A Five-Year Review of Temporal Bone Fractures at a Level One Trauma Center and Examination of the Impact of the COVID-19 Pandemic

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. Authors did not include hearing loss associated with these fractures. 

2. Patients with otic capsule violating fractures were more likely to develop facial paralysis, CSF leak,  hearing loss, and intracranial complications such as epidural hematoma and subarachnoid hemorrhage.  Is there odd ratio of these complications in otic vs. non-otic fracture?  

3.  For those with CSF leak, was treatment flat bed rest, antibiotic, and how long did it take for resolution?

4.  For facial paralysis, how long did it take for recovery?

5.  Same for hearing loss, duration and rate of recovery?

 

 

Author Response

Comment 1:  Authors did not include hearing loss associated with these fractures

Reply: The authors unfortunately cannot include data on hearing loss due to lack of follow up and lack of audiograms by the patients. 

Comment 2: Patients with otic capsule violating fractures were more likely to develop facial paralysis, CSF leak, hearing loss, and intracranial complications such as epidural hematoma and subarachnoid hemorrhage.  Is there odd ratio of these complications in otic vs. non-otic fracture?  

Reply: Yes. The OR has been included in the manuscript, lines 171-175, and then lines 102-104 were added to the methods. 

Comment 3.  For those with CSF leak, was treatment flat bed rest, antibiotic, and how long did it take for resolution?

Reply: The authors have added the treatment for CSF leaks, which was head of bed elevation to 30 degrees, stool softeners, and one individual required lumbar drain placement. The time to resolution was noted to be between 7 and 17 days. This has been added to the manuscript at line 170 - 172. 

Comment 4: For facial paralysis, how long did it take for recovery?

Reply: The authors have added the length of recovery time for those with facial nerve injury, this ranged from 2 days to 15 days after injury. This has been added to the manuscript lines 182 - 183. 

Comment 5.  Same for hearing loss, duration and rate of recovery?

Reply: The authors unfortunately cannot report data on hearing loss, duration and rate of recovery as the data was incomplete due to poor patient follow up in terms of hearing outcomes. 

Reviewer 2 Report

Comments and Suggestions for Authors

1. A brief review of the different classification methods of temporal bone fractures, reported in the literature, could be added to the introduction. This would help readers contextualize the study findings.
2. What does the reader take home based on understanding temporal bone fractures before, during and after a pandemic induced lockdown? Authors must therefore explain the significance of comparing the findings in relation to the COVID-19 pandemic.
3. Multiple objectives are stated. It would be clear if they are revised and listed out as primary and secondary objectives.
4. It is interesting to note that the authors have used a large set of ICD codes to screen for cases. However, as a reader, I would be interested to know how each part of this code applies to a specific type of craniofacial trauma.
5. Apart from the effect of COVID-19 pandemic on duration of hospital stay, did the authors observe any other factor such as severity of the fracture affecting the duration of stay. It would be valuable to discuss about this irrespective whether it was evaluated or not. (Suggested reference: Role of maxillofacial trauma scoring systems in determining the economic burden to maxillofacial trauma patients in India. J Int Oral Health. 2015 Apr;7(4):38-43. PMID: 25954069)
6. It would be better to include a brief note about the different surgical and non-surgical management strategies for post-traumatic facial nerve injury.
7. The clinical significance of the study from a surgical practice perspective is missing in the discussion. Authors need to include the same.
8. Similarly, what are the recommendations based on the study findings. Include them too.
9. Since temporal fractures are predominantly diagnosed based on clinical and CT imaging, it would add value to include representative images (clinical and radiographic) for the different types of temporal bone fractures reported in the study.

Author Response

Comment 1: A brief review of the different classification methods of temporal bone fractures, reported in the literature, could be added to the introduction. This would help readers contextualize the study findings.

 Reply: A brief review of the classification methods of temporal bone fractures is included in the revised manuscript, lines 54 - 65. 

Comment 2: What does the reader take home based on understanding temporal bone fractures before, during and after a pandemic induced lockdown? Authors must therefore explain the significance of comparing the findings in relation to the COVID-19 pandemic.

