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CURRENT THERAPY

J Oral Maxillofac Surg 66:513-522, 2008

Temporal Bone Fractures: A Review for the Oral and Maxillofacial Surgeon
Michael Gladwell, DMD,* and Christopher Viozzi, DDS, MD†
Fracture of the temporal bone is, by definition, a fracture of the skull base. Even though the oral and maxillofacial surgeon (OMS) may not provide definitive management of temporal bone fractures or their sequelae, a working knowledge of this area is important for any surgeon participating in the care of patients with craniomaxillofacial trauma, because temporal bone fractures are often associated with injuries to other areas of the craniomaxillofacial skeleton and because these fractures are relatively frequent. In many centers, particularly community hospitals, the OMS may be the primary provider of care for facial trauma and will treat patients with clinical or radiographic evidence of temporal bone fractures. Immediate access to other specialists to manage or observe these injuries may not be possible, making the OMS responsible for early evaluation and management. This article briefly reviews the epidemiology of temporal bone injuries, as well as the pertinent anatomy, radiographic imaging findings, and ancillary testing maneuvers. It then presents a more detailed description of the various clinical findings and the associated management strategies. It concludes with a discussion of the subset of temporal bone fractures involving the temporomandibular joint. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:513-522, 2008

Epidemiology
Skull fractures affect 23% to 66% of patients with head trauma,1,2 with 21% of these patients suffering trauma to the skull base.3 Trauma to the skull base is a common component of head injuries, particularly blunt head trauma. In adults, up to 75% of patients with a skull base fracture have a temporal bone fracture as a component of the injury.4-6 Multiple important anatomic structures are affected by these injuries, including the facial nerve, middle and inner ear, and intracranial contents; thus, these are serious injuries, with the potential for significant long-term sequelae. Risk factors for and causes of temporal bone fractures are similar to those in any patient with head injury: younger age, male gender, motor vehicle accidents, falls,
*Resident, Department of Surgery, Division of Oral and Maxillofacial Surgery, Mayo Clinic, Rochester, MN. †Consultant, Department of Surgery, Division of Oral and Maxillofacial Surgery, Mayo Clinic, and Assistant Professor of Surgery, Mayo Clinic College of Medicine, Rochester, MN. Address correspondence and reprint requests to Dr Viozzi: Mayo Clinic, Department of Surgery, Division of Oral and Maxillofacial Surgery, 200 First Street SW, Rochester, MN 55905; e-mail: viozzi. Christopher@mayo.edu
© 2008 American Association of Oral and Maxillofacial Surgeons

recreational injuries, and assaults. Penetrating trauma is also a relatively frequent cause of temporal bone fracture. Other unusual reported causes of temporal bone injury include lightning strikes, chiropractic manipulation, and even flying fish.7-9

Anatomy
The skull base is composed of the occipital bone, 2 temporal bones, the sphenoid bone, and the frontal bone. A skull base fracture may involve only 1, several, or all of these bones. The temporal bone itself is composed of 5 parts: the squamous, petrous, mastoid, and tympanic portions, as well as the styloid process (Fig 1). The squamous portion is smooth and convex; the temporalis muscle attaches to this region. The zygomatic arch projects forward from the inferior part of the squamous portion, giving rise to the articular tubercle just anterior to the glenoid fossa. The fossa is bounded posteriorly by the tympanic portion of the temporal bone, the bony external auditory canal. The pyramidshaped petrous portion of the temporal bone is wedged between the sphenoid and occipital bone at the base of the skull. Through it pass many important structures, including the carotid canal, internal jugular vein, and facial nerve (Fig 2). Fractures of the temporal bone have generally been classified into 2 types, longitudinal and transverse, 513

