temporal bone fractures

Dr. Naim Manhas 3/25/2013 1

trauma symposium-6th
 As long as cars are on road and increasing
military conflicts in world the number of
trauma patients are increasing day by day.

 The trauma symposium have become a
common ground where exchange of ideas and
experiences takes place between surgeons of
different specialties.


Introduction
 Over the past centuary technological advances
have revolutionized the diagnosis and treatment
of trauma to face , head and neck.

 As with other surgical discipline significant
advances in ent related trauma care have
occurred.


temporal bone
 Although temporal bone
fractures are relatively
uncommon, they present
many complex diagnostic and
therapeutic challenges,
because it houses many vital
structures including the
cochlear and vestibular end
organs, the facial nerve, the
carotid artery and the jugular
vein


temporal bone fractures
 It has been observed that 20%
of patients with significant
head trauma and skull base
fractures will sustain temporal
bone fractures, because
although the temporal bone is
very thick and hard structure
located in the base of skull but
the multiple foramina creating
areas of decreased resistance
susceptible to traumatic injury.


 The temporal complex is a non
weight bearing region, thus
displaced fracture does not
have any cosmetic sequel, but
if facial nerve is involved can
lead to devastating cosmetic
and functional injuries.
 The extent of the injuries
based on physical examination
and imaging studies, will
determine the urgency and
type of surgical interventions
required.

 The evaluation of the temporal bone in a
patient with multiple traumatic injuries can
often be incomplete or overlooked, delaying
diagnosis and management.

 A quick otoscopy examination is an excellent
screening for evidence of a temporal bone
injury and can guide additional diagnostic
testing


Diagnosis of temporal bone fracture
Presumptive diagnosis of
fracture is based on three
physical findings:-
Hemotympanum
Post auricular ecchymosis
(Battle’s sign)
Perioribital ecchymosis
(raccoon sign)

These signs along with
the history of head
trauma are sufficient for
the diagnosis of temporal
bone fracture


Temporal bone fractures

 The management of temporal bone fractures
is generally aimed at restoring functional
deficits, rather than reducing and fixating
bone fragments.

 Common injuries requiring surgical
management include hearing loss, facial nerve
dysfunction and cerebrospinal fluid leak.


Management:-principles

 The emphasis is laid over new modalities to
reduce the percentage of complication.

 Once complication present , needs further
evaluation and management.


Brain
herniation
(encephloceole)
in middle
ear,mastoid or
ext.acoustic Emergency
meatus surgical
intervention
Intratemporal in temporal
part of carotid bone trauma
artery
laceration
massive
bleeding


Temporal bone fractures-sequele
 Conductive hearing loss:-
 Frequently observed with longitudinal
fractures.
 Hemotympanum
 Tympanic membrane perforation
 partial
 Ossicular chain disruption
 complete


Hemotympanum
Usually occurs in longtudinal
fractures.
May or may not be
associated with tympanic
membrane perforation
Hearing impairment present
Conductive type of deafness
Follow up serial pure tone
audiometry
Usually resolves within 3-4
weeks

Tympanic membrane perforation
Isolated tympanic membrane
perforation without ossicular
disruption - usually heals in 4-6
weeks.
If no evidence of sensorineural
hearing loss is found no specific
treatment is required.
Strict dry ear precautions are followed
to prevent water from getting into the
ear.
A serial audiogram is performed up to
the total healing of the perforation.
If the perforation has not healed by 3
months then tympanoplasty is
performed. Dr. Naim Manhas 3/25/2013 15

Ossicular- chain disruption
Common in longitudinal
fractures as middle ear is usually
involved.
Conductive hearing loss more
than 50-60 dB.
Incudostapedial joint dislocation
(82%)
Incus dislocation (57%)
Fracture of the stapes crura
(30%)
Fixation of the ossicles in the
attic (25%)

Management of ossicular chain disruption:-
middle ear exploration and reconstruction of
ossicles (ossiculoplasty)


Cerebrospinal fluid otorrhea

Csf otorrhea occurs both in
longitudinal and transverse
fractures with, when dural
tear occurs (17%).
Flow increases with
exertional or leaning
forward.
Usually closes spontanously
with conservative
management within one
week.


Otic capsule sparing :-
Floor of the middle crainal fossa and into the
epitympanum,antrum & mastoid air cells.
Otic capsule disrupting :-
Posterior crainal fossa through the disrupted otic
capsule into the middle ear. Dr. Naim Manhas 3/25/2013 19

Management:- csf otorrehea
 Diagnostic:-
 Halo sign
 Confirmation by beta-2 transferrin
 Management :-
 Elevation of the head
 Bed rest
 Stool softners



100%
90%
80%
70%
60%
Column1
50%
with a/b
40%
without a/b
30%
20%
10%
0%
Category 1 Category 2 Category 3 Category 4

Antibiotcs are not routinely prescribed in
cases with csf otorrehea for possibility of
masking early signs

Management:- csf otorrhea
 Csf otorrhea usually resolves
spontaneously within 2 weeks without
intervention
 Meningitis is diagnosed on clinical basis
and if suspected confirmed by lumbar
puncture.
 Surgery is indicated for continuous csf
otorrhea persisting longer than 14 days.
 Lumbar drainage for 72 hours if fails
 Surgical exploration is recommended for
closure of dural tear & prevention of
meningitis.


