5 OtoscopyOtorrhea: bloody or clear and pulsatile (send for β2 transferrin)Pneumatic otoscopy: vertigo or flaccid TMLaceration of canal wall
6 Others Nasal exam for rhinorrhea Facial nerve exam Extraocular movement exam for nystagmus or diplopiaTuning fork examAudiometric testing
7 Imaging High resolution CT is the gold standard MRI for cranial nerve injuryMRA or angiogram for vascular injury
8 Types of fracturesLongitudinal: along long axis of the petrous temporal boneTranverse: 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 resistanceOssicular chain and the perigeniculate ganglion region of the facial nerve can be involvedOtic capsule involvement is rareFacial nerve injury in 10-20%
14 The Good NewsFor vast majority of temporal bone fractures, we do nothing!
15 Indications for Surgical Intervention Facial nerve injuryHearing lossCSF leak
16 Facial Nerve InjuryOverall 7% of temporal bone fractures, 25% of these being permanentDelayed onset vs Immediate onsetDelayed 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 InjuryGoal: to explore only those nerves with crush injury or some degree of transectionNeuropraxia: 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 ENOGIf EMG shows voluntary activity, then good prognosisEMG will show fibrillation potentials if nerve out in 2 wks (not very helpful)Operate when ENOG shows 90% degenerationWallerian 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 degeneratedThe efficacy of decompression of a posttraumatic, nonsevered nerve remains to be proven in a randomized, prospective studyNote: ENOG requires normal side for comparison
19 Hearing Loss 80% of conductive hearing loss resolves spontaneously SNHL worse prognosis of recoveryIf 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 fracturesUsually associated with longitudinal fractures involving the tegmenHigh resolution CT usually sufficient; CT cisternogram may be helpful for specific siteTypically involves tear in dura of tegmenLeaks 2/2 otic capsule disruption less likely to heal spontaneously
21 Conservative Treatment HOB elevation > 30 degLumbar drainStool softenersNo noseblowing, coughingBrodie and Thompson et al.820 T-bone fractures/122 CSF leaksSpontaneous resolution with conservative measures95/122 (78%): within 7 days21/122(17%): between 7-14 days5/122(4%): Persisted beyond 2 weeks
22 Preventing Meningitis: Antibiotics?? Same study: 7% developed meningitis with no significant difference between those treated with antibiotics and notMany studies demonstrate no benefit but difficult to see differences from overall low numbersHoff et al conducted a prospective randomized trial; no patients in either arm got meningitisMetaanalysis by Brodie demonstrates difference of 8% vs 2% for abx vs no abx
24 TechniqueMeta-analysis showed that both techniques have similar success ratesOnlay: if adjacent structures at risk, or if the underlay is not possible
25 TechniqueMuscle, fascia, fat, cartilage, Duragen, bone pate, hydroxyapatite cementThe 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 transmastoidTaken from Myers
28 Leaks of the Medial Tegmen May require transmastoid combined with middle fossa approach
29 ReferencesBailey, 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, pMckennan 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, p50-56Thaler 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.