pediatric temporal bone fractures: evaluation and management
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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. Bleeding from ear canal - PowerPoint PPT PresentationTRANSCRIPT
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Pediatric Temporal Bone Fractures: Evaluation and
ManagementDennis J Kitsko, DO, FACS, FAOCO
Assistant Professor of OtolaryngologyChildren’s Hospital of Pittsburgh
University of Pittsburgh School of Medicine
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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
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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
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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)
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Longitudinal Fracture Injury to the roof of
the middle ear (tegmen tympani)
CSF otorrhea
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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
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Longitudinal Fracture
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Transverse Fracture
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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
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CSF Leak 20-25% of pediatric temporal bone
fractures (McGuirt 1992) Skull fracture + meningeal tear Permanent pathway for bacterial
contamination and meningitis
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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
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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
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Hearing Loss
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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)
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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
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Ossicular Disruption Incudostapedial
joint separation (#1)
Incudomalleolar dislocation
Stapes crural fracture
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Vertigo
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Vertigo Labyrinthine concussion Fracture through the labyrinth
(transverse fx) Perilymphatic fistula Shearing of 8th nerve (IAC)
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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
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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
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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
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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
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Facial Paralysis Delayed onset:
– Usually secondary to edema rather than direct injury
– Spontaneous recovery may occur
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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
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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
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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
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Questions?