Temporal bone fracture

Last revised by Daniel J Bell on 21 Apr 2023

Temporal bone fracture is usually a sequela of significant blunt head injury. In addition to potential damage to hearing and the facial nerve, associated intracranial injuries, such as extra-axial hemorrhage, diffuse axonal injury and cerebral contusions are common. Early identification of temporal bone trauma is essential to managing the injury and avoiding complications.

Although the temporal bone includes the squamous part, forming the inferolateral part of the skull vault, generally the term temporal bone fracture refers to the involvement of the petrous part. 

Temporal bone fracture is thought to occur in ~20% (range 14-22%) of all calvarial fractures. They have a prevalence of 3% of all trauma patients in one series 6

Temporal bone fracture is suggested by Battle sign (post-auricular ecchymosis) and bleeding from the external auditory canal. As the fracture can sometimes involve the ossiclesinner ear and facial nerve, symptoms such as hearing loss, vertigo, balance disturbance, or facial paralysis may be present.

Fracture of the petrous temporal bone is usually classified according to the main orientation of the fracture plane and/or involvement of the otic capsule

Temporal bone fracture is described relative to the long axis of the petrous temporal bone, which runs obliquely from the petrous apex posterolaterally through the mastoid air cells. Using this plane, fractures may be classified as follows: 

Other classifications have been proposed as being more clinically relevant, specifically focusing on whether or not the otic capsule is involved, that is otic capsule-violating (OCV) versus otic capsule-sparing (OCS) injuries 4,5,9. Involvement of the otic capsule is a predictor of several serious complications 5,6:

Head CT with petrous temporal bone fine slice (≤1 mm) multiplanar bone window reformats is the imaging modality of choice. Aside from the fracture lucency itself, which may be subtle on thicker slices or some planes, there may be secondary imaging features that, while less specific, raise concern in the setting of trauma for temporal bone fracture 7:

Treatment is based on managing facial nerve injury, hearing loss, vestibular dysfunction, and CSF leakage. If immediate facial nerve paralysis occurs with loss of electrical response, surgical exploration should be considered. Delayed-onset or incomplete facial paralysis almost always resolves with conservative management, including the use of tapered-dose corticosteroids.

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Cases and figures

  • Case 1: mixed fracture
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  • Case 2: longitudinal temporal bone fracture
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  • Case 3: with ossicular disruption
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  • Case 4: longitudinal temporal bone fracture
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  • Case 5: transverse temporal bone fracture
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  • Case 6: mixed
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