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TMJ discomfort or dysfunction.10 or should describe fractures in a manner that correlates with the optimal surgical approach to repair the facial nerve. such as facial nerve injury or cerebrospinal fluid (CSF) leak. Transverse fractures are more commonly caused by intense blows to the occipital region or by a direct frontal injury. indicating the relationship of the fracture line to the long axis of the petrous portion of the temporal bone. and facial paralysis. then turn anteriorly toward the foramen lacerum (Fig 4). because the fracture traverses lateral or anterior to the otic capsule (Fig 3). temporal bone fractures were diagnosed on the basis of history of head injury accompanied by otorrhea. because of the difficulty in describing many fractures as either longitudinal or transverse. Because studies have suggested that the traditional classification system may not predict the presence of sequelae. run through the external auditory canal. As a general rule. Temporal Bone Fractures. Studies citing the radiographic incidence of each fracture type span a time period during which advances in imaging technology have led to much more detailed radiographic images and thus differences in the frequency of each radiographic diagnosis. then turn anteriorly toward the foramen lacerum. Gladwell and Viozzi. Longitudinal fractures begin at the squamous portion of the temporal bone. nausea and vomiting. and hearing loss or changes. particularly from the standpoint of facial nerve evaluation.10-14 Longitudinal fractures are most frequently caused by a lateral blow to the skull in the parietal region. J Oral Maxillofac Surg 2008. run through the otic capsule containing the middle ear structures.16 Clinical Examination and General Findings Before the development and widespread use of computed tomography (CT). One alternative scheme that has demonstrated better correlation classifies fractures based on whether they are otic capsule–sparing or otic capsule–violating. Temporal bone. classic longitudinal fracture accounts for about 80% of cases. lateral view. The middle ear is spared in this type of fracture. Transverse fractures begin from the foramen magnum. with the remaining 20% tranvserse fractures. Evaluating an obtunded patient with a suspected temporal bone fracture is problematic. hemotympanum. but rather are a combination of longitudinal and transverse. alternatives to the traditional classification scheme have been developed. The reported incidence of these fracture patterns is variable.17 Nonobtunded patients with temporal bone fractures may complain of such symptoms as vertigo. The latter are more frequently serious or fatal injuries.15 Others have suggested that fracture classifications should include more specifics regarding fracture location.514 TEMPORAL BONE FRACTURES FIGURE 1. Some fractures are not purely of a single type. A fracture with significant comminution or fracture lines running in both longitudinal and transverse directions is termed a mixed fracture. . facial muscle weakness.

Gladwell and Viozzi. Sensorineural or conductive hearing loss also is commonly found. occurring in 20% of temporal bone fractures. Other Diagnostic Maneuvers Formal facial nerve testing and audiologic testing are additional tests that may be of use in evaluating and treating temporal bone injuries. Audiology is of particular use in a patient with suspected inner ear injury. can indicate injury to the carotid artery. Temporal Bone Fractures. Temporal bone fracture is frequently first noted during this routine head CT examination. or nystagmus does not necessarily need further CT evaluation. particulary in the periorbital region due to anterior or middle cranial fossa trauma (“raccoon eyes” sign). CSF leak. It is routinely ordered to rule out life-threatening intracranial hemorrhage. but can be performed later in a patient with Imaging Studies Today. a patient with conductive hearing loss with no evidence of facial nerve injury. Skull base viewed from above. initial workup and treatment of polytrauma patients. Clinical signs may include ecchymosis. and. if hemorrhage from the external auditory canal (EAC) is severe. CT scanning is performed routinely to evaluate head-injured patients and is part of the routine . for instance. The need for subsequent. or in the postauricular region due to bleeding from the mastoid veins or postauricular artery (Battle’s sign). more highly detailed CT imaging of the temporal bone should be guided by the subsequent evaluation of the patient. J Oral Maxillofac Surg 2008. Facial nerve function should be fully assessed and documented. Hemotympanum is a very common finding in both fracture patterns. CSF otorrhea or rhinorrhea is a frequent finding.GLADWELL AND VIOZZI 515 FIGURE 2.

