to delay surgery. In fact the otic capsule does not repair but the bone step is covered by a thin layer of fibrous tissue. For this reason patients, with clear damage to the otic capsule, risk meningitis. Fistulas in the ethmoid are the most difficult to diagnose and the easiest to underestimate. It is fundamental to follow the appropriate diagnostic procedure.     

Tympanometry and isolated fracture of the stapes

Introduction

Temporal bone fractures are frequently associated with ossicular dislocations or fractures, most commonly involving the incus. To our knowledge, isolated fracture of the posterior crus of the stapes has not been previously reported.

Temporal bone fracture with ossicular dislocation caused by a blow to the opposite side of the head

We report an indirect temporal bone fracture with ossicular chain injury occurring only on the side opposite a facial bone fracture caused by a direct blow. A 45-year-old female was referred to our clinic complaining of right hearing loss. She had suffered a left facial bone fracture in a traffic accident 6 months earlier. Her right hearing impairment was conductive. Exploration of her right middle ear revealed a temporal bone fracture, with ossicular chain separation and a dislocated stapes with a perilymphatic fistula. These injuries were considered to be caused by an indirect force following a blow to the face on the opposite side. Well-developed mastoid cells are composed of sparse, light bone in contrast to the compact bone of the bony canal, ossicles, and otic capsule, and therefore their mechanical compliance may differ.     

Temporal bone fracture: evaluation and management in the modern era

Temporal bone fractures occur from high-energy mechanisms, typically but not limited to motor vehicle accidents. However, as the automotive industry continues to introduce improved safety measures, violence and falls account for a larger proportion of cases. Given the great forces involved, temporal bone fractures rarely occur in isolation and initial evaluation must focus on the fundamental ABCs of Advanced Trauma Life Support with special attention to Glasgow Coma Scale, intracranial injury, and cervical spine injury. Subsequent evaluation relies on physical examination, high-resolution CT, and electrodiagnostic testing to address the neurotologic consequences of temporal bone fracture, including cerebrospinal fluid leak, facial nerve injury, and injury to the peripheral hearing and balance organs. Management algorithms must address immediate (eg, ABCs, neurosurgical issues), short-term (eg, cerebrospinal fluid leak, facial nerve injury, hearing loss), long-term (eg, facial nerve injury, hearing loss, vestibular injury), and delayed (eg, encephalocele, cholesteatoma, late meningitis) issues. This article reviews the current state of temporal bone fracture evaluation and management with special attention to mechanisms of injury, clinical presentations and emergency evaluation, and diagnostic workup, including the evolution of radiographic fracture classification systems and electrodiagnostic testing. Discussion of treatment approaches address management of immediate, short-term, long-term, and delayed complications.     

Fibrous dysplasia of the temporal bone

Fibrous dysplasia of the temporal bone is a rare disease which may lead to progressive stenosis of the external auditory canal with conductive hearing loss. Sensorineural hearing loss has usually been attributed to involvement of the otic capsule or inner auditory canal. The case of fibrous dysplasia of the temporal bone in 11 years old girl was described. The conductive hearing loss with sensorineural component improved after surgical treatment.