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Temporal Bone TraumaTemporal Bone Trauma
October 12, 2005October 12, 2005
Steven T. Wright, M.D.Steven T. Wright, M.D.
Matthew Ryan, M.D.Matthew Ryan, M.D.
Temporal Bone TraumaTemporal Bone Trauma
Wide spectrum of Wide spectrum of clinical findingsclinical findings
Knowledge of the Knowledge of the anatomy is vital to anatomy is vital to proper diagnosis and proper diagnosis and appropriate appropriate managementmanagement
Incidence and EpidemiologyIncidence and Epidemiology
Motorized TransportationMotorized Transportation 30-75% of blunt head trauma had associated 30-75% of blunt head trauma had associated
temporal bone traumatemporal bone trauma
Penetrating TraumaPenetrating Trauma More dismal prognosisMore dismal prognosis
BarotraumaBarotrauma Inner ear decompression sicknessInner ear decompression sickness
• The “bends”The “bends” Perilymphatic fistulaPerilymphatic fistula Blast InjuriesBlast Injuries
Evaluation and ManagementEvaluation and Management
ATLSATLS AirwayAirway BreathingBreathing CirculationCirculation
H & PH & P Thorough head & neck Thorough head & neck
examinationexamination
Physical ExaminationPhysical Examination
Basilar Skull Basilar Skull FracturesFractures Periorbital Ecchymosis Periorbital Ecchymosis
(Raccoon’s Eyes)(Raccoon’s Eyes) Mastoid Ecchymosis Mastoid Ecchymosis
(Battle’s Sign)(Battle’s Sign) HemotympanumHemotympanum
Physical ExaminationPhysical Examination
Tuning Fork examTuning Fork exam Pneumatic OtoscopyPneumatic Otoscopy
Flaccid TMFlaccid TM NystagmusNystagmus
ImagingImaging
HRCTHRCT MRIMRI Angiography/ MRAAngiography/ MRA
Longitudinal fracturesLongitudinal fractures
80% of Temporal 80% of Temporal Bone FracturesBone Fractures
Lateral Forces along Lateral Forces along the petrosquamous the petrosquamous suture linesuture line
15-20% Facial Nerve 15-20% Facial Nerve involvementinvolvement
EAC lacerationEAC laceration
Transverse fracturesTransverse fractures
20% of Temporal 20% of Temporal Bone FracturesBone Fractures
Forces in the Antero-Forces in the Antero-Posterior directionPosterior direction
50% Facial Nerve 50% Facial Nerve InvolvementInvolvement
EAC intactEAC intact
Temporal Bone TraumaTemporal Bone Trauma
Hearing LossHearing Loss Dizziness/VertigoDizziness/Vertigo CSF OtorrheaCSF Otorrhea Facial Nerve InjuriesFacial Nerve Injuries
Hearing LossHearing Loss
Formal Audiometry Formal Audiometry vs. Tuning Forkvs. Tuning Fork
71% of patients with 71% of patients with Temporal Bone Temporal Bone Trauma have hearing Trauma have hearing lossloss
TM PerforationsTM Perforations CHL > 40db CHL > 40db
suspicious for suspicious for ossicular discontinuityossicular discontinuity
Hearing LossHearing Loss
Longitudinal FracturesLongitudinal Fractures Conductive or mixed hearing lossConductive or mixed hearing loss 80% of CHL resolve spontaneously80% of CHL resolve spontaneously
Transverse FracturesTransverse Fractures Sensorineural hearing lossSensorineural hearing loss Less likely to improveLess likely to improve
Hearing LossHearing Loss
Tympanic Membrane PerforationsTympanic Membrane Perforations Ossicular fracture or discontinuityOssicular fracture or discontinuity HemotympanumHemotympanum Treatment: Treatment:
ObservationObservation Otic solutions may only mask CSF leaksOtic solutions may only mask CSF leaks
DizzinessDizziness
Fracture through the otic capsule or a Fracture through the otic capsule or a labyrinthine concussionlabyrinthine concussion
Difficult diagnosis- bed rest, obtundation, Difficult diagnosis- bed rest, obtundation, sedationsedation
Treatment: reserved for vomiting, Treatment: reserved for vomiting, limitation of activity limitation of activity Vestibular suppressantsVestibular suppressants Allow for maximal central compensationAllow for maximal central compensation
DizzinessDizziness Perilymphatic FistulasPerilymphatic Fistulas
SCUBA diver with ETDSCUBA diver with ETD Fluctuating dizziness and/or hearing lossFluctuating dizziness and/or hearing loss Tullio’s PhenomenonTullio’s Phenomenon ManagementManagement
• Conservative treatment in first 10-14 daysConservative treatment in first 10-14 days• 40% spontaneously close40% spontaneously close• Surgical management for persistent vertigo or Surgical management for persistent vertigo or
hearing losshearing loss• Regardless of visualization of fistula site, the Regardless of visualization of fistula site, the
majority of patients get bettermajority of patients get better
DizzinessDizziness
Inner Ear Inner Ear Decompression Decompression SicknessSickness Too rapid an ascent Too rapid an ascent
leads to percolation of leads to percolation of nitrogen bubbles within nitrogen bubbles within the otic capsule.the otic capsule.