In myringoplasty. Longitudinal fracture traversing external auditory canal but sparing otic capsule. is placed over the defect. allografts are used. Facial nerve testing is indicated in a patient with delayed facial nerve palsy. Fracture pattern dictates the auditory structures involved. Temporal Bone Fractures. with revisions carrying high success rates as well. or from TM perforation or ossicular chain disruption (particularly in cases of prolonged conductive loss). many (up to 70%) of these cases of conductive hearing loss will resolve within 4 weeks. typically with conductive hearing loss. The mem- . Again. Because the more common longitudinal fracture traverses the EAC (sparing the middle/inner ear). conductive hearing loss. and thus the type of hearing impairment noted. the TM itself is directly injured or perforation is observed. If conductive hearing loss persists to 3 months. Gladwell and Viozzi. J Oral Maxillofac Surg 2008. Occasionally. Management Conductive hearing loss generally resolves over time (usually within 3 to 4 weeks). Electroneuronography (ENoG) and nerve excitability testing (NET) can be performed to document the degree of facial nerve dysfunction. then myringoplasty (for small perforations) or formal tympanoplasty (for larger perforations or in cases where myringoplasty has failed) may be performed. branous labyrinth can be subjected to concussive injuries or direct injury with disruption.516 TEMPORAL BONE FRACTURES FIGURE 3. Persistence of conductive hearing loss after multiple attempts at repair suggests ossicular chain disruption. transverse fractures can violate the otic capsule and result in severe sensorineural hearing loss (Fig 5). allowing time for the hemotympanum to resolve. This procedure is successful in 90% to 95% of patients. In contrast. as the blood behind the TM dissipates. This can be due to the hemotympanum itself behind the tympanic membrane (TM). although this treatment is controversial. A graft. and a paper patch or steristrip is placed over the perforation to promote healing. because this patient may benefit from surgical decompression of the facial nerve. the edges of the perforation are freshened. Pure hemotympanum generally resolves without sequelae within this time period as well. In other cases. Tympanoplasty involves an incision to gain access to the medial or lateral portion of the TM. Inspection of the ossicles during tympanoplasty Specific Clinical Findings and Management Correlations HEARING LOSS This common complication is noted in the large majority of patients with temporal bone fractures and suggests that audiometry is appropriate for any patient with a temporal bone fracture. it produces hemotympanum. most commonly an autogenous graft of postauricular fascia.

is thus considered appropriate. Taken as a whole.GLADWELL AND VIOZZI 517 FIGURE 4.22 Persistent vertigo with fluctuating SNHL may indicate a PLF.20 SNHL not only involves a reduction in sound level.19 There is no effective medical treatment for sensorineural hearing loss (SNHL). Gladwell and Viozzi.18 indicating the need for prosthetic reconstruction of the ossicle or ossicles. The patient’s sensation of such movement is termed subjective vertigo. sensory inputs from the vestibular system. Temporal Bone Fractures. an abnormal connection . Treatment for SNHL is rehabilitative with hearing aids or cochlear implants. decisions should be guided by the portion of the ossicular chain requiring reconstruction. brainstem/nuclei injury.21. but also can affect speech intelligibility and understanding. reported as ranging between 24% to 78% of patients with temporal bone fractures. concussive injury to the labyrinth. and the perception of movement in surrounding objects by the patient is termed objective vertigo. and proprioceptive inputs from other body structures.4. VERTIGO Vertigo refers to the sensation of spinning or whirling resulting from a disturbance in balance. and perilymphatic fistula (PLF). no case of total SNHL from a transverse fracture showed improvement over time. A study of hearing loss from temporal bone fracture found that whereas 80% of cases of conductive hearing loss from a longitudinal fracture resolved spontaneously. including direct otic capsule injury. High-resolution CT scans can detect ossicular chain disruption. Transverse fracture with violation of otic capsule. J Oral Maxillofac Surg 2008. Vestibular symptoms secondary to temporal bone injury can result from various causes. the incidence is variable. In general. undamaged ossicles as possible and uses the lightest-weight prosthetic material available produces the best audiologic outcomes. There are many variations in technique and materials. which results from damage to the cochlea or nerve pathways to the brain. an approach that leaves as much of the functional. The vestibular system is responsible for integrating sensory stimuli utilizing visual inputs. This complex process of neural inputs is integrated to provide the subject with position sense.

