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Temp-bone-trauma-slides-051012 - Temporal Bone Trauma...

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Unformatted text preview: Temporal Bone Trauma Temporal October 12, 2005 Steven T. Wright, M.D. Matthew Ryan, M.D. Temporal Bone Trauma Temporal Wide spectrum of Wide clinical findings clinical Knowledge of the Knowledge anatomy is vital to proper diagnosis and appropriate management management Incidence and Epidemiology Incidence Motorized Transportation Penetrating Trauma 30-75% of blunt head trauma had associated 30-75% temporal bone trauma temporal More dismal prognosis Barotrauma Inner ear decompression sickness • The “bends” Perilymphatic fistula Blast Injuries Evaluation and Management Evaluation ATLS Airway Breathing Circulation H&P Thorough head & neck Thorough examination examination Physical Examination Physical Basilar Skull Basilar Fractures Fractures Periorbital Ecchymosis Periorbital (Raccoon’s Eyes) (Raccoon’s Mastoid Ecchymosis Mastoid (Battle’s Sign) (Battle’s Hemotympanum Physical Examination Physical Tuning Fork exam Pneumatic Otoscopy Flaccid TM Nystagmus Imaging Imaging HRCT MRI Angiography/ MRA Longitudinal fractures Longitudinal 80% of Temporal 80% Bone Fractures Bone Lateral Forces along Lateral the petrosquamous suture line suture 15-20% Facial Nerve 15-20% involvement involvement EAC laceration Transverse fractures Transverse 20% of Temporal 20% Bone Fractures Bone Forces in the AnteroPosterior direction 50% Facial Nerve 50% Involvement Involvement EAC intact Temporal Bone Trauma Temporal Hearing Loss Dizziness/Vertigo CSF Otorrhea Facial Nerve Injuries Hearing Loss Hearing Formal Audiometry Formal vs. Tuning Fork vs. 71% of patients with 71% Temporal Bone Trauma have hearing loss loss TM Perforations CHL > 40db CHL suspicious for ossicular discontinuity ossicular Hearing Loss Hearing Longitudinal Fractures Conductive or mixed hearing loss 80% of CHL resolve spontaneously Transverse Fractures Sensorineural hearing loss Less likely to improve Hearing Loss Hearing Tympanic Membrane Perforations Ossicular fracture or discontinuity Hemotympanum Treatment: Treatment: Observation Otic solutions may only mask CSF leaks Dizziness Dizziness Fracture through the otic capsule or a Fracture labyrinthine concussion labyrinthine Difficult diagnosis- bed rest, obtundation, Difficult sedation sedation Treatment: reserved for vomiting, Treatment: limitation of activity Vestibular suppressants Allow for maximal central compensation Dizziness Dizziness Perilymphatic Fistulas SCUBA diver with ETD Fluctuating dizziness and/or hearing Fluctuating loss loss Tullio’s Phenomenon Management • • • Conservative treatment in first 10-14 days 40% spontaneously close Surgical management for persistent Surgical vertigo or hearing loss vertigo • Regardless of visualization of fistula site, Regardless the majority of patients get better the Dizziness Dizziness Inner Ear Inner Decompression Sickness Sickness Too rapid an ascent Too leads to percolation of nitrogen bubbles within the otic capsule. within Greater than 30 ft…. Greater Decompression stages upon ascent are needed needed Dizziness Dizziness BPPV Acute, latent, and Acute, fatiguable vertigo fatiguable Can occur any time Can following injury following Dix Hallpike Epley Maneuver CSF Otorrhea CSF Acquired Postoperative (58%) Trauma (32%) Nontraumatic (11%) Spontaneous Bony defect theory Arachnoid granulation theory Temporal bone fractures Temporal Longitudinal 80% of Temp bone fx Anterior to otic capsule Involve the dura of the Involve middle fossa middle Temporal bone fractures Temporal Transverse 20% of Temp bone fx High rate of SNHL due High to violation of the otic capsule capsule 50% facial nerve 50% involvement involvement Testing of Nasal Secretions Testing Beta-2-transferrin is highly sensitive and Beta-2-transferrin specific specific 1/50th of a drop Gold top tube, may need to send a sample of Gold the patients serum also. the Found in Vitreous Humor, Perilymph, CSF Electronic nose has shown early success Faster (<24hrs) Very Accurate Imaging CSF Otorrhea Imaging High resolution CT Convenience Speed CT Cisternography MRI Heavily weighted T2 Slow flow MRI MRI cisternography Imaging Imaging Slow flow MRI Diffusion weighted Diffusion MRI MRI Fluid motion down to Fluid 0.5mm/sec 0.5mm/sec Ex. MRA/MRV Treatment of CSF Otorrhea Treatment Conservative measures Bed rest/Elev HOB>30 Stool softeners No sneezing/coughing +/- lumbar drains Early failures Assoc with hydrocephalus Recurrent or persistent leaks Treatment of CSF Otorrhea Treatment Brodie and Thompson et al. 820 T-bone fractures/122 CSF leaks Spontaneous resolution with conservative Spontaneous measures measures 95/122 (78%): within 7 days 21/122(17%): between 7-14 days 5/122(4%): Persisted beyond 2 weeks Temporal bone fractures Temporal