Pediatric Temporal Bone Fractures: Evaluation and

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Pediatric Temporal Bone
Fractures: Evaluation and
Management
Dennis J Kitsko, DO, FACS, FAOCO
Assistant Professor of Otolaryngology
Children’s Hospital of Pittsburgh
University of Pittsburgh School of Medicine
Clinical Findings - Overview
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Bleeding from ear canal
Tympanic membrane perforation
Hemotympanum
Hearing loss
– Conductive (43%)
– Sensorineural (52%)
 CSF leak (28%)
 Facial paralysis (6%)
 Vestibular symptoms
 McGuirt 1992
Imaging
 CT temporal bones is the preferred study
– Contrast not necessary
– Coronal sections if possible
– Classified as longitudinal and transverse
– Indications:
• Fracture on initial head CT
• CSF otorrhea, CSF rhinorrhea, facial paralysis, hearing
loss, severe vertigo
 MRA/MRV, CTA/CTV
– May be indicated if suspicion of injury to dural
sinus, jugular bulb, or ICA
Longitudinal Fracture
 Parallel to long axis of t
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

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bone
More common (70-90%)
Lateral blow
EAC fracture
TM rupture
Ossicular disruption
Around otic capsule
Foramen lacerum
Facial nerve injury
uncommon (often
delayed sec. to edema)
Longitudinal Fracture
 Injury to the roof of
the middle ear
(tegmen tympani)
 CSF otorrhea
Transverse Fracture
 Perpendicular to long
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axis of t-bone
Less common (10-30%)
Frontoocciptal blow
Otic
capsule/vestibule/lateral
IAC
Sensorineural hearing
loss and vertigo
Facial paralysis
TM often intact
CSF rhinorrhea
Longitudinal Fracture
Transverse Fracture
External Auditory Canal Injury
 Identify source of
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


bleeding
Assess extent of TM
injury
Clean cerumen and
blood clots
Check TMJ
If significant
displacement, may
need ear packing
CSF Leak
 20-25% of pediatric temporal bone
fractures (McGuirt 1992)
 Skull fracture + meningeal tear
 Permanent pathway for bacterial
contamination and meningitis
CSF Leak
 If TM rupture, will have otorrhea
 If TM intact, will appear as serous effusion
– Lean the patient forward – if CSF, may drain down
eustachian tube and out the nose (CSF
rhinorrhea)
 Collect fluid
– Beta-2-transferrin – protein found in CSF,
perilymph
• High sensitivity and specificity
• Contamination with blood does not affect interpretation
CSF Leak
 Initial management
– Bed rest, head of bed elevation, avoid straining
– Usually will stop spontaneously in 4-5 days
– Prophylactic abx controversial
 Lumbar drain if persists >4-5 days
 Surgery when:
– Leak persists >1-2 wks
– Large bony defect
– Brain herniation
– Recurrent meningitis
Hearing Loss
Sensorineural Hearing Loss
 MUST get
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audiogram on all tbone fractures
More common (50%)
May be due to direct
cochlear trauma
(transverse fx)
May also be
concussive
Treat expectantly
(serial audiograms)
Conductive Hearing Loss
 20-65% of T-bone
fractures
 Hemotympanum
– Intact TM
– Resolves spontaneously
– Follow up 4-6 wks
 TM rupture
– May heal spontaneously
 Ossicular disruption
– Surgical intervention
– Wait at least 6 wks
Ossicular Disruption
 Incudostapedial
joint separation
(#1)
 Incudomalleolar
dislocation
 Stapes crural
fracture
Vertigo
Vertigo
 Labyrinthine concussion
 Fracture through the labyrinth
(transverse fx)
 Perilymphatic fistula
 Shearing of 8th nerve (IAC)
Vertigo
 Treat expectantly
– CNS compensates and usually resolves within 6
wks
– Exception – if strongly suspect perilymph fistula,
consider exploration and round/oval window graft
 If persistent:
– Consider electronystagmography
– Rarely, surgical vestibular neurectomy or
labyrinthectomy
Facial Paralysis
 50% of transverse
fractures
– Nerve transection
 5-25% of longitudinal
fractures
– Often delayed secondary
to edema and may
spontaneously resolve
 Usually occurs in
horizontal portion,
between geniculate
ganglion and second
genu
Facial Paralysis – Physical Exam
 Evaluate upper and
lower face
– Lower 2/3 only,
consider CNS injury
 Difficulties:
– Lacerations,
ecchymosis, swelling,
LOC
 If unconscious,
attempt to elicit
grimace and assess
facial tone
Facial Paralysis
 If immediate and
complete:
– CT T-bone
• Localize site of injury
– Audiogram
• Helps determine
surgical approach
– Electrical testing
• Inaccurate for 48-72
hrs
Facial Paralysis
 Delayed onset:
– Usually secondary to
edema rather than
direct injury
– Spontaneous
recovery may occur
Facial Paralysis - Testing
 Nerve Excitability Test and Maximum
Stimulability Test
– Subjective
– Can be performed after 48-72 hrs
 ENoG – evoked EMG
– Objective
– Can be performed after 6 days
– >90% degeneration suggests poor outcome and
may be used to determine if surgical intervention
is necessary
Facial Paralysis - Surgery
 3 approaches:
– Transmastoid – perigeniculate to stylomastoid foramen
– Translabyrinthine – no cochlear function, allows
exposure to labyrinthine segment and lateral IAC
– Middle fossa – intact cochlear function, labyrinthine
segment and IAC
 Decompress the nerve sheath
 If lacerated:
– Direct reanastomosis if tension free
– Greater auricular n graft
• No return of function for at least 6 months
• Incomplete return of function
Summary
 Clinical examination:
– Bleeding from ear canal
– Tympanic membrane perforation
– Hemotympanum
– CSF leak
– Vestibular signs and symptoms
– Facial paralysis
 Studies:
– Temporal bone CT scan
– Audiogram
Questions?
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