Fracture of temporal boneFracture of temporal bone

Chunfu Dai M.D & Ph.DChunfu Dai M.D & Ph.DOtolaryngology Department Otolaryngology Department

Fudan UniversityFudan University

Classifications Classifications 1.1. Longitudinal fracturesLongitudinal fractures2.2. Transverse fracturesTransverse fractures3.3. Mixed fracturesMixed fractures

Longitudinal fracturesLongitudinal fractures 80% of Temporal Bo80% of Temporal Bone Fracturesne Fractures Lateral Forces along Lateral Forces along the petrosquamous sthe petrosquamous suture lineuture line 15-20% Facial Nerve 15-20% Facial Nerve involvementinvolvement EAC lacerationEAC laceration

Transverse fracturesTransverse fractures 20% of Temporal 20% of Temporal Bone FracturesBone Fractures Forces in the AntForces in the Antero-Posterior direro-Posterior directionection Inner ear injuryInner ear injury 50% Facial Nerve 50% Facial Nerve InvolvementInvolvement EAC intactEAC intact

Physical ExaminationPhysical Examination Tuning Fork examTuning Fork exam Pneumatic OtoscopyPneumatic Otoscopy

Imaging Imaging HRCTHRCT MRIMRI Angiography/ MRAAngiography/ MRA

symptomssymptoms Hearing Loss & tinnitHearing Loss & tinnitus us DizzinessDizziness CSF Otorrhea and RhCSF Otorrhea and Rhinorrheainorrhea Facial Nerve InjuriesFacial Nerve Injuries

Hearing lossHearing loss Formal Audiometry vs. Tuning ForkFormal Audiometry vs. Tuning Fork 71% of patients with Temporal Bone Tra71% of patients with Temporal Bone Trauma have hearing lossuma have hearing loss TM PerforationsTM Perforations

CHL > 40db suspicion for ossicular discontinCHL > 40db suspicion for ossicular discontinuityuity

Hearing lossHearing lossLongitudinal FracturesLongitudinal Fractures

Conductive or mixed hearConductive or mixed hearing lossing loss 80% of CHL resolve spont80% of CHL resolve spontaneouslyaneously

Transverse FracturesTransverse Fractures Sensorineural hearing losSensorineural hearing losss Less likely to improveLess likely to improve

Dizziness Dizziness Otic capsule fracture, labyrinthine concuOtic capsule fracture, labyrinthine concussion, Perilymphatic Fistulassion, Perilymphatic Fistula Perilymphatic FistulasPerilymphatic Fistulas

Fluctuating dizziness and/or hearing lossFluctuating dizziness and/or hearing loss Tulio’s PhenomenonTulio’s Phenomenon ManagementManagement

40% spontaneously close40% spontaneously close Surgical managementSurgical management

Dizziness Dizziness BPPVBPPV

Acute, latent, and fatiAcute, latent, and fatigable vertigogable vertigo Can occur any time fCan occur any time following injuryollowing injury Dix HallpikeDix Hallpike Epley ManeuverEpley Maneuver

CSF Otorrhea and RhinorrheaCSF Otorrhea and Rhinorrhea Temporal bone Fractures are the most cTemporal bone Fractures are the most common cause of CSF Otorrheaommon cause of CSF Otorrhea Beta-2-transferrinBeta-2-transferrin HRCTHRCT

CSF Otorrhea and RhinorrheaCSF Otorrhea and Rhinorrhea ManagementManagement

Conservative therapyConservative therapy Lie in bed with Head elevated 30-45°Lie in bed with Head elevated 30-45°

AntibioticsAntibiotics SurgerySurgery

CSF Otorrhea and RhinorrheaCSF Otorrhea and RhinorrheaSurgical ManagementSurgical Management Surgical approachSurgical approach

Status of hearing Status of hearing Meningocele/encephaloceleMeningocele/encephalocele Fistula locationFistula location