nonnoxious everyday activities.23. the decision to pursue surgical treatment can be difficult. avoiding the Valsalva maneuver.30. Past diagnostic tests for CSF leakage included the halo sign and double-ring test. If no obvious leak is seen. This test has been found to be 100% sensitive and 95% specific in identifying CSF leakage. then the footplate and round window are covered with a graft.518 TEMPORAL BONE FRACTURES FIGURE 5. Temporal Bone Fractures. perichondrium. intraoperative Valsalva maneuver. and antinausea medications may be needed. these exercises improve the dysfunctional vertiginous response of the patient’s balance system to both noxious vertigo-inducing inputs and. including Trendelenberg positioning.28 The ␤2-transferrin test evaluates fluid for the presence of a protein found exclusively in CSF and perilymph but not in blood.27. due to the varying presentations. J Oral Maxillofac Surg 2008. . and administering sedative agents. Diagnosis is based on physical findings. the fluid is collected and sent for ␤2-transferrin evaluation. which may indicate the presence of perilymph. The treatment for PLF is controversial. and closure of the communicating defect. Gladwell and Viozzi. fascia. Fat is no longer used. Stool softeners are used. nasal secretions. Axial view of right temporal bone fracture crossing middle ear structures. Glucose content also is unreliable for testing for CSF. PLF repair is accomplished by placing a graft over the leak. due to high failure rates. The utility of other maneuvers to aid in the identification of perilymph. Some of these communications are thought to heal without intervention over time. some of which are very subtle. using stool softeners. or middle ear secretions.31 If there is doubt regarding the validity of CSF leakage. with a reported falsepositive rate of 45% to 75%.1. elevating the head of the bed. including fat. The technique for PLF repair includes development of a tympanomeatal flap to permit visualization of the round and oval window niche. The incidence of CSF leaks is generally low when taking all skull fractures as a group.26 CEREBROSPINAL FLUID LEAK CSF leakage may be noted both from the ear and nose in skull base injuries. and positional changes can increase or decrease the amount of fluid leak. heavy lifting. as well as accurate identification of the leaked fluid. between the perilymph-filled inner ear structures and the air-filled middle ear structures. The decision to pursue surgery is often more clear-cut in a patient with a clear history of temporal bone trauma and symptoms of PLF. and internal jugular vein compression. Specific techniques for this may include Cawthorne-Cooksey exercises and other activities that create sensory inputs that tax the visual.25 Many surgeons will perform grafting in cases with no obvious leak seen at surgery (prophylactic grafting). vestibular. on the assumption that this is the most likely area for the leak. Postoperative care includes minimizing intracranial pressure by avoiding Valsalva maneuvers.24 Nonsurgical treatments include maintaining bed rest. The definitive treatment for PLF is surgical exploration. Vestibular rehabilitation involves exercises aimed at stressing the vestibular system so as to encourage compensation and accelerate recovery. PLF occurs most commonly at the round or oval window. Management Vestibular symptoms with disequilibrium generally improve as activity resumes. and proprioceptive neural systems to integrate inputs in a functional way. and parotid-masseteric fascia. or a head-down position. The usual manifestations are sudden or progressively fluctuating vertigo with SNHL. Over time. Separation of CSF from serum is suggestive but not conclusive for the presence of CSF. but identifying this fluid intraoperatively is not feasible at the present time. identification of the fistula. other possible symptoms are a sensation of aural fullness and tinnitus. is not clear at present. more importantly. and even the presence of irrigating fluids. Various graft materials have been and are currently used.29 but the incidence in temporal bone fractures has been reported to range from 11% to 45%. False-positive identification is possible because of the presence of transudates from the middle ear. Perilymph is one of the few body fluids that contains ␤2-transferrin.27 Leaks can present in a delayed fashion. The prognosis for full recovery is excellent in most patients. In nontraumatic cases of PLF. The surgical site is then observed for clear fluid.

