Trauma

Types of trauma:
1. Temporal bone # ( the most common cause)
2. Penetrating trauma
3. Iatrogenic trauma

temporal bone # most often occur in conjugation with multiple bone injury

Accidental Temporal Bone Fractures Classification Schemes:

a) Longitudinal Versus Transverse (classification is based on the relation between the #

line and the long axis of the temporal bone:

1. Longitudinal 80%
2. Transverse 10-15%
3. Mixed/oblique: 5-10%

b) Otic Capsule Sparing Versus Otic Capsule Involving:

This classification correlates better at predicting the clinical outcome
1. Otic capsule Sparing
2. Otic capsule Disrupting: 5-7%

Otic disturbing #:

1. almost always result in SNHL

2. Higher incidence of facial nerve palsy
3. 2-4 X CSF fistula

 The most common cause of

a) Blunt trauma: motor vehicle accident
b) Penetrating trauma: gun shoot

Temporal bone # in children:

There is a higher incidence of intracranial complications (58%)
and a lower incidence of facial nerve paralysis (3%)
starts at the squamous bone: post-sup EUC: Tegmen tympani : ant to the genigulate: foramen lacerum

Foramen magnum: IAC: Otic capsule: foramen spinosum: foramen lacerum

Diagnosis: High resolution CT scan ≤1.5 mm

CSF leak is ass with longitudinal fracture involving tegmen tympani and result in otorrhea

CSF leak ass with transverse: rhinorrhea

SNHL in transverse # is High frequency

Note transverse # may or may not disturb the otic capsule

Battle sign: indicates skull base fracture and occur due to blood in the mastoid air
cells
The most posttraumatic ossicular injury: Subluxation of the incudostapedial joint

Facial Nerve paralysis

 The overall incidence of facial nerve palsy form all types of fractures is 3%

 What is the incidence of facial nerve injury after transverse fracture of the
temporal bone?
50%.
 What is the incidence of facial nerve paralysis in patients with longitudinal
temporal bone fractures?
20.
 Which of these accounts for the majority of facial nerve injuries?
Longitudinal.
 Which of these fractures is most likely to result in facial nerve paralysis?
Transverse.

 The worst prognostic factor: total paralysis of acute onset

 The most common site of FN injury in longtiduinal #:
1. Perigenigulate: most common(by causing traction on superficial greater
petrosal nerve)
2. distal to the pyramidal eminence: The next most common site.

 In transverse fractures:
1. distal labyrinthine and tympanic segments are most commonly injured.

 Transverse temporal bone fractures are generally associated with more severe
AND IMMEDIATE injury to the facial nerve, including transection

 In penetrating trauma: The facial nerve is commonly injured at its vertical or

extratemporal segments.

 Paralysis causes:
a. intraneural haematoma
b. compression by a bony spicule
c. transection of nerve

 It is important to know whether onset was of immediate or delayed onset:

1. Delayed onset: treated conservatively like Bell's palsy

2. immediate onset: paralysis may require surgery in the form of
decompression, re-anastomosis of cut ends or cable nerve graft
 Treatment:

a. Incomplete: see tx of delayed Iatrogenic FNP

b. Complete: surgical exploration

 If the nerve is partial transected: only nerve graft
 If the axon is > 50% separated: interposition graft

Approach:
1. Longitudinal: perigenigulate: Transmastoid
2. Transverse with otic sparing: labyrinth segment: middle cranial
fossa
Transverse with otic involvement: translabyrinthe

Timing of the surgery:

 Fisch criteria: of >90% degeneration within 6 days of onset.

 The timing of surgery, however, does not have to be within 6 days; in fact,
there may be some advantage to delaying surgery up to 3 weeks after an
immediate paralysis to allow resolution of edema and hematoma and make
the surgical field more discernible

3.

