Last Updated on 06/23/2017 by Perelomanet
Any head injury has unpredictable consequences and often leads to a change in the quality of life, regardless of how positive and favorable the outcome of its treatment. Seriousness lies in constant, throughout life, monitoring the health status of the injured person and monitoring vital indicators in the functioning of the body.
A fracture of the temporal bone occurs as a result of severe traumatic brain injury and is associated with excessive impact, pressure on it, as a result of which a change in structure is observed, integrity is disrupted, leading to serious complications.
A fracture can be detected using x-rays, using survey x-rays of the skull in two projections - lateral and direct. Examination of the skull is complicated by the presence of minor structural damage that is not visible on the apparatus. In this case, a histological analysis or computed tomography scan is prescribed.
Clinical manifestations
Typical symptoms:
A fracture of the temporal bone can be longitudinal or transverse.
Longitudinal fracture:
- Acute hearing loss in 65% of cases (tamponade of the tympanic cavity with blood, rupture of the eardrum, displacement of the auditory ossicles)
- Liquororrhea in 40-50% of cases
- Neuritis of the facial nerve, usually transient, in 20-25% of cases.
Transverse fracture:
- Damage to the inner ear in 50% of cases (sensorineural hearing loss, dizziness, nystagmus)
- In 30-50% of cases, neuritis of the facial nerve develops.
Therapeutic measures
The set of therapeutic measures is selected individually depending on the clinical picture. Treatment depends on the severity of the injury and the patient's general health. First of all, the victim receives restorative drugs and pain relief. Surgery is indicated in cases where there is no concussion or brain contusion or when vital signs are stable.
The use of restorative therapy includes measures aimed at preventing the development of edema in the head area. There is a risk of infection of wound surfaces. To prevent it, antiseptic drugs are used.
Which method of diagnosing a fracture of the temporal bone to choose: MRI or CT
Selection method
- CT
In what cases is a CT scan of the temporal bone performed for a fracture?
- Tomograms often show uneven linear clearing crossing anatomical structures
- The fracture line may be indistinguishable from the skull suture
- Spread of the fracture to adjacent structures (external auditory canal, temporomandibular joint)
- Fracture of the roof of the tympanic cavity
- Contrasting the tympanic cavity
- Dissection or occlusion of the internal carotid artery
What MRI images of the temporal bone will show in case of a pyramidal fracture
- Hematoma or swelling of the pyramid of the temporal bone
- Interruption of cranial nerves
- Change in signal intensity from blood moving through the internal carotid artery (MR angiography)
- Digital subtraction angiography (carotid angiography) may be required to differentiate between dissection and occlusion.
Distinctive signs of a fracture
- The fracture line can be parallel or perpendicular to the axis of the pyramid.
First aid
If this type of injury occurs, it is necessary to urgently provide the person with the necessary assistance. First of all, you need to apply a sterile bandage to the damaged area and immediately call an ambulance. Under no circumstances should you try to set a protruding bone. It is strictly forbidden to fill the wound with peroxide or brilliant green. Adequate medical care to the victim can only be provided in a medical institution by qualified personnel.
It is likely that the patient may need surgery. Such measures are carried out after the patient’s general condition has stabilized. In this case, the symptoms of a concussion or brain injury should be neutralized.
In the acute period, it is extremely important to properly carry out prophylaxis to prevent swelling of the soft tissues of the meninges. Measures are also required to prevent the wound from becoming infected with pathogenic bacteria, which can cause inflammation. Antibiotics and diuretics are used for this.
Possible consequences
Injuries to the temporal bone significantly increase the risk of future meningitis. They pose a particular danger to those who suffer from chronic diseases of the ENT organs. In this case, there is a high probability that the infection will spread to the affected, injured tissues.
If the eardrum ruptures, blood may leak from the ear canal. Such bleeding poses a danger to human life. Even with a small amount of blood that enters the brain structures, it can cause inflammation of its membranes. Such a situation can lead to extremely serious consequences and even death. "Doctor Yaroslav Filatov" - author of the blog Otravmah.Online
If the middle ear is damaged due to injury to the temporal bone, disturbances in the activity of the vestibular apparatus may occur.
