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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 110-113

Hearing loss with pneumolabyrinth posttransverse temporal bone fracture


Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission19-Sep-2021
Date of Decision18-Jan-2022
Date of Acceptance16-Feb-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Prerna Anup Patwa
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_346_21

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  Abstract 


Head injury caused by high force can lead to severe complications if fracture of the temporal bone is present. It is rare that temporal bone fracture causes pneumolabyrinth; there is an entry of air into the vestibulocochlear system due to the fracture line communicating inner ear to the middle ear. Vestibular pneumolabyrinth is more common than cochlear pneumolabyrinth. For initial evaluation of polytrauma patients with fracture of the temporal bone, multidetector computed tomography (CT) with high resolution and multiplanar reformation play an important role in the identification of important structures lying in close relation to the temporal bone that may lead to severe complications if fracture line is traversing through them. We herein present an interesting case of a 39-year-old man who underwent a road traffic accident leading to transverse temporal bone fracture and cerebral contusion. After discharge from the hospital, the patient complained of decreased hearing in the ipsilateral ear and difficulty in maintaining balance. On CT, otic capsule violating fracture was noted with pneumolabyrinth. First, the patient was treated conservatively, following no improvement in his condition, he was surgically treated and gained full recovery. Early detection of otic capsule involvement in cases of temporal bone fracture can provide effective treatment which will further lead to decrease in complications which if left untreated could have resulted in drastic consequences contributing to irrecoverable hearing loss. One should always pay attention while reporting for CT scans and always look for the location of air bubbles in the otic capsule as the line of fracture is not visualized properly in the presence of mastoid collection.

Keywords: Hearing loss, pneumolabyrinth, temporal bone fracture, trauma


How to cite this article:
Singh RK, Mishra GV, Dhande RP, Phatak SV, Patwa PA. Hearing loss with pneumolabyrinth posttransverse temporal bone fracture. J Datta Meghe Inst Med Sci Univ 2022;17:110-3

How to cite this URL:
Singh RK, Mishra GV, Dhande RP, Phatak SV, Patwa PA. Hearing loss with pneumolabyrinth posttransverse temporal bone fracture. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:110-3. Available from: http://www.journaldmims.com/text.asp?2022/17/1/110/352234




  Introduction Top


Temporal bone fractures in adults are invariably due to motor vehicle accidents or road traffic accidents (RTA). Hearing loss is the most common complaint after temporal bone fracture but attention to it is frequently overlooked as there may be other life-threatening complications associated with it that may require immediate attention of the caregiver.[1] Temporal bone fractures can cause either immediate or long-term devastating results due to grave injuries to temporal bone contents such as facial nerve, glossopharyngeal nerve, ear ossicles, and otic capsule.[2] According to the old traditional classification system, temporal bone fractures were classified as longitudinal, transverse, or mixed based on the direction of the line of fracture in relation to the long axis of the petrous bone.[1] RTAs are the leading cause of fracture of the temporal bone in head trauma patients accounting for 30%–70% of skull fractures.[3] The anatomy of the temporal bone is very complex and many structures are in close relation to it, such as various cranial nerves, internal carotid artery, jugular bulb, and sigmoid sinus. Head trauma causing temporal bone fracture can lead to potential risk if any of these structures are involved. Fractures of the temporal bone can present without any symptoms or they can result in grave complications such as hearing loss of sensorineural, conductive or mixed type, dysfunction of balance mechanism, cerebrospinal fluid leaks, nerve paralysis leading to facial nerve palsy, and vascular injury.[4] The presence of air bubbles in the semicircular canals, cochlea, and vestibule due to fracture line traversing through the otic capsule can lead to pneumolabyrinth. It can also result due to subluxation of stapes, stapedectomy, or injury by barotraumas. On the basis of the presence of air bubbles in various parts of the otic capsule, pneumolabyrinth has been divided into vestibular pneumolabyrinth, cochlear pneumolabyrinth, and combined pneumolabyrinth.[5] As less amount of time and manipulation is required for image acquisition, CT scan plays an important role in polytrauma patients that present to the emergency department. Due to multiplanar reformation ability of multi-detector, CT image processing of acquired data is quiet fast with detailed temporal bone anatomy and base of the skull making it an important tool for knowing extent of injury to affected structures and changing management of patient care.[6]