32 The use of prophylactic antibiotics remains controversial. other series have shown lower rates of meningitis with otorrhea. The surgical approach depends on the status of the patient’s hearing. Mouth: slightly weak with maximal effort Grade 4: Moderately severe facial nerve dysfunction Gross 1. because this is one of the few indications for rapid surgical management. whereas in a patient without functional hearing. Disfiguring asymmetry Rest: Normal symmetry and tone Motor examination 1. Highresolution CT scanning is the gold standard for imaging the facial nerve in temporal bone trauma. acetazolamide to decrease CSF production. Use of a lumbar drain to decrease circulating CSF may be helpful. Obvious difference between sides (not disfiguring) 2. Mouth: slight asymmetry Grade 3: Moderate facial nerve dysfunction Gross: 1. this identification can be challenging. rising to 23% in cases where the leak persists for more than 7 days. transection. Forehead: no motor function 2. Staphylococcus spp. Mouth: slight movement Grade 6: Total facial nerve paralysis NOTE.27 Patients in whom a craniotomy has been performed to treat intracranial hemorrhage generally already have an intraventricular drain in place. One large series of head-injured patients with CSF otorrhea found that 20% developed meningitis without the use of prophylactic antibiotics.30 Gladwell and Viozzi. The risk of meningitis is low in cases of CSF leak that ceases spontaneously within 7 days post-trauma (3%). Eyes: complete closure with minimum effort 3.GLADWELL AND VIOZZI 519 Management Because most CSF leaks will close spontaneously. Synkinesis noticeable Rest: Normal symmetry and tone Motor examination 1. Forehead: no motor function 2. Forehead: moderate to good function 2. focal enhancement. As discussed earlier. fat graft. a combined middle-fossa craniotomy–transmastoid approach with repair is indicated. and so do not also need a lumbar drain. whereas others contend that prophylactic antibiotic use does indeed prevent meningitis. Synkinesis slight Rest: Normal symmetry and tone Motor examination 1.29 CSF leaks that persist longer than 2 to 3 weeks are most likely to require surgical repair. The HouseBrackman system of grading facial nerve injuries is most commonly used to describe the extent of injury and can help predict the likelihood of spontaneous recovery of facial nerve function (Table 1). Mouth: asymmetric with maximal effort Grade 5: Severe facial nerve dysfunction Gross: Barely perceptible motion Rest: Asymmetry Motor examination 1.32 medical management is always attempted first.13. In a patient with functional hearing.34 Some contend that the prophylactic doses of antibiotics typically given are insufficient to treat meningitis and may mask a subclinical infection and possibly even create resistant organisms. gadolinium-enhanced magnetic resonance imaging may be useful in some patients to help localize the site of injury. Slight weakness on close examination 2. and diffuse enhancement. Causes of injury include edema. and head elevation). In contrast. decreased ipsilateral salivation and lacrimation. Eyes: complete closure with effort 3.35 The most common organisms causing meningitis in this situation include Pneumococcus spp. Possible patterns of enhancement include no enhancement. Eyes: incomplete closure 3.1 Clinical findings will include single-sided facial musculature paralysis including the forehead. as can maneuvers to avoid increasing pressure within the subarachnoid space (such as stool softeners to avoid straining. intraneural hematoma. it is important to identify patients with immediate or delayed facial nerve palsy. Because many of these patients have sustained a severe head injury or are comatose. HOUSE-BRACKMAN FACIAL NERVE INJURY SCALE Grade 1: Normal facial nerve function Grade 2: Mild facial nerve dysfunction Gross 1. Streptococcus spp.33. whereas delayed loss is more likely due to edema from fracture. with progressive compression within bone resulting in loss of function. and Haemophilus influenzae. and plugging of the Eustachian tube can be performed. Eyes: incomplete closure 3. Focal enhancement has been .36 Rapid loss of facial nerve function (immediate to within the first few hours of injury) is likely due to transection. The incidence of facial nerve injury is 10% to 25% in longitudinal fractures and 38% to 50% in transverse fractures. Temporal Bone Fractures. Data from Dahiya et al. obliteration of the ear with a transmastoid approach. Forehead: slight to moderate movement 2. J Oral Maxillofac Surg 2008. General measures used to encourage resolution of CSF leaks include bedrest and head elevation. and hyperacusis. Obvious weakness 2. and bony impingement on the nerve. decreased ipsilateral taste in the anterior two thirds of the tongue. FACIAL NERVE INJURY Table 1.