After undergoing medical treatment, the victim is registered with a doctor - a neurologist. In the presence of headaches, nervous disorders, vestibular disorders, hearing loss and other relevant symptoms, appropriate therapy is prescribed.
If an injury causes a visible cosmetic defect, a set of measures is carried out in the first six months to eliminate it. Untimely plastic correction can lead to the appearance of bone growths or rough scars, which are much more difficult to correct.
Types of zygomatic bone fractures
In accordance with the accepted classification, there are several types of fractures, for differentiation of which various criteria are used:
- The presence or absence of displacement, which determines the severity of the damage;
- The area of localization of the injury;
- The period that has passed since the damage occurred;
- Single or multiple, as well as one- or two-sided nature of the injury;
- The specificity of the line along which the fracture runs (straight or oblique).
Characteristic signs of pathology include:
- Limitation of jaw mobility;
- Pain that occurs when trying to open your mouth;
- Distortion of the facial contour and deformation of the bone structure;
- Hemorrhage into mucous tissue, eyelid structure, or conjunctiva;
- Bleeding from the nose from the side of the injured cheekbone;
- Visual disturbances, swelling of the areas around the eyes, severe headache.
At the first suspicion of a fracture of the zygomatic bone, you should consult a doctor and undergo a comprehensive diagnosis.
Diagnosis of depressed skull fractures
Before developing treatment tactics, CELT specialists conduct a comprehensive diagnosis of the injury. It allows you to accurately determine its location, size and consequences to which it led. The optimal method is still radiography - projection craniography. It provides an overview of the damage from all sides and allows you to understand exactly how the fracture occurred, which is important when preparing for treatment.
In addition to radiography, computed tomography or magnetic resonance imaging is used to diagnose depressed skull fractures using the bone mode. It allows you to determine the condition of the subosseous space. Along with instrumental techniques, a neurological examination is carried out aimed at checking reflexes, assessing sensitivity and muscle strength.
Fractures of the base of the skull are often accompanied by a fracture of the pyramid of the temporal bone [1, 2]. Cracks of the temporal bone are visualized by computed tomography, but the possibility of a wide variety of fracture lines passing through the pyramid requires a detailed study of the condition of the bone capsule of the labyrinth, internal auditory canal and facial nerve canal [3]. Transverse fractures are less common than longitudinal ones; As a rule, they affect only one temporal bone and are accompanied by a pronounced clinical picture of unilateral damage to the cochleovestibular analyzer, manifested by mixed or sensorineural hearing loss on the side of the fracture, nystagmus of depression, statocoordination disorders and autonomic symptoms [4, 5]. In such cases, with adequate rehabilitation, it is usually possible to fully socialize the patient. On the contrary, bilateral loss of vestibular function with a transverse fracture of the pyramids of both temporal bones leads, in the absence of vestibular rehabilitation, to severe chronic vestibular or combined cochleovestibular dysfunction [6-8]. It is characteristic that with combined fractures of the base of the skull and bilateral localization of the fracture, the clinical picture can be masked by general cerebral symptoms, the general severity of the patient’s condition, and also occur atypically, which leads to an incorrect diagnosis. In such cases, a thorough otoneurological examination of the patient is of particular importance [9]. In this article we present a clinical case of a bilateral temporal bone fracture.
Patient Sh., 46 years old, was taken by an ambulance team to the emergency department of City Clinical Hospital No. 1 named after. N.I. Pirogov with complaints of headache, pain in the neck, nausea, vomiting, deafness in both ears. Hospitalized in the neurosurgical department. From the anamnesis it is known that 3 days before admission she fell backward, hit the back of her head on the floor, and lost consciousness. She cannot clarify how long she was unconscious, but she immediately noted a progressive decrease in hearing in both ears, nausea, repeated vomiting that lasted 3 days, and the inability to get out of bed, as coordination was significantly impaired. When examined by an ENT doctor on the day of admission: otoscopy on both sides was unremarkable; the patient could not hear whispered or spoken speech. On computed tomography (CT) of the brain with slice thickness and tomograph step 4 and
7 mm: small focal cortical contusions of the frontal lobes, convexital subarachnoid hemorrhage, fracture of the occipital bone. The neurosurgical department made a clinical diagnosis: closed craniocerebral injury, mild brain contusion, fracture of the occipital bone. Treatment was prescribed, including analgesic, sedative, dehydration and vascular therapy, against which no positive effect was noted.