Greater than 30 ft…. Greater than 30 ft…. Decompression stages Decompression stages upon ascent are upon ascent are neededneeded
DizzinessDizziness
BPPVBPPV Acute, latent, and Acute, latent, and
fatiguable vertigofatiguable vertigo Can occur any time Can occur any time
following injuryfollowing injury Dix HallpikeDix Hallpike Epley ManeuverEpley Maneuver
CSF OtorrheaCSF Otorrhea
AcquiredAcquired Postoperative (58%)Postoperative (58%) Trauma (32%)Trauma (32%) Nontraumatic (11%)Nontraumatic (11%)
SpontaneousSpontaneous Bony defect theoryBony defect theory Arachnoid granulation theoryArachnoid granulation theory
Temporal bone fracturesTemporal bone fractures
LongitudinalLongitudinal 80% of Temp bone fx80% of Temp bone fx Anterior to otic capsuleAnterior to otic capsule Involve the dura of the Involve the dura of the
middle fossamiddle fossa
Temporal bone fracturesTemporal bone fractures
TransverseTransverse 20% of Temp bone fx20% of Temp bone fx High rate of SNHL due High rate of SNHL due
to violation of the otic to violation of the otic capsulecapsule
50% facial nerve 50% facial nerve involvementinvolvement
Testing of Nasal SecretionsTesting of Nasal Secretions
Beta-2-transferrin is highly sensitive and Beta-2-transferrin is highly sensitive and specificspecific 1/501/50thth of a drop of a drop Gold top tube, may need to send a sample of Gold top tube, may need to send a sample of
the patients serum also.the patients serum also. Found in Vitreous Humor, Perilymph, CSFFound in Vitreous Humor, Perilymph, CSF
Electronic nose has shown early successElectronic nose has shown early success Faster (<24hrs)Faster (<24hrs) Very AccurateVery Accurate
Imaging CSF OtorrheaImaging CSF Otorrhea
High resolution CTHigh resolution CT ConvenienceConvenience SpeedSpeed
CT CisternographyCT Cisternography MRIMRI
Heavily weighted T2Heavily weighted T2 Slow flow MRISlow flow MRI MRI cisternographyMRI cisternography
ImagingImaging
Slow flow MRISlow flow MRI Diffusion weighted Diffusion weighted
MRIMRI Fluid motion down to Fluid motion down to
0.5mm/sec0.5mm/sec Ex. MRA/MRVEx. MRA/MRV
Treatment of CSF OtorrheaTreatment of CSF Otorrhea
Conservative measuresConservative measures Bed rest/Elev HOB>30Bed rest/Elev HOB>30 Stool softenersStool softeners No sneezing/coughingNo sneezing/coughing +/- lumbar drains+/- lumbar drains
Early failuresEarly failures Assoc with hydrocephalusAssoc with hydrocephalus Recurrent or persistent leaksRecurrent or persistent leaks
Treatment of CSF OtorrheaTreatment of CSF Otorrhea
Brodie and Thompson et al.Brodie and Thompson et al. 820 T-bone fractures/122 CSF leaks820 T-bone fractures/122 CSF leaks Spontaneous resolution with conservative Spontaneous resolution with conservative
measuresmeasures 95/122 (78%): within 7 days95/122 (78%): within 7 days 21/122(17%): between 7-14 days21/122(17%): between 7-14 days 5/122(4%): Persisted beyond 2 weeks5/122(4%): Persisted beyond 2 weeks
Temporal bone fracturesTemporal bone fractures
MeningitisMeningitis 9/121 (7%) developed meningitis. Found no 9/121 (7%) developed meningitis. Found no
significant difference in the rate of meningitis significant difference in the rate of meningitis in the ABX group versus no ABX group.in the ABX group versus no ABX group.
