What is the recommended initial work‑up and management for a high‑energy temporal bone fracture, including imaging, otolaryngology and neurosurgery consultation, treatment of cerebrospinal fluid (CSF) otorrhea, facial nerve palsy, and hearing loss?

Temporal Bone Fracture: Initial Work-Up and Management

Immediate Imaging

High-resolution CT of the temporal bone without contrast is the mandatory initial imaging study for any suspected temporal bone fracture, providing superior delineation of osseous structures and detection of subtle nondisplaced fractures. 1

• Obtain multidetector CT (MDCT) maxillofacial without contrast as the gold standard, which has replaced plain radiographs and detects 98.6% of temporal bone fractures on initial trauma imaging. 1, 2
• Add complementary CT head without contrast because 56-87% of frontal bone fractures have associated intracranial injuries, with 8-10% requiring surgical intervention for subdural or epidural hematoma. 1
• Include cervical spine CT in high-velocity trauma, as cervical spine injuries occur in 6-19% of patients with significant maxillofacial trauma. 1
• Request 3D reconstructions for surgical planning and better characterization of complex fractures. 1
• High-resolution temporal bone CT with thin sections (1 mm or less) using bone window algorithm is essential for evaluating the facial nerve canal and otic capsule integrity. 3, 4

Specialist Consultation

Obtain immediate otolaryngology consultation for all temporal bone fractures to assess for facial nerve injury, CSF leak, and hearing loss. 5

• Request neurosurgery consultation when intracranial hemorrhage, elevated intracranial pressure, or ongoing hemorrhage is present, as these life-threatening injuries take precedence over temporal bone fracture repair. 1
• Otolaryngology should evaluate facial nerve function as soon as possible following injury, as this greatly facilitates clinical decision-making. 6

Fracture Classification and Risk Stratification

Classify fractures as otic capsule-sparing versus otic capsule-violating, as this system demonstrates statistically significant predictive ability (P < .001) for serious complications, unlike the traditional longitudinal/transverse classification (P = .71). 7

• Otic capsule-violating fractures carry 5 times higher risk of facial nerve injury, 25 times higher risk of sensorineural hearing loss, and 8 times higher risk of CSF otorrhea compared to otic capsule-sparing fractures. 7
• Otic capsule-sparing fractures are more common (approximately 80%) and have better prognosis. 8

Management of CSF Otorrhea

Initiate prophylactic antibiotics for CSF leak, as critical analysis of existing literature supports their use despite ongoing controversy. 6

• Most CSF leaks resolve spontaneously with conservative management including head elevation and avoidance of straining. 5
• Surgical repair via bifrontal craniotomy with sinus cranialization or obliteration is indicated for persistent CSF leak beyond 7-10 days or when associated with nasofrontal duct obstruction. 1
• Monitor for delayed complications including meningitis, mucocele formation, and osteomyelitis. 1

Facial Nerve Palsy Management

Perform immediate facial nerve examination and document function using House-Brackmann grading, as timing and completeness of paralysis determine management. 5, 6

• Obtain high-resolution temporal bone CT to identify facial canal fractures, foraminal expansion, or bone erosion patterns that suggest nerve injury. 4, 3
• CT identifies injury indirectly through osseous abnormalities along the facial nerve canal, as the nerve itself cannot be directly visualized on CT. 3
• Consider electrodiagnostic testing (electroneuronography) within 3-14 days of injury if complete immediate paralysis occurs, as this guides surgical exploration decisions. 5
• Immediate complete facial paralysis or progressive deterioration warrants surgical exploration, while delayed-onset paralysis typically has better prognosis with observation. 5, 6
• Trace the facial nerve canal systematically through all intratemporal segments: meatal, labyrinthine, geniculate ganglion, tympanic, mastoid, and stylomastoid foramen. 3

Hearing Loss Evaluation and Management

Perform pure tone audiometry once the patient is stable enough to cooperate, typically within the first week, to document baseline hearing and classify loss as conductive, sensorineural, or mixed. 8

• Conductive hearing loss (60% of cases) shows maximum improvement over time, with statistically significant improvement by six months. 8
• Sensorineural hearing loss is 25 times more likely with otic capsule-violating fractures and has poorer prognosis for recovery. 7
• MRI with dedicated internal auditory canal protocol using thin-section high-resolution T2-weighted images is indicated if retrocochlear pathology is suspected or hearing loss persists. 4
• Repeat audiometry at one month and six months to monitor for improvement or delayed deterioration. 8
• Consider amplification or cochlear implant evaluation for persistent severe-to-profound hearing loss after six months. 4

Surgical Timing Algorithm

Stabilize life-threatening injuries first—management of ongoing hemorrhage or intracranial hypertension takes absolute precedence over temporal bone fracture repair. 1

• Perform definitive temporal bone surgery as early as safely possible once ABCs are secured and neurosurgical issues are addressed. 1
• Immediate surgical indications include: complete immediate facial paralysis with electrodiagnostic evidence of degeneration, persistent CSF leak beyond 7-10 days, and displaced fractures with nasofrontal duct obstruction. 1, 5, 6

Common Pitfalls

• Do not rely on routine CT head alone—dedicated high-resolution temporal bone CT is required to adequately assess the facial nerve canal and otic capsule. 4, 3
• Do not use the traditional longitudinal/transverse classification system for clinical decision-making, as it fails to predict complications; use otic capsule-sparing versus otic capsule-violating instead. 7
• The incidence of facial nerve paralysis (1.6%), CSF leak (1.7%), and hearing loss (18.6%) in modern series is lower than historically reported, likely due to improved imaging and safety measures. 2
• Temporal bone fractures rarely occur in isolation—77.9% have associated intracranial hemorrhage and 67.3% have additional skull fractures. 2