On the 6th day after the injury, she was examined by an otoneurologist, and a comprehensive examination of vestibular and auditory functions was performed. The patient performed statocoordination tests (finger-nose, finger-finger, Barre-Fisher). In the Romberg position it was unstable; in the sensitized Romberg position there was a fall in both directions. When walking in a straight line - severe ataxia, falling in different directions. She performed flank walking uncertainly in both directions. Obvious spontaneous horizontal nystagmus in both directions of the 1st degree was also determined. In the head turn test, the vestibulo-ocular reflex was reduced on both sides. In a mask, during videonystagmography, gaze-induced nystagmus was determined in both directions: when looking to the right - right horizontal, to the left - left horizontal. Examination of saccadic eye movements, optokinetic nystagmus, and smooth visual pursuit revealed no abnormalities. With bithermal bilateral calorization, as well as with the rotational sinusoidal pendulum test, bilateral areflexia of both labyrinths was determined. During an audiological examination: hearing - deafness on both sides, tympanometry - type “A” on both sides, acoustic reflexes in the range from 500 to 4000 Hz were not registered, otoacoustic emissions were not registered on both sides. Study of taste sensitivity: reduced in the anterior 2/3 of the tongue on the left. No signs of facial nerve paresis were found.
Thus, the examination revealed bilateral loss of function of the auditory and vestibular analyzer, as well as a slight lesion of the chorda tympani on the left. The absence of unilateral nystagmus is explained by symmetrical damage to the vestibular analyzers of both ears, and the presence of bilateral spontaneous gaze-induced horizontal obvious and latent nystagmus is probably explained by dysfunction of the neuronal integrator due to the side effects of sedative therapy received by the patient, or contusional damage to the nystagmus centers in the brain stem.
Based on the studies, the patient was suspected of having a bilateral transverse fracture of the pyramids of the temporal bones. It is recommended to perform a repeat computed tomography scan of the temporal bones with a thickness of less than 1 mm.
On CT of the temporal bones according to the volumetric scanning program with a slice thickness of 0.67 mm: a fracture of the occipital bone with transition to the base of the skull, a fracture of the pyramids of the temporal bones with the transition of the fracture line to the system of semicircular canals and the vestibule on both sides, signs of their depressurization (gas density content in the semicircular canals on both sides) (see figure).
Figure 1. CT scan of the temporal bones of patient Sh. (axial projection). Arrows indicate fracture lines.
The patient underwent vestibular gymnastics in the hospital, which was significantly hampered by the patient’s decreased motivation. After discharge, the patient stopped following the developed individual rehabilitation program and refused outpatient sessions. It should be noted that spontaneous recovery of vestibular function occurs extremely rarely after bilateral lesions, and physical rehabilitation is recognized as the main direction in treatment throughout the world [10, 11].
After discharge, the patient was sent for additional examination to decide on the possibility of cochlear implantation, available under the compulsory health insurance program. Cochlear implantation is the only and most promising direction of hearing rehabilitation in case of preservation of the function of the auditory nerve, as well as the integrity and patency of the translymphatic spaces of the cochlea of the inner ear [12, 13]. A successful operation and adequate auditory and speech rehabilitation in the postoperative period would allow the patient to significantly improve her quality of life and social adaptation.
The given clinical example demonstrates the need for an integrated approach to the examination of patients with post-traumatic cochleovestibular disorders. It is important to note that the use of modern objective examination methods, such as computed tomography, does not always immediately allow for accurate differential diagnosis, while routine examination of auditory and vestibular functions in combination with high-tech methods makes it possible to establish the correct clinical diagnosis in a short time and begin timely social rehabilitation of the patient.