Following a trip and fall onto his chin, the patient presented with bilateral haemotympanum and mild hearing loss; skull x-rays and subsequently CT were performed.
The patient tripped and fell onto his chin when returning home with shopping in both hands. His family brought him into hospital as he had suffered a brief loss of consciousness following the fall. He had no obvious head injury per se but had marked bruising to his chin. The man's main presenting symptom was sudden onset of poor hearing and he was noted to have blood oozing from both ears. The patient also had minor pain on articulating speech.
Skull x-rays were performed initially. Although these were felt to be normal, there was a strong clinical suspicion of a base of skull fracture, so CT of the brain and base of skull/temporal bones was subsequently performed.
Auditory canal haemorrhage is usually a sign of a base of skull fracture and certainly needs excluding as part of the initial management work-up for any patient with maxillofacial trauma. It is not commonly known, or reported in the literature, that this sign can also be a symptom of fracture of the external auditory canal (EAC). In turn, this may also be combined with a fracture of the mandibular condyle. This is particularly so if the mechanism of injury is direct chin trauma, as in this case. The mandibular condyle(s) may also be dislocated.
The EAC consists of an outer cartilaginous third and an inner bony two-thirds, which is a complete cylinder. The temporomandibular joint (TMJ) is located immediately anterior to the EAC and the glenoid fossa produces a convexity in the anterior wall of the bony canal. It is this proximity that leaves the EAC susceptible to injury following trauma, surgery or other pathological processes resulting in TMJ prolapse. In particular, blows to the mandible are associated with EAC fractures located in the anterior wall (tympanic plate) resulting from direct impact of the mandibular condyle on this region. Therefore, it is easy to see why this may on occasion also result in fracture of the mandibular condyle itself or indeed fracture dislocation of the TMJ. It is worth noting that if trauma comes in the form of a blow to the lateral or posterior aspects of the cranium and result in longitudinal temporal bone fracture, these can also be associated with EAC fractures but tend to involve the supero-posterior quadrant of the EAC. Following direct chin trauma, this patient suffered bilateral EAC fractures and also an undisplaced fracture of his right mandibular condyle. There was haematoma present in both EACs causing mild hearing loss, although the tympanic membranes themselves were intact within the limitations of CT. The temporal bones were normal, as expected, as was the brain scan.
A base of skull fracture is the most serious entity needing diagnosis or exclusion in a patient presenting with trauma and auditory canal haemorrhage. However, posterior dislocation of the mandibular condyles resulting in EAC fracture should not be overlooked in this clinical setting, particularly in the context of direct mandibular trauma. This is equally true with children. There may be resulting hearing loss due to injury to the tympanic membrane, disruption of the middle ear ossicles or simply due to the presence of haematoma, and these areas also need careful review.
Fractures of the external auditory canals and mandibular condyle
1. Fracture lines are visible in the bilateral External Auditory Canals (EAC), mainly located on the anterior walls, with soft tissue density shadows or signs of hematoma.
2. A fracture line with no obvious misalignment is observed at the right mandibular condyle (mandibular condyle fracture with minimal displacement).
3. CT shows that the overall shape of both temporal bones is essentially normal, with no evidence of basilar skull fracture. Within the scanned intracranial range, no apparent intracranial hemorrhage or other abnormal lesions are noted.
4. No clear signs of tympanic membrane rupture are observed on either side; however, there is blood accumulation in both EACs, corresponding to bilateral bloody discharge and hearing loss clinically.
1. Basilar Skull Fracture
● Characterized in part by bleeding or bloody discharge from the external auditory canal, but this CT scan does not show any clear basilar skull fracture lines. While it is a consideration, it has largely been excluded in this case.
2. Fracture of the EAC
● On this CT, bilateral disruption of the bony continuity along the anterior wall of the EAC is seen, accompanied by hematoma, which is consistent with a fracture of the external auditory canal.
3. Mandibular Condyle Fracture
● The mechanism is often an impact to the chin causing posterior displacement of the mandibular condyle that collides with the anterior wall of the EAC. In this case, a minimally displaced fracture line is observed on the right condyle.
4. Condylar Dislocation or Temporomandibular Joint (TMJ) Injury
● When there is a condylar fracture and external auditory canal damage, TMJ dislocation should be considered. Currently, no obvious TMJ dislocation is seen, but clinical examination is necessary to confirm.
Based on the imaging findings, the patient’s mechanism of injury (fall impacting the chin), and clinical symptoms (bloody discharge from both ear canals and mild hearing loss), the most likely diagnosis is:
• Bilateral external auditory canal fractures with a minimally displaced fracture of the right mandibular condyle.
• No definite tympanic membrane rupture, but bilateral hematomas are causing hearing loss.
No evidence of basilar skull fracture is found, thus basilar skull fracture can be excluded at this time.
1. Treatment Strategy
● Conservative Management: For minimally displaced condylar fractures and external auditory canal fractures, conservative observation is generally adopted, including pain control, anti-inflammatory measures, infection prevention, and close follow-up of hearing and fracture healing. If there is a significant amount of hematoma in the external auditory canal, safe evacuation of blood clots may be considered to relieve canal obstruction and improve hearing.
● Surgical Intervention: If there is significantly displaced condylar fracture or injury leading to TMJ dysfunction, or if external auditory canal fractures result in severe deformity or recurrent infections, surgical evaluation should be considered.
● Hearing Assessment and Otologic Follow-up: Based on the extent of bleeding and hearing changes, regular audiometric tests and otoscopic evaluations are recommended to rule out middle ear damage or persistent external ear canal problems.
2. Rehabilitation/Exercise Prescription
The focus of rehabilitation is the gradual restoration of TMJ range of motion and prevention of joint ankylosis, while also addressing overall health considerations. Given that the patient is 72 years old, particular attention should be paid to safety and a gradual approach.
This report provides a reference-based analysis derived from the given medical history and imaging data. It does not replace an in-person consultation or professional medical advice. If you have any concerns or if symptoms worsen, please seek medical attention promptly.
Fractures of the external auditory canals and mandibular condyle
