Fracture of temporal bone Chunfu Dai M D

Fracture of temporal bone Chunfu Dai M. D & Ph. D Otolaryngology Department Fudan University

Classifications 1. 2. 3. Longitudinal fractures Transverse fractures Mixed fractures

Longitudinal fractures n n 80% of Temporal Bone Fractures Lateral Forces along the petrosquamous suture line 15 -20% Facial Nerve involvement EAC laceration

Transverse fractures n n n 20% of Temporal Bone Fractures Forces in the Antero-Posterior direction Inner ear injury 50% Facial Nerve Involvement EAC intact

Physical Examination n n Tuning Fork exam Pneumatic Otoscopy

Imaging n n n HRCT MRI Angiography/ MRA

symptoms n n Hearing Loss & tinnitus Dizziness CSF Otorrhea and Rhinorrhea Facial Nerve Injuries

Hearing loss n n n Formal Audiometry vs. Tuning Fork 71% of patients with Temporal Bone Trauma have hearing loss TM Perforations n CHL > 40 db suspicion for ossicular discontinuity

Hearing loss Longitudinal Fractures n n n Conductive or mixed hearing loss 80% of CHL resolve spontaneously Transverse Fractures n n Sensorineural hearing loss Less likely to improve

Dizziness n n Otic capsule fracture, labyrinthine concussion, Perilymphatic Fistulas Fluctuating dizziness and/or hearing loss n Tulio’s Phenomenon n Management n 40% spontaneously close n Surgical management n

Dizziness n BPPV n n Acute, latent, and fatigable vertigo Can occur any time following injury Dix Hallpike Epley Maneuver

CSF Otorrhea and Rhinorrhea n n n Temporal bone Fractures are the most common cause of CSF Otorrhea Beta-2 -transferrin HRCT

CSF Otorrhea and Rhinorrhea n Management n Conservative therapy n Lie in bed with Head elevated 30 -45° Antibiotics n Surgery n

CSF Otorrhea and Rhinorrhea Surgical Management n Surgical approach Status of hearing n Meningocele/encephalocele n Fistula location n Transmastoid Middle Cranial Fossa

Facial Nerve Injuries n Evaluation Previous status n Time n Onset and progression n Complete vs. Incomplete n

House Brackman grading system I Normal facial function II Mild Slight synkinesis/weakness IIIModerate Complete eye closure, noticeable synkinesis, slight forehead movement IVModerately Severe Incomplete eye closure, symmetry at rest, no forehead movement V Severe Assymetry at rest, barely noticeable motion VITotal No movement

Electrophysiologic Testing n n n NET MST ENo. G

Nerve Excitability Test Maximal Stimulation Test n >3. 5 m. A difference suggests a poor prognosis for return of facial function

Electroneuronography n n Most accurate, qualitative measurement Reduction of >90% amplitude correlates with a poor prognosis for spontaneous recovery

Electromyography n n Limited use until 10 -14 days Polyphasic potentials= Good

Facial Nerve Injuries n Decision to treat is primarily based on whethere is complete vs. incomplete paralysis

Treatment n n Conservative treatment candidates Surgical candidates

Conservative Treatment Candidates n Chang and Cass Normal Facial Function regardless of progression n Incomplete paralysis and no progression to complete paralysis n Less than 95% degeneration by ENo. G n

Surgical Candidates n Critical Prognostic factors Immediate vs. Delayed n Complete vs. Incomplete paralysis n ENo. G criteria n

Algorithm for Facial Nerve Injury

Surgical Approach n n Suspect location of neural injury Presence or absence of hearing

Surgical Approach n Lateral to the geniculate ganglion n n transmastoid Medial to the Geniculate Ganglion n No useful hearing n n Transmastoid-translabyrinthine Intact hearing Transmastoid-trans-epitympanic n Middle Cranial Fossa n

Surgical findings n Nerve repair n n n Direct anastomosis Nerve graft Decompression

Case Report n 32 yr old fisherman was wading n n Minding his own business Hit in head by a flying fish Immediate profound vertigo, hearing loss CT scan revealed longitudinal Temp bone fracture