SYMPTOMS POINTING TO FRACTURE OF THE MIDDLE FOSSA

External hæmorrhages.

(a) Hæmorrhage into the temporal region.

The extravasated blood may either be confined to the temporal region—temporal hæmatoma—or diffused throughout the subaponeurotic space. A temporal hæmatoma is always highly suggestive of a fracture involving the temporal fossa, especially in the event of marked outward bulging, with stretching and discoloration of the overlying tissues. In many cases also the hæmatoma pulsates, in which case it can be presumed that the fracture of the temporal fossa is associated with hæmorrhage from a lacerated middle meningeal artery (see [Fig. 38]). In such cases the application of pressure to the hæmatoma may lead to the development of fits on the contra-lateral side, originating in the face or arm regions and spreading to the higher cortical motor area.

Fig. 38. To illustrate the probable Source of Profuse Hæmorrhage from the Ear. A, The fracture the roof of the external auditory meatus. B, Comminution of the tegmen tympani, the fracture involving the groove for the posterior branch of the middle meningeal artery.

(b) Hæmorrhage from the ear and mouth. The great majority of middle fossa fractures involve the external auditory meatus, passing inwards across the roof and floor of the middle ear towards the body of the sphenoid. Examination will show that the fracture passes inwards towards the junction of the inner and anterior walls of the middle ear, that is to say, towards the tympanic orifice of the Eustachian tube. The membrana tympani undergoes a variable degree of destruction. In the lesser cases the membrane is torn in its upper and front part only—in the region of the membrane of Shrapnell—whilst in the more serious cases it may be completely destroyed. The blood that escapes from the ear is derived from those vessels that supply the lining cuticle of the external and middle ears, from the numerous tympanic vessels, from the lateral sinus, and from the middle meningeal artery. The amount of blood which escapes varies according to the source of the hæmorrhage. When hæmorrhage occurs from the smaller vessels, the blood either clots in the external meatus or trickles from the ear. In the most severe cases the hæmorrhage is profuse and long-continued. Some years ago a case came under my observation that threw light on the probable source of such severe hæmorrhages.

A man was admitted into the hospital, suffering from profuse hæmorrhage from the ear as the result of a fall down an area. The bleeding continued for fourteen hours, soaking the dressings and continuing so long as the man lived. At the post-mortem examination an extensive comminution of the tegmen tympani was discovered, the fracture being associated with great extra-dural extravasation of blood from a lacerated middle meningeal artery. The extra-dural hæmorrhage was enabled to escape through the tegmen tympani into the middle ear, and thence by means of the lacerated membrana tympani (see [Fig. 38]).

Profuse and long-continued hæmorrhage from the ear should always arouse suspicion as to the possibility of injury to the middle meningeal artery. Since meeting the case recounted above, many similar cases have come under my care, and, in several instances, guided by this symptom alone, operative measures have been carried out successfully.

The two following cases show, however, that the extra-dural extravasation may be derived not only from the middle meningeal artery but also from the lateral sinus.

‘A man fell down an area and suffered from continuous hæmorrhage from the ear. He remained in bed for a few days, and then, becoming tired of confinement, got up, walked some distance on a cold and frosty day, and visited a sage femme. On returning home he complained of feeling ill, the hæmorrhage from the ear ceased, and shortly afterwards he became unconscious and died. The autopsy showed an extensive fracture of the petrous bone with extensive extra-dural hæmorrhage from a torn lateral sinus and from a lacerated meningeal artery.’[18]

The man had remained fairly well so long as the extra-dural blood was permitted a free means of escape through the tegmen tympani and external auditory meatus, but, so soon as clotting occurred, compression symptoms developed and the man died in that condition.

