pediatric temporal bone fractures: evaluation and management

Pediatric Temporal Bone Fractures: Evaluation and

ManagementDennis J Kitsko, DO, FACS, FAOCO

Assistant Professor of OtolaryngologyChildren’s Hospital of Pittsburgh

University of Pittsburgh School of Medicine

Clinical Findings - Overview Bleeding from ear canal Tympanic membrane perforation Hemotympanum Hearing loss

– Conductive (43%)– Sensorineural (52%)

CSF leak (28%) Facial paralysis (6%) Vestibular symptoms

McGuirt 1992

Imaging CT temporal bones is the preferred study

– Contrast not necessary– Coronal sections if possible– Classified as longitudinal and transverse– Indications:

• Fracture on initial head CT• CSF otorrhea, CSF rhinorrhea, facial paralysis, hearing loss,

severe vertigo MRA/MRV, CTA/CTV

– May be indicated if suspicion of injury to dural sinus, jugular bulb, or ICA

Longitudinal Fracture Parallel to long axis of t-

bone More common (70-90%) Lateral blow EAC fracture TM rupture Ossicular disruption Around otic capsule Foramen lacerum Facial nerve injury

uncommon (often delayed sec. to edema)

Longitudinal Fracture Injury to the roof of

the middle ear (tegmen tympani)

CSF otorrhea

Transverse Fracture Perpendicular to long axis

of t-bone Less common (10-30%) Frontoocciptal blow Otic

capsule/vestibule/lateral IAC

Sensorineural hearing loss and vertigo

Facial paralysis TM often intact CSF rhinorrhea

Longitudinal Fracture

Transverse Fracture

External Auditory Canal Injury Identify source of

bleeding Assess extent of TM

injury Clean cerumen and

blood clots Check TMJ If significant

displacement, may need ear packing

CSF Leak 20-25% of pediatric temporal bone

fractures (McGuirt 1992) Skull fracture + meningeal tear Permanent pathway for bacterial

contamination and meningitis

CSF Leak If TM rupture, will have otorrhea If TM intact, will appear as serous effusion

– Lean the patient forward – if CSF, may drain down eustachian tube and out the nose (CSF rhinorrhea)

Collect fluid– Beta-2-transferrin – protein found in CSF, perilymph

• High sensitivity and specificity• Contamination with blood does not affect interpretation

CSF Leak Initial management

– Bed rest, head of bed elevation, avoid straining– Usually will stop spontaneously in 4-5 days– Prophylactic abx controversial

Lumbar drain if persists >4-5 days Surgery when:

– Leak persists >1-2 wks– Large bony defect– Brain herniation– Recurrent meningitis

Hearing Loss

Sensorineural Hearing Loss MUST get audiogram

on all t-bone fractures More common (50%) May be due to direct

cochlear trauma (transverse fx)

May also be concussive

Treat expectantly (serial audiograms)

Conductive Hearing Loss 20-65% of T-bone

fractures Hemotympanum

– Intact TM– Resolves spontaneously– Follow up 4-6 wks

TM rupture– May heal spontaneously

Ossicular disruption– Surgical intervention– Wait at least 6 wks

Ossicular Disruption Incudostapedial

joint separation (#1)

Incudomalleolar dislocation

Stapes crural fracture

Vertigo

Vertigo Labyrinthine concussion Fracture through the labyrinth

(transverse fx) Perilymphatic fistula Shearing of 8th nerve (IAC)

Vertigo Treat expectantly

– CNS compensates and usually resolves within 6 wks

– Exception – if strongly suspect perilymph fistula, consider exploration and round/oval window graft

If persistent:– Consider electronystagmography– Rarely, surgical vestibular neurectomy or

labyrinthectomy

Facial Paralysis 50% of transverse

fractures– Nerve transection

5-25% of longitudinal fractures– Often delayed secondary to

edema and may spontaneously resolve

Usually occurs in horizontal portion, between geniculate ganglion and second genu

Facial Paralysis – Physical Exam Evaluate upper and

lower face– Lower 2/3 only, consider

CNS injury Difficulties:

– Lacerations, ecchymosis, swelling, LOC

If unconscious, attempt to elicit grimace and assess facial tone

Facial Paralysis If immediate and

complete:– CT T-bone

• Localize site of injury– Audiogram

• Helps determine surgical approach

– Electrical testing• Inaccurate for 48-72

hrs

Facial Paralysis Delayed onset:

– Usually secondary to edema rather than direct injury

– Spontaneous recovery may occur

Facial Paralysis - Testing Nerve Excitability Test and Maximum

Stimulability Test– Subjective– Can be performed after 48-72 hrs

ENoG – evoked EMG– Objective– Can be performed after 6 days– >90% degeneration suggests poor outcome and may

be used to determine if surgical intervention is necessary

Facial Paralysis - Surgery 3 approaches:

– Transmastoid – perigeniculate to stylomastoid foramen– Translabyrinthine – no cochlear function, allows exposure to

labyrinthine segment and lateral IAC– Middle fossa – intact cochlear function, labyrinthine segment

and IAC Decompress the nerve sheath If lacerated:

– Direct reanastomosis if tension free– Greater auricular n graft

• No return of function for at least 6 months• Incomplete return of function

Summary Clinical examination:

– Bleeding from ear canal– Tympanic membrane perforation– Hemotympanum– CSF leak– Vestibular signs and symptoms– Facial paralysis

Studies:– Temporal bone CT scan– Audiogram

Questions?