Transcript PPT Temporal Bone Fractures - UCLA Head and Neck Surgery

Temporal Bone Fractures and
Surgical Approaches for CSF Leaks
Arthur Wu, MD
UCLA Division of Head and Neck Surgery
Incidence and Epidemiology
• Blunt head trauma typically MVA
• Penetrating trauma eg. GSW have worse
prognosis 2/2 carotid or brain injury
Symptoms
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Hearing loss: conductive or sensorineural
Dizziness
Facial weakness or paralysis (7% overall)
Otorrhea
Rhinorrhea
More rare: facial numbness and diplopia
Physical Examination
• Hemotympanum
• Battle’s sign:
postauricular
ecchymosis
• Raccoon sign:
periorbital
ecchymosis
Otoscopy
• Otorrhea: bloody or clear and pulsatile (send for
β2 transferrin)
• Pneumatic otoscopy: vertigo or flaccid TM
• Laceration of canal wall
Others
• Nasal exam for rhinorrhea
• Facial nerve exam
• Extraocular movement exam for
nystagmus or diplopia
• Tuning fork exam
• Audiometric testing
Imaging
• High resolution CT is the gold standard
• MRI for cranial nerve injury
• MRA or angiogram for vascular injury
Types of fractures
• Longitudinal: along long axis of the
petrous temporal bone
• Tranverse: perpendicular to the long axis
of the petrous bone (commonly from the
jugular foramen or foramen magnum to
the middle cranial fossa)
• Mixed: in reality most fractures are mixed
type
Longitudinal Fractures
• Most common (up to 80%)
• Path of least resistance
• Ossicular chain and the
perigeniculate ganglion region
of the facial nerve can be
involved
• Otic capsule involvement is
rare
• Facial nerve injury in 10-20%
Longitudinal Fractures
Transverse Fractures
• Commonly involves
bony labrynth leading
to SNHL and vertigo
• Facial nerve injury
quoted as up to 50%
• Higher impact injuries
• Anterior-Posterior
force
Transverse Fractures
Mixed Fractures
The Good News
• For vast majority of temporal bone fractures, we
do nothing!
Indications for Surgical Intervention
• Facial nerve injury
• Hearing loss
• CSF leak
Facial Nerve Injury
• Overall 7% of temporal bone fractures,
25% of these being permanent
• Delayed onset vs Immediate onset
• Delayed onset: complete recovery in 94%
• Immediate onset: complete recovery in 5075%
• Site of injury: 80-90% perigeniculate ie
tympanic segment (followed by labrynthine
and meatal)
Facial Nerve Injury
• Goal: to explore only those nerves with
crush injury or some degree of transection
– Neuropraxia: Transient block of axoplasmic
flow ( no neural atrophy/damage)
– Axonotmesis: damage to nerve axon with
preservation of the epineurium (regrowth)
– Neurotmesis: Complete disruption of the
nerve ( no chance of organized regrowth)
Nerve Conduction Testing
• EMG and ENOG
• If EMG shows voluntary activity, then good prognosis
• EMG will show fibrillation potentials if nerve out in 2 wks
(not very helpful)
• Operate when ENOG shows 90% degeneration
• Wallerian degeneration is not documented on
electrodiagnostic testing for 3 to 5 days after the
neurotmesis, surgical intervention is delayed until
several days after the nerve has degenerated
• The efficacy of decompression of a posttraumatic,
nonsevered nerve remains to be proven in a
randomized, prospective study
• Note: ENOG requires normal side for comparison
Hearing Loss
• 80% of conductive hearing loss resolves
spontaneously
• SNHL worse prognosis of recovery
• If persistent CHL, then can take later to
OR for possible ossicular reconstruction or
tympanoplasty depending on etiology
CSF Leak
• Otorrhea, rhinorrhea, dizziness, serous effusion,
meningitis
• 15-20% of all temporal bone fractures
• Usually associated with longitudinal fractures
involving the tegmen
• High resolution CT usually sufficient; CT
cisternogram may be helpful for specific site
• Typically involves tear in dura of tegmen
• Leaks 2/2 otic capsule disruption less likely to
heal spontaneously
Conservative Treatment
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HOB elevation > 30 deg
Lumbar drain
Stool softeners
No noseblowing, coughing
Brodie and Thompson et al.
– 820 T-bone fractures/122 CSF leaks
• Spontaneous resolution with conservative
measures
– 95/122 (78%): within 7 days
– 21/122(17%): between 7-14 days
– 5/122(4%): Persisted beyond 2 weeks
Preventing Meningitis: Antibiotics??
• Same study: 7% developed meningitis with no
significant difference between those treated with
antibiotics and not
• Many studies demonstrate no benefit but difficult
to see differences from overall low numbers
• Hoff et al conducted a prospective randomized
trial; no patients in either arm got meningitis
• Metaanalysis by Brodie demonstrates difference
of 8% vs 2% for abx vs no abx
Surgical Intervention
From Cummings
Technique
• Meta-analysis
showed that both
techniques have
similar success rates
• Onlay: if adjacent
structures at risk, or if
the underlay is not
possible
Technique
• Muscle, fascia, fat, cartilage, Duragen,
bone pate, hydroxyapatite cement
• The success rate is significantly higher for
those patients who undergo primary
closure with a multi-layer technique versus
those patients who only get single-layer
closure.
• Refractory cases may require closure of
the EAC and obliteration.
Leaks of the Lateral Tegmen
• Accessed through
transmastoid
Taken from Myers
Leaks of the Medial Tegmen
• May require
transmastoid
combined with middle
fossa approach
References
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