Intratemporal Bone Trauma Workup

  • Author: Noah Massa, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Feb 29, 2012
 

Imaging Studies

  • CT scanning
    • A high-resolution CT scan of the temporal bone can reveal findings diagnostic of temporal bone fracture, as depicted in the images below.High-resolution CT scan of the temporal bone demonHigh-resolution CT scan of the temporal bone demonstrates a longitudinal temporal bone fracture. Number sign marks the lateral extent of the fracture. High-resolution CT scan of the temporal bone demonHigh-resolution CT scan of the temporal bone demonstrates a transverse temporal bone fracture. Number sign marks the lateral extent of the fracture.
    • Scans reveal multiple fracture lines in most cases, and they may reveal bony impingement of the facial canal.
    • Whenever possible, direct axial and coronal scanning should be performed with 0.6 mm sections and with bone-algorithm views.
    • The integrity of the ossicular chain may also be evaluated with an optimal CT scan.
  • Magnetic resonance imaging
    • Gadolinium-enhanced MRI has been used to study facial nerve injuries after trauma.
    • MRI is often warranted to evaluate concomitant intracranial injuries.
    • The usefulness of MRI is limited because global signal enhancement makes interpretation of images difficult.
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Other Tests

  • Audiometric testing: When the patient's condition permits, formal audiologic testing should be performed to characterize the extent of hearing loss. The findings help in determining the surgical approach if and when surgery is necessary.
  • Electrophysiologic assessment of the facial nerve: The most common electrodiagnostic tests used are ENoG and EMG.
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Histologic Findings

On a histopathologic level, most injuries to the facial nerve occur in the labyrinthine segment and perigeniculate region, resulting in anterograde and retrograde axonal degeneration. This area includes the narrowest portion of the facial canal, or the meatal foramen, which measures 0.68 mm in diameter. Edema or hematoma in this confined space may result in ischemic injury to the facial nerve secondary to compression of its vascular supply. In some patients, formation of intraneural fibrosis at the site of injury impedes distal regeneration of axons, resulting in poor functional recovery though proximal regeneration seems to occur.

Ulug et al described surgical findings in 11 patients with complete facial paralysis after temporal bone fracture treated with surgical exploration.[7] Fibrosis at the geniculate ganglion was seen in 5 fractures, impingement of the facial nerve by bone spicules at the geniculate ganglion in 2 fractures, disruption or laceration at the origin of the greater superficial petrosal nerve in 2 fractures, and perigeniculate ganglion edema in the remaining 2 fractures.

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Contributor Information and Disclosures
Author

Noah Massa, MD, FRCSC  Staff Physician, Department of Otolaryngology, Vernon Jubilee Hospital, Canada

Noah Massa, MD, FRCSC, is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Brian D Westerberg, MD, FRCSC  Clinical Associate Professor, Division of Otolaryngology, University of British Columbia Faculty of Medicine, Canada

Brian D Westerberg, MD, FRCSC is a member of the following medical societies: American Laryngological Rhinological and Otological Society, British Columbia Medical Association, and Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Hassan H Ramadan, MD, MSc  Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Stephen G Batuello, MD  Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

References

  1. May M. Trauma to the facial nerve. Otolaryngol Clin North Am. Aug 1983;16(3):661-70. [Medline].

  2. Gurdjian ES, Lissner HR. Deformation of the skull in head injury studied by the "stresscoat" technique, quantitative determinations. Surg Gynecol Obstet. 1946;83:219-233.

  3. Dahiya R, Keller JD, Litofsky NS, Bankey PE, Bonassar LJ, Megerian CA. Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J Trauma. Dec 1999;47(6):1079-83. [Medline].

  4. Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol. Mar 1997;18(2):188-97. [Medline].

  5. Chang CY, Cass SP. Management of facial nerve injury due to temporal bone trauma. Am J Otol. Jan 1999;20(1):96-114. [Medline].

