1. Temporal Bone Fractures and Surgical Approaches for CSF Leaks
Arthur Wu, MD
UCLA Division of Head and Neck Surgery

2. Incidence and Epidemiology
Blunt head trauma typically MVA
Penetrating trauma eg. GSW have worse prognosis 2/2 carotid or brain injury

3. Symptoms Hearing loss: conductive or sensorineural Dizziness
Facial weakness or paralysis (7% overall)
Otorrhea
Rhinorrhea
More rare: facial numbness and diplopia

4. Physical Examination Hemotympanum
Battle’s sign: postauricular ecchymosis
Raccoon sign: periorbital ecchymosis

5. Otoscopy
Otorrhea: bloody or clear and pulsatile (send for β2 transferrin)
Pneumatic otoscopy: vertigo or flaccid TM
Laceration of canal wall

6. Others Nasal exam for rhinorrhea Facial nerve exam
Extraocular movement exam for nystagmus or diplopia
Tuning fork exam
Audiometric testing

7. Imaging High resolution CT is the gold standard
MRI for cranial nerve injury
MRA or angiogram for vascular injury

8. 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

9. Longitudinal Fractures
Most common (up to 80%)
Path of least resistance
Ossicular chain and the perigeniculate ganglion region of the facial nerve can be involved
Otic capsule involvement is rare
Facial nerve injury in 10-20%

10. Longitudinal Fractures

11. Transverse Fractures
Commonly involves bony labrynth leading to SNHL and vertigo
Facial nerve injury quoted as up to 50%
Higher impact injuries
Anterior-Posterior force

12. Transverse Fractures

13. Mixed Fractures

14. The Good News
For vast majority of temporal bone fractures, we do nothing!

15. Indications for Surgical Intervention
Facial nerve injury
Hearing loss
CSF leak

16. 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 ie tympanic segment (followed by labrynthine and meatal)

17. Facial Nerve Injury
Goal: to explore only those nerves with crush injury or some degree of transection
Neuropraxia: Transient block of axoplasmic flow ( no neural atrophy/damage)
Axonotmesis: damage to nerve axon with preservation of the epineurium (regrowth)
Neurotmesis: Complete disruption of the nerve ( no chance of organized regrowth)

18. 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 on electrodiagnostic testing for 3 to 5 days after the neurotmesis, 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 a randomized, prospective study
Note: ENOG requires normal side for comparison

19. 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

20. CSF Leak Otorrhea, rhinorrhea, dizziness, serous effusion, meningitis
15-20% of all temporal bone fractures
Usually associated with longitudinal fractures involving the tegmen
High resolution CT usually sufficient; CT cisternogram may be helpful for specific site
Typically involves tear in dura of tegmen
Leaks 2/2 otic capsule disruption less likely to heal spontaneously

21. 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 conservative measures
95/122 (78%): within 7 days
21/122(17%): between 7-14 days
5/122(4%): Persisted beyond 2 weeks

22. 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 difficult to 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

23. Surgical Intervention
From Cummings

24. Technique
Meta-analysis showed that both techniques have similar success rates
Onlay: if adjacent structures at risk, or if the underlay is not possible

25. Technique
Muscle, fascia, fat, cartilage, Duragen, bone pate, hydroxyapatite cement
The success rate is significantly higher for those patients who undergo primary closure with a multi-layer technique versus those patients who only get single-layer closure.
Refractory cases may require closure of the EAC and obliteration.

27. Leaks of the Lateral Tegmen
Accessed through transmastoid
Taken from Myers

28. Leaks of the Medial Tegmen
May require transmastoid combined with middle fossa approach

29. 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. 4th edition.
Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. American Journal of Otology; 18: , 1997.
Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and Neck Surgery; 123; , 1997.
Black, et al. Surgical Management of Perilymphatic Fistulas: A Portland experience. American Journal of Otology; 3: , 1992.
Chang CY, Cass SP. Management of Facial Nerve Injury Due to Temporal Bone Trauma. The American Journal of Otology; 20: , 1999.
Coker N, Traumatic Intratemporal Facial Nerve Injuries: Management Rationale for Preservation of Function. Otolaryngology- Head and Neck Surgery; 97: , 1987.
Green, JD. Surgical Management of Iatrogenic Facial Nerve Injuries. Otolaryngolgoy- Head and Neck Surgery; 111; , 1994.
Lambert PR, Brackman DE. Facial Paralysis in Longitudinal Temporal Bone Fractures : A Review of 26 cases. Laryngoscope; 94: , 1984.
Lee D, Honrado C, Har-El G. Pediatric Temporal Bone Fractures. Laryngoscope: vol 108(6). June 1998, p
Mckennan KX, Chole RA. Facial Paralysis in Temporal Bone Trauma. American Journal of Otology; 13: , 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.