What are the symptoms and treatment options for a temporal bone fracture and hemotympanum (presence of blood in the middle ear)?

Temporal Bone Fracture: Symptoms and Treatment of Hemotympanum

Temporal bone fractures commonly present with hemotympanum (blood in the middle ear), along with several other characteristic symptoms, and treatment is primarily conservative with careful monitoring for complications.

Clinical Presentation of Temporal Bone Fractures

Common Symptoms

• Hemotympanum (blood in the middle ear) - present in up to 89% of cases 1
• Hearing loss - occurs in 65-99% of cases 2, 1
  • Conductive hearing loss (65.8%) - most common 2
  • Mixed hearing loss (55%) 1
  • Sensorineural hearing loss (5.4-14%) 2, 1
• Blood otorrhea (bleeding from the ear) - seen in 61.2% of cases 2
• Tympanic membrane perforation - occurs in 25.6% of cases 2
• Facial nerve paralysis - affects 12.3% of patients 2
• Cerebrospinal fluid (CSF) otorrhea - present in 8.5-25% of cases 2, 1

Less Common Symptoms

• Vestibular symptoms/vertigo - reported in 30% of cases 1
• Cranial nerve palsies 1:
  • Abducens (CN VI) paralysis - unilateral (2.67%) or bilateral (4%)
  • Trigeminal (CN V) paralysis (1.33%)
• Aseptic sigmoid sinus thrombosis (1.33%) 1
• Tinnitus (often pulsatile) 3

Diagnostic Evaluation

Imaging

• High-resolution CT scan of the temporal bone without IV contrast is the first-line imaging modality for suspected temporal bone fractures 4, 3

  • Provides excellent delineation of the external auditory canal, ossicular chain, and bony labyrinth 3
  • Can demonstrate fractures extending across the otic capsule 3
  • Helps identify the fracture pattern (longitudinal, transverse, or oblique/mixed) 2, 1

• MRI may be indicated if there are concerns for intracranial complications or soft tissue injuries 4

Treatment of Hemotympanum and Temporal Bone Fractures

Management of Hemotympanum

• Conservative treatment is the mainstay for uncomplicated hemotympanum
• Observation with serial examinations to monitor for resolution
• Avoid water exposure to the affected ear until healing occurs
• Pain management with appropriate analgesics

Overall Fracture Management

• Systematic evaluation using a management algorithm 2:

  1. Stabilize patient and address life-threatening injuries
  2. Perform detailed otologic examination
  3. Obtain high-resolution CT imaging
  4. Assess for complications requiring intervention

• Specific interventions based on complications:

  • Facial nerve paralysis: May require decompression if complete and immediate, or if deteriorating on monitoring 5
  • CSF leak: Initial conservative management with head elevation; persistent leaks may require surgical repair 5
  • Hearing loss: Treatment depends on the type and severity; conductive hearing loss often improves spontaneously as hemotympanum resolves 2, 1

Important Considerations and Pitfalls

• High association with other injuries: Temporal bone fractures frequently occur with other skull fractures (77%) and intracranial injuries 2, 6

• Delayed complications: Some complications may present days to weeks after the initial trauma, necessitating follow-up 5

• Pediatric considerations: In children, motor vehicle accidents and falls are the most common causes of temporal bone fractures 6

• Misdiagnosis risk: Certain anatomic structures may mimic fracture lines on imaging, leading to potential misclassification 7