How should a 12-year-old female with a penetrating temporal‑bone injury from a metal rod and presenting with vertigo, vomiting, and hyperacusis be urgently evaluated and managed?

Urgent Evaluation and Management of Penetrating Temporal Bone Injury

This 12-year-old requires immediate high-resolution CT of the temporal bone to assess for temporal bone fracture, ossicular disruption, and otic capsule involvement, as her constellation of vertigo, vomiting, and hyperacusis following penetrating trauma suggests significant inner ear or vestibular injury that demands urgent imaging and potential otolaryngology consultation. 1, 2, 3

Immediate Diagnostic Workup

Primary Imaging: High-Resolution CT Temporal Bone

• Obtain non-contrast high-resolution CT of the temporal bone with bone algorithm reconstructions in axial and coronal planes to evaluate for fracture lines, ossicular chain disruption, otic capsule involvement, and perilymphatic fistula 2, 3, 4
• This is the gold standard for evaluating bony structures of the temporal bone and can identify fractures extending across the otic capsule, which correlate with her vestibular symptoms 1, 2, 5
• Standard head CT lacks sufficient resolution to visualize the small ossicular structures and should not be substituted 2

Additional Intracranial Assessment

• Obtain head CT to evaluate for intracranial injury (ICI), given the mechanism and her symptoms of vomiting 1, 6
• Vomiting is a risk factor for intracranial complications in pediatric head trauma, and penetrating injuries carry higher risk 1
• The CDC guidelines emphasize that head CT is the preferred diagnostic tool in acute settings to rapidly identify ICI in children 1

Critical Clinical Assessment

Neurological Examination

• Document Glasgow Coma Scale score immediately, as this is a critical risk factor for intracranial injury 6, 3, 4
• Assess pupil size and reactivity 6
• Evaluate for signs of basilar skull fracture (Battle sign, raccoon eyes, hemotympanum) 3, 7

Otologic Examination

• Examine for hemotympanum, bloody otorrhea, or CSF otorrhea - these are common findings in temporal bone fractures occurring in 58-81% of pediatric cases 7, 8
• Look for evidence of tympanic membrane perforation at the site of penetration 3, 4
• Do NOT perform otoscopy if there is concern for penetrating injury extending into the middle or inner ear until imaging is obtained 3

Facial Nerve Assessment

• Document facial nerve function immediately, as this is critical for clinical decision-making and occurs in 3-8% of pediatric temporal bone fractures 3, 7, 8
• Early assessment helps differentiate immediate versus delayed facial nerve injury 3, 4

Audiologic Evaluation

• Formal audiometry should be performed once the patient is stable, as hearing loss occurs in 82% of pediatric temporal bone fractures 7, 8
• Conductive hearing loss is most common (56%), but sensorineural and mixed patterns also occur 7, 8

Management Priorities

Immediate Concerns

• Ensure airway, breathing, circulation stability first - temporal bone fractures typically result from high-energy mechanisms and rarely occur in isolation 3, 4
• Assess for associated intracranial injuries, which occur in 58% of pediatric temporal bone fractures 7
• Evaluate for cervical spine injury given the mechanism 4

CSF Leak Management

• If CSF otorrhea is identified (common with bloody otorrhea in 42 patients in one pediatric series), initiate prophylactic intravenous antibiotics 3, 7
• While controversial, the evidence supports antibiotic use to prevent meningitis in temporal bone fractures with CSF leak 3
• Most CSF leaks resolve spontaneously without prolonged otorrhea or meningitis 7

Specialist Consultation

• Obtain urgent otolaryngology consultation for penetrating temporal bone injury with vestibular symptoms 3, 4
• Consider neurosurgery consultation if intracranial injury is identified on imaging 3, 4

Symptom-Specific Considerations

Vertigo and Vomiting

• These symptoms suggest otic capsule disruption or labyrinthine injury, which occurs more commonly with transverse fracture patterns 3, 4, 5
• Otic capsule-disrupting fractures carry higher risk of sensorineural hearing loss and vestibular dysfunction 3

Hyperacusis (Sound Sensitivity)

• This can indicate stapedius muscle dysfunction or ossicular chain disruption 1
• May also suggest superior semicircular canal dehiscence, though less likely with acute penetrating trauma 1

Common Pitfalls to Avoid

• Do not rely on skull radiographs - they have only 63% sensitivity for skull fractures and cannot detect intracranial injuries 1
• Do not use MRI acutely - while more sensitive for soft tissue, it is insufficient for bony detail evaluation and requires longer acquisition times 1
• Do not delay imaging - the combination of penetrating mechanism with vestibular symptoms warrants urgent evaluation for temporal bone and intracranial injury 3, 4
• Do not assume minor injury - even seemingly minor penetrating trauma can cause significant otic capsule or ossicular damage 3, 7

Follow-Up Considerations

• Serial audiometric testing will be needed, as hearing outcomes may evolve 7, 8
• Monitor for delayed complications including cholesteatoma, encephalocele, or late meningitis 4
• Vestibular rehabilitation may be necessary if labyrinthine injury is confirmed 3, 4