‘A man, 50 years of age, fell down, striking his head against the kerb. On admission it was seen that blood was trickling freely through a torn membrana tympani. He rapidly became unconscious and died. The post-mortem examination revealed a fracture involving the middle ear and external auditory meatus, passing backwards across the lateral sinus, in which region there was a large extra-dural extravasation of blood.’[19]

The above statements are confirmed by Dwight,[20] who, in 146 autopsies, found that, in 69 per cent. cases of fracture of the middle fossa of the skull, there was bleeding from the ear, and that in 29 per cent. cases the fracture was associated with laceration of branches of the middle meningeal artery.

Although hæmorrhage from the external auditory meatus may be regarded as almost diagnostic of a middle fossa fracture, especially of that variety previously described as the ‘typical basic fracture’, yet the blood may be derived from a torn membrana tympani or from laceration of the lining cuticle of the external meatus. Aural examination will soon prove whether the blood is coming through a rent in the membrane, in which case the diagnosis is clear. Sometimes bleeding takes place from both ears, a symptom practically diagnostic of the transverse middle fossa fracture known as the ‘typical basic fracture’.

The following statistics will supply further information as to the relative frequency with which hæmorrhage occurs from ears, nose, and mouth, and the proportionate mortality. The cases were collected and tabulated by Crandon and Wilson.

	Cases.	Lived.	Died.	Mortality.
Hæmorrhage from the ear	281	170	111	39 per cent.
Hæmorrhage from both ears	47	16	31	66 per cent.
Hæmorrhage from the nose	44	17	27	61 per cent.
Hæmorrhage from the mouth	168	73	93	33 per cent.

Special points in prognosis and treatment.

It is not possible to formulate any very definite prognosis when the hæmorrhage takes place from one ear only, though the mortality is about 40 per cent. When bleeding takes place from both ears the outlook is more grave, the mortality being about 66 per cent.

With regard to special treatment, two points are obvious: (1) that syringing of the ear is absolutely contra-indicated, on the ground that such treatment carries with it a considerable risk of bringing about meningeal infection; and (2) that plugging the external meatus with strips of gauze is an unsurgical form of treatment, insomuch as the escape of blood from the ear is an important factor in preventing compression of the brain, more especially in those cases where hæmorrhage is profuse. Under the last named conditions, operative measures—exploration for a torn meningeal artery or lacerated venous sinus—are to be carried out.

Hæmorrhage from the mouth may be slight or copious, according to the source from which the blood is derived. In the former case, the bleeding takes place from sphenoidal and pharyngeal vessels, in the latter from the cavernous sinus or from the internal carotid artery (see [p. 148]), the bone being shattered in the region of the sphenoidal body, with comminution of the walls of the contained air-sinus.

Escape of cerebro-spinal fluid.

This condition was first investigated by Van der Wiel in 1727, and more completely by Langier in 1839. The majority of those middle fossa fractures which involve the petrous portion of the temporal bone pass immediately anterior to the genu of the facial nerve (see [p. 102]), and it follows, therefore, that the fracture cannot so involve the dural and arachnoid prolongations of that nerve in such a manner as to allow of the escape of cerebro-spinal fluid. This fact probably explains another fact, namely, that aural cerebro-spinal discharge is an infrequent symptom in middle fossa fractures. On the other hand, as a result of blows applied to the occipital region, a fracture originating in the posterior fossa may cut across the petrous bone, almost at right angles, in such a manner as to sever the seventh nerve in the region of the genu (see [Fig. 41]). This is the usual nature of a basic fracture associated with the escape of cerebro-spinal fluid from the external auditory meatus. More rarely, this particular class of fracture is unaccompanied by any injury to the tympanic membrane, in which case the fluid may escape along the Eustachian tube into the nose and naso-pharynx (see [p. 91]). Cerebro-spinal fluid may also escape from the nose and mouth in middle fossa fractures in the event of extensive injury to the basi-sphenoid with involvement of the overlying cisterna basalis. The following case exemplifies that condition:—

A man suffered from a severe fracture of the middle fossa. Three weeks later there was a sudden and profuse discharge of cerebro-spinal fluid from the nose. Meningitis developed and the patient died. The basi-sphenoid was extensively comminuted, the overlying membranes torn, whilst a probe could be passed readily from the cranial cavity into the naso-pharynx.

