The patient is a 26 year old male, seen in a medical office that had only the “basic” equipment: audiometer and tympanometer.

He reported that he had been in a bar-room brawl just over a month ago and was “hit upside the head” by a man whom he proceeded to describe in most unflattering terms, recounting a history of problems that preceded the altercation.   (He was politely asked to focus on his current problems).  The patient reported bleeding from the ear subsequent to the brawl and says he now hears “nothing” from the affected right ear.  He has retained an attorney and is pursing a wrongful injury claim. He is not reporting any dizziness nor tinnitus.  He says that he had tremendous pain initially but that it is less painful now.

He was specifically asked about the direction of the blow to the head – was it to the ear or to the back of the head?  He reported that it was directly to the ear and likely with the palm of the hand.  He reiterated that he was bleeding from the ear after the trauma.

Otoscopic inspection showed an intact eardrum.  There is no bruising nor blood, but it is noted that the incident occurred more than a month ago.  Also of note is that there is no evidence of the injury having damaged the facial nerve: he is not complaining of those symptoms and his facial expression is normal and symmetrical.

Tympanometry indicated that the TM movement was normal – there is no hole in the eardrum and it is unlikely that there is a dislocation of the ossicular chain given these normal findings.

• Research temporal bone fractures. There are two types of fractures that can result from blunt head injury: transverse and longitudinal.  Note that he reports that the force was to the side of his head – or in medical terms, lateral to medial.  Which type of fracture would be anticipated from this direction trauma. What area(s) of the ear would be damaged?