temporal bone fractures

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presented in makkah on 3rd april 2013

Text of temporal bone fractures

  • 1. Dr. Naim Manhas 3/25/2013 1

2. trauma symposium-6th As long as cars are on road and increasingmilitary conflicts in world the number oftrauma patients are increasing day by day. The trauma symposium have become acommon ground where exchange of ideas andexperiences takes place between surgeons ofdifferent specialties. Dr. Naim Manhas 3/25/2013 2 3. Introduction Over the past centuary technological advanceshave revolutionized the diagnosis and treatmentof trauma to face , head and neck. As with other surgical discipline significantadvances in ent related trauma care haveoccurred.Dr. Naim Manhas 3/25/2013 3 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 veinDr. Naim Manhas 3/25/2013 4 5. temporal bone fractures It has been observed that 20%of patients with significanthead trauma and skull basefractures will sustain temporalbone fractures, becausealthough the temporal bone isvery thick and hard structurelocated in the base of skull butthe multiple foramina creatingareas of decreased resistancesusceptible to traumatic injury. Dr. Naim Manhas 3/25/2013 5 6. temporal bone fractures The temporal complex is a nonweight bearing region, thusdisplaced fracture does nothave any cosmetic sequel, butif facial nerve is involved canlead to devastating cosmeticand functional injuries. The extent of the injuriesbased on physical examinationand imaging studies, willdetermine the urgency andtype of surgical interventionsrequired. Dr. Naim Manhas 3/25/2013 6 7. Dr. Naim Manhas 3/25/2013 7 8. temporal bone fractures The evaluation of the temporal bone in apatient with multiple traumatic injuries canoften be incomplete or overlooked, delayingdiagnosis and management. A quick otoscopy examination is an excellentscreening for evidence of a temporal boneinjury and can guide additional diagnostictestingDr. Naim Manhas 3/25/2013 8 9. Diagnosis of temporal bone fracturePresumptive diagnosis offracture is based on threephysical findings:-HemotympanumPost auricular ecchymosis(Battles sign)Perioribital ecchymosis(raccoon sign)These signs along withthe history of headtrauma are sufficient forthe diagnosis of temporalbone fracture Dr. Naim Manhas 3/25/2013 9 10. Temporal bone fractures The management of temporal bone fracturesis generally aimed at restoring functionaldeficits, rather than reducing and fixatingbone fragments. Common injuries requiring surgicalmanagement include hearing loss, facial nervedysfunction and cerebrospinal fluid leak.Dr. Naim Manhas 3/25/2013 10 11. Management:-principles The emphasis is laid over new modalities toreduce the percentage of complication. Once complication present , needs furtherevaluation and management. Dr. Naim Manhas 3/25/2013 11 12. Brain herniation(encephloceole) in middle ear,mastoid orext.acousticEmergency meatus surgical intervention Intratemporalin temporal part of carotid bone trauma artery lacerationmassivebleeding Dr. Naim Manhas 3/25/2013 12 13. Temporal bone fractures-sequele Conductive hearing loss:-Frequently observed with longitudinalfractures. Hemotympanum Tympanic membrane perforationpartial Ossicular chain disruptioncompleteDr. Naim Manhas 3/25/2013 13 14. HemotympanumUsually occurs in longtudinalfractures.May or may not beassociated with tympanicmembrane perforationHearing impairment presentConductive type of deafnessFollow up serial pure toneaudiometryUsually resolves within 3-4weeksDr. Naim Manhas 3/25/2013 14 15. Tympanic membrane perforationIsolated tympanic membraneperforation without ossiculardisruption - usually heals in 4-6weeks.If no evidence of sensorineuralhearing loss is found no specifictreatment is required.Strict dry ear precautions are followedto prevent water from getting into theear.A serial audiogram is performed up tothe total healing of the perforation.If the perforation has not healed by 3months then tympanoplasty isperformed. Dr. Naim Manhas 3/25/2013 15 16. Ossicular- chain disruptionCommon in longitudinalfractures as middle ear is usuallyinvolved.Conductive hearing loss morethan 50-60 dB.Incudostapedial joint dislocation(82%)Incus dislocation (57%)Fracture of the stapes crura(30%)Fixation of the ossicles in theattic (25%) Dr. Naim Manhas 3/25/2013 16 17. Management of ossicular chain disruption:-middle ear exploration