Meningitis 9/121 (7%) developed meningitis. Found no 9/121 significant difference in the rate of meningitis in the ABX group versus no ABX group. in A later meta-analysis by the same author later did reveal a statistically significant reduction in the incidence of meningitis with the use of prophylactic antibiotics. with Pediatric temporal bone fractures Pediatric Much lower incidence (10:1, adult:pedi) Undeveloped sinuses, skull flexibility otorrhea>> rhinorrhea Prophylactic antibiotics did not influence Prophylactic the development of meningitis. the CSF Otorrhea Surgical Management Management Surgical approach Status of hearing Status Meningocele/encephalocele Fistula location Transmastoid Middle Cranial Fossa Overlay vs Underlay Overlay technique Meta-analysis showed Meta-analysis that both techniques have similar success rates rates Onlay: adjacent Onlay: structures at risk, or if the underlay is not possible possible Technique of closure Technique Muscle, fascia, fat, cartilage, etc.. The success rate is significantly higher for The those patients who undergo primary closure with a multi-layer technique versus those patients who only get single-layer closure. closure. Refractory cases may require closure of Refractory the EAC and obliteration. the Facial Nerve Injuries Facial Loss of forehead wrinkles Bell’s Phenomenon Nasal tip pointing away Flattened Nasofacial groove Facial Nerve Anatomy Facial Facial Nerve Injuries Facial Initial Evaluation is the most important Initial prognostic factor prognostic Previous status Time Onset and progression Complete vs. Incomplete House Brackman Scale House I II Normal Mild Normal facial function Slight synkinesis/weakness III Moderate Complete eye closure, noticeable Complete synkinesis, slight forehead movement movement IV Moderatel Incomplete eye closure, symmetry Incomplete y Severe at rest, no forehead movement, dysfiguring synkinesis dysfiguring V Severe Assymetry at rest, barely Assymetry noticeable motion noticeable VI Total No movement Electrophysiologic Testing Electrophysiologic NET: Nerve Excitability Test MST: Maximal Stimulation Test ENoG: Electroneurography Goal is to determine whether the lesion is partial Goal or complete? or Neuropraxia: Transient block of axoplasmic flow ( no Neuropraxia: neural atrophy/damage) neural Axonotmesis: damage to nerve axon with Axonotmesis: preservation of the epineurium (regrowth) preservation Neurotmesis: Complete disruption of the nerve ( no Neurotmesis: chance of organized regrowth) chance Nerve Excitability Test Nerve Maximal Stimulation Test Stimulating electrodes are placed and a Stimulating gross movement is recorded gross Not as objective and reliable >3.5mA difference suggests a poor >3.5mA prognosis for return of facial function. prognosis Correlates with >90% degeneration on ENoG Electroneuronography Electroneuronography Most accurate, qualitative measurement Sensing electrodes are placed, a voluntary Sensing response is recorded response Accurate after 3 days Requires an intact side to compare to Reduction of >90% amplitude correlates Reduction with a poor prognosis for spontaneous recovery recovery Electromyography Electromyography Electrode is placed within the muscle and Electrode voluntary movement is attempted. voluntary Normal Muscle is electrically silent. Normal After 10-14 days, the denervated muscle After begins to spontaneously fire: begins Diphasic/Polyphasic potentials: Good Loss of voluntary potentials: Bad Facial Nerve Injuries Facial WHO GETS TREATMENT? Conservative treatment candidates Surgical treatment candidates Facial Nerve Injuries Facial Chang & Cass Medline search back to 1966 Individually reviewed each article 1) Understand the pathophysiology of facial 1) nerve damage in temporal bone trauma. nerve 2) What is the effect of surgical intervention 2) on the ultimate outcome of the facial nerve. on 3) Propose a rational course for evaluation 3) and treatment. and Facial Nerve Injuries Facial Chang & Cass Pathophysiology based on findings by Fisch and Pathophysiology Lambert and Brackmann: Lambert Where? Perigeniculate, Labyrinthine, and meatal segments Concern over findings of endoneural fibrosis and neural atrophy Concern proximal to the lesions proximal In an untreated human specimen found intraneural edema and In demyelinization that extended proximally to the meatal foramen demyelinization How? Longitudinal Fractures • 15% transection • 33% bony impingement, 43% hematoma Transverse Fractures • 92% transection Does Facial Nerve decompression result in superior functional outcomes compared with no treatment? no Not enough human data! Boyle-monkey: prophylactic epineural decompression in Boyle-monkey: complete paralysis did not improve recovery of facial nerve function after induced complete paralysis nerve Kartush: Prophylactic decompression of the meatal Kartush: segment during