Temporal Bone Fracture

What to do now

1. Call 911 or your local emergency number for any significant head injury.
2. Keep the person still, especially if a neck injury is possible.
3. Do not pack the ear or nose or try to stop clear fluid draining; cover the ear loosely with a clean dressing.
4. Do not let the person blow their nose.
5. Monitor breathing and alertness until help arrives.

Anatomy: why this fracture matters

The temporal bone contains:

• the ear canal and eardrum
• the middle ear with the three hearing bones (ossicles)
• the inner ear (cochlea for hearing and vestibular system for balance), inside the hard otic capsule
• the facial nerve, which controls the muscles of facial expression
• major blood vessels and the lining of the brain

A fracture can damage any of these, and it often occurs with traumatic brain injury and other skull fractures.

Types of temporal bone fracture

Doctors increasingly use the otic capsule classification because it better predicts outcomes.

Symptoms and signs

• bleeding from the ear, or blood behind the eardrum (hemotympanum)
• clear fluid from the ear or nose (cerebrospinal fluid leak)
• bruising behind the ear (Battle sign), usually appearing after 1 to 2 days
• hearing loss, muffled hearing or ringing in the ear
• vertigo, dizziness and nausea
• weakness or paralysis of one side of the face, starting immediately or developing over hours to days
• headache and signs of brain injury

Complications

• Facial nerve palsy: immediate, complete paralysis suggests nerve disruption; delayed or partial weakness usually recovers
• Conductive hearing loss: from blood in the middle ear, a torn eardrum or disrupted ossicles; often improves
• Sensorineural hearing loss: inner ear damage, often permanent
• Vertigo: from inner ear injury, a fistula or BPPV after trauma
• Cerebrospinal fluid leak: usually stops within 7 to 10 days, but raises the risk of meningitis
• Cholesteatoma: skin trapped in the middle ear, which can develop years later
• Vascular injury to nearby arteries or veins

Diagnosis

• Head and neck examination, including otoscopy of the ear canal and eardrum
• Facial nerve testing: observing facial movement as early as possible
• High-resolution CT scan of the temporal bones and CT of the brain
• Hearing tests (audiometry) once the person is stable
• Testing ear or nose fluid for beta-2 transferrin to confirm a spinal fluid leak
• Facial nerve electrical tests (electroneurography) for complete paralysis
• CT or MR angiography if blood vessel injury is suspected

Treatment

Initial care

• treatment of any brain injury takes priority
• keeping the ear dry and clean; avoiding nose blowing
• head elevation and rest for spinal fluid leaks
• vestibular suppressant medicines for short-term severe vertigo

Facial nerve injury

• steroids are often given for facial weakness
• eye protection with lubricants and taping if the eye cannot close
• surgical decompression or repair for immediate complete paralysis with severe nerve degeneration on testing

Spinal fluid leak

• most stop on their own with bed rest and head elevation
• a lumbar drain or surgical repair if the leak persists

Hearing and balance

• conductive hearing loss is rechecked after 6 to 8 weeks; surgery (ossiculoplasty or eardrum repair) if it persists
• hearing aids or cochlear implants for permanent sensorineural loss
• vestibular rehabilitation for ongoing dizziness

Outlook

Many patients recover well. Conductive hearing loss and partial facial weakness usually improve. Otic capsule-violating fractures more often leave permanent deafness on that side. Long-term follow-up with ear examinations is recommended to detect late cholesteatoma.

Frequently asked questions

What are the signs of a temporal bone fracture?

Signs include bleeding or clear fluid from the ear, bruising behind the ear, hearing loss, ringing in the ear, vertigo and weakness on one side of the face after a head injury. Many people also have a brain injury and need emergency assessment.

Can hearing come back after a temporal bone fracture?

Often, yes. Conductive hearing loss from blood in the middle ear or a torn eardrum usually improves within weeks, and surgery can fix damaged hearing bones. Sensorineural hearing loss from inner ear damage is more often permanent.

What does clear fluid from the ear after a head injury mean?

Clear fluid from the ear or nose after a head injury may be cerebrospinal fluid, which surrounds the brain. It indicates a skull base fracture and needs emergency care. Most leaks stop on their own, but there is a risk of meningitis.

Does facial paralysis from a temporal bone fracture recover?

Facial weakness that develops gradually or is partial usually recovers well. Paralysis that is immediate and complete is more likely to need surgery to decompress or repair the nerve, and recovery may be incomplete.

How long does a temporal bone fracture take to heal?

The bone typically heals over several weeks to a few months. Hearing, balance and facial nerve recovery can take longer, sometimes up to a year. Follow-up with an ear specialist is important.