Case Report
A 16-year old adolescent male patient presented to our
otorhinolaryngologic emergency service a few hours after being struck by
a hockey puck to the left mastoid during a recreational hockey match for
further evaluation. The patient denied any discharge from the left ear,
any signs of dizziness, vertigo, dysphagia, dyspnoea, chest pain, vision
problems, or problems with equilibrium. By report, immediately after the
hit, he lost his hearing on the left ear for approximately 3 to 5
minutes, describing this period as ”a feeling of ear fullness”.
Subsequently, he describes a subjective restoration of hearing on the
left ear, with no tinnitus or earache. The patient has repeatedly blown
his nose a few minutes after the injury incident, but fails to recall
whether it was due to the ear fullness or because of a feeling of
blocked nose.
Physical examination revealed a 3x3.5cm ecchymosis around the left
mastoid tip which was tender on palpation, but differed from a Battle’s
sign. Crepitus was not palpable over the mastoid, while only after
meticulous palpation was minor crepitation identified posteriorly to the
upper third of the sternocleidomastoid muscle ipsilaterally to the
injury site. Further palpation revealed minor crepitation cranially at
the posterior triangle of the neck contralaterally, with the patient
describing a sense of ”feeling as if there is something present” when
the emphysematous cavities were palpated - but no tenderness was
described. Neck movement was free and painless in all directions.
Physical examination did not reveal any focal neurologic findings or
deficits, and the function of the facial nerve was normal
(House-Brackmann grade 1). No hematoma or swelling was present on the
left external auditory canal and the left tympanic membrane was intact.
There was no fluid collection present in the middle ear. Rinne test was
positive bilaterally, Weber test showed no lateralization, while
tympanometry was of A-type, with stapedial reflex being present
ipsilaterally at 85dB/500Hz bilaterally. For suspicion of subcutaneous
emphysema and a temporal bone fracture, a High-Resolution Computed
Tomography (HRCT) scan was ordered.
The HRCT scan of the head and neck demonstrated no intracranial injury.
No mass effect or midline shift on the brain was observed. No temporal
bone fracture was present, but an isolated left linear mastoid apex
fracture with a compromise of the pneumatization of the surrounding air
cells was observed on the left side (FIGURE 1,2). Extensive left deep
cervical emphysema extending from the fracture to involve the skull base
(at the level of C1-C2) ipsilaterally and the cervical soft tissues
bilaterally along with the adjacent suboccipital musculature was
identified.(FIGURE 3,4). There was no involvement of the lower neck,
below the level of the thyroid cartilage. There was no violation of the
otic capsule and ossicular alignment was normal.
Chest X-ray image demonstrated no mediastinal extension of the cervical
emphysema.
The patient was admitted for monitoring, while intravenous analgesia and
antibiotic treatment (amoxicillin/clavulanate) were administered. The
hospitalization lasted for three days and was uneventful. The patient
had no signs of respiratory distress and did not complain of pain at any
instance. He was restricted to bed as well as strongly advised to
refrain from coughing or nose blowing. Seventy-two hours after the
accident an ultrasound of the neck revealed a hardly detectable amount
of air, while the control chest x-ray was again without any pathological
findings. At 10-day outpatient otorhinolaryngologic follow-up, he was
asymptomatic, demonstrating no oto/audiological or other sequelae from
the injury, with his audiogram being normal.