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Temporal bone fractures
The key classification today is whether the fracture crosses the otic capsule: a capsule-sparing fracture causes mainly conductive hearing loss and blood behind the eardrum, while a capsule-violating fracture causes sensorineural loss, vertigo, facial palsy and a higher rate of CSF leak.
Why it matters in the exam
The old classification separated longitudinal fractures (70% to 90%) from transverse ones, but classification by the otic capsule predicts complications better. In a capsule-sparing fracture: haemotympanum, eardrum tear, ossicular chain damage (usually incus dislocation) and facial palsy in about 6% of cases, usually near the geniculate ganglion. In a capsule-violating fracture: severe sensorineural hearing loss, vertigo and nystagmus, and facial palsy in 30% to 50%.
The exam asks mostly about the facial palsy: immediate complete palsy indicates severe injury; CT and ENoG are performed, and if degeneration reaches 90% or more within 14 days, surgical nerve decompression is considered. Delayed or partial palsy usually comes from oedema, is treated with steroids, and its prognosis is very good. Delayed or partial palsy does not need surgery.
CSF leak from the ear or the nose (via the Eustachian tube) is confirmed by beta-2 transferrin. Most leaks close with conservative care within 7 to 10 days: rest with the head raised, avoiding straining and constipation, and sometimes lumbar drainage. Prophylactic antibiotics are not routinely recommended; pneumococcal vaccination is advised. Conductive loss persisting more than 3 months after the blood has cleared indicates ossicular damage and justifies exploration and ossicular reconstruction (ossiculoplasty). Battle sign (bruising behind the ear) appears after a day or two. In a child, as in an adult, hearing is tested after the blood has cleared, because a persistent conductive loss or an unrecognised sensorineural loss can affect speech and schooling. In every severe head injury the neurological state and the cervical spine are assessed first, and only then the ear.
Key points
- Capsule-sparing: conductive, haemotympanum.
- Capsule-violating: sensorineural, vertigo, facial palsy.
- Immediate complete palsy — ENoG and consider surgery.
- Delayed palsy — steroids.
- Leak — conservative care for 7 to 10 days.
Summary table
| Aspect | Capsule-sparing fracture | Capsule-violating fracture |
|---|---|---|
| Frequency | Most fractures | A minority |
| Hearing | Conductive loss, haemotympanum | Severe sensorineural loss |
| Facial palsy | About 6% | 30% to 50% |
| CSF leak | Less common | More common |
| Vertigo | Rare | Common |
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Sources
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Temporal bone trauma
- Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures, 1997 — CSF fistula and facial paralysis outcomes
- Little SC, Kesser BW. Radiographic classification of temporal bone fractures, 2006 — Otic capsule-sparing versus otic capsule-violating
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.