You are on page 1of 29

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
Hearing loss: conductive or sensorineural
Facial weakness or paralysis (7% overall)
More rare: facial numbness and diplopia

Physical Examination
Battles sign:
Raccoon sign:
Otorrhea: bloody or clear and pulsatile (send for
2 transferrin)
Pneumatic otoscopy: vertigo or flaccid TM
Laceration of canal wall

Nasal exam for rhinorrhea
Facial nerve exam
Extraocular movement exam for
nystagmus or diplopia
Tuning fork exam
Audiometric testing

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

Longitudinal Fractures
Most common (up to 80%)
Path of least resistance
Ossicular chain and the
perigeniculate ganglion region
of the facial nerve can be
Otic capsule involvement is
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
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 50-
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
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
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,
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
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
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
showed that both
techniques have
similar success rates
Onlay: if adjacent
structures at risk, or if
the underlay is not

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
Refractory cases may require closure of
the EAC and obliteration.
Leaks of the Lateral Tegmen
Accessed through
Taken from Myers
Leaks of the Medial Tegmen
May require
combined with middle
fossa approach
Bailey, Byron J., ed. Head and Neck surgery- Otolaryngology. Philadelphia, P.A. J.B. Lippincott Co., 1993.
Cummings, ed. Otolaryngology: Head and Neck Surgery. 4
Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. American
Journal of Otology; 18: 188-197, 1997.
Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and Neck
Surgery; 123; 749-752, 1997.
Black, et al. Surgical Management of Perilymphatic Fistulas: A Portland experience. American Journal of
Otology; 3: 254-261, 1992.
Chang CY, Cass SP. Management of Facial Nerve Injury Due to Temporal Bone Trauma. The American Journal
of Otology; 20: 96-114, 1999.
Coker N, Traumatic Intratemporal Facial Nerve Injuries: Management Rationale for Preservation of Function.
Otolaryngology- Head and Neck Surgery; 97:262-269, 1987.
Green, JD. Surgical Management of Iatrogenic Facial Nerve Injuries. Otolaryngolgoy- Head and Neck Surgery;
111; 606-610, 1994.
Lambert PR, Brackman DE. Facial Paralysis in Longitudinal Temporal Bone Fractures : A Review of 26 cases.
Laryngoscope; 94:1022-1026, 1984.
Lee D, Honrado C, Har-El G. Pediatric Temporal Bone Fractures. Laryngoscope: vol 108(6). June 1998, p816-
Mckennan KX, Chole RA. Facial Paralysis in Temporal Bone Trauma. American Journal of Otology; 13: 354-261,
Savva A, Taylor M, Beatty C. Management of Cerebrospinal Fluid Leaks involving the Temporal Bone: Report on
92 Patients. Laryngoscope: vol 113(1). January 2003, p50-56
Thaler E, Bruney F, Kennedy D, et al. Use of an Electronic Nose to Distinguish Cerebrospinal Fluid from Serum.
Archives of Otolaryngology; vol 126(1). Jan 2000, p71-74.