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Case Report

Concomitant “Ear Bleed and Styloid Fracture”:
An Unusual Complication of Impacted
Mandibular Third Molar Removal
Krishnakumar Raja, MDS1 Gayathri Gopi, MDS2 Elavenil Panneerselvam, MDS, MBA, FAM1
Jegatheesan Ramamoorthy, MDS3 Guruprasad Thulasi Doss, MDS1 Aditi Rajendra Sharma, MDS1

1 Department of Oral and Maxillofacial Surgery, SRM Dental College, Address for correspondence Elavenil Panneerselvam, MDS, MBA, FAM,
Chennai, Tamil Nadu, India Department of Oral and Maxillofacial Surgery, SRM Dental College,
2 Oral and Maxillofacial Surgeon, Private Practice Chennai, India Ramapuram, Chennai, Tamil Nadu 600089, India
3 Endodontist, Private Practice, Chennai, India (e-mail:

Craniomaxillofac Trauma Reconstruction

Abstract The removal of impacted mandibular third molar is associated with potential compli-
cations such as dry socket, paresthesia, uncontrolled socket bleeding, angle fracture,

Downloaded by: Universite Laval. Copyrighted material.
etc., which are commonly encountered in dental practice. This article presents a
peculiar case of “ear bleed” concomitant with “isolated styloid” fracture following
Keywords removal of impacted mandibular third molar, not reported in the literature till date. Ear
► ear bleed bleed is a bothersome clinical sign that requires thorough investigation and prompt
► impacted third molar treatment because it is frequently related to fractures of the skull base. Isolated fracture
► styloid fracture of the styloid process is rare; its diagnosis, impact on adjacent vital structures, and
► tympanic plate treatment protocol are less discussed in maxillofacial literature. The case report
fracture elucidates the etiopathogenesis of ear bleed and styloid fracture which have great
► temporomandibular clinical implications. The clinical correlation between the two entities and dental
joint extraction is discussed in this report to guide a dental practitioner in its management.

The most prevalent complications associated with the remov- bleed following third molar extraction has been reported in
al of impacted mandibular third molar are dry socket, bleed- the literature so far.4
ing, trismus, dysesthesia, angle fracture, etc.1 The following is The report also features isolated fracture of ipsilateral
an unusual clinical report featuring a rare traumatic event in a styloid process during the removal of impacted mandibular
dental office comprising concurrent “ear bleed and styloid molar, which is uncommon. Two cases of isolated styloid
fracture” as a complication of removal of impacted mandibu- fracture in a dental operatory have been reported till date;
lar third molar. one which occurred during administration of local anesthe-
Ear bleed is generally considered an ominous clinical sign sia5 and the other following extraction.6 Styloid fractures
that demands prompt diagnosis and astute management.2 It usually occur secondary to trauma either in isolation or in
is commonly linked to fractures of the base of skull3 and association with other fractures such as condyle, angle, and
requires immediate attention. Nevertheless, awareness re- body.5–8 The sparse incidence of styloid fracture is because it
garding the other less worrying causes of ear bleeding is is positioned deeper and angulated favorably that precludes
necessary, to avoid undue apprehension. Only one case of ear its fracture. However, the styloid process is prone to fracture if

received Copyright © by Thieme Medical DOI
January 18, 2016 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1592086.
accepted after revision New York, NY 10001, USA. ISSN 1943-3875.
April 10, 2016 Tel: +1(212) 584-4662.

However. Also. promptly ruled out because of lack of derangement of occlu- strated fracture of right styloid process. A computed tomography (CT) brain condyle on the EAC or the tympanic plate was considered. However. Copyrighted material. is considered a grave clinical sign the fracture of styloid fracture is indicative of the traumatic because it is commonly related to a traumatic event. Inciden. pharyngeal. increase in pain while turning the head to the affected side The possibility of a condylar fracture was suspected and were elicited. On evaluation.13 Thus. ear rupture of auditory canal. facial paresis.9. Assessment of the patient revealed history of tant to differentiate ear bleed due to posterior displacement dysphagia. because of negative history of trauma. Radiographic examination re. sion or restriction of condylar movement. Tender. laughter. in general. Orthopantomography (OPG) (►Fig. 2). as A 23-year-old female patient reported to a dental practitioner reported here.Concomitant “Ear Bleed and Styloid Fracture” Raja et al. Downloaded by: Universite Laval. condyle by only a pad of fibrofatty tissue and the tympanic analgesics. The fracture such as ruptured tympanic membrane. the yngologist’s opinion was obtained to rule out perforation of traumatic impact of a posteriorly displaced nonfractured the tympanic membrane. espe. In this case. 30 minutes postoperatively. Craniomaxillofacial Trauma and Reconstruction . ear bleed following dental extraction.11. It was discounted as arising from a skull base fracture removal of the tooth was made and implemented. This occurs especially when the dental extraction procedure: bleed from the ear and fracture mouth is wide open as during removal of an impacted tooth or of the ipsilateral styloid process.3 It is very impor- management. not have bony support posteriorly. 1) demon. In tympanic cially fractures of the skull base. 1 Orthopantomography demonstrating fracture. the lateral third of the condyle does Complete resolution of symptoms was observed on review. color and passive which subsided with a pressure pack in an vealed a distoangular impacted 48. OPG demonstrating Ear bleed. A decision of surgical hour. positive findings are EAC stenosis and skin critical assessment when encountered.2 was also simultaneously taken and the presence of basal skull This is because anatomically. and restriction in mouth opening for 2 weeks. the EAC is separated from the fracture was negated. and temporomandibular joint (TMJ) pain. pain in the preauricular. is exceedingly rare. and retro. following day. ear bleed was observed immediately molar region which was diagnosed as pericoronitis secondary after extraction. intervention or packing of EAC in the latter can introduce tinnitus. extraction of posterior teeth. cerebrospinal fluid otorrhea.14 Examination of the ear in this Fig. an otolar. assault.2 The precipitating etiology of ear bleed is invariably road traffic accident.10 Fractures have also bleed may occur due to other innocuous causes such as been evidenced due to sudden uncoordinated muscle spasms ruptured ear drum and lacerations in anterior aspect of such as during epileptic seizures. with complaints of pain and swelling in the right lower third In the case presented. otalgia. bleeding from the ipsilater. and bleed which was nonper- al ear was noticed which subsided with a pressure pack sistent. Nevertheless. and coughing. infection into the cranium and complicate the clinical ness in the above-mentioned regions and characteristic scenario. displacement of the condyle during extraction.12 external acoustic meatus associated with or without concom- itant condylar fracture. nil tally. The patient was advised soft diet. Certain other characteristic features of skull base within the external auditory canal (EAC) for an hour. absent Battle sign. it is elongated or shaped abnormally. of condyle from bleed due to skull base fracture because any mandibular regions with restricted mouth opening.13 The report presents two peculiar observations following a leading to ear bleed (►Fig.3 It therefore mandates plate fracture. posterior displace- ment of the condyle by traumatic forces at the chin or angle can cause injury to the delicate cartilage bone junction of the Discussion EAC or sometimes even fracture of the tympanic plate2. Promptly. the patient visited our institution for further and hearing impairment were also absent. it was found to be bright red in to an impacted third molar. plate or cartilage. or sports Case Report injury.

