Acute management of temporal bone fractures guideline
Initial resuscitation
ATLS approach CT head
Primary management under
Consider trauma ‘pan scan’
emergency medicine, ITU
and/or neurosurgical teams Consider high resolution CT temporal bones
• Define involvement of otic capsule and facial
Suspected vascular injury nerve canal
Angiogram + embolization, • Determine site of CSF leak
balloon occlusion or stenting • Delineate fracture line for surgical planning
• If fracture suspected but not seen on initial CT
Assess for complications
• Assess facial nerve function at earliest possible
opportunity (i.e. admission or extubation)
• Perform otoscopy and anterior rhinosocopy
• Ask about hearing loss, vertigo, and symptoms
of CSF leak
Facial nerve palsy CSF leak Vertigo
• Eye protection: Viscotears QDS + PRN, Lacrilube ON, • β2-transferrin sample to • Manage
tape eye closed at night confirm diagnosis conservatively
• If delayed onset consider 5 days prednisolone 60mg • Give pneumococcal vaccine where possible
• Delayed onset has better prognosis, as does partial • Monitor for signs of • Avoid vestibular
palsy (grade by House-Brackmann) meningitis suppressants
beyond 48 hours
• If not contraindicated,
elevate head and give stool • Give vestibular
softeners rehabilitation
exercises
Complete Partial • Consider lumbar drain if
not settling
Monitor for deterioration
Worsening
Nerve conduction studies Surgical repair if Admission
Nerve clearly transected or persisting >10 days
impinged on imaging? • Electroneuronography (ENoG)
No Imaging
+ electromyography (EMG)
High resolution CT temporal
bones if not already performed • Not sooner than 72 hours
• E.g. at 7 and 14 days Medical Management
Yes Surgical Management
Outpatient Treatment
Surgical decompression Yes Summating
+/- nerve grafting potential <10%
Follow up
• Follow up in ENT skull base clinic (e.g. at 6 weeks) Refer for hearing
• Perform pure tone audiometry + tympanometry aids if needed
• Reassess for late complications
References
Initial resuscitation
Patients with temporal bone fractures will have suffered a significant head injury in order to impart
sufficient force to fracture this bone1,2. Many will have significant intracranial injuries3 requiring
neurosurgical intervention and these will take priority. Many such patients will require monitoring in
a Level 2 or Level 3 setting4. Overall management is beyond the scope of this guideline but should
follow the Brain Trauma Foundation guidelines5.
CT head
As per NICE guidelines, patients with any sign of basal skull fracture should have a CT head performed
within 1 hour6.
Suspected vascular injury
Vascular injury may be suspected clinically or by the involvement of the carotid canal on CT7. CT
angiography is specific but not sensitive in diagnosing blunt cerebrovascular injury and therefore
conventional angiography is preferred8.
Consider high resolution CT temporal bones
Helical CT as performed in a trauma setting will identify over 98% temporal bone fractures3; high-
resolution dedicated CT of the temporal bones is indicated particularly where there are complications
in order to precisely delineate the fracture line, or where a fracture is clinically suspected but not
identified on initial helical CT9. It is also useful after the acute period in diagnosis and surgical planning
regarding ossicular dislocation and labyrinthitis ossificans10.
Assess for complications
Complications of temporal bone fractures are common11. Clinical examination should include the
cranial nerves, otoscopy and anterior rhinoscopy.
Facial nerve palsy
The literature regarding management of traumatic facial nerve palsies remains inconclusive and large
prospective studies are lacking12. Modern high-resolution CT scans give excellent anatomic definition
and can accurately predict the site of facial nerve injury in most cases13,14; thus if obvious nerve
compromise is demonstrated at CT, early surgical intervention is warranted. Earlier surgery has better
outcomes than late intervention15 and it is therefore important to identify surgical candidates in a
timely matter. Nerve conduction studies are used to identify candidates for surgery12.
Electroneuronography, if available, is ideal16 but should be performed not sooner than 72 hours as it
is unreliable before Wallerian degeneration has taken place17. Timings will vary by local availability;
the example of 7 and 14 days post-injury is performed at the authors’ trust. The prognosis in the case
of delayed onset palsy is excellent with conservative management18 and very few cases will require
surgery. The evidence for prednisolone is weak19
CSF leak
Most traumatic CSF leaks will resolve with conservative management and therefore a period of bed
rest with measures to reduce fluctuations in intracranial pressure is recommended20. β2-transferrin is
reliable in diagnosing the presence of cerebrospinal fluid21. The use of prophylactic antibiotics is
controversial, but generally not recommended as there is a low rate of meningitis in traumatic CSF
leak 22.
Vertigo
Vertigo is common following temporal bone fractures. Vestibular suppressants impair adaption and
should therefore be avoided or, if required, used for as short a period as possible23. Vestibular
rehabilitation is effective and should be offered early24.
Follow up
A majority of patients have long term complications 12 months after temporal bone fractures, which
significantly affect quality of life and are frequently disabling25. Further management is beyond the
scope of this acute guideline, but further elective surgery may include ossiculoplasty for dislocation,
tympanotomy for perilymph fistula, or repair of persistent CSF leak.
Refer for hearing aids if needed
All patients with hearing loss affecting their ability or hear or communicate should be referred for
hearing aids26.
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