Temporal Bone Fractures
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Direct answer
Longitudinal fractures are the common kind — they run along the petrous axis from the squamous temporal bone, spare the inner ear in most cases, and produce conductive hearing loss, a torn drum with blood from the canal, CSF otorrhoea and facial palsy in only 10 to 20 per cent. Transverse fractures cross the petrous pyramid at right angles, tear the cochlea and internal auditory canal, and present with a dead ear, severe vertigo with nystagmus and facial palsy in 30 to 50 per cent — rarer, but far more devastating. Modern practice also classifies fractures by whether they spare or violate the otic capsule, which predicts inner ear function better than the classical division; either way, the immediate priorities are the trauma ABCs, then facial nerve status, hearing, CSF leak and the delayed complications of cholesteatoma and stenosis.
What you must remember
- Longitudinal (about 70–80 per cent of temporal bone fractures): canal laceration, tympanic membrane tear, haemotympanum, conductive loss, CSF otorrhoea via the torn drum, facial palsy 10–20 per cent (often delayed), Battle sign and raccoon eyes.
- Transverse (about 20 per cent): fracture line crossing the petrous ridge through the inner ear or internal auditory canal; profound sensorineural loss or dead ear, severe vertigo and vomiting, horizontal nystagmus away from the ear, facial palsy 30–50 per cent (often immediate and complete).
- Otic-capsule-sparing versus otic-capsule-violating classification: violation predicts dead ear, CSF leak that persists, and facial palsy more reliably than the longitudinal/transverse label.
- Facial nerve status must be documented early and repeatedly; immediate complete paralysis (more typical of transverse and otic capsule violating injuries) carries the worst prognosis and, with electroneuronography degeneration over 90 per cent, raises the question of decompression.
- Hearing loss patterns: conductive from haemotympanum or ossicular disruption (incudostapedial disarticulation), sensorineural from cochlear injury; audiometry once the patient is stable, since blood behind an intact drum can mask the true picture for weeks.
- Battle sign (mastoid ecchymosis) and periorbital bruising indicate a base-of-skull fracture — clues that appear a day or two after injury, not at the scene.
- Late complications: post-traumatic cholesteatoma from epithelium driven into the middle ear (surveillance for years), canal stenosis, ossicular fixation needing ossiculoplasty, and delayed facial palsy from nerve oedema.
Comparing the two patterns, the way a viva expects
Picture two patients after road accidents. The first walks in with a bandage over a bleeding right ear; the drum is torn, hearing is muffled but present, and he jokes in a normal voice. This is the longitudinal pattern: force struck the temporoparietal region, the fracture ran from the squama forward of the labyrinth through the middle ear, and the ear is bloody but the cochlea survived. Assess him for CSF leak (clear fluid mixing with blood), document facial function at every shift (his palsy, if it comes, is usually delayed and partial, from oedema over the nerve's bony canal), and obtain audiometry once the canal cleans. His hearing will likely need review in two months for an ossicular problem — a 40–50 dB conductive gap that does not resolve as the haemotympanum clears means incudostapedial disarticulation, fixable with ossiculoplasty.
The second patient arrives immobilised, vomiting, with eyes beating rhythmically and no hearing whatsoever on the left; the drum is intact with a dark haemotympanum behind it. This is the transverse pattern: occipital impact drove a fracture across the petrous pyramid through the otic capsule. His dead ear will not recover; his vertigo settles over weeks as the brain compensates; his facial nerve, if injured, was likely transected or crushed at the labyrinthine segment, so document the grade immediately and get electroneuronography — degeneration beyond 90 per cent with no voluntary units within the first fortnight is the classical indication to explore and decompress or graft the nerve.
The practical synthesis for the exam: the fracture direction predicts the deficit. Along the axis — conductive loss, blood from a torn drum, decent facial nerve odds. Across the axis — dead ear, violent vertigo, coin-flip facial risk. And whichever pattern, the same follow-up applies: audiometry, facial monitoring, CSF leak precautions, and years of watchfulness for cholesteatoma growing from implanted skin.
Where students slip
Candidates swap the percentages — remember "longitudinal 80 per cent of fractures, 20 per cent facial palsy; transverse 20 per cent of fractures, 40 per cent palsy" as a paired contrast. They also forget that an intact drum does not exclude a temporal bone fracture (haemotympanum behind it is the clue), and that the CSF from a longitudinal fracture exits the ear precisely because the drum is torn, whereas transverse fractures leak into the Eustachian tube. A subtle favourite: vertigo with a dead ear after head injury is not Ménière disease or BPPV; it is labyrinthine destruction. Finally, do not promise hearing recovery in a transverse fracture, and do not miss the slowly growing post-traumatic cholesteatoma that surfaces years later behind a healed drum.
Frequently asked questions
Which temporal bone fracture causes conductive hearing loss?
The longitudinal fracture, by tearing the tympanic membrane, causing haemotympanum and disrupting the ossicular chain — classically incudostapedial disarticulation.
Which fracture carries the higher risk of facial paralysis?
The transverse fracture, 30–50 per cent versus 10–20 per cent for longitudinal, because the fracture line crosses the facial canal's labyrinthine and tympanic segments.
What is the significance of the otic capsule in modern classification?
Whether the fracture spares or violates the otic capsule predicts sensorineural hearing outcome, CSF leak persistence and facial palsy better than the classical longitudinal/transverse division.
What is Battle sign?
Ecchymosis over the mastoid appearing a day or two after injury, indicating a base-of-skull fracture; with periorbital bruising it flags temporal bone trauma.
Why do temporal bone fractures cause cholesteatoma years later?
Skin epithelium is implanted through the canal wall tear or drum perforation into the middle ear and grows silently into a cholesteatoma, so long-term otoscopic surveillance is mandatory.