7 The jaw and neck movements are restricted usually with intermaxillary fixation and cervical collar. An undisplaced styloid fracture may be managed conser- vatively with soft diet. due to its relatively secure anatomic position. retromandibular. muscle relaxants. as well as the styloid case revealed a breach in the anterior wall of the EAC process.19 An immobilization period of 2 weeks would suffice to allow healing of styloid fracture. However. During extraction procedures. it fractures None. 1 explaining fracture is done clinically by symptoms such as dysphagia. Pathol 1993. even when undisplaced or asymptomatic im- mediately after trauma.15 symptoms due to fractured styloid and treated surgically. otalgia. Aydin E.2(2–3):126–128 3 Lu C. Side effects and complications gives a clear spatial orientation of the fragment in relation to associated with third molar surgery. External auditory canal injury ulotemporal nerves.10.65(7):1372–1374 Craniomaxillofacial Trauma and Reconstruction . and the management strategy is aimed at preven. (e) styloid. Pressure effects may be seen clinically following removal of an impacted third molar: a case report.17 Regardless of the treatment protocol. when it is abnormally elongated16 (radiographic length on OPG more than one-third of the posterior ramal Conflict of Interest height) and shaped10 as appreciated in this case. Yang C. internal external auditory canal bleeding? J Oral Maxillofac Surg 2014. J such as glossopharyngeal neuralgia. this 1 Chiapasco M. syncope. which has been waived. Ear bleed not associated with skull which may be managed conservatively. The styloid process may also possibly fracture due to the pull exerted by the stylomandibular ligament during extremes of Patient Consent mandibular movements. and TMJ region.9 which is a painful condition similar to Eagle syndrome. Marrone G. (a) Articular eminence. 4 Bayram B. jugular vein. be under observation for development of potential pressure tion of these complications. increases the chances of traumatic forces to the EAC. (b) external auditory canal. to prevent the displacement of fractured fragments during jaw movements. This can precipitate styloid fracture and ear bleeding (cartilaginous part). Adequate care needs to be taken to prevent retropositioning of the mandible during extraction maneuvers. restricted mandibular movements. and (f) condyle. management to alleviate patient anxiety and embarrassment to the dentist. Karakasis D. (d) mastoid. the cranial nerves 9 to 12. Fig. The procedure may be accomplished by intraoral or extraoral approach.17. The primary diagnosis of styloid Informed consent has been obtained for ►Fig. (c) tympanic Conclusion plate. if Fractures of the styloid process during dental extraction necessary. medication such as nonsteroidal anti- inflammatory drugs. De Cicco L. On the contrary. are rare. and the sympathetic 72(1):121–126 chain. Bleeding from the ear in maxillofacial displaced styloid by virtue of its close proximity to the carotid injuries. her right to privacy. impingement of fractured styloid on any of these structures. Which craniofacial fractures are associated with space which houses the internal carotid artery. respectively. Oral Surg Oral Med Oral the adjacent vital structures. 2 Biomechanics of styloid fracture and injury to external auditory canal. However. Uckan S.76(4):412–420 It is important to realize the potential complications of 2 Martis C. etc. the ear base fracture poses two problems: ear infection and aural bleed mandates critical evaluation and the patient needs to stenosis. Furthermore. and local anesthetic injections—infiltrations or blocks.7.. Copyrighted material. He D. such episodes of ear bleed or styloid fracture require prompt identification and Downloaded by: Universite Laval. Though OPG may be used to confirm the fracture. carbamazepine. and pain in the preauricular. the fibrosis or infection around a fractured styloid can later result in posttraumatic styloid syndrome. J Maxillofac Surg 1974. when conservative treatment fails or when there is potential harm to vital structures due to the fractured tip. due to Oral Maxillofac Surg 2007. surgical removal of the fragment is warranted. excessive force delivered to the mandible especially when directed posteriorly.18 Anterior to the styloid are the lingual and auric. the displacement of the References fractured fragment of styloid process is assessed by CT. when force is directed on it by posteriorly displaced condyle. Concomitant “Ear Bleed and Styloid Fracture” Raja et al. and steroids.

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