Anatomic studies have shown that in children.44 This is often seen as a component of skull base injuries. Avrahimi57 reported TMJ trismus. presumably due to stabilization of the petrous temporal bone as a result of healing over that period. the decision to proceed with surgery is based on the timing of the presentation of weakness and the results of electrical testing. Patients without functional hearing can be managed with a translabyrinthine approach.43 With this information in mind.45-47 Again. In this instance. Injuries can involve fracture of the glenoid fossa or articular eminence. inability to chew.48-54 This pattern of fracture is most common in the pediatric population.55. Patients with over TEMPORAL BONE FRACTURES 95% degeneration on electrical testing also are candidates for surgery. TEMPOROMANDIBULAR JOINT CORRELATIONS Injury to the temporal bone portion of the craniomandibular articulation (glenoid fossa or articular eminence) is of particular interest to the OMS. 7 were transactions. hearing status is a crucial factor in determining the optimal surgical approach.41 The prognosis for spontaneous recovery without intervention has been studied. as well as the timing of onset of the weakness. Isolated fracture of the glenoid fossa has been reported without condylar fracture or displacement. This latter approach allows visualization of the nerve from the brainstem to the geniculate ganglion. Many of these injuries are noted as incidental findings on head CT in an obtunded patient with severe closed/open head injury. Likely. Most clinicians today agree that the patient with delayed-onset weakness (paresis) of the facial nerve can be closely monitored. Studies have found that patients with over 90% loss of function on ENoG or NET recover poorly without surgery. At one end of the injury severity spectrum is the patient with immediate complete loss of facial nerve function.42 Since this initial study. the relatively thinner fossa and the less welldeveloped medial and lateral poles that produce a rounded condylar head increase the risk of puncture of the condyle through the fossa. but more likely propagates throughout the skull base with the energy dissipating from a lateral or occipital blow. presumably due to transection injury or other severe injury. Ort et al17 found involvement of TMJ structures in the fracture pattern in 43% of cases. those with intact hearing are managed with a combined middle fossa– transmastoid approach.57 Injury to the temporal bone during surgery for post-traumatic ankylosis also has been reported. although there is no clear research evidence to support this practice. the fracture is not necessarily caused by the condylar head impacting the fossa. particularly high-energy injuries with significant comminution. the resulting reduction of secondary swelling and surrounding edema provides improved healing conditions.40. The patients in that study recovered their normal range of motion and function within 6 to 8 months. 75% of patients had good outcomes without intervention and 15% had no or minimal recovery at 3 months. due to several factors. Many clinicians use steroids in the setting of facial nerve injuries. with CT scans demonstrating instability of the fractured portion of the petrous temporal bone. In the 33 patients who had delayed-onset weakness. have been used to evaluate nerve function and guide treatment.38.38 Other studies suggest that bony impingement is the most common issue. all but 2 had good outcomes.37 Audiologic testing also is important in patients with facial nerve injuries. This injury is presumably due to edema of the nerve.520 shown to accurately predict the location of direct nerve injury. In the 36 of his patients who had immediate paralysis. therefore.39 Management The treatment of facial nerve injuries is based on the degree of injury (paresis vs paralysis). The condylar process of the mandible can be dislocated into the middle cranial fossa as a component of this type of injury. preoperative documentation of audiologic status is crucial. In