Pediatric Temporal Bone Fractures: Evaluation and Management

1. 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

6. Clinical Findings - Overview • Bleeding from ear canal • Tympanic membrane perforation • Hemotympanum • Hearing loss • Conductive (43%) • Sensorineural (52%) • CSF leak (28%) • Facial paralysis (6%) • Vestibular symptoms • McGuirt 1992

7. 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

8. Longitudinal Fracture • Parallel to long axis of t-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)

9. Longitudinal Fracture • Injury to the roof of the middle ear (tegmen tympani) • CSF otorrhea

10. Transverse Fracture • Perpendicular to long 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

11. Longitudinal Fracture

12. Transverse Fracture

13. External Auditory Canal Injury • Identify source of bleeding • Assess extent of TM injury • Clean cerumen and blood clots • Check TMJ • If significant displacement, may need ear packing

14. CSF Leak • 20-25% of pediatric temporal bone fractures (McGuirt 1992) • Skull fracture + meningeal tear • Permanent pathway for bacterial contamination and meningitis

15. 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

16. 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

17. Hearing Loss

18. Sensorineural Hearing Loss • MUST get audiogram on all t-bone fractures • More common (50%) • May be due to direct cochlear trauma (transverse fx) • May also be concussive • Treat expectantly (serial audiograms)

19. 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

20. Ossicular Disruption • Incudostapedial joint separation (#1) • Incudomalleolar dislocation • Stapes crural fracture

21. Vertigo

22. Vertigo • Labyrinthine concussion • Fracture through the labyrinth (transverse fx) • Perilymphatic fistula • Shearing of 8th nerve (IAC)

23. 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

24. 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

25. 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

26. 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

27. Facial Paralysis • Delayed onset: • Usually secondary to edema rather than direct injury • Spontaneous recovery may occur

28. 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

29. 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

30. 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

31. Questions?