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.