patients in whom surgical exploration for transection is being contemplated. injury can result from either impact of the condylar head or propagation along fracture lines. Surgical approaches are based on the presence or absence of SNHL. Turner42 reported on 69 patients with traumatic facial nerve paralysis. and 7 were due to bony impingement on the nerve by fracture segments without transection. and localized pain in 6 patients with temporal bone fractures. including ENoG and NET. electrical nerve studies. to allow preservation of hearing. This patient likely would benefit from immediate exploration. because it is a common component of temporal skull injuries and a common reason for consultation to the OMS.56 In their review of temporal bone fractures. The pathophysiology of the injury varies widely. Specific procedures performed are based on the findings at surgery and can range from simple decompression to interpositional nerve grafting in cases with transection or segmental deficits. with . One study of 28 longitudinal fractures with facial nerve injury found that 14 of the injuries were intraneural hematomas. Solitary fracture of the articular eminence also has been reported.38. whereas those with better function typically do quite well with conservative nonsurgical treatment.

Murr AH: Current perspective on temporal bone trauma. Goldenberg D. Stool SE: Temporal bone fractures in children: A review with emphasis on long-term sequelae. Bernstein T: A case of subdural hematoma and temporal bone fracture as complications of chiropractic manipulation. Arch Otolaryngol 109:285. Ghorayeb BY. Arch Otolaryngol Head Neck Surg 114:1184. having a working knowledge of them is important.59 Various materials have been used. Laryngoscope 102:600. Kwok P. osseous recontouring to reduce the eminence in the References 1. the decision to intercede operatively should be guided by the other components of the temporal bone fracture and other craniofacial injuries. In a patient who eventually recovers but has limited mandibular range of motion due to impingement on an inferiorly displaced articular eminence. Yeakley JW: Pediatric temporal bone fractures. then a brief period of maxillomandibular fixation (7 to 10 days). Ishman SL. many of the affected patients have significant head injuries and are obtunded. at all times. Jennett B. Conservative nonoperative management should be used in most cases. Kotsanis CA. Mayo Clinic. As stated at the beginning of this article. et al: Temporal bone fractures: State-of-the-art review. with a return to premorbid occlusion. This can be delayed until the patient recovers from the initial injuries. generally provides adequate treatment. Access to other specialists may not be immediately available. 1988 9. noted as an incidental finding on head CT.55. Stuart PJ. Otolaryngol Clin North Am 21:295. Otolaryngol Head Neck Surg 117:67. 1988 5. or zygomatic bones. Articular eminence fractures. J Neurol Neurosurg Psychiatry 43:289. However. Again. Ledington JA: Traumatic injuries of the temporal bone. Hasso AN. Karam M. Fry J. possible reconstruction of the glenoid fossa. Clin Pediatr (Phila) 31:12. followed by nighttime elastics and daytime physiotherapy (bite-reproducing exercises). Williams WT. temporal bone fractures are frequent components of craniomaxillofacial trauma. 2004 . the degree of injury required to produce such a displacement is significant. Jahrsdoerfer RA: Temporal bone fractures: Review of 90 cases. J Laryngol Otol 112:959. MST. Danino J. Nicol JW. Teasdale G. Shapiro RS: Temporal bone fractures in children. Valvassori GE. et al: Treatment for severe head injury.60 Management of isolated glenoid fossa fractures without condylar intrusion involves pain control. articular eminence. Director of Medical Illustration and Animation. Laryngoscope 114:1734. malocclusion is uncommon in a typical fossa fracture. Laryngoscope 102:129. Ghorayeb BY. Craniotomy is indicated for patients with preoperative neurologic abnormalities attributable to the intrusion of the condyle into the cranial vault. for his expertise and meticulous preparation of the illustrations used in this article. Johnstone AJ: Temporal bone fractures in children: A review of 34 cases. Morreale. delayed treatment. 