CSF Leak:

 CSF leak is more common in the transverse #

 Transverse # will have intact tympanic membrane: so CSF leak will present as
Rhinorrhea
 Most leaks heal spontaneously in 4-5 days without surgical intervention

 Indication of surgery in case of CSF Leak post temporal bone #:

1. persistent leak despite adequate conservative therapy (1-2 WK)

2. Complications of the leak, such as meningitis.
Vertigo:
 DDX of vertigo post temporal bone #:
1. Membrane labyrinthine concussion
2. BPPV
3. Otic capsule #
4. Perilymphatic fistula: fluctuating SNHL
5. Trauma induced endolymphatic hydrops ( years later)

Hearing loss:
 The most common type of hearing loss in temporal bone # is:
Temporary CHL
 the most common mechanism of CHL in longitudinal fractures is
Incudostapedial joint dislocation.

 The most affected ossicles is:

 The most commonly affected ossicle is the incus.

 The malleus is supported by multiple ligaments in the epitympanum, the
tensor tympani, and its attachment to the tympanic membrane.
 The stapes is supported by the stapedial tendon and its association with
the otic capsule at the oval window.
 The incus, on the other hand, is poorly stabilized. The torsion forces on
the incus due to a severe blow to the temporal bone can result in
incudostapedial joint separation, fracture of the incus, or dislocation of
the incus. Although the incus is most prone to injury, in practice a variety
of injuries to all of the ossicles may occur

 Timing of the surgery in case of CHL:

 Surgical intervention with exploration of the middle ear is usually
considered 3-6 months after temporal bone trauma.
 Some 75% of patients with CHL after trauma return to normal

 The mechanism of sensorineural hearing loss:

 1. otic capsule fracture\
2. injury to the CN VIII
3. perilymphatic fistula
4. noise-induced hearing loss
5. concussion injury to the inner ear without evidence of labyrinthine
fracture
6. direct injury to the auditory central nervous system

Iatrogenic:

 Most common overall surgery with FN injury is parotidectomy.

 Most common otologic procedures with FN paralysis:

 Mastoidectomy: 55%
 Tympanoplasty: 14%
 Exostoses removal: 14%
 stapedectomy

 Mechanism of injury:
1. direct mechanical injury
2. Heat generated from drilling.

 Most common area of injury: tympanic portion ( high incidence of

dehiscence )

 Unrecognized injury during surgery in nearly 80% of cases

 Birth trauma
Forceps delivery with compression of the facial nerve against the spine

Note: facial nerve exposure in case of Temporal bone # via middle cranial fossa
Management:
 partial injuries (< 50%) are best treated by decompression proximal and
distal to injury injuries
 > 50% require primary anastomosis or cable grafting

Penetrating Facial Nerve palsy:

Nature of injury:

 Transection = Immediate facial nerve palsy

 Contusion= Delayed facial nerve palsy

Indication of exploration and repair of the facial nerve:

 Immediate FN palsy +complete + penetrating injury lateral to the lateral

canthus

 We do not explore delayed F.N palsy because it is due to edema as a result

of contusion that will resolve with steroid

 We do not explore F.N palsy ass with penetrating injury medial to the
lateral canthus as the regeneration is excellent in this area

Exploration Timming of immediate FN paralysis lateral to the lateral canthus post

penetrating injury:

Depends on the state of the distal part of the F.N

1. Stimulated: within 3 days (after which the stimulation is lost)

2. Non-stimulated: wait 20 days because the nerve can max synthesize
protein

Types of repair:

1. Tension free primary repair:

 perineural anastomosis
  rerouting is needed to give extra length
2. Cable graft repair

 When the nerve ends are separated by more than 1 cm and cannot be
easily released, a nerve graft should be considered to avoid repairing
the nerve under tension

Types of Graft

greater auricular sural nerves

close and often within the operating field Leave a scar
short 7cm longer 30 cm
Lobe numbness that may be bothersome Numbness is
to some ppl tolerated

The outcome:

 Grade 3-4 house brackmann regardless of the way of the injury

3. Cross over technique:

a. Hypoglossal-facial: most popular
b. Accessory nerve-facial
c. Facial-facial

Pre-request:
 irreversible facial nerve injury
 intact mimetic function
 intact motor endplate function
 intact proximal donor nerve
 intact distal facial nerve

4. muscle transfer technique:

a. temporalis
b. masseter muscles
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