Temporal Bone Trauma

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Temporal Bone Trauma

Trauma
Author Credentials 

Samuel Spear, MD
Mostafa Ahmed, MD
Department of Otolaryngology
Brooke Army Medical Center
Ft Sam Houston, TX

Module Summary

Temporal bone trauma is a common ENT consult. The complex neurovascular anatomy of the temporal bone directly correlates to significant clinical findings. It is essential to obtain a thorough history and physical especially when determining onset of facial nerve weakness. Recognition of when and which electrodiagnostic tests to order will help guide medical or surgical treatments for facial nerve paralysis. Establishing hearing status also is important to determine nature of hearing loss for purposes of rehabilitation. Identification of CSF otorhinorrhea is important given incidence of meningitis.

Module Learning Objectives 
  1. Explain changes in classification of temporal bone fracture.
  2. Review differences in pediatric temporal bone trauma.
  3. Describe importance of initial thorough examination.
  4. Recognize when the appropriate electrodiagnostic test is needed.
  5. Cite limitations of electrodiagnostic tests.
  6. Determine when facial nerve decompression is indicated.
  7. Recognize potentially life-threatening complications.

Anatomy

Learning Objectives 

Understand how otic capsule healing impacts temporal bone trauma outcomes.

References 
  1. Schuknecht HF, and Gulya AJ: Anatomy of the Temporal Bone with Surgical Implications. Philadelphia: Lea & Febiger, 1986.

Pathogenesis

Learning Objectives 
  1. Recognize how temporal bone anatomy results in common fracture patterns.
  2. Recognize how the temporal bone heals and potential sequelae from this.
  3. Describe how transverse and longitudinal fractures develop and the frequency of each pattern.
  4. Understand common structures and sequelae involved with otic capsule-disrupting or sparing fractures.
  5. Appreciate advantages of otic-capsule classification.
  6. Describe key features associated with penetrating temporal bone injury.
  7. Recognize differences in pediatric temporal bone trauma.
References 
  1. Wiet RJ, Valvassori GE, Kotsanis CA, and Parahy C. Temporal bone fractures. State of the art review. Am J Otol. 1985 May;6(3):207-15. 
  2. Little SC, and Kesser BW. Radiographic classification of temporal bone fractures: clinical predictability using a new system. Arch Otolaryngol Head Neck Surg. 2006 Dec;132(12):1300-4.
  3. Kelly KE, and Tami TA. Temporal bone and skull trauma. In Jackler RK, and Brackmann DE (eds): Neurotology. St Louis: Mosby, 1994. pp. 1127-1147
  4. Dahiya R, Keller JD, Litofsky NS, Bankey PE, Bonassar LJ, and Megeriam CA. Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J Trauma. 1999 Dec;47(6):1079-83.
  5. Dunklebarger, J. et al., Pediatric temporal bone fractures: Current trends and comparison of classification schemes. Laryngoscope. Mar;124(3):781-4. doi: 10.1002/lary.21891. Epub 2013 Dec 17.
  6. Moore, P. L., Selby, G. & Irving, R. M. Gunshot injuries to the temporal bone. J Laryngol Otol. 2003;117:71–74.

Basic Science

Learning Objectives 

Describe Sunderland nerve injury categories.

References 
  1. Sunderland S: Some anatomical and pathophysiological data relevant to facial nerve injury and repair. In Fisch U (eds): Facial Nerve Surgery. New York: Aesculapius, 1977. pp. 47-61

Incidence

Learning Objectives 
  1. Be familiar with most common mechanism for temporal bone trauma.
  2. Appreciate demographics for temporal bone trauma.
  3. Recognize differences with pediatric temporal bone fracture.
References 
  1. Brodie HA, and Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol. 1997;18:188
  2. Lee D, Honrado C, Har-El G, et al., Pediatric temporal bone fractures. Laryngoscope. 1998 Jun;108(6):816-21.

Patient Evaluation

Learning Objectives 
  1. Describe common physical exam findings during a thorough temporal bone trauma evaluation, in particular
    1. Facial nerve function immediately following injury
    2. Hearing status
    3. Tympanic membrane and EAC integrity
    4. Presence of nystagmus
    5. Fistula test
  2. Recognize importance of common use of muscle relaxants in a thorough neurotologic exam
  3. Understand how vertigo can manifest following temporal bone trauma
References 
  1. Darrouzet V, Duclos JY, Liguoro D, et al: Management of facial paralysis resulting from temporal bone fractures: our experience in 115 cases. Otolaryngol Head Neck Surg. 2001;125:77.
  2. Ylikoski J, Palva T, and Sanna M: Dizziness after head trauma: clinical and morphologic findings. Am J Otol. 1982;3:343.

