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6th Annual Trauma Symposium

Temporal bone fractures

Dr. M. Naim Manhas M.S.,M.B.B.S.,F.I.C.S.

King Abdul Aziz HospitalMakkah Al- Mukarma

3/25/2013

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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.

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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.

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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

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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.

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temporal bone fractures 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.

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temporal bone fractures 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

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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

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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.

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Management:-principles

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

Once complication present , needs further evaluation and management.

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Brain herniation (encephloceole) in

middle ear,mastoid or

ext.acoustic meatus

Intratemporal part of carotid

artery laceration massive bleeding

Emergency surgical

intervention in temporal

bone trauma

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Temporal bone fractures-sequele Conductive hearing loss:-

Frequently observed with longitudinal fractures.

Hemotympanum Tympanic membrane perforation

partial Ossicular chain disruption

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Hemotympanum

Usually occurs in longtudinal fractures.May or may not be associated with tympanic membrane perforationHearing impairment presentConductive type of deafnessFollow up serial pure tone audiometryUsually resolves within 3-4 weeks

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Tympanic membrane perforationIsolated 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.

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Ossicular- chain disruptionCommon 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%)

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

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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.

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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. 3/25/2013

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Management:- csf otorrehea

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

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

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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.

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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

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perilymphatic fistula

post operativeTemporal bonefr acture involving otic capsule

diseasesPresentation:-Fluctuating hearing loss associated with

vertigoVertigo increases with straining ,

sudden decompression of atmospheric pressure, scuba divers and even loud sound( tullio phenomena)

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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

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Management

Conservative treatment:-

Bed rest with head elevated

-3-6 weeksPrevention of

strainingSerial

audiometery

Surgical exploration:-Symptoms

persistSNHL worsens

Approach:- transcanal & identification

of leak ,closure with fascia

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Facial nerve injuries

50%

20%

transverse fracture

longitudnal fracture

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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

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Facial nerve – intratympanic part

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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

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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

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Management of f.n.injury

Facial nerve

paralysis

APPROACH

Decision regarding surgery

TIMING

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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.

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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

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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 .

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Electroneurography (EnOG)

The results are expressed as a percentage of the amplitude of the action-potential on the paralysed side as compared with non paralysed side.90% degeneration is considered if the amplitude of action potential is less than 10.

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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.

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Electroneurography (EnOG) 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.

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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

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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%3/25/2013

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Peadrtic temporal bone trauma

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transverse fractures longi-tudnal fractures

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Hearing loss5% will have persistant hearing loss due to ossicular disruption, especially Incudo-stapedial joint.

The exploration of middle ear is done if the conductive loss on audiometery continued for 3-4 weeks and is more than 30-50 dB.

SNHL (high frequencies) is less common in children than adults, occur less than 20%.

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Peadrtic temporal bone trauma 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.

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