temporal bone fractures arthur wu 1-27-10

8/12/2019 Temporal Bone Fractures Arthur Wu 1-27-10

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Incidence and Epidemiology

Blunt head trauma typically MVA

Penetrating trauma eg. GSW have worse

prognosis 2/2 carotid or brain injury


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Symptoms

Hearing loss: conductive or sensorineural

Dizziness

Facial weakness or paralysis (7% overall) Otorrhea

Rhinorrhea

More rare: facial numbness and diplopia


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Physical Examination

Hemotympanum

Battles sign:

postauricular

ecchymosis Raccoon sign:

periorbital

ecchymosis
http://images.google.com/imgres?imgurl=http://me.hawkelibrary.com/albums/hemotympanum/26_L.jpg&imgrefurl=http://me.hawkelibrary.com/hemotympanum/26_L&h=2366&w=2403&sz=817&tbnid=AFxH9iBWP8QJ:&tbnh=147&tbnw=150&hl=en&start=3&prev=/images%3Fq%3Dhemotympanum%26svnum%3D10%26hl%3Den%26lr%3D


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Otoscopy

Otorrhea: bloody or clear and pulsatile (send for

2 transferrin)

Pneumatic otoscopy: vertigo or flaccid TM

Laceration of canal wall


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Others

Nasal exam for rhinorrhea

Facial nerve exam

Extraocular movement exam fornystagmus or diplopia

Tuning fork exam

Audiometric testing


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Imaging

High resolution CT is the gold standard

MRI for cranial nerve injury

MRA or angiogram for vascular injury


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Types of fractures

Longitudinal: along long axis of the

petrous temporal bone

Tranverse: perpendicular to the long axis

of the petrous bone (commonly from the

jugular foramen or foramen magnum to

the middle cranial fossa)

Mixed: in reality most fractures are mixed

type


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Longitudinal Fractures

Most common (up to 80%)

Path of least resistance

Ossicular chain and the

perigeniculate ganglion regionof the facial nerve can be

involved

Otic capsule involvement is

rare

Facial nerve injury in 10-20%


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Transverse Fractures

Commonly involves

bony labrynth leading

to SNHL and vertigo

Facial nerve injuryquoted as up to 50%

Higher impact injuries

Anterior-Posteriorforce


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Transverse Fractures


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Mixed Fractures


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The Good News

For vast majority of temporal bone fractures, we

do nothing!


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Indications for Surgical Intervention

Facial nerve injury

Hearing loss

CSF leak


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Facial Nerve Injury

Overall 7% of temporal bone fractures,25% of these being permanent

Delayed onset vs Immediate onset

Delayed onset: complete recovery in 94%

Immediate onset: complete recovery in 50-75%

Site of injury: 80-90% perigeniculate ietympanic segment (followed by labrynthineand meatal)


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Nerve Conduction Testing

EMG and ENOG

If EMG shows voluntary activity, then good prognosis

EMG will show fibrillation potentials if nerve out in 2 wks(not very helpful)

Operate when ENOG shows 90% degeneration

Wallerian degeneration is not documented onelectrodiagnostic testing for 3 to 5 days after theneurotmesis, surgical intervention is delayed until

several days after the nerve has degenerated The efficacy of decompression of a posttraumatic,

nonsevered nerve remains to be proven in arandomized, prospective study

Note: ENOG requires normal side for comparison


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Hearing Loss

80% of conductive hearing loss resolves

spontaneously

SNHL worse prognosis of recovery

If persistent CHL, then can take later to

OR for possible ossicular reconstruction or

tympanoplasty depending on etiology


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CSF Leak

Otorrhea, rhinorrhea, dizziness, serous effusion,meningitis

15-20% of all temporal bone fractures

Usually associated with longitudinal fracturesinvolving the tegmen

High resolution CT usually sufficient; CTcisternogram may be helpful for specific site

Typically involves tear in dura of tegmen Leaks 2/2 otic capsule disruption less likely to

heal spontaneously


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Conservative Treatment

HOB elevation > 30 deg

Lumbar drain

Stool softeners

No noseblowing, coughing Brodie and Thompson et al. 820 T-bone fractures/122 CSF leaks

Spontaneous resolution with conservativemeasures 95/122 (78%): within 7 days

21/122(17%): between 7-14 days

5/122(4%): Persisted beyond 2 weeks


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Preventing Meningitis: Antibiotics??

Same study: 7% developed meningitis with no

significant difference between those treated with

antibiotics and not

Many studies demonstrate no benefit but difficultto see differences from overall low numbers

Hoff et al conducted a prospective randomized

trial; no patients in either arm got meningitis

Metaanalysis by Brodie demonstrates difference

of 8% vs 2% for abx vs no abx


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Surgical Intervention

From Cummings


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Technique

Meta-analysis

showed that both

techniques have

similar success rates Onlay: if adjacent

structures at risk, or if

the underlay is not

possible


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Technique

Muscle, fascia, fat, cartilage, Duragen,bone pate, hydroxyapatite cement

The success rate is significantly higher for

those patients who undergo primaryclosure with a multi-layer technique versusthose patients who only get single-layerclosure.

Refractory cases may require closure ofthe EAC and obliteration.


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Leaks of the Lateral Tegmen

Accessed through

transmastoid

Taken from Myers


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Leaks of the Medial Tegmen

May require

transmastoid

combined with middle

fossa approach


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References

Bailey, Byron J., ed. Head and Neck surgery- Otolaryngology. Philadelphia, P.A. J.B. Lippincott Co., 1993. Cummings, ed. Otolaryngology: Head and Neck Surgery. 4thedition.

Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. AmericanJournal of Otology; 18: 188-197, 1997.

Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and NeckSurgery; 123; 749-752, 1997.

Black, et al. Surgical Management of Perilymphatic Fistulas: A Portland experience. American Journal ofOtology; 3: 254-261, 1992.

Chang CY, Cass SP. Management of Facial Nerve Injury Due to Temporal Bone Trauma. The American Journal

of Otology; 20: 96-114, 1999. Coker N, Traumatic Intratemporal Facial Nerve Injuries: Management Rationale for Preservation of Function.Otolaryngology- Head and Neck Surgery; 97:262-269, 1987.

Green, JD. Surgical Management of Iatrogenic Facial Nerve Injuries. Otolaryngolgoy- Head and Neck Surgery;111; 606-610, 1994.

Lambert PR, Brackman DE. Facial Paralysis in Longitudinal Temporal Bone Fractures : A Review of 26 cases.Laryngoscope; 94:1022-1026, 1984.

Lee D, Honrado C, Har-El G. Pediatric Temporal Bone Fractures. Laryngoscope: vol 108(6). June 1998, p816-821.

Mckennan KX, Chole RA. Facial Paralysis in Temporal Bone Trauma. American Journal of Otology; 13: 354-261,

1982. Savva A, Taylor M, Beatty C. Management of Cerebrospinal Fluid Leaks involving the Temporal Bone: Report on

92 Patients. Laryngoscope: vol 113(1). January 2003, p50-56

Thaler E, Bruney F, Kennedy D, et al. Use of an Electronic Nose to Distinguish Cerebrospinal Fluid from Serum.Archives of Otolaryngology; vol 126(1). Jan 2000, p71-74.

temporal bone fractures arthur wu 1-27-10

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