  6. Fisch U. Surgery for Bell's palsy. Arch Otolaryngol. Jan 1981;107(1):1-11. [Medline].

  7. Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol. Jul-Aug 2005;26(4):230-8. [Medline].

  8. Bodenez C, Darrouzet V, Rouanet-Larriviere M, et al. [Facial paralysis after temporal bone trauma]. Ann Otolaryngol Chir Cervicofac. Feb 2006;123(1):9-16. [Medline].

  9. Nash JJ, Friedland DR, Boorsma KJ, Rhee JS. Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope. Jul 2010;120(7):1397-404. [Medline].

  10. Patel A, Groppo E. Management of temporal bone trauma. Craniomaxillofac Trauma Reconstr. Jun 2010;3(2):105-13. [Medline]. [Full Text].

  11. Kim J, Moon IS, Shim DB, Lee WS. The effect of surgical timing on functional outcomes of traumatic facial nerve paralysis. J Trauma. Apr 2010;68(4):924-9. [Medline].

  12. McKennan KX, Chole RA. Facial paralysis in temporal bone trauma. Am J Otol. Mar 1992;13(2):167-72. [Medline].

  13. Darrouzet V, Duclos JY, Liguoro D, Truilhe Y, De Bonfils C, Bebear JP. Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases. Otolaryngol Head Neck Surg. Jul 2001;125(1):77-84. [Medline].

  14. Quaranta A, Campobasso G, Piazza F, Quaranta N, Salonna I. Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery. Acta Otolaryngol. Jul 2001;121(5):652-5. [Medline].

  15. Aguilar EA 3rd, Yeakley JW, Ghorayeb BY, Hauser M, Cabrera J, Jahrsdoerfer RA. High resolution CT scan of temporal bone fractures: association of facial nerve paralysis with temporal bone fractures. Head Neck Surg. Jan-Feb 1987;9(3):162-6. [Medline].

  16. Baxter A. Dehiscence of the Fallopian canal. An anatomical study. J Laryngol Otol. Jun 1971;85(6):587-94. [Medline].

  17. Bergman I, May M, Wessel HB, Stool SE. Management of facial palsy caused by birth trauma. Laryngoscope. Apr 1986;96(4):381-4. [Medline].

  18. Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol. Mar 1997;18(2):188-97. [Medline].

  19. Guerrissi JO. Facial nerve paralysis after intratemporal and extratemporal blunt trauma. J Craniofac Surg. Sep 1997;8(5):431-7. [Medline].

  20. Haberkamp TJ, Harvey SA, Daniels DL. The use of gadolinium-enhanced magnetic resonance imaging to determine lesion site in traumatic facial paralysis. Laryngoscope. Dec 1990;100(12):1294-300. [Medline].

  21. Nosan DK, Benecke JE Jr, Murr AH. Current perspective on temporal bone trauma. Otolaryngol Head Neck Surg. Jul 1997;117(1):67-71. [Medline].

  22. Pulec JL. Total facial nerve decompression: technique to avoid complications. Ear Nose Throat J. Jul 1996;75(7):410-5. [Medline].

 
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Proposed algorithm for the management of intratemporal injury to the facial nerve.
Fracture pattern of longitudinal temporal bone fractures. The axis of fracture is parallel to the petrous ridge after a person receives lateral blows to the skull (arrow).
Potential fracture plane and structures involved in longitudinal temporal bone fractures.
Fracture pattern of transverse temporal bone fractures. The axis of fracture is perpendicular to the petrous ridge extending to the foramen magnum after a person receives frontal or occipital blows to the skull (arrow).
Potential fracture plane and structures involved in transverse temporal bone fractures.
High-resolution CT scan of the temporal bone demonstrates a longitudinal temporal bone fracture. Number sign marks the lateral extent of the fracture.
High-resolution CT scan of the temporal bone demonstrates a transverse temporal bone fracture. Number sign marks the lateral extent of the fracture.
 
 
 
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