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Temporal Bone Trauma
RebeccaSCornelius,MD,FACRProfessorofRadiology&Otolaryngology
UniversityofCincinnatiCollegeofMedicine
Goals & Objectives • Classifytemporalbonefracturesusingthetraditionalandoticcapsuleclassificationmethods
• Identifyclassificationmethodwhichbestpredictspatientoutcomes
• Recognizethemostcommoncomplicationsassociatedwithtemporalbonefracture
Parts of Temporal Bone Fracture Classification • Traditional-categorizedinregardtopositionofthefracturerelativetopetrousridge
• Newerfractureclassificationcategorizesfracturesrelativetoinvolvementoftheoticcapsule
Traditional Classification • Basedonexperimentalfracturesproducedincadavers
• Similartoclinicallyobservedfractures
• Anatomicfracturelocationusedinanattempttopredictclinicalsequelae
Clinical sequelae • CHL• SNHL• VIInerveparalysis• CSFleak/meningitis• Vertigo• Vascular–carotiddissection,pseudoaneurysm,sigmoidsinusthrombosis
• Acquiredcholesteatoma
Why does it matter? • Importanceoffractureclassificationistotrytopredictclinicalsequelaeandclinicaloutcome
• Morerecentstudiessuggestthatthetraditionalclassificationsystemfailstoreliablypredictanycomplication
How do I report T-bone fractures? Ireportbothclassifications:E.G.“Thereisalongitudinalpetroustemporalbonefracturewhichtraversesthemiddleearcavitybutsparestheoticcapsulestructures.”• Traditionalclassificationgivesabetter“visualpicture”offracture
• Oticcapsuleclassificationsystembetterpredictspatientmorbidity
Fracture Classification-Traditional • Longitudinal=Paralleltolongaxisofpetroustemporalbone
• Transverse=Perpendiculartolongaxisofpetroustemporalbone
• Intruthmostfracturesarecomplexwithasomewhatserpiginouscourse
• In1992,arevisedclassificationsystemincludedanobliquefracture
New Classification • Oticcapsulesparingvs• Oticcapsuleviolating
• Severalstudiessupportbetterpredictiveabilityforseriousclinicaloutcomeusingnewclassificationsystem
Little & Kessler 2006 Univ Virginia, Charlottesville Little&Kessler2006UnivVirginia,Charlottesville
Little&Kessler2006UnivVirginia,Charlottesville Little&Kessler2006UnivVirginia,Charlottesville
Pts with otic capsule violating fx • 5xmorelikelytohavefacialnerveinjury
• 25xmorelikelytohaveSNHL
• 8xmorelikelytohaveCSFleak
Review of Traditional Classification Longitudinal Transverse
Longitudinal Fracture • Mostcommon,duetotemporoparietaltrauma• CommonlyassociatedsquamousT-bonefx• UsuinvolvestheTM,EACwhemotympanum• Ofteninvolvesossicles• MayinvolveCNVII• Mayextendtocarotidcanal
Longitudinal fracture- otic capsule sparing
Conductive Hearing Loss • Hemotympanum• TMdamage• Ossicularderangement• AnteriorEACfxandsubsequentstenosis
Longitudinal fracture with hemotympanum
EAC fracture requiring canalplasty EAC fractures • Directtraumacanresultinalocalizedfractureofthemastoidand/orEAC
• IndirecttraumaviaablowtothemandiblecanresultinananteriorwallEACfx
Ossicular Derangement 1. Incudostapedialjointsubluxation2. Completeincusdislocation3. Fractureofstapesarch• Fractureofmalleus• Isolatedmalleoincudalsubluxation
Mayalsobenoiseinducedorsecondarytobarotrauma
Malleoincudal subluxation
Fracture with ossicular dislocation
Longitudinal fracture with incus dislocation
Longitudinal fracture with incudostapedial dislocation
Transverse Fracture • Lesscommon,duetofrontaloroccipitalimpact• OssiclesandTMusuallyspared• HigherincidenceofVIIparalysis**oftenimmediateandcomplete• Labyrinthineinvolvementcommon• CantransectIAC• MayhaveacutecompleteSNHL&vertigo
SNHL • FractureIAC(TransectionofCNVIII)• Fractureinvolvingcochlea• Labyrinthineconcussion
Vertigo • FractureIAC(TransectionCNVIII)• Transectionofvestibuleorvestibularaqueduct
• Labyrinthineconcussion• Perilymphfistula
Facial Nerve Paralysis • Resultsfrom:*Transection*Intraneuronalhematoma*Impingement/ischemia
Transverse otic capsule sparing fracture Transverse otic capsule violating fracture
Perilymph fistula • Disruptionofovalorroundwindow
• Pneumolabyrinth• Persistentvertigoandfluctuatingsensorineuralhearingloss
Longitudinal fracture with pneumolabyrinth
Air in TMJ associated with T-bone fracture CSF Leak • Resultsfromdisruptionoftegmenanddura
• CSFotorrheaifTMdisrupted• CSFrhinorrheaifTMintact• Canresultinmeningitis
Complex fracture with tegmen disruption Fracture with tegmen involvement and CSF leak
Vascular Sequelae
Lambdoid diastasis, longitudinal fracture, epidural hematoma & venous thrombosis
Longitudinal fracture with sigmoid/IJ thrombosis Squamous T-bone fx, skull base fx, ICH and occlusive cervical ICA dissection
T-bone fx, sphenoid fx, ICA dissection Acquired Cholesteatoma • Occursinlongitudinalormixedfracture• SecondarytoinvasionofsquamousepithelialdebrisintoEACormiddleearalongfractureline
• Canbeveryaggressive
EAC Cholesteatoma
CourtesyofRaviSamy,MD
Thanks for your attention!