A later meta-analysis by the same author A later meta-analysis by the same author did reveal a statistically significant did reveal a statistically significant reduction in the incidence of meningitis reduction in the incidence of meningitis with the use of prophylactic antibiotics.with the use of prophylactic antibiotics.
Pediatric temporal bone fracturesPediatric temporal bone fractures
Much lower incidence (10:1, adult:pedi)Much lower incidence (10:1, adult:pedi) Undeveloped sinuses, skull flexibilityUndeveloped sinuses, skull flexibility
otorrhea>> rhinorrheaotorrhea>> rhinorrhea Prophylactic antibiotics did not influence Prophylactic antibiotics did not influence
the development of meningitis.the development of meningitis.
CSF Otorrhea Surgical CSF Otorrhea Surgical ManagementManagement
Surgical approachSurgical approach Status of hearing Status of hearing Meningocele/encephaloceleMeningocele/encephalocele Fistula locationFistula location
TransmastoidTransmastoid Middle Cranial FossaMiddle Cranial Fossa
Overlay vs UnderlayOverlay vs Underlaytechniquetechnique
Meta-analysis Meta-analysis showed that both showed that both techniques have techniques have similar success ratessimilar success rates
Onlay: adjacent Onlay: adjacent structures at risk, or if structures at risk, or if the underlay is not the underlay is not possiblepossible
Technique of closureTechnique of closure
Muscle, fascia, fat, cartilage, etc..Muscle, fascia, fat, cartilage, etc.. The success rate is significantly higher for The success rate is significantly higher for
those patients who undergo primary those patients who undergo primary closure with a multi-layer technique versus closure with a multi-layer technique versus those patients who only get single-layer those patients who only get single-layer closure.closure.
Refractory cases may require closure of Refractory cases may require closure of the EAC and obliteration.the EAC and obliteration.
Facial Nerve InjuriesFacial Nerve Injuries
Loss of forehead wrinklesLoss of forehead wrinkles Bell’s PhenomenonBell’s Phenomenon Nasal tip pointing awayNasal tip pointing away Flattened Nasofacial grooveFlattened Nasofacial groove
Facial Nerve AnatomyFacial Nerve Anatomy
Facial Nerve InjuriesFacial Nerve Injuries
Initial Evaluation is the most important Initial Evaluation is the most important prognostic factorprognostic factor Previous statusPrevious status TimeTime Onset and progressionOnset and progression Complete vs. IncompleteComplete vs. Incomplete
House Brackman ScaleHouse Brackman ScaleII NormalNormal Normal facial functionNormal facial function
IIII MildMild Slight synkinesis/weaknessSlight synkinesis/weakness
IIIIII ModerateModerate Complete eye closure, noticeable Complete eye closure, noticeable synkinesis, slight forehead synkinesis, slight forehead movementmovement
IVIV ModeratelModerately Severey Severe
Incomplete eye closure, symmetry Incomplete eye closure, symmetry at rest, no forehead movement, at rest, no forehead movement, dysfiguring synkinesisdysfiguring synkinesis
VV SevereSevere Assymetry at rest, barely Assymetry at rest, barely noticeable motionnoticeable motion
VIVI TotalTotal No movementNo movement
Electrophysiologic TestingElectrophysiologic Testing
NET: Nerve Excitability TestNET: Nerve Excitability Test MST: Maximal Stimulation TestMST: Maximal Stimulation Test ENoG: ElectroneurographyENoG: Electroneurography Goal is to determine whether the lesion is partial Goal is to determine whether the lesion is partial
or complete?or complete? Neuropraxia: Transient block of axoplasmic flow ( no Neuropraxia: Transient block of axoplasmic flow ( no
neural atrophy/damage)neural atrophy/damage) Axonotmesis: damage to nerve axon with Axonotmesis: damage to nerve axon with
preservation of the epineurium (regrowth)preservation of the epineurium (regrowth) Neurotmesis: Complete disruption of the nerve ( no Neurotmesis: Complete disruption of the nerve ( no
chance of organized regrowth)chance of organized regrowth)
Nerve Excitability TestNerve Excitability TestMaximal Stimulation TestMaximal Stimulation Test
Stimulating electrodes are placed and a Stimulating electrodes are placed and a gross movement is recordedgross movement is recorded Not as objective and reliableNot as objective and reliable
>3.5mA difference suggests a poor >3.5mA difference suggests a poor prognosis for return of facial function.prognosis for return of facial function. Correlates with >90% degeneration on ENoGCorrelates with >90% degeneration on ENoG
ElectroneuronographyElectroneuronography
Most accurate, qualitative measurementMost accurate, qualitative measurement Sensing electrodes are placed, a voluntary Sensing electrodes are placed, a voluntary
response is recordedresponse is recorded Accurate after 3 daysAccurate after 3 days Requires an intact side to compare toRequires an intact side to compare to Reduction of >90% amplitude correlates Reduction of >90% amplitude correlates
with a poor prognosis for spontaneous with a poor prognosis for spontaneous recoveryrecovery
ElectromyographyElectromyography
Electrode is placed within the muscle and Electrode is placed within the muscle and voluntary movement is attempted.voluntary movement is attempted.