Special points in prognosis and treatment.

The question of cerebro-spinal discharges has been discussed previously (see [p. 91]). It is therefore merely necessary to lay further stress on the fact that syringing of the ear is absolutely contra-indicated, for reasons already stated. The ear should be cleaned out with wool and gauze and lightly packed with strips of gauze, these to be renewed when soaked with fluid. When the cerebro-spinal discharge is long continued, acute eczema of the side of the neck may develop as a result of the irritating effect of the fluid. Under these circumstances it is advisable to adopt precautionary measures, painting the skin with ‘new skin’ or collodion. Ointments are of but little use. The eczema will clear up so soon as the discharge ceases.

Escape of brain-matter.

The conditions needful for the discharge of brain-matter from ear or nose have been enumerated previously (see [p. 93]). There are but few cases recorded in literature, and one case only has come under my own observation:—

A lad, 11 years of age, fell some distance out of window on to his head. He was admitted under the care of my colleague, Mr. Lockwood. On admission he was unconscious, and was bleeding freely from the right ear and nose. Shortly afterwards it was noticed that brain-matter was issuing from the right external auditory meatus, sufficient brain-matter being obtained to fill a teaspoon. The extensive nature of the brain-injury was confirmed by the fact that the left arm and leg were paralysed for some days. On the fourth day the boy regained consciousness and recognized his relations. From this period onwards he made an uninterrupted recovery. I have seen the lad on various occasions, the last time one year after the accident. At that time he was an exceedingly bright and intellectual boy.

Special points in treatment and prognosis.

The brain-matter should be gently wiped away from the ear, and the meatus cleansed and lightly plugged with gauze. Operative measures are required in the event of the development of symptoms pointing to brain compression. The prognosis must necessarily be unfavourable, but, as the conditions are almost entirely confined to the young, the most astonishing recoveries are reported.

Involvement of nerves.

The second and third divisions of the fifth nerve pass respectively through the foramen ovale and the foramen rotundum, two foramina which lie anterior to the petro-sphenoidal suture, a suture traversed by the majority of middle fossa fractures. These two nerves are therefore seldom involved.

In all the cases of fractured base which have come under my observation I have never seen the foramen rotundum implicated, and in one case only was the foramen ovale involved.

In certain rare instances, a fracture, passing in the antero-posterior direction, may cut across the apex of the petrous bone in close relation to the cavum Meckelii—the bed of the Gasserian ganglion—in which case all three terminal divisions of the fifth nerve may suffer. Thus, a case was reported by Lee in 1853 in which, seven weeks after the accident, the following symptoms were present:—anæsthesia of the left face and forehead, anterior two-thirds of tongue, and left nostril, together with weakness of the left masticating muscles, and an opaque left cornea.

The sixth nerve.

The sixth nerve may be involved either by itself or in conjunction with other cranial nerves. In the latter case the paresis is due to blood extravasated in the sphenoidal fissure or in the orbital cavity. In the former case the nerve is injured where it grooves the lateral aspect of the dorsum ephipii, a process frequently fractured in lesions of the middle fossa. Fractures tend to pass obliquely across this process, one nerve usually escaping. The prognosis as to functional recovery is very problematical.

The seventh and eighth nerves.

There can be no doubt that the seventh nerve, on account of its complicated intrapetrous course, is more frequently involved than any other cranial nerve. Köhler records 22 cases in 48 middle fossa fractures. My own experience coincides closely with Köhler’s, facial paresis or paralysis being noted in nearly 50 per cent. cases of middle fossa fracture.