Sensori-neural hearing loss
 Sensori-neural hearing loss:-
 Occurs in transverse fractures
 Otic capsule involvement

 Partial SNHL occurs in
 Cochlear concussion
 Severe to profound SNHL if present later on
 needs cochlear implant


perilymphatic fistula
post operative
Temporal bone
fr acture involving otic capsule
diseases
Presentation:-
Fluctuating hearing loss associated with vertigo
Vertigo increases with straining , sudden
decompression of atmospheric pressure, scuba
divers and even loud sound( tullio phenomena)


perilymphatic fistula
 Diagnosis:-
 Fistula test:- not recommended now as it can
lead to aggreviation of symptoms &
complications.
 History
 Computed tomography:- only sensitive in 20%
 Serial audiometery:- fluctuating SNHL
 Exploration of middle ear & visualization of
leak,fluid in middle ear & sent it for
B2Transferrin testing


Management

Conservative treatment:- Surgical exploration:-
Bed rest with head Symptoms persist
elevated -3-6 weeks
SNHL worsens
Prevention of straining
Approach:- transcanal
Serial audiometery & identification of leak
,closure with fascia


Facial nerve injuries

transverse fracture

longitudnal fracture

20%

50%


Facial nerve-intatemporal part
• Meatal
– Portion of the facial nerve traveling from porus acusticus to the
meatal foramen of IAC
– Travels in the anterior superior portion of the IAC
» Posterior superior – superior vestibular nerve
» Posterior inferior – inferior vestibular nerve
» Anterior inferior – cochlear nerve
• Labyrinthine
– From fundus to the geniculate ganglion
– Runs in the narrowest portion of the IAC (0.68mm in diameter)
– Greater superficial petrosal nerve comes off at this point
• Tympanic
– Runs from geniculate ganglion to the second genu
– Highest incidence of dehiscence here (40-50% of population)
• Mastoid
– From second genu to stylomastoid foramen
– Gives off branches to the stapedius muscle and the chorda
tympani

Facial nerve – intratympanic part


longitudnal fractures(otic capsule sparing)

 Although the otic capsule
is spared but the middle
ear is always involved
 Common site of facial
nerve involvement is the
horizontal segment of
intratympanic portion.
 Usually caused by
compression and
ischemia rather than
disruption


Transverse fractures(otic capsule involving)

Incidence of facial paralysis
is 50% as otic capsule is
involved.
Facial nerve paralysis is
usually immediate in onset
and complete.
Nerve is avulsed or severed
by the comminuted bone
fragment


Management of f.n.injury


Electrodiagnostic studies

 Maximal stimulation test :-
 Done between 3-14 days of injury
 Used in complete facial nerve paralysis.
 Affected side is compared with the normal
side using same stimulating current.
 Absent or markedly reduced response
indicates poor and incomplete return of facial
nerve function.


Electrodiagnostic studies

Nerve excitability test :-
 After 3rd day of injury
 Principle - comparison of the amperage from
site to site necessary to initiate a barely visible
response on the affected side.
 A difference of 3.5mA or more is significant
regarding poor recovery


Electroneurography (EnOG)

 Technique designed by
renowned skull base surgeon
“Fisch”.

 Test is done after 3rd day of
trauma and repeated every 2
days until 21 days .


The results are expressed 100%
as a percentage of the 90%
amplitude of the action- 80%
potential on the paralysed 70%

side as compared with non 60% normal
50% side
paralysed side. affected
40%
side
90% degeneration is 30%
Column1
considered if the amplitude 20%
of action potential is less 10%
than 10. 0%


time to act

 “Fisch” recommended:-
 Exploration,decompression or repair when
EnOG indicates 90% degeneration
 If delayed “Fisch” found histologically that
traumatic injury at the geniculate ganglion
induces retrograde degeneration through
Labrynthine and distal meatal segments of
the facial nerve.


 EnOG is of paramount importance in
determining the need for and the timing of
surgery for facial paralysis after trauma.
 This has made determination of the clinical
onset of paralysis less necessary and that
patients with delayed paralysis can have more
severe injuries than those patients with rapid
EnOG degeneration.


Surgical approach
Surgical approaches is controversial between various
surgeons.
“Fisch” recommends total facial nerve exploration and
decompression by trans-mastoid and middle fossa
approach.
Trans mastoid approach is suitable for patients whose
nerve injury lies distal to Geniculate ganglion.
Facial nerve is located and any bone chips are
removed and the area is examined for
stretching,compression,laceration or transection
Translabrynthine approach in total sensorineural
hearing loss


Peadrtic temporal bone trauma


Usually occurs with peak distrubution
3-12 years.
 Main cause is due to fall and Road
traffic Accidents
 Common is longitudnal type fractures
 Transverse fractures – 4-13%



2
transverse
1.5 fractures
13%

1
longitudnal
0.5 fractures
85%
0 csf otorrhea


Hearing loss
5% will have persistant
hearing loss due to 100%
ossicular 90%
disruption, especially
80%
Incudo-stapedial joint.
70%
The exploration of middle
ear is done if the 60%
conductive loss on 50%
audiometery continued for Series 3
40%
3-4 weeks and is more than 30%
Series 1
30-50 dB.
20%
SNHL (high frequencies) is
10%
less common in children
than adults, occur less than 0%
20%.



 Regarding Facial nerve paralysis in temporal
bone trauma in pediatric patients is much
lower than adults, (3%)
 One of the hypothesis is that decreased
ossification and resultant flexibility of
children’s skull may contribute to this
difference.
 However if it occurs the line of management is
similar to the adults.


temporal bone fractures

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temporal bone fractures