  Case Report Top


A 39-year-old male visited the emergency department of Acharya Vinoba Bhave Rural Hospital, Sawangi Meghe, Maharashtra, with complaints of decreased hearing on the left side, vertigo on standing or forward bending, and difficulty in walking since 2 weeks after discharge from the hospital. On careful history, the patient told he had a RTA 1 month ago with left ear bleeding and loss of consciousness after fall. The patient was well built and properly nourished with no history of previous ear pathology related to hearing loss or balance. For further evaluation, the patients CT was reevaluated, and it revealed the patient had transverse fracture of the left temporal bone [Figure 1] with small gas bubbles within the vestibule of the left otic capsule [Figure 2] with thin fracture line traversing through superior semicircular canal and crossing perpendicular to left petrous pyramid [Figure 3]. Even a gas bubble was noted in the facial canal [Figure 2]. He also had left internal carotid canal fracture [Figure 4]. For further evaluation, the patient was referred to the ENT department for pure-tone audiometry to know type and degree of hearing loss. A moderate degree of sensorineural hearing loss was seen on pure-tone audiometry. Auditory evoked brainstem responses and electrocochleography were not performed. The patient was treated conservatively with proper bed rest, antibiotics, and intravenous steroids. However, after conservative treatment, there was no improvement in his condition; hence he was switched to surgical treatment. Transcanal approach was done, and ossicles were found intact and mobile with no subluxation of foot plates of stapes into vestibule. No perilymph leakage was found in an area close to an oval or round window. There was an undisplaced linear fracture line crossing through a superior semicircular canal and vestibule with perilymph leakage around the fracture line. By using temporalis fascia graft over the fracture, the line fistula was sealed. Vestibular symptoms improved significantly after surgery, but recovery of hearing was slow.
Figure 1: Computed tomography showing transverse fracture of the left temporal bone

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Figure 2: CT scan showing pneumolabyrinth, air bubbles noted in the vestibule and facial canal. CT: Computed tomography

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Figure 3: Transverse fracture traversing through the superior semicircular canal of the left temporal bone

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Figure 4: CT scan showing transverse fracture with fracture line traversing through left internal carotid canal. CT: Computed tomography

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  Discussion Top


Head injury due to RTA in the modern-day world is among the common killers. Traumatic brain injury due to road accidents is increasing as traffic is increasing, besides other factors such as fall from height. Head injuries account for nearly 25%–33% of all accidental deaths and 67% of deaths due to trauma in hospitals.[7] Temporal bone fractures and base of skull fractures are mainly associated with head trauma of high velocity. Temporal bone fracture can result in complications such as facial nerve injury, meningitis secondary to an infection, perilymphatic fistula, and hearing loss. Thin slice high-resolution temporal bone CT scan with 1 mm section gives a better platform for visualization of fracture line and its route with involved internal structures. For better visualization of subtle fractures of the temporal bone and air bubbles in the inner ear CT is a better modality of choice. According to the old traditional classification system, temporal bone fractures were classified as longitudinal, transverse, or mixed based on the direction of line of fracture in relation to the long axis of the petrous bone. However, new classification is based on whether fracture line involves or spares the otic capsule.[8] Temporal bone fractures can result in hemorrhage, ossicular chain disruption, and cerebral contusion if the impact is high. The ear is the most common sensory organ injured in an RTA. Since major brain parenchymal injuries associated with RTAs need immediate care, fractures of the temporal bone are often missed and later on, these patients present with hearing loss. High-resolution CT (HRCT) of the temporal bone is sensitive as well as specific for diagnosing temporal bone fractures. With the help of HRCT, it is easy to know details of anatomy and in assessing till what extent is fracture line in case of temporal bone trauma. Even if most of these temporal bone fractures are not life-threatening, they affect the quality of life of a person since they are associated with severe morbidity, and such patients need long-term rehabilitation. Image analysis of HRCT can be used in fracture of temporal bone either to detect the hearing loss or to know the type and classify the fracture or to find the correlation between the types of fracture and clinical hearing loss. The presence of air inside the inner ear seen as small black areas of air density changing position with head movement and having Hounsfield unit (HU) value of −800 to −1000, confirms pneumolabyrinth. Since bone and air do not give signal intensity on magnetic resonance imaging, so it's not the modality of choice. Pneumolabyrinth is rare; that's why studies regarding its management are not properly described in the literature. Fifty percent of patients are treated surgically, and the other half are managed conservatively. Conservative management includes proper bed rest, use of steroids, and regular follow-up with CT scan, while the main motive of surgery is to seal the fracture between air spaces of the middle ear and inner ear using fat or fascia.[7] The frequency of pneumolabyrinth is more in otic capsule involving fractures in comparison to otic capsule–sparing fractures. Vestibule and semicircular canal are the most common sites for air bubbles, followed by air in the cochlea.[9] In our case, using temporalis fascia graft over the fracture, the line fistula was sealed. Vestibular symptoms of the patient improved significantly after surgery, but recovery of hearing was slow. It is assumed that decrease in vestibular symptoms and slight improvement in hearing were due to the absorption of air bubbles from the inner ear.[7]


