ARTICLE

Contralateral Labyrinthine Concussion in Temporal Bone

Fractures
Tuncay Ulug, MD and S. Arif Ulubil, MD

ABSTRACT
In this case presentation, three cases of labyrinthine concussion in the opposite ears of patients who had unilateral traumatic
temporal bone fractures with facial paralysis are reported. The first patient was a 30-year-old male who had a right-sided longitudinal
temporal bone fracture and labyrinthine concussion showing pure sensorineural hearing loss with a characteristic notch of 60 dB at
4000 Hz on the left side. The second patient was a 42-year-old male who had a right-sided traumatic facial paralysis owing to a mixed-
type temporal bone fracture and labyrinthine concussion, demonstrating pure sensorineural hearing loss reaching its peak of 50 dB at
4000 Hz on the left. The third patient was a 19-year-old male who had a left-sided mixed-type temporal bone fracture and a right
labyrinthine concussion exhibiting pure sensorineural hearing loss reaching 60 dB at 4000 Hz. For their facial paralyses, all three
patients underwent middle cranial fossa or combined approach operations. The labyrinthine concussion in these patients was
managed expectantly. At their 1-year follow-up, it was observed that the hearing loss owing to labyrinthine concussion persisted.
Although labyrinthine concussion is not a rare complication of head injuries, it has rarely been reported in the medical literature. The
main symptoms of labyrinthine concussion are hearing loss, tinnitus, and dizziness. The diagnosis mainly relies on audiometric tests,
which reveal characteristic tracings reminiscent of acoustic trauma.

SOMMAIRE
Nous rapportons ici le cas de trois patients ayant subi une fracture unilaterale de I'os temporal causant une paralysie faciale et chez
qui nous avons aussi diagnostique une commotion labyrinthine contralaterale. Les trois patients ont du subir une operation par
approche de la fosse moyenne ou par approche combinee. La commotion labyrinthique a ete traitee de fa^on conservatrice chez ces
patients. La surdite persistait a la visite annuelle. Bien que la commotion labyrinthique ne soit pas une complication rare du trauma
cranien, elle n'est que rarement discutee dans la litterature scientifique. Les principaux symptomes sont une surdite, un acouphene
et un etourdissement. Le diagnostic repose sur I'audiologie qui montre un trace qui rappelle le trauma acoustique.

Key words: hearing loss, labyrinthine concussion, temporal bone trauma

r he term labyrinthine concussion is used to describe

high-frequency sensorineural hearing loss with or
without vestibular symptoms following head trauma with-
out a demonstrable labyrinthine fracture. The symptoms of
labyrinthine concussion are sensorineural hearing loss with a
characteristic notch in the 4 to 6 kHz range resembling
acoustic trauma, tinnitus, and positional vertigo.' Although
labyrinthine concussion is not a rare complication of head
injuries, it has rarely been reported in the medical literature.
Received 06/12/05. Received revised 08/23/05. Accepted for publication
08/24/05.
Tuncay Ulug: Department of Otolaryngology, Istanbul University
Faculty of Medicine, Istanbul, Turkey; S. Arif Ulubil: Department of
Otolaryngology, University of Miami, Miami, Florida.
Address reprint requests to: Dr. Tuncay Ulug, Akdogan Sokak 30/11
Besiktas, Istanbul, Turkey; e-mail: tuncayu@superonline.com.
DOI 10.2310/7070.2006.0069
In this case presentation, three cases of labyrinthine
concussion in the opposite ears of patients who were
treated surgically for traumatic temporal bone fractures
resulting in facial paralysis are discussed.
Case Reports
This study was conducted at the Department of
Otolaryngology of the Istanbul Faculty of Medicine
Hospital. It included patients with temporal bone fractures
resulting in facial paralysis who were treated surgically. The
patients were referred from different emergency trauma
centres after the treatment of critical surgical and medical
conditions. Of 10 consecutive patients treated surgically for
facial paralysis, 3 cases of labyrinthine concussion demon-
strating high-frequency hearing loss were found in the
radiologically normal contralateral temporal bones. All
patients underwent a full audiologic evaluation, including

