Temporal bone trauma can cause a wide range of clinical issues involving hearing loss, dizziness, CSF leaks, and facial nerve injuries. Knowledge of temporal bone anatomy is important for diagnosis and management. The most common causes are motor vehicle accidents and penetrating trauma. Evaluation involves a thorough head and neck exam and imaging like CT and MRI. Findings may include basilar skull fractures, mastoid ecchymosis, and hemotympanum. Treatment depends on the specific problems but may include observation, antibiotics, surgery to repair CSF leaks, and facial nerve decompression. Prognosis relates to the severity and location of injuries as well as how quickly they are identified and addressed.
Five pearls and pitfalls in using head CT for diagnosis of traumatic brain injury. This was presented at the 51st Annual Scientific Meeting of the Royal College of Radiologists of Thailand (6 Aug 2014)
Five pearls and pitfalls in using head CT for diagnosis of traumatic brain injury. This was presented at the 51st Annual Scientific Meeting of the Royal College of Radiologists of Thailand (6 Aug 2014)
Transcatheter Aortic Valve Replacement (TAVR) is a transformational and rapidly evolving treatment for the patients with aortic stenosis which require valve replacement surgery. Get more details at website.
For More Information:
http://www.keystoneheart.com/us/clinical-evidence/clinical-studies/
info@keystoneheart.com
1 877 575 4433
Spine surgeon Dr Arun L Naik Bangalore india Dr Arun L Naik
Dr Arun L Naik is a Spine Surgeon practicing in India Bangalore for 14 years. He was trained at AIIMS New Delhi in 2000. He is well known for his surgery for ''failed back surgery syndrome'' where previous surgery was gone wrong. He has expertise in 'minimal invasive key hole spine surgery'' . He operates on complex spinal cord tumors which are challenges to any surgeon. Dr Naik is one of the few neurosurgeons in India to operate on cranio vertebral junction with excellent surgical results. Spinal cord injuries are special areas of interest to him. He has successfully treated hundreds of spinal injured patients many of whom are walking today. He has trained many surgeons in developing spine surgery technique.
Late onset jugular foramen syndrome following head traumaNeuro Surgeon
Dr Vineet Saggar is an alumnus of D.A.V college Chandigarh sec-10.After his MBBS from Maulana Azad Medical College (M.A.M.C) New Delhi in 2002 , he did his Post Graduation in General Surgery from Safdarjung Hospital (2002-2005). He went for his training in MCh Neuro Surgery at S.M.S Medical College Jaipur. At Jaipur he got the privilege of working with one of the pillars of Spinal Surgery -Prof. R.S. Mittal under whom he trained for almost 2yrs. After completing his MCh in July 2009, he trained under Prof. S.R. Dharker one of the pioneers of Micro- Vascular Neurosurgery in Rajasthan and India. During this time he also assisted Dr S.K Basandani another eminent Spinal Surgeon at Jaipur. Before joining Ivy Hospital as consultant Neuro Spinal Surgeon, he headed Department of Neurosurgery at Adesh Medical College Bathinda for some time. He has special interest in Spinal Surgery and Skull-Based Micro Neurosurgery. Apart from many national and international publications on Spine Surgeries, he also has research publications on Head Injury to his credit .
Late onset jugular foramen syndrome following head traumaNeuro Surgeon
Recklinghausen's disease. Neurological examination revealed spastic quadriparesis, prominent in the left extremities. Posterior column sensations were lost in all four limbs. Deep tendon reflexes were exaggerated in all four limbs. A positive Hoffman s and Babinsky signs and sign were present bilaterally. Gait was broad-based due to spasticity. Difficulty in urination was present .MRI of cervical spine was done at some other institute revealed a large well defined homogenously enhancing intradural extramedullary mass at C1-2 level on left side markedly compressing the cord, there was associated cord edema at adjacent cervical levels(fig.1&2). A provisional diagnosis of schwannoma or neurofibroma was kept since there was no dural tail or broad based attachment of tumor to dura.
Patient was advised surgical removal of tumour . Tumor was approached via midline incision in neck and C-1 to C-3 laminectomy was done. Dura was opened under microscope and tumor was found on left side and whole of the tumor was intra arachnoidal. To our surprise though tumor was mainly extra medullary on left side ,it had an intra-medullary extension. Extramedullary component was completely removed followed by intatumoral decompression of intra medullary part.Capsule of intramedullary component was densely adherent to spinal cord and small amount of tumor tissue had to be left behind to avoid post operative neurological deficit(fig.4). Duraplasty was done. In the postoperative period the power of the patient improved gradually and by the end of the first week she could walk without support and at the end of one month power in all four limbs was 5/5 , though spasticity remained in all four limbs. Her gait remain broad based and there is clumsiness while walking.
DISCUSSION
Intramedullary schwannomas are rare tumors . The first surgical description of a spinal tumor was made in 1888 by Sir Victor Horsley(3). In 1907 Von Eiselberg published the successful resection of an intramedullary neurofibrosarcoma. First intramedullary schwannoma was reported by Kernohanin1952 though Penfield had already described an intramedullary lesion with schwannoma characteristics in 1932(4).
We found 52 cases in the literature, in addition to our case. Of these cases only three have been reported as having both intramedullary and extramedullary component . Gorman etal., have reported the extramedullary component to be an exophytic extension of the intramedullary tumor from the enlarged spinal cord(5).
Mean age at presentation of these lesions is 40-years . They are usually single lesions affecting the cervical spinal cord (63%), the thoracic spinal cord (26%) and the lumbar spinal cord (11%). They have a slow growth pattern and because of this the average interval between first symptoms and diagnosis is 28.2 months (from six months to 20 years)(6). The most described clinical manifestation is the pyramidal syndrome followed by sensitivity complaints and sphincter dysfunctio
Transcatheter Aortic Valve Replacement (TAVR) is a transformational and rapidly evolving treatment for the patients with aortic stenosis which require valve replacement surgery. Get more details at website.
For More Information:
http://www.keystoneheart.com/us/clinical-evidence/clinical-studies/
info@keystoneheart.com
1 877 575 4433
Spine surgeon Dr Arun L Naik Bangalore india Dr Arun L Naik
Dr Arun L Naik is a Spine Surgeon practicing in India Bangalore for 14 years. He was trained at AIIMS New Delhi in 2000. He is well known for his surgery for ''failed back surgery syndrome'' where previous surgery was gone wrong. He has expertise in 'minimal invasive key hole spine surgery'' . He operates on complex spinal cord tumors which are challenges to any surgeon. Dr Naik is one of the few neurosurgeons in India to operate on cranio vertebral junction with excellent surgical results. Spinal cord injuries are special areas of interest to him. He has successfully treated hundreds of spinal injured patients many of whom are walking today. He has trained many surgeons in developing spine surgery technique.
Late onset jugular foramen syndrome following head traumaNeuro Surgeon
Dr Vineet Saggar is an alumnus of D.A.V college Chandigarh sec-10.After his MBBS from Maulana Azad Medical College (M.A.M.C) New Delhi in 2002 , he did his Post Graduation in General Surgery from Safdarjung Hospital (2002-2005). He went for his training in MCh Neuro