  Conclusions Top


Pneumolabyrinth is a relatively specific sign of an otic capsule violating fracture of the temporal bone, especially with history of trauma. Hence, visualization of air in vestibule, cochlea, or semicircular canals should prompt careful evaluation of petrous temporal bone and inner ear structures to look for fractures and associated complications. Early detection of otic capsule involvement in cases of temporal bone fracture can provide an effective treatment which will further lead to decrease in complications which if left untreated could have resulted in drastic consequences contributing to irrecoverable hearing loss. One should always pay attention while reporting for CT scans and always look for the location of air bubbles in the otic capsule as the line of fracture cannot be seen in case of mastoid collection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maradi N, Somanath BM. Hearing loss following temporal bone fractures – A study on classification of fractures and the prognosis. Int J Otorhinolaryngol Head Neck Surg 2017;3:390.  Back to cited text no. 1
    
2.
Imtiaz S. Temporal bone fractures in patients with head injury: A retrospective one year study. PJR. 2016;26.  Back to cited text no. 2
    
3.
Amin Z, Sayuti R, Kahairi A, Islah W, Ahmad R. Head injury with temporal bone fracture: One year review of case incidence, causes, clinical features and outcome. Med J Malaysia 2008;63:373-6.  Back to cited text no. 3
    
4.
Basavaraju U, Jayaramaiah SK, Turamari RU, Prakash V, Mankani S. Temporal bone fractures and its classification: Retrospective study of incidence, causes, clinical features, complications and outcome. Int J Anat Radiol Surg 2017;6:RO57-61.  Back to cited text no. 4
    
5.
Bacciu A, Vincenti V, Prasad SC, Tonni D, Ventura E, Bacciu S, et al. Pneumolabyrinth secondary to temporal bone fracture: A case report and review of the literature. Int Med Case Rep J 2014;7:127-31.  Back to cited text no. 5
    
6.
Zayas JO, Feliciano YZ, Hadley CR, Gomez AA, Vidal JA. Temporal bone trauma and the role of multidetector CT in the emergency department. Radiographics 2011;31:1741-55.  Back to cited text no. 6
    
7.
Prisman E, Ramsden JD, Blaser S, Papsin B. Traumatic perilymphatic fistula with pneumolabyrinth: Diagnosis and management. Laryngoscope 2011;121:856-9.  Back to cited text no. 7
    
8.
Lee GH, Lee DH. Pneumolabyrinth after otic capsule-disrupting temporal bone fracture without direct connection with the middle ear space. J Int Adv Otol 2013;9:131.  Back to cited text no. 8
    
9.
Choi HG, Lee HJ, Lee JS, Kim DH, Hong SK, Park B, et al. The rates and clinical characteristics of pneumolabyrinth in temporal bone fracture. Otol Neurotol 2015;36:1048-53.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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