Otic capsule fracture with preservation of hearing and delayed-onset facial paralysis

Post-traumatic bilateral longitudinal temporal bone fracture with bilateral facial nerve palsy: a rare case

Facial paralysis is a potentially disabling complication of temporal bone fractures. Although unilateral palsy is commonly encountered, bilateral facial nerve palsy is rare, especially in post-traumatic situations. Other recognised causes of bilateral facial palsy are neurologic, infectious, neoplastic, idiopathic or metabolic disorders. A 25-year-old male patient presented with difficulty in talking, eating and closing eyes for 15 days since a post-vehicular accident. CT of skull showed bilateral longitudinal temporal bone fractures. Bilateral facial palsy was confirmed by clinical and topodiagnostic tests. Patient was given a course of steroids which led to an early improvement on left side followed by a delayed right-sided improvement at 6 months.

Using temporal bone computed tomography to predict sensorineural hearing loss in otic capsule-sparing temporal bone fracture

OBJECTIVES

The purpose of this study was to investigate the efficacy of otic capsule-sparing (OCS) length for the prediction of sensorineural hearing loss (SNHL) in patients with OCS temporal bone fracture.

METHODS

Thirty-four patients with OCS temporal bone fracture were enrolled, and their temporal bone computed tomography (TBCT), audiogram, and medical records were reviewed. The TBCT measured the shortest length between the otic capsule and fracture line. This length was referred to as the OCS length and was used to predict SNHL. Ossicular dislocation and fracture were also evaluated. Patients were divided into two groups according to the presence of SNHL. Univariate and multivariate analyses were performed for age, gender, brain hemorrhage, mean bone conduction threshold on the contralesional side, OCS length, and ossicular dislocation and fracture on TBCT. A receiver operating characteristic (ROC) curve was produced to evaluate the efficacy of OCS length for the prediction of SNHL. To determine an association between degree of SNHL and OCS length, regression analysis was conducted in the SNHL group.

RESULTS

The mean OCS lengths of the SNHL and non-SNHL groups were 4.42±1.67mm and 8.00±5.71mm, respectively. In the univariate analysis, a relatively significant association (P <0.20) was found between SNHL and age, brain hemorrhage, mean bone conduction threshold on the contralesional side, OCS length, and incus dislocation. Multivariate analysis was performed using these factors. On multivariate analysis, OCS length (P=0.030, odds ratio=0.598; 95% confidence interval 0.375-0.952) was the only independent factor associated with SNHL. The area under the curve (AUC) was 0.747. When the cut-off value of OCS length was 5.27mm, the sensitivity and specificity for the prediction of SNHL were 71.4% and 69.2%, respectively. In the regression analysis, OCS length showed a significant association with degree of SNHL in the SNHL group (P=0.025, β=-12.822, SE=5.282).

CONCLUSIONS

The major finding of our study was that OCS length was significantly associated with SNHL in patients with OCS temporal bone fracture. Such patients with a short OCS length had a higher likelihood of SNHL.

Imaging of labyrinthine fistula after repair with bone pate

OBJECTIVES/HYPOTHESIS

To demonstrate imaging of labyrinthine fistula due to cholesteatoma and illustrate outcome following repair with bone pate.

STUDY DESIGN

Retrospective review.

METHODS

Patients with labyrinthine fistula due to cholesteatoma were identified, and pre- and postoperative imaging was assessed. Method of repair was recorded. The fistula site was examined for patency and bone density after repair.

RESULTS

Twenty-nine fistulae were seen in a cohort of 375 cholesteatoma cases (8%). Preoperative computed tomography (CT) imaging for fistula detection showed sensitivity of 96% and specificity of 90%. The lateral semicircular canal was the most common site of dehiscence occurring in all cases. Facial nerve dehiscence is observed in 91% of fistula cases and stapes erosion in 69%. Severe hearing loss was present preoperatively in four (14%) cases. Bone pate was used to repair the fistula with CT-documented restoration of the otic capsule in 11/13 cases with postoperative imaging. When bone pate was not used, the otic capsule defect persisted.

CONCLUSIONS

Spontaneous repair of the otic capsule following treatment of cholesteatoma is expected to be an uncommon occurrence. Repair of the fistula with bone can result in long-lasting restoration of the otic capsule.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1643-1648, 2018.

Treatment of Temporal Bone Fractures

Traumatic injury to the temporal bone can lead to significant morbidity or mortality and knowledge of the pertinent anatomy, pathophysiology of injury, and appropriate management strategies is critical for successful recovery and rehabilitation of such injured patients. Most temporal bone fractures are caused by motor vehicle accidents. Temporal bone fractures are best classified as either otic capsule sparing or otic capsule disrupting-type fractures, as such classification correlates well with risk of concomitant functional complications. The most common complications of temporal bone fractures are facial nerve injury, cerebrospinal fluid (CSF) leak, and hearing loss. Assessment of facial nerve function as soon as possible following injury greatly facilitates clinical decision making. Use of prophylactic antibiotics in the setting of CSF leak is controversial; however, following critical analysis and interpretation of the existing classic and contemporary literature, we believe its use is absolutely warranted.

Delayed Facial Palsy After the Anterior Petrosal Approach

OBJECTIVE

In this case report, delayed facial palsy developed in a patient without any direct manipulation of the main part of the facial nerve during an anterior petrosal approach. We discuss putative etiologies and management techniques that may help avoid this problem.

CLINICAL PRESENTATION

A 21-year-old woman underwent anterior petrosectomy for gross total resection of a low-grade chondrosarcoma. Six days later, the patient presented with left-sided facial weakness in the emergency department.

RESULTS

Examination revealed evidence of House-Brackmann grade V/VI left-sided facial palsy, and repeat magnetic resonance imaging revealed diffuse enhancement of the contents of the internal auditory canal that was not present immediately after surgery. After a 10-day course of acyclovir and a tapering dose of methylprednisolone, the facial palsy slowly diminished and resolved 2 months after the onset.

CONCLUSION

This unique development of delayed facial palsy after an isolated anterior petrosal approach is evidence that this complication should be considered when dissecting along the floor of the middle fossa. Exposure of the intracranial or intracanalicular segment of the facial nerve is not necessary for delayed facial palsy to develop. Proposed mechanisms (ie, viral reactivation, vasospasm, neural edema) of this condition remain unproven. Prognosis for recovery has been reported to be excellent, with or without treatment.