temporal bone fractures

presented in makkah on 3rd april 2013

1. 6 th Annual Trauma Symposium Temporal bone fractures Dr. M. Naim Manhas M.S.,M.B.B.S.,F.I.C.S. King Abdul Aziz Hospital Makkah Al- Mukarma 3/25/2013 1 Dr. Naim Manhas

2. 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. 3/25/2013 2 Dr. Naim Manhas

3. 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. 3/25/2013 3 Dr. Naim Manhas

4. 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 3/25/2013 4 Dr. Naim Manhas

5. 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. 3/25/2013 5 Dr. Naim Manhas

6. 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. 3/25/2013 6 Dr. Naim Manhas

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8. 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 3/25/2013 8 Dr. Naim Manhas

9. 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 3/25/2013 Dr. Naim Manhas 9

10. 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. 3/25/2013 10 Dr. Naim Manhas

11. Management:-principles The emphasis is laid over new modalities to reduce the percentage of complication. Once complication present , needs further evaluation and management. 3/25/2013 11 Dr. Naim Manhas

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13. Temporal bone fractures- sequele Conductive hearing l oss :- Frequently observed with longitudinal fractures. Hemotympanum Tympanic membrane perforation partial Ossicular chain disruption complete 3/25/2013 13 Dr. Naim Manhas

14. 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 3/25/2013 14 Dr. Naim Manhas

15. 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 . 3/25/2013 15 Dr. Naim Manhas

16. 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%) 3/25/2013 16 Dr. Naim Manhas

17. Management of ossicular chain disruption:- middle ear exploration and reconstruction of ossicles ( ossiculoplasty ) 3/25/2013 17 Dr. Naim Manhas

18. 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. 3/25/2013 18 Dr. Naim Manhas

19. 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 19 Dr. Naim Manhas

20. Management:- csf otorrehea Diagnostic:- Halo sign Confirmation by beta-2 transferrin Management :- Elevation of the head Bed rest Stool softners antibiotics controversial 3/25/2013 20 Dr. Naim Manhas

21. Antibiotcs are not routinely prescribed in cases with csf otorrehea for possibility of masking early signs 3/25/2013 21 Dr. Naim Manhas

22. 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. 3/25/2013 22 Dr. Naim Manhas

23. 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 3/25/2013 23 Dr. Naim Manhas

24. 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) 3/25/2013 24 Dr. Naim Manhas

25. 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 3/25/2013 25 Dr. Naim Manhas

26. Management 3/25/2013 26 Dr. Naim Manhas

27. Facial nerve injuries 3/25/2013 27 Dr. Naim Manhas

28. 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 3/25/2013 28 Dr. Naim Manhas

29. Facial nerve – intratympanic part 3/25/2013 29 Dr. Naim Manhas

30. 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 3/25/2013 30 Dr. Naim Manhas

31. 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 3/25/2013 31 Dr. Naim Manhas

32. Management of f.n.injury 3/25/2013 32 Dr. Naim Manhas

33. 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. 3/25/2013 33 Dr. Naim Manhas

34. Electrodiagnostic studies Nerve excitability test :- After 3 rd 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 3/25/2013 34 Dr. Naim Manhas

35. Electroneurography ( EnOG ) Technique designed by renowned skull base surgeon “ Fisch ”. Test is done after 3 rd day of trauma and repeated every 2 days until 21 days . 3/25/2013 35 Dr. Naim Manhas

36. 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. 3/25/2013 36 Dr. Naim Manhas

37. 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. 3/25/2013 37 Dr. Naim Manhas

38. 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. 3/25/2013 38 Dr. Naim Manhas

39. 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 3/25/2013 39 Dr. Naim Manhas

40. 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 40 Dr. Naim Manhas

41. Peadrtic temporal bone trauma 3/25/2013 41 Dr. Naim Manhas

42. Hearing loss 5% 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%. 3/25/2013 42 Dr. Naim Manhas

43. 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. 3/25/2013 43 Dr. Naim Manhas

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