Normal Muscle is electrically silent. Normal Muscle is electrically silent. After 10-14 days, the denervated muscle After 10-14 days, the denervated muscle
begins to spontaneously fire:begins to spontaneously fire: Diphasic/Polyphasic potentials: GoodDiphasic/Polyphasic potentials: Good Loss of voluntary potentials: BadLoss of voluntary potentials: Bad
Facial Nerve InjuriesFacial Nerve InjuriesWHO GETS TREATMENT?WHO GETS TREATMENT?
Conservative treatment candidatesConservative treatment candidates Surgical treatment candidatesSurgical treatment candidates
Facial Nerve InjuriesFacial Nerve Injuries
Chang & CassChang & Cass Medline search back to 1966Medline search back to 1966 Individually reviewed each articleIndividually reviewed each article 1) Understand the pathophysiology of facial 1) Understand the pathophysiology of facial
nerve damage in temporal bone trauma.nerve damage in temporal bone trauma. 2) What is the effect of surgical intervention 2) What is the effect of surgical intervention
on the ultimate outcome of the facial nerve.on the ultimate outcome of the facial nerve. 3) Propose a rational course for evaluation 3) Propose a rational course for evaluation
and treatment.and treatment.
Facial Nerve InjuriesFacial Nerve InjuriesChang & CassChang & Cass
Pathophysiology based on findings by Fisch and Pathophysiology based on findings by Fisch and Lambert and Brackmann:Lambert and Brackmann:
Where?Where? Perigeniculate, Labyrinthine, and meatal segmentsPerigeniculate, Labyrinthine, and meatal segments Concern over findings of endoneural fibrosis and neural atrophy Concern over findings of endoneural fibrosis and neural atrophy
proximal to the lesionsproximal to the lesions In an untreated human specimen found intraneural edema and In an untreated human specimen found intraneural edema and
demyelinization that extended proximally to the meatal foramendemyelinization that extended proximally to the meatal foramen How?How?
Longitudinal FracturesLongitudinal Fractures• 15% transection15% transection• 33% bony impingement, 43% hematoma33% bony impingement, 43% hematoma
Transverse FracturesTransverse Fractures• 92% transection92% transection
Does Facial Nerve decompression result in Does Facial Nerve decompression result in superior functional outcomes compared with superior functional outcomes compared with
no treatment?no treatment? Not enough human data!Not enough human data! Boyle-monkey: prophylactic epineural decompression in Boyle-monkey: prophylactic epineural decompression in
complete paralysis did not improve recovery of facial complete paralysis did not improve recovery of facial nerve function after induced complete paralysisnerve function after induced complete paralysis
Kartush: Prophylactic decompression of the meatal Kartush: Prophylactic decompression of the meatal segment during acoustic neuroma decreased the segment during acoustic neuroma decreased the incidence of delayed paralysisincidence of delayed paralysis
Adour: compared patients with complete paralysis found:Adour: compared patients with complete paralysis found: Equal outcome with observation vs. decompression without Equal outcome with observation vs. decompression without
nerve slittingnerve slitting Worse outcome with decompression with nerve slittingWorse outcome with decompression with nerve slitting
Does Facial Nerve decompression result in Does Facial Nerve decompression result in superior functional outcomes compared with superior functional outcomes compared with
no treatment?no treatment? Many difficulties in Study designs, Many difficulties in Study designs,
controls, etc, but they made some rough controls, etc, but they made some rough estimates:estimates: 50% of patients who undergo facial nerve 50% of patients who undergo facial nerve
decompression obtain excellent outcomesdecompression obtain excellent outcomes The true efficacy of facial nerve The true efficacy of facial nerve
decompression surgery for trauma decompression surgery for trauma remains uncertainremains uncertain
Conservative Treatment Conservative Treatment CandidatesCandidates
Chang and CassChang and Cass Present with Present with Normal Facial FunctionNormal Facial Function
regardless of progressionregardless of progression Incomplete paralysis and no Incomplete paralysis and no
progressionprogression to complete paralysis to complete paralysis
Less than Less than 95%95% degeneration by ENoG degeneration by ENoG• Most data comes from Bell’s palsy/tumor studies Most data comes from Bell’s palsy/tumor studies
by Fisch.by Fisch.