TransmastoidTransmastoid Middle Cranial FossaMiddle Cranial Fossa

Facial Nerve InjuriesFacial Nerve Injuries EvaluationEvaluation

Previous statusPrevious status TimeTime Onset and progressionOnset and progression Complete vs. IncompleteComplete vs. Incomplete

House Brackman grading systemHouse Brackman grading systemII NormalNormal Normal facial functionNormal facial functionIIII MildMild Slight synkinesis/weaknessSlight synkinesis/weaknessIIIModerate Complete eye closure, noticeable syIIIModerate Complete eye closure, noticeable synkinesis, slight forehead movementnkinesis, slight forehead movementIVModerately SevereIVModerately Severe Incomplete eye closure, Incomplete eye closure, symmetry at rest, no forehead movementsymmetry at rest, no forehead movementVV SevereSevere Assymetry at rest, barely noticeablAssymetry at rest, barely noticeable motione motionVITotalVITotal No movementNo movement

Electrophysiologic TestingElectrophysiologic Testing NETNET MSTMST ENoGENoG

Nerve Excitability TestNerve Excitability TestMaximal Stimulation TestMaximal Stimulation Test

>3.5mA difference suggests a poor >3.5mA difference suggests a poor prognosis for return of facial functionprognosis for return of facial function

ElectroneuronographyElectroneuronography Most accurate, qualitative measurementMost accurate, qualitative measurement Reduction of >90% amplitude correlates Reduction of >90% amplitude correlates with a poor prognosis for spontaneous rwith a poor prognosis for spontaneous recoveryecovery

ElectromyographyElectromyography Limited use until 10-14 daysLimited use until 10-14 days Polyphasic potentials= GoodPolyphasic potentials= Good

Facial Nerve InjuriesFacial Nerve Injuries Decision to treat is primarily based on wDecision to treat is primarily based on whether there is complete vs. incomplete hether there is complete vs. incomplete paralysisparalysis

TreatmentTreatment Conservative treatment candidatesConservative treatment candidates Surgical candidatesSurgical candidates

Conservative Treatment Conservative Treatment CandidatesCandidates

Chang and CassChang and Cass Normal Facial Function regardless of progreNormal Facial Function regardless of progressionssion Incomplete paralysis and no progression to Incomplete paralysis and no progression to complete paralysiscomplete paralysis Less than 95% degeneration by ENoGLess than 95% degeneration by ENoG

Surgical CandidatesSurgical Candidates Critical Prognostic factorsCritical Prognostic factors

Immediate vs. DelayedImmediate vs. Delayed Complete vs. Incomplete paralysisComplete vs. Incomplete paralysis ENoG criteriaENoG criteria

Algorithm for Facial Nerve Algorithm for Facial Nerve InjuryInjury

Surgical ApproachSurgical Approach Suspect location of neural injurySuspect location of neural injury Presence or absence of hearingPresence or absence of hearing

Surgical ApproachSurgical Approach Lateral to the geniculate ganglionLateral to the geniculate ganglion

transmastoidtransmastoid Medial to the Geniculate GanglionMedial to the Geniculate Ganglion

No useful hearingNo useful hearing Transmastoid-translabyrinthineTransmastoid-translabyrinthine

Intact hearingIntact hearing Transmastoid-trans-epitympanicTransmastoid-trans-epitympanic Middle Cranial FossaMiddle Cranial Fossa

Surgical findingsSurgical findings Nerve repairNerve repair

Direct anastomosisDirect anastomosis Nerve graftNerve graft

DecompressionDecompression

Case ReportCase Report 32 yr old fisherman was wading32 yr old fisherman was wading

Minding his own businessMinding his own business Hit in head by a flying fishHit in head by a flying fish Immediate profound vertigo, hearing losImmediate profound vertigo, hearing losss CT scan revealed longitudinal Temp bonCT scan revealed longitudinal Temp bone fracturee fracture