acoustic neuroma decreased the incidence of delayed paralysis incidence Adour: compared patients with complete paralysis found: Equal outcome with observation vs. decompression without Equal nerve slitting nerve Worse outcome with decompression with nerve slitting Does Facial Nerve decompression result in superior functional outcomes compared with no treatment? no Many difficulties in Study designs, Many controls, etc, but they made some rough estimates: estimates: 50% of patients who undergo facial nerve 50% decompression obtain excellent outcomes decompression The true efficacy of facial nerve The decompression surgery for trauma remains uncertain remains Conservative Treatment Candidates Candidates Chang and Cass Present with Normal Facial Function Present Normal regardless of progression regardless Incomplete paralysis and no Incomplete progression to complete paralysis progression Less than 95% degeneration by ENoG Less 95% • Most data comes from Bell’s palsy/tumor studies Most by Fisch. by Conservative Treatment Candidates Candidates Brodie and Thompson All patients that presented with normal facial All nerve function initially that progressed to complete paralysis recovered to a HB complete 1 or 2. or Surgical Candidates Surgical Critical Prognostic factors Immediate vs. Delayed Complete vs. Incomplete paralysis ENoG criteria Algorithm for Facial Nerve Injury Algorithm Facial Nerve Injuries Facial Chang & Cass What time frame is best to operate? Fisch-cats: Decompression of the nerve within Fisch-cats: a 12 day period resulted in “excellent” functional recovery. Presumption was that it preserved endoneural tubules. (limits the damage to axonotmesis at worst) damage Limits the accuracy of your patient selection Limits because EMG is not reliable until day 10-14. because Surgical Approach Surgical Medial to the Geniculate Ganglion No useful hearing • Transmastoid-translabyrinthine Intact hearing • Transmastoid-trans-epitympanic • Middle Cranial Fossa Lateral to Geniculate Ganglion Transmastoid Surgical Approach Surgical Chang & Cass Histopathologic study Severe facial nerve Severe injury results in retrograde axonal degeneration to the level of the labyrinthine and probably meatal segments segments Surgical findings of greater than 50% nerve transection/damage 50% Nerve repair via primary anastamosis or Nerve cable graft repair cable HB 1 or 2: 0% HB 3 or 4: 82% HB 5 or 6: 18% Iatrogenic Facial Nerve Injuries Iatrogenic Mastoidectomy (55%) Tympanoplasty (14%) Bony Exostoses (14%) Lower tympanic segment is the most Lower common location injury common 79% were not identified at the time of 79% surgery surgery Management of Iatrogenic Facial Nerve Injuries Facial Green, et al. <50% damage: perform decompression 75% had HB of 3 or better! >50% damage: perform nerve repair No patients had better than a HB 3 Beware of local anesthetics General consensus: acute, complete, General postoperative paralysis should be explored as soon as possible. explored Emergencies Emergencies Brain Herniation Massive Hemorrhage Pack the EAC Carotid arteriography with embolization Bibliography Bibliography Bailey, Byron J., ed. Head and Neck surgery- Otolaryngology. Philadelphia, P.A. J.B. Lippincott Co., 1993. Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. American Brodie, Journal of Otology; 18: 188-197, 1997. Journal Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and Neck Brodie Surgery; 123; 749-752, 1997. Surgery; Black, et al. Surgical Management of Perilymphatic Fistulas: A Portland experience. American Journal of Black, Otology; 3: 254-261, 1992. Otology; Chang CY, Cass SP. Management of Facial Nerve Injury Due to Temporal Bone Trauma. The American Journal Chang of Otology; 20: 96-114, 1999. of Coker N, Traumatic Intratemporal Facial Nerve Injuries: Management Rationale for Preservation of Function. Coker Otolaryngology- Head and Neck Surgery; 97:262-269, 1987. OtolaryngologyGreen, JD. Surgical Management of Iatrogenic Facial Nerve Injuries. Otolaryngolgoy- Head and Neck Surgery; Green, 111; 606-610, 1994. 111; Lambert PR, Brackman DE. Facial Paralysis in Longitudinal Temporal Bone Fractures : A Review of 26 cases. Lambert Laryngoscope; 94:1022-1026, 1984. Laryngoscope; Lee D, Honrado C, Har-El G. Pediatric Temporal Bone Fractures. Laryngoscope: vol 108(6). June 1998, p816821. Mckennan KX, Chole RA. Facial Paralysis in Temporal Bone Trauma. American Journal of Otology; 13: 354-261, Mckennan 1982. 1982. Savva A, Taylor M, Beatty C. Management of Cerebrospinal Fluid Leaks involving the Temporal Bone: Report on Savva 92 Patients. Laryngoscope: vol 113(1). January 2003, p50-56 92 Thaler E, Bruney F, Kennedy D, et al. Use of an Electronic Nose to Distinguish Cerebrospinal Fluid from Serum. Thaler Archives of Otolaryngology; vol 126(1). Jan 2000, p71-74. Archives ...
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