380 The Journal of Otolaryngology, Vol 35, No 6 (December), 2006: pp 380-383

 ulug, Contralateral Labyrinthine Concussion 381

air and bone conduction, pure-tone audiometry, tympano- high-frequency sensorineural hearing loss on the unin-
metry, and stapedial reflex measurement. The medical volved side persisted.
histories of all three patients were negative for noise exposure,
ototoxic drug use, or familial hearing loss. The patients were
Case 2
followed for at least 1 year following the operations.
A 42-year-old man with right-sided traumatic facial paralysis
owing to falling from a building was referred to our clinic
Case 1
after 10 days following the trauma. A HRCT scan was
This patient was a 30-year-old male who developed ordered, and a mixed type of temporal bone fracture on the
immediate facial paralysis following a crush injury to the right was seen. A 35 dB air-bone gap and high-frequency
temporal bone. On high-resolution computed tomo- sensorineural hearing loss on the right and pure sensor-
graphic (HRCT) scans of the temporal bone, a long- ineural hearing loss reaching its peak of 50 dB at 4000 Hz on
itudinal fracture was observed on the right. The left the left were seen in the preoperative audiogram (Figure 2).
temporal bone appeared to be normal on HRCT scans. The facial nerve of the patient was decompressed using a
The audiogram of the patient revealed a 40 dB air-bone combined approach consisting of the transmastoid and MCF
gap and high-frequency sensorineural hearing loss on the approaches on the fourteenth day following the trauma.
right and pure sensorineural hearing loss reaching 60 dB at Owing to the persistence of the air-bone gap on the right,
4000 Hz on the left (Figure 1). The patient also had the patient was offered an ossiculoplasty, which he declined.
abducens paralysis on the fractured side. As indicated by At the 1-year follow-up, the facial paralysis showed House-
the neurophysiologic test results and the HRCT findings, Brackmann grade 2 healing; however, the high-frequency
the patient underwent surgery on the fiftieth day following sensorineural hearing loss attributed to 'labyrinthine con-
the initial trauma through the middle cranial fossa (MCF) cussion on the left side persisted.
approach. After the surgery for facial paralysis, the patient
declined the offer of a second-stage procedure involving an
Case 3
ossiculoplasty for the mixed hearing loss on the right side.
At 1 year following the procedure, although the facial Immediate left-sided facial paralysis occurring after a fall was
paralysis showed grade 1 House-Brackmann recovery, the the reason for the referral of this 19-year-old male patient to

1,, K
2 JO Figure 1. Audiogram of case 1 show-
•1) tm ing labyrinthine concussion on the
^ . • - ' ' ti... X
tit '^ left.
•-•.. 40

So 51*
*(* XI

I.D

l:s :'iO 58-

t—.^ 1
s^ w ^ ^
.....— \ Figure 2. Audiogram of case 2 show-
• ' • - • . . . .
\ ...""1 v (•y.-. .Ill ing labyrinthine concussion on the
left.
/
/
382 Journal of Otolaryngology, Volume 35, Number 6, 2006
our clinic. A mixed-type left temporal bone fracture was
found on HRCT. The preoperative audiogram showed a 40
dB air-bone gap and high-frequency sensorineural hearing
loss on the involved side and pure sensorineural hearing loss
reaching 60 dB at 4000 Hz in the contralateral ear (Figure 3).
A combined approach consisting of the MCF and transmas-
toid approaches was chosen for the facial decompression of
the patient on the thirty-second day following the fall. After
having undergone major surgery, this patient also declined
an ossiculoplasty for the persisting air-bone gap on the left
side. The patient had grade 1 House-Brackmann facial
recovery. At his routine follow-up at 1 year, right-sided
sensorineural hearing loss owing to labyrinthine concussion
remained.
Discussion
Labyrinthine concussion is a common finding in head
traumas. However, our search of the medical literature did
not reveal much information about this clinical entity in
head traumas or any study specifically addressing its
presence in unilateral temporal bone fractures.
According to the classic classification proposed by
Ulrich, temporal bone fractures are divided as long-
itudinal, transverse, and mixed.^"^ In the literature, there
are many different numbers regarding the incidence of
temporal fracture types. Approximately. 70 to 80% of
temporal bone fractures are longitudinal, 10 to 30% are
transverse, and 0 to 20% are mixed.^'^ According to
Schuknecht and Davidson, labyrinthine concussion occurs
most frequently in longitudinal fractures.'' Next in
frequency are ears opposite a temporal bone fracture and
head trauma without fracture. In the present study,
labyrinthine concussion was seen in the opposite side of
two mixed fractures and in the opposite side of a
longitudinal fracture severe enough to cause abducens
palsy. Based on these findings, we can speculate that
contralateral labyrinthine concussion occurs as a result ofa
strong impact to the temporal bone.
•
1- .
w Figure 3. Audiogram of case 3 show-
//
- - ,
The diagnostic workup for a temporal bone trauma
includes several studies. A neuro-otologic examination is
of prime importance. The presence of facial paresis or
paralysis, hearing loss, vertigo, or dizziness should raise the
suspicion of a severe temporal bone trauma. HRCT of the
temporal bone should be ordered to investigate the
presence of a fracture. In the presence of facial paralysis,
electrophysiologic tests such as electroneuronography and
electromyography are required. Vestibular tests may be
performed in selected cases. Audiometric studies comprise
a significant part of the diagnostic battery. Temporal bone
trauma may be accompanied by all types of hearing loss.
The diagnosis of labyrinthine concussion mainly relies on
audiometric tests. Sensorineural hearing loss maximal in
the 4000 to 6000 Hz range resembling an acoustic trauma
is the typical audiogram tracing in this disorder. In the
present study, the audiograms of the patients showed
maximal hearing loss that reached up to 60 dB at 4000 Hz.
Scott and colleagues also demonstrated that, in addition to
4000 Hz notches, patients with a history of head trauma
may also show notches in midfrequencies.^ Vestibular tests
may be helpful in cases with severe vertigo. Electro-
nystagmography may show ipsilateral vestibular paresis or
spontaneous nystagmus beating away from the involved
side. In the present study, the diagnosis of labyrinthine
concussion was made by audiometric tests only. We found
it inappropriate to employ vestibular tests on our patients
who had undergone major trauma.
According to the literature, hearing loss in labyrinthine
concussion may be temporary or permanent.^ In addition,
a recent study has shown that fiuctuation in the
sensorineural hearing loss owing to head trauma usually
fluctuates within the first year after trauma, after which the
hearing loss stabilizes.'" In all three patients, no change in
the degree of their hearing loss was observed at their 1-year
follow-up.
The mechanism of injury in labyrinthine concussion is
not clear. It is speculated that high-pressure waves caused
by a severe blow to the head are directly transmitted to the
ing labyrinthine concussion on the
right.
 Uhig, Contralaterat Labyrinthine Coneussion
cochlea by bone conduction.' This is very similar to
acoustic trauma. Indeed, the audiometric changes
observed in both disorders are identical. The histopatho-
logic changes observed in labyrinthine concussion range
from mild alterations of the internal and external hair cells
to complete degeneration of organ of Corti and cochlear
neurons. Aside from labyrinthine concussion, sensori-
neural deafness can result from other pathophysiologic
mechanisms as well. Acute bleeding into the cochlear duct
may organize and destroy the sensory epithelium.
Sensorineural hearing loss can also be caused by direct
disruption of the membranous labyrinth with inflamma-
tory healing by fibrotic connective tissue, scarring, and
new bone formation."
Two other clinical entities resulting from temporal
bone trauma may be confused with labyrinthine concus-
sion. These diseases are characterized mainly by vertigo.
Benign paroxysmal positional vertigo can be seen as a
result of head trauma. The blow may cause a tear in the
otolithic membrane of the" utricle, and otoconia may be
displaced into the posterior semicircular canal, resulting in
paroxysmal attacks of vertigo. The most important
symptom of labyrinthine concussion, hearing loss, is not
seen in this disease. The diagnosis may be established by a
Dix-Hallpike manoeuvre, which reveals fatigable direc-
tional nystagmus. The other disorder that is included in
the differential diagnosis is perilymph fistula. With
perilymph fistula, the patients usually complain of
fluctuating hearing loss, vertigo, ear fullness, and tinnitus.
The fistula test can aid in the diagnosis, although a
negative fistula test does not rule out the presence of a
fistula. Electronystagmography reveals caloric paresis in
the affected ear. The definitive diagnosis can be made only
at surgery.
There is no specific treatment for labyrinthine concus-
sion. In cases with severe vertigo, labyrinth-suppressant
drugs such as first-generation antihistamines and benzo-
diazepines may be used. The use of corticosteroids is
controversial. In the present study, because the cases were
not isolated labyrinthine concussion but labyrinthine
concussion opposite a severe temporal bone fracture, the
main focus of attention was directed towards the severe
fractures and the resulting facial palsies. Moreover, the
383
patients were referred from other trauma centres and their
initial therapies were started in these centres. The
labyrinthine concussions were managed expectantly with
serial audiograms.
Conclusion
Although not a major complication of head injuries,
labyrinthine concussion may adversely affect the quality of
life of these trauma patients. Complaints of hearing loss,
tinnitus, and dizziness after a head trauma may be the
symptoms of a labyrinthine concussion. The main
diagnostic tools are the audiometric tests. However,
vestibular tests can also be ordered in selected cases.
Patients should be warned about the risk of permanent
hearing loss in this disorder.
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