Reply: The connection between temporal bone fractures and the COVID-19 pandemic lockdown has been stated in the revised manuscript, lines 250 - 269. 

Comment 3: Multiple objectives are stated. It would be clear if they are revised and listed out as primary and secondary objectives.

Reply: Objectives have been edited in the revised manuscript and sorted into primary and secondary objectives, lines 69 - 74. 

Comment 4: It is interesting to note that the authors have used a large set of ICD codes to screen for cases. However, as a reader, I would be interested to know how each part of this code applies to a specific type of craniofacial trauma.

Reply: The authors acknowledge that there is a large set of ICD codes used to screen for cases, this was necessary considering the large body of screened data, duplicates were removed. 

Comment 5: Apart from the effect of COVID-19 pandemic on duration of hospital stay, did the authors observe any other factor such as severity of the fracture affecting the duration of stay. It would be valuable to discuss about this irrespective whether it was evaluated or not. (Suggested reference: Role of maxillofacial trauma scoring systems in determining the economic burden to maxillofacial trauma patients in India. J Int Oral Health. 2015 Apr;7(4):38-43. PMID: 25954069). 

Reply: The authors did not evaluated whether severity of fracture affected the duration of stay. We acknowledge that in many patients temporal bone fractures were one of many injuries and believed that there would be too many confounding factors and concurrent injuries to correlate temporal bone fracture type with length of stay. 

Comment 6: It would be better to include a brief note about the different surgical and non-surgical management strategies for post-traumatic facial nerve injury.

Reply: The authors have included a section on the surgical and non-surgical management strategies of temporal bone fractures in the discussion, lines 270-288.

Comment 7: The clinical significance of the study from a surgical practice perspective is missing in the discussion. Authors need to include the same.

Reply: The authors have added a section in the revised manuscript to highlight the clinical significance from a surgical perspective, lines 270-288.

Comment 8: Similarly, what are the recommendations based on the study findings. Include them too.

Reply: The authors have added specific recommendations to the revised manuscript, lines 270-288. 

Comment 9: Since temporal fractures are predominantly diagnosed based on clinical and CT imaging, it would add value to include representative images (clinical and radiographic) for the different types of temporal bone fractures reported in the study.

Reply: The authors have added two representative images from the data collection to highlight the different types of temporal bone fractures reported in this study, inserted as Figure 2 in the revised manuscript, lines 123 - 124 and 191,192. 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for revising the manuscript based on review comments.

If there is one aspect in which the manuscript could further be enhanced, it would be with respect to discussing a bit more about the outcomes of logistic regression analysis performed in this study.

Including this information is not only important but will also provide insights from a practice perspective.

Author Response

Comment 1: If there is one aspect in which the manuscript could further be enhanced, it would be with respect to discussing a bit more about the outcomes of logistic regression analysis performed in this study.

 

Reply: Thank you for your comment. The following was added to the revised manuscript to address this comment: 

Statistical Methods A logistic regression model was used to model factors individually associated with facial nerve injury. Odds ratios (ORs) with 95% confidence intervals (CIs) and p-values were reported.   Results Fracture orientation and otic capsule involvement were each individually associated with facial nerve injury. In a logistic regression model including both variables, otic capsule involvement remained statistically significant (p = 1.24 × 10⁻⁵). The odds ratio for otic capsule involvement (compared to sparing) was 29.87 (95% CI: 6.51–137.02). In contrast, fracture orientation was no longer statistically significant (p = 0.267), although the odds ratios comparing transverse and oblique to longitudinal were substantial, 2.43 (95% CI 0.58 to 10.10) and 0.80 (95% CI 0.14 to 4.48), respectively.   Discussion In the multivariate logistic regression model that included both fracture orientation and otic capsule, only otic capsule remained statistically significant, while fracture orientation did not, despite all odds ratios being practically significant. The wide confidence intervals suggest uncertainty in the odds ratio estimates, due to limited power in detecting smaller but meaningful effect sizes, such as those associated with fracture orientation. A larger study is needed to replicate our findings and account for potential confounding factors that may bias the observed associations.