1992 12. 1992 15. 1970 3. 1985 6. Yeakley JW: Temporal bone fractures: Longitudinal or oblique? The case for oblique temporal bone fractures. CMI. 1994 13. associated facial fractures. Deck J. Some researchers advocate immediate reconstruction to prevent condylar dislocations. 1998 10. including alloplasts and autogenous bone. 1997 2. the OMS may be the primary provider of care for facial trauma and will encounter patients with clinical or radiographic evidence of temporal bone fractures. and physiotherapy to prevent decreased mandibular range of motion.59 who advocated attempted closed reduction under general anesthesia with postoperative CT to confirm appropriate reduction and any new intracranial injuries. if displaced. et al: Temporal bone fracture following blunt trauma caused by a flying fish. In our experience. In the neurologically intact patient. Acknowledgment The authors thank Robert F. and restore joint function. and failed closed reduction. J Emerg Med 7:615. Although most OMSs do not provide definitive management of these injuries. McGuirt WF Jr. 1979 14. reduction. as well as the patient’s injury pattern and overall prognosis. Benecke JE Jr. thereby placing at least some responsibility on the OMS for early evaluation and treatment of these injuries. 1983 7. Friedland DR: Temporal bone fractures: Traditional classification and clinical relevance. transection of the intratemporal facial nerve occurring during osteotomies to free ankylosed condylar segments from the glenoid fossa.GLADWELL AND VIOZZI 521 standard fashion can be considered to improve mouth opening. Proc R Soc Med 63:23. Otolaryngol Head Neck Surg 87:323. slight malocclusions due to edema or joint effusion frequently will settle within 3 to 7 days. Wiet RJ. may preclude normal excursive movement of the disk– condyle complex. restore posterior facial height. In many centers. 1980 4. and appropriate postsurgical treatment to prevent ankylosis. Youngs R. and many of these patients are obtunded or do not survive due to concomitant intracranial injuries. et al: Severe sensorineural hearing loss caused by lightning: A temporal bone case report. particularly community hospitals. J Accid Emerg Med 11:218. An algorithmic approach to management was outlined by Kroetsch et al. Cannon CR.56. Steadman JH. Graham JG: Head injuries: An analysis and follow-up study. Am J Otol 6:207. management of occlusal discrepancies. If this does not occur. Use of a Therabite appliance is also reasonable to allow a return to normal mandibular range of motion. Minor displacements may respond well to Therabite physiotherapy. 1992 11. Nosan DK. 1989 8.58 Management Fracture of the fossa with condylar displacement has been managed with approaches ranging from attempts at closed reduction to a combined maxillofacial–neurosurgical approach with direct visualization of the displaced condyle.

2001 48. van der Linden WJ: Dislocation of the mandibular condyle into the middle cranial fossa: Report of a case with 5-year CT follow-up. Ear Nose Throat J 76:79. 1985 37. Hart MJ. Ort S. Zimmerman RA. and a proposal management protocol. Gusenbauer AW. Wolf SM: Solitary fracture of the articular eminence. Brackmann DE: Facial paralysis in longitudinal temporal bone fractures: A review of 26 cases. Radecki CA. Raaf J: Posttraumatic cerebrospinal fluid leaks. Kunishio K. Amsterdam. Fisch U: Facial paralysis in fractures of the petrous bone. Keith O. Kloppedal E. Int J Oral Surg 3:89. 1990 47. Stool SE: Cerebrospinal fluid fistula: The identification and management in pediatric temporal bone fractures. p 285 44. Oral Surg Oral Med Oral Pathol 49:405. Coker NJ. 1985 55. McGuirt WF Jr. Glasscock ME 3rd. et al: Magnetic resonance imaging in temporal bone fracture. Isaacson J: Pediatric temporal bone fractures in a rural population. 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