Measurement of Functional Status

Learning Objectives 
  1. Understand what are limitations of electrodiagnostic testing.
  2. Describe predictive value on electroneurongraphy and electromyography.
References 
  1. Fisch U: Prognostic value of electrical tests in acute facial paralysis. Am J Otol. 1984;5:494.
  2. Brodie HA, and Thompson TC: Management of complications from 820 temporal bone fractures. Am J Otol. 1997;18:188.
  3. Claflin, E. S. & Robinson, L. R. How soon after temporal bone fracture should we perform electroneurography? Muscle Nerve. 44, 304 (2011).
  4. May M, Blumenthal F, and Klein SR: Acute Bell's palsy: prognostic value of evoked electromyography, maximal stimulation, and other electrical tests. Am J Otol. 1983;5:1.

Imaging

Learning Objectives 
  1. Appreciate key findings on High resolution computed tomography of temporal bone<./li>
  2. Determine when CT angiography would be obtained.
References 
  1. Collins, J. M., Krishnamoorthy, A. K., Kubal, W. S., Johnson, M. H. & Poon, C. S. Multidetector CT of Temporal Bone Fractures. Seminars in Ultrasound, CT and MRI 33, 418–431 (2012).
  2. Resnick DK, Subach BR, and Marion DW: The significance of carotid canal involvement in basilar cranial fractures. Neurosurgery. 1997;40:1177.
  3. Kahn JB, Stewart MG, and Diaz-Marchan PJ: Acute temporal bone trauma: utility of high-resolution computed tomography. Am J Otol. 2000;21:743.
  4. Ishman, S. L. & Friedland, D. R. Temporal bone fractures: traditional classification and clinical relevance. Laryngoscope. 114, 1734–1741 (2004).
  5. Schubl, S. D. et al. Temporal bone fracture: Evaluation in the era of modern computed tomography. Injury 47, 1893–1897 (2016).
  6. Little, S. C. & Kesser, B. W. Radiographic classification of temporal bone fractures: clinical predictability using a new system. Arch. Otolaryngol. Head Neck Surg. 132, 1300–1304 (2006).
  7. Song, S. W., Jun, B. C. & Kim, H. Clinical features and radiological evaluation of otic capsule sparing temporal bone fractures. Journal of Laryngology and Otology 131, 209–214 (2017).
  8. Kerwin AJ, Bynoe RP, Murray J, et al: Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001; 51: pp. 308

Pathology

Learning Objectives 
  1. Appreciate most common location for facial nerve injury.
  2. List ways facial nerve is injured.
  3. Recognize natural history of traumatic facial nerve injury.
  4. Describe ways hearing loss develops.
References 
  1. Turner JWA. Facial palsy in closed head injuries. Lancet. 1944;243:756.
  2. Fisch U. Facial paralysis in fractures of the petrous bone. Laryngoscope. 1974;84:2141
  3. Tos M. Prognosis of hearing loss in temporal bone fractures. Laryngol Otol. 1971;85:1147
  4. Dommerby H, and Tos M. Sensorineural hearing loss in posttraumatic incus dislocation. Arch Otolaryngol. 1983;109:257
  5. Podoshin L, and Fradis M. Hearing loss after head injury. Arch Otolaryngol. 1975;101:15

Treatment

Learning Objectives 

Recognize role of observation and decompression in facial nerve paralysis.

References 
  1. Brodie HA, and Thompson TC: Management of complications from 820 temporal bone fractures. Am J Otol. 1997;18:188.
  2. Darrouzet V, Duclos JY, Liguoro D, et al: Management of facial paralysis resulting from temporal bone fractures: our experience in 115 cases. Otolaryngol Head Neck Surg. 2001;125:77.

Medical Therapies

Learning Objectives 

Determine role of steroids in facial nerve paralysis.

References 
  1. Chang JCY, and Cass S: Management of facial nerve injury due to temporal bone trauma. Am J Otol 1999; 20: pp. 96

Surgical Therapies

Learning Objectives 
  1. Determine role of surgery in complete facial nerve paralysis.
  2. List electrodiagnostic criteria for surgical decompression.
  3. Describe surgical approaches and their indications for facial nerve decompression.
  4. Understand outcomes for early and late decompression.
References 
  1. Chang JCY, and Cass S: Management of facial nerve injury due to temporal bone trauma. Am J Otol 1999; 20: pp. 96
  2. Nash J, Friedland D, Boorsma K, et al: Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope 2010; 120: pp. 1397
  3. Kim, J., Moon, I. S., Shim, D.-B. & Lee, W. S. The effect of surgical timing on functional outcomes of traumatic facial nerve paralysis. Journal of Trauma - Injury, Infection and Critical Care 68, 924–929 (2010).
  4. Xie, S. et al. The timing of surgical treatment of traumatic facial paralysis: a systematic review. Acta Oto-Laryngologica 136, 1197–1200 (2016).
  5. Quaranta, A., Campobasso, G., Piazza, F., Quaranta, N. & Salonna, I. Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery. Acta Otolaryngol. 121, 652–655 (2001).
  6. Hough JVD, and Stuart WD: Middle ear injuries in skull trauma. Laryngoscope 1968; 78: pp. 899
  7. Tos M: Prognosis of hearing loss in temporal bone fractures. Laryngol Otol 1971; 85: pp. 1147