Conservative Treatment Conservative Treatment CandidatesCandidates
Brodie and ThompsonBrodie and Thompson All patients that presented with normal facial All patients that presented with normal facial
nerve function initially that progressed to nerve function initially that progressed to
complete paralysiscomplete paralysis recovered to a recovered to a HB HB 1 or 2.1 or 2.
Surgical CandidatesSurgical Candidates
Critical Prognostic factorsCritical Prognostic factors ImmediateImmediate vs. Delayed vs. Delayed CompleteComplete vs. Incomplete paralysis vs. Incomplete paralysis ENoG criteriaENoG criteria
Algorithm for Facial Nerve InjuryAlgorithm for Facial Nerve Injury
Facial Nerve InjuriesFacial Nerve InjuriesChang & CassChang & Cass
What time frame is best to operate?What time frame is best to operate? Fisch-cats: Decompression of the nerve within Fisch-cats: Decompression of the nerve within
a 12 day period resulted in “excellent” a 12 day period resulted in “excellent” functional recovery. Presumption was that it functional recovery. Presumption was that it preserved endoneural tubules. (limits the preserved endoneural tubules. (limits the damage to axonotmesis at worst)damage to axonotmesis at worst)
Limits the accuracy of your patient selection Limits the accuracy of your patient selection because EMG is not reliable until day 10-14.because EMG is not reliable until day 10-14.
Surgical ApproachSurgical Approach
Medial to the Geniculate GanglionMedial to the Geniculate Ganglion No useful hearingNo useful hearing
• Transmastoid-translabyrinthineTransmastoid-translabyrinthine Intact hearingIntact hearing
• Transmastoid-trans-epitympanicTransmastoid-trans-epitympanic• Middle Cranial FossaMiddle Cranial Fossa
Lateral to Geniculate GanglionLateral to Geniculate Ganglion TransmastoidTransmastoid
Surgical ApproachSurgical Approach
Chang & CassChang & Cass Histopathologic studyHistopathologic study Severe facial nerve Severe facial nerve
injury results in injury results in retrograde axonal retrograde axonal degeneration to the level degeneration to the level of the labyrinthine and of the labyrinthine and probably meatal probably meatal segmentssegments
Surgical findings of Surgical findings of greater than greater than 50%50% nerve transection/damage nerve transection/damage
Nerve repair via primary anastamosis or Nerve repair via primary anastamosis or cable graft repaircable graft repair HB 1 or 2: 0%HB 1 or 2: 0% HB 3 or 4: 82%HB 3 or 4: 82% HB 5 or 6: 18%HB 5 or 6: 18%
Iatrogenic Facial Nerve InjuriesIatrogenic Facial Nerve Injuries
Mastoidectomy (55%)Mastoidectomy (55%) Tympanoplasty (14%)Tympanoplasty (14%) Bony Exostoses (14%)Bony Exostoses (14%) Lower tympanic segment is the most Lower tympanic segment is the most
common location injurycommon location injury 79% were not identified at the time of 79% were not identified at the time of
surgerysurgery
Management of Iatrogenic Management of Iatrogenic Facial Nerve InjuriesFacial Nerve Injuries
Green, et al.Green, et al. <50% damage: perform decompression<50% damage: perform decompression
75% had HB of 3 or better!75% had HB of 3 or better! >50% damage: perform nerve repair>50% damage: perform nerve repair
No patients had better than a HB 3No patients had better than a HB 3 Beware of local anestheticsBeware of local anesthetics General consensus: acute, complete, General consensus: acute, complete,
postoperative paralysis should be explored postoperative paralysis should be explored as soon as possible.as soon as possible.
EmergenciesEmergencies
Brain HerniationBrain Herniation Massive HemorrhageMassive Hemorrhage
Pack the EACPack the EAC Carotid arteriography with embolizationCarotid arteriography with embolization
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