The question of facial nerve implication is so intimately associated with involvement of the eighth nerve that the two subjects must be considered together. Thus, cases may be classified as follows:—

1. Cases of paresis of the facial nerve with a variable degree of deafness.

2. Cases of complete facial paralysis with complete deafness.

The greater number of middle fossa fractures involve the middle and external ears, as is evidenced, amongst other symptoms, by hæmorrhage from the ear. Some degree of facial paralysis is frequently existent, not always evident at first sight, but requiring careful examination and comparison between the two sides of the face. The fracture involves both roof and floor of the external ear and passes inwards towards the junction of anterior and inner walls of the middle ear, the membrana tympani undergoing a variable degree of destruction whilst the ossicles may also be injured. Thence, the fracture passes inwards towards the petro-sphenoidal suture in such a manner that the geniculate ganglion of the facial nerve is exposed and laid bare on the anterior aspect of the posterior portion of the skull.

The facial nerve, therefore, escapes direct injury except in so far that the ganglion may be compressed by blood-clot or fragments of bone. Partial loss of function results. In most cases the blood is absorbed and a complete recovery may be anticipated. The degree of deafness is directly proportionate to the damage incurred by the membrana tympani and ossicles.

Fig. 39. To show the Relation of a Typical Basic Fracture to the Middle Ear and its Adjuncts. A, Malleus; B, Middle ear and aditus; C, Geniculate ganglion (facial nerve); D, Groove for great superficial petrosal nerve; E, Canal for tensor tympani muscle; F, Processus cochleariformis; G, Eustachian tube; H, External auditory meatus; I, Membrana tympani; J, Mastoid cells.

[Larger illustration]

In the second group of cases a different picture is obtained. Usually the result of blows applied to the occipital region, the fracture traverses the thin cerebellar fossa towards the outer angle of the jugular foramen, thence cutting across the petrous bone, external to the internal auditory meatus, and terminating, usually by comminution, in the tegmen tympani. It is in the transpetrous part of the fracture that the damage is done, for, not only is the facial nerve cut across in the region of the ganglion, but the auditory apparatus is also severed into two parts. The exact line of the fracture is shown in [Figs. 40] and [41].

Fig. 40. To show the Relation of Basic Fractures to the Petrous Bone. A, The basic fracture, resulting from a force applied to the left occipital region, follows the course depicted in [Fig. 36]. B, The inner half of the petrous bone, being loose, is thrown forward so as to show the relation of the fracture to the integral parts of the petrous bone.

In this class of fracture, though facial paralysis and deafness are both immediate in onset and permanent in duration, there is, in many cases, no bleeding from the ear as the membrana tympani may be uninjured.

The facial nerve may also be implicated in that rare type of basic fracture which was described by Lèon Boullet in 1878, under the title of ‘Fracture of the Mastoid portion of the Temporal bone’. This fracture is fully described on [p. 108]. It will suffice to mention that the mastoid process may be torn away from the base of the skull, the facial nerve being lacerated as it descends the aqueductus Fallopii.

Bilateral facial paralysis is exceedingly rare. Two cases were described by the late Professor von Bergmann. Its occurrence is pathognomonic of the typical basic fracture (see [p. 84]).

Fig. 41. To show the Relation of Basic Fractures to the Petrous Bone. A shows the course pursued by an antero-posterior fracture of the petrous bone. Note that it lies external to the internal auditory meatus. B shows—enlarged—the inner aspect of the outer fragment. Note the relation of the fracture to the semicircular canals, and that the membrana tympani and ossicles are quite uninjured.

Complete facial paralysis may be associated with the following symptoms:—

Epiphora, conjunctivitis, and keratitis (from paralysis of the orbicularis palpebrarum).

Loss of taste (from involvement of the chorda tympani).

Impaired nasal air-entry (from paralysis of dilator alæ muscle).

Impaired acoustic sensibility (from paralysis of the stapedius).

Impaired mastication (from involvement of the buccinator muscle).

Impaired secretion of saliva (from the cutting off of the secretory and vaso-dilator fibres of the chorda tympani).

Lastly, it is necessary to add that facial paralysis developing some days or weeks after the accident, though sometimes dependent on degeneration of nerve-fibres as the result of pressure in the region of the geniculate ganglion, may also arise from an ascending neuritis or from meningeal infection.