eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Trauma

Temporal Bone Fractures: Workup

Author: Antonio Riera March, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine
Coauthor(s): Sarah Connell, MD, Fellow, Department of Otolaryngology, Head and Neck Surgery, University of Miami, Jackson Memorial Hospital; Peter C Belafsky, MD, MPH, PhD, Assistant Professor, Department of Otolaryngology, University of California at Davis; Mark L Belafsky, MD, FACS, Clinical Instructor, Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University
Contributor Information and Disclosures

Updated: Mar 20, 2008

Workup

Imaging Studies

Most patients with temporal bone fracture have already had a CT scan of the head to rule out or identify intracranial injuries.

  • High-resolution CT (HRCT) of the temporal bone is useful in assessing injuries complicated by CSF leak, facial paralysis, or suspected vascular injury (see Image 5). Axial and coronal images are usually obtained with 1-mm sections, as are magnified views of the temporal bone. Bone windows are necessary.  
  • HRCT of the temporal bone is indicated if surgical intervention for management of otologic complications is required.
  • If transient or persistent neurologic deficits are present in a patient with basilar skull fracture, HRCT of temporal bone with CT angiography is indicated to evaluate for petrous carotid injury.
  • Magnetic resonance imaging (MRI) can not identify temporal bone fracture. MRI has both poor sensitivity and specificity.Furthermore, MRI is not helpful in the assessment of the facial nerve after temporal bone trauma. However, it can identify intralabyrinthine hemorrhage, brainstem injury, and nerve compression.

Other Tests

Maximum stimulation test

This test is based on the observation of twitch of the facial musculature using the Hilger facial nerve stimulator after the third day of the injury.  It is used only in the case of complete facial nerve paralysis (as determined by the House-Brackman grading) because of the pain caused by the facial stimulation. Supramaximal stimulation is applied with a maximal tolerated current on the normal side. The affected side is compared with the normal side, using the same stimulating current. An absent or markedly decreased response (barely perceptible movement) indicate a poor and incomplete return of facial nerve function.

Nerve excitability test (minimal nerve excitability test)

This test is similar to the previous test that used the Hilger nerve stimulator after the third day of injury; this test compares the amperage site-to-site necessary to initiate a barely visible response on the affected side. A difference of 3.5 mA or more is significant, carries a poor prognosis, and indicates the need to consider surgical exploration.

Electroneurography

Electroneurography (ENOG) is the technique designed by Fisch. It is used every 2 days between the third and the 21st day after the initial trauma. The results are expressed as a percentage of the amplitude of the action potentials on the paralyzed side as compared with the nonparalyzed side. The results correlate well with the percentage of nerve degeneration. According to Fisch, 90% degeneration of the involved nerve is considered significant and represents the threshold for surgical management.9

Fisch has developed accepted indications for surgical management based on the “percentage of nerve degeneration,” advocating exploration and decompression or repair when the ENOG indicates 90% degeneration. In other words, degeneration with 10% or less of nerve function compared with the normal side is considered the critical turning point for surgical management recommendation. Fisch found, histologically, that traumatic injury at the geniculate ganglion induces retrograde degeneration through the labyrinthine and distal meatal segments of the facial nerve. Fisch believes that fibrosis occurs and blocks regenerating fibers and, therefore, advises early surgery in order to avoid this fibrotic complication within the fallopian canal.

Nosan et al believe that ENOG is of paramount importance in determining the need for and the timing of surgery for facial paralysis after trauma. They believe that ENOG has made the determination of the clinical onset of paralysis less necessary and that patients with delayed paralysis can have more severe injuries than those patients with more rapid ENOG degeneration. They believe that the time of paralysis from onset of injury should not confuse the issue.

Electromyography

Normal resting muscle does not produce spontaneous electrical activity. Spontaneous electromyographic activity (fibrillation potentials) found in the muscle indicates complete denervation. Take into consideration that fibrillation potentials take at least 3 weeks to be detected with electromyography. The presence of voluntary motor units (polyphasic action potentials), on the contrary, is a good prognostic factor and the best indicator that regeneration is taking place.

The surgical approach is controversial. Some authorities advocate limited exploration of the facial nerve based on clinical and radiographic information. Fisch, on the other hand, advocates total facial nerve exploration and decompression by a middle fossa and transmastoid approach. In patients who have total sensorineural hearing loss, Fisch suggests a translabyrinthine approach.

More on Temporal Bone Fractures

Overview: Temporal Bone Fractures
Workup: Temporal Bone Fractures
Treatment: Temporal Bone Fractures
Multimedia: Temporal Bone Fractures
References
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Further Reading

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Keywords

temporal bone injuries, temporal bone trauma, basilar skull fractures, longitudinal fractures, transverse fractures, oblique fractures, mixed fractures, otic capsule sparing fractures, otic capsule disrupting fractures, head trauma, motor vehicle accidents, MVAs, motor vehicle collisions, MVCs, stab wounds, gunshot wounds, penetrating wounds, tympanic membrane laceration, tympanic membrane perforation, ossicular chain disruption, ossicular chain disruption, ossicular chain fracture, conductive hearing loss, sensorineural hearing loss, mixed hearing loss, facial nerve paralysis, vertigo, posttraumatic vertigo, positional vertigo, postural vertigo, benign paroxysmal postural vertigo

BPPV, nystagmus, spontaneous nystagmus, positional nystagmus, postural nystagmus, third degree nystagmus, second degree nystagmus, first degree nystagmus, hemotympanum, CSF otorrhea, CSF leak, SF fistula, otorrhagia, incudostapedial joint separation, incudomalleolar joint separation, incus dislocation, malleus dislocation, stapes crura fracture, stapes avulsion-stapediovestibular joint separation, labyrinthitis ossificans, cochlear implants, traumatic endolymphatic hydrops, perilymphatic fistula, meningitis, Maximun Stimulation Test, MST, Nerve Excitability test, Minimal Nerve Excitability test, NET, electroneuronography, ENOG, electromyelography, EMG, abducens paralysis, sigmoid sinus thrombosis, posttraumatic cholesteatoma, Eagle syndrome, sympathetic cochleolabyrintitis

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Contributor Information and Disclosures

Author

Antonio Riera March, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine
Antonio Riera March, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, and Society for Ear, Nose and Throat Advances in Children
Disclosure: Nothing to disclose.

Coauthor(s)

Sarah Connell, MD, Fellow, Department of Otolaryngology, Head and Neck Surgery, University of Miami, Jackson Memorial Hospital
Sarah Connell, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and Triological Society
Disclosure: Nothing to disclose.

Peter C Belafsky, MD, MPH, PhD, Assistant Professor, Department of Otolaryngology, University of California at Davis
Peter C Belafsky, MD, MPH, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Mark L Belafsky, MD, FACS, Clinical Instructor, Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University
Mark L Belafsky, MD, FACS is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jack A Shohet, MD, Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California Irvine; Otolaryngologist, Shohet Ear Associates Medical Group, Inc
Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, American Tinnitus Association, and California Medical Association
Disclosure: Envoy Medical Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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, Department of Otolaryngology-Head and Neck Surgery, 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 unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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