Management of petrous temporal bone fractures: a 5-year experience from an Australian major trauma centre

Abstract

Background: Petrous temporal bone (PTB) fractures result from high energy head trauma and are associated with specific neurological and otological complications, as well as substantial intracranial injuries. Timely and appropriate management is required to ensure optimal outcomes. This study aims to describe the incidence and complications of PTB fractures in an Australian adult population and produce an evidencebased clinical practice guideline for their management. Methods: Five-year retrospective case series of all patients with a PTB fracture from a single levelone tertiary major trauma centre in Melbourne, Australia. Data was collected on demographic and injury characteristics as well as specific PTB fracture-related complications including blunt cerebrovascular injury (BCVI), traumatic facial nerve palsy (FNP), cerebrospinal fluid (CSF) leak and hearing outcomes. Both the traditional anatomical and otic capsule violating (OCV) classification systems were assessed on their ability to predict these complications. Results: There were a total of 377 patients with 419 PTB fractures (42 bilateral). The main complications were FNP (9.3%), CSF leak (12.6%), all cause hearing loss (76.5%), and BCVI (9%). Most patients were male (78.2%). The most common mechanism was falls (52.5%), of which the majority were low falls from standing height, which has not previously been reported. All FNP were managed conservatively, with 81.3% achieving a good outcome. There was no significant association with steroid therapy and facial nerve outcome (P=0.37). Twenty-two fractures (5.3%) were OCV and this was significantly associated with increased risk of facial nerve injury, profound sensorineural hearing loss (SNHL) and vertigo. There was no association with the traditional anatomical classification and complications. Conclusions: PTB fractures should still be suspected in 'lower' mechanism injuries such as a fall from standing height, particularly in the elderly. They are associated with severe traumatic brain injury (TBI) and initial management strategies should focus on stabilisation of other injuries. Ideally only the otic capsule classification system be used in future clinical practice as it better predicts clinical outcomes. We introduce an evidence-based clinical practice guideline for the management of PTB fractures at our centre, which could be used at any similar-level trauma centres across the world.