Case Studies

You are consulted on a 24 year old male who sustained multiple head fractures, including a right temporal bone fracture from an ATV accident. He is now 5 days since the accident and recently awake after extubation. He has complete right facial paralysis and also reports hearing loss and clear otorrhea. It is unclear when the facial paralysis started. What is the workup for this patient? What testing is involved? Will you recommend surgical decompression?

Complications

Learning Objectives 
  1. Describe mechanism for CSF fistula formation and healing.
  2. Describe detection methods and management for CSF fistula.
  3. Understand importance of CSF fistula duration and development of meningitis.
  4. Recognize development of progressive or fluctuating hearing loss post injury.
  5. Appreciate formation of cholesteatoma in temporal bone trauma.
  6. Describe sensorineural hearing loss outcomes
  7. Determine when to perform ossicular reconstruction.
References 
  1. Brodie HA, and Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol. 1997 March;18(2):188-97. 
  2. Chang CY, and Cass SP. Management of facial nerve injury due to temporal bone trauma. Am J Otol. 1999 Jan;20(1):96-114.
  3. Diaz RC, Cervenka B, and Brodie, HA. Treatment of Temporal Bone Fractures. J Neurol Surg Skull Base. 2016 Oct;77(5):419-29. doi: 10.1055/s-0036-1584197. Epub 2016 Jun 2.
  4. McKennan KX, and Chole RA. Facial paralysis in temporal bone trauma. Am J Otol. 1992 Mar;13(2):167-72.
  5. Nash JJ, Friedland DR, Boorsma KJ, and Rhee JS. Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope. 2010;120 Suppl 4:S214. doi: 10.1002/lary.21681.
  6. Grahne B. Traumatic cranionasal fistulas persistent cerebrospinal fluid rhinorrhea and their repair with frontal sinus osteoplasty. Acta Otolaryngol. 1970 Nov-Dec;70(5):392-400.
  7. Savva A, Taylor MJ, and Beatty CW. Management of cerebrospinal fluid leaks involving the temporal bone: report on 92 patients. Laryngoscope. 2003 Jan;113(1):50-6.
  8. Meurman OH, Irjala K, Suonpää J, and Laurent B. A new method for the identification of cerebrospinal fluid leakage. Acta Otolaryngol. 1979 Mar-Apr;87(3-4):366-9.
  9. Arrer E, Meco C, Oberascher G, et al., Beta-trace protein as a marker for cerebrospinal fluid rhinorrhea. Clin Chem. 2002 Jun;48(6 Pt 1):939-41.
  10. Stone JA, Castillo M, Neelon B, and Mukerji SK. Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography. AJNR Am J Neuroradiol. 1999 Apr;20(4):706-12.
  11. Ratilal BO, Costa J, Pappamikail L, and Sampaio C.Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015 Apr 28;(4):CD004884. doi: 10.1002/14651858.CD004884.pub4.
  12. Coker NJ, Jenkins HA, and Fisch U. Obliteration of the middle ear and mastoid cleft in subtotal petrosectomy. Indications, technique and results. Ann Otol Rhinol Laryngol. 1986;95(1):5-11.
  13. Lyos AT, Marsh MA, Jenkins HA, and Coker NJ. Progressive hearing loss after transverse temporal bone fracture. Arch Otolaryngol Head Neck Surg. 1995 Jul;121(7):795-9.
  14. Choi, H. G. et al. The Rates and Clinical Characteristics of Pneumolabyrinth in Temporal Bone Fracture. Otol Neurotol. 2015 Jul;36(6):1048-53. doi: 10.1097/MAO.0000000000000662.
  15. Rizvi SS, and Gibbin KP. Effect of transverse temporal bone fracture on the fluid compartment of the inner ear. Ann Otol Rhinol Laryngol. 1979 Nov-Dec;88(Pt 1):741-8.

Review

Review Questions 
  1. What are common clinical findings with otic capsule involving or sparing fractures?
  2. What is earliest time electrodiagnostic tests are valid?
  3. How are facial nerve decompression techniques influenced by hearing status?
  4. What is role of antibiotics in temporal bone fracture?
  5. When is CT angiography indicated?