Pediatric Trauma Patients with Temporal Bone Fractures Are at Risk for Multiple Cranial CT Scans

Background: High energy traumatic brain injury (TBI) patients suspected of having a fracture often receive a significant amount of radiation in diagnostic imaging studies. Computed tomography of the head (CT-H) is a widely accepted tool for initial radiographic evaluation of traumatic brain injury (TBI); however, patients with suspected temporal bone fracture (TBF) often undergo additional scans of the maxillofacial bones (CT-MF) and of the temporal bones (CT-TB) to better characterize skull base injuries that may put the patient at risk for cranial nerve injuries and hearing loss. CT-TB is commonly performed on adult TBF patients; however, it has been found that this scan is largely unnecessary for adequate injury evaluation and treatment. No such studies have been performed in the pediatric population. With the well-documented increase risk of malignancy linked to excess CT usage amongst pediatric patients, we aim to characterize temporal bone injuries and imaging in children and identify over-use of ionizing imaging in this population.

Methods: After institutional IRB approval a retrospective review of all pediatric trauma patients (<18 y) with diagnosed skull fracture from a 10-year period, data on patient demographics, mechanism of injury, initial physical exam, imaging, and complications, were compiled into a database.

Results: A total of 412 patients were identified who met inclusion criteria for the study. TBFs accounted for 108 (26.21%) patients while the remaining 304 (73.79%) patients were diagnosed with a non-TBF skull fractures. The most common mechanism of injury for TBF was motor vehicle collision (27.78%) followed by fall (25.00%) and bike/scooter/skateboard accident (19.44%). Presenting signs of TBF included hemotympanum (41.67%), blood otorrhea (25.00%), and hearing loss (25.00%). In association with TBF, complications included facial nerve injury (FNI) (6.48%), CSF leak (8.33%), permanent hearing loss (15.74%), and arterial dissection (0.93%). Imaging performed on all skull fracture patients yielded 31 (28.70%) patients with a TBF received CT-H, CT-MF, and CT-TB while only 3 (0.99%) patients with a nontemporal skull fracture received similar scanning. Of patients with TBF, CT imaging changed clinical management in 34 (31.48%) patients, of which 7 (6.48%) received treatment for FNI and 29 (26.85%) received vascular imaging of the head/neck. Dedicated CT-TB changed clinical management in 11 (10.19%) patients, of which 1 (0.93%) patient received treatment for FNI and 10 (9.26%) patients received vascular imaging of the head/neck.

Conclusion: These data demonstrate nearly 30% of children with temporal bone fracture, underwent three complete separate cranial CT scans including high resolution imaging. Additionally, most temporal bone fractures in children do not result in hearing loss, facial nerve injury, vascular injury, nor CSF leak. This suggests that, for children whose fracture is well characterized on CT-H or CT-MF, additional ionizing high resolution imaging such as CT-TB does not significantly change clinical management and should be obtained thoughtfully as to minimize radiation exposure in diagnostic work-up.