and reconstruction ofossicles (ossiculoplasty) Dr. Naim Manhas 3/25/2013 17 18. Cerebrospinal fluid otorrheaCsf otorrhea occurs both inlongitudinal and transversefractures with, when duraltear occurs (17%).Flow increases withexertional or leaningforward.Usually closes spontanouslywith conservativemanagement within oneweek.Dr. Naim Manhas 3/25/2013 18 19. Otic capsule sparing :-Floor of the middle crainal fossa and into theepitympanum,antrum & mastoid air cells.Otic capsule disrupting :-Posterior crainal fossa through the disrupted oticcapsule into the middle ear.Dr. Naim Manhas 3/25/2013 19 20. Management:- csf otorrehea Diagnostic:- Halo sign Confirmation by beta-2 transferrin Management :- Elevation of the head Bed rest Stool softnersDr. Naim Manhas 3/25/2013 20 21. 100%90%80%70%60%Column150%with a/b40%without a/b30%20%10% 0% Category 1 Category 2 Category 3Category 4 Antibiotcs are not routinely prescribed incases with csf otorrehea for possibility ofmasking early signsDr. Naim Manhas 3/25/2013 21 22. Management:- csf otorrhea Csf otorrhea usually resolvesspontaneously within 2 weeks withoutintervention Meningitis is diagnosed on clinical basisand if suspected confirmed by lumbarpuncture. Surgery is indicated for continuous csfotorrhea persisting longer than 14 days. Lumbar drainage for 72 hours if fails Surgical exploration is recommended forclosure of dural tear & prevention ofmeningitis.Dr. Naim Manhas 3/25/2013 22 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 Dr. Naim Manhas 3/25/2013 23 24. perilymphatic fistula post operativeTemporal bonefr acture involving otic capsule diseasesPresentation:-Fluctuating hearing loss associated with vertigoVertigo increases with straining , suddendecompression of atmospheric pressure, scubadivers and even loud sound( tullio phenomena)Dr. Naim Manhas 3/25/2013 24 25. perilymphatic fistula Diagnosis:- Fistula test:- not recommended now as it canlead to aggreviation of symptoms &complications. History Computed tomography:- only sensitive in 20% Serial audiometery:- fluctuating SNHL Exploration of middle ear & visualization ofleak,fluid in middle ear & sent it forB2Transferrin testing Dr. Naim Manhas 3/25/2013 25 26. ManagementConservative treatment:- Surgical exploration:- Bed rest with head Symptoms persistelevated -3-6 weeks SNHL worsens Prevention of strainingApproach:- transcanalSerial audiometery& identification of leak ,closure with fascia Dr. Naim Manhas 3/25/2013 26 27. Facial nerve injuriestransverse fracturelongitudnal fracture20%50% Dr. Naim Manhas 3/25/2013 27 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 tympaniDr. Naim Manhas 3/25/2013 28 29. Facial nerve intratympanic partDr. Naim Manhas 3/25/2013 29 30. longitudnal fractures(otic capsule sparing) Although the otic capsuleis spared but the middleear is always involved Common site of facialnerve involvement is thehorizontal segment ofintratympanic portion. Usually caused bycompression andischemia rather thandisruptionDr. Naim Manhas 3/25/2013 30 31. Transverse fractures(otic capsule involving)Incidence of facial paralysisis 50% as otic capsule isinvolved.Facial nerve paralysis isusually immediate in onsetand complete.Nerve is avulsed or severedby the comminuted bonefragmentDr. Naim Manhas 3/25/2013 31 32. Management of f.n.injuryDr. Naim Manhas 3/25/2013 32 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 normalside using same stimulating current. Absent or markedly reduced responseindicates poor and incomplete return of facialnerve function. Dr. Naim Manhas 3/25/2013 33 34. Electrodiagnostic studiesNerve excitability test :- After 3rd day of injury Principle - comparison of the amperage fromsite to site necessary to initiate a barely visibleresponse on the affected side. A difference of 3.5mA or more is significantregarding poor recovery Dr. Naim Manhas 3/25/2013 34 35. Electroneurography (EnOG) Technique designed byrenowned skull base surgeonFisch. Test is done after 3rd day oftrauma and repeated every 2days until 21 days . Dr. Naim Manhas 3/25/2013 35 36. Electroneurography (EnOG)The results are expressed 100%as a percentage of the90%amplitude of the action-80%potential on the paralysed70%side as compared with non 60%normal50%sideparalysed side.affected40% side90% degeneration is 30% Column1considered if the amplitude 20%of action potential is less 10%than 10. 0% Dr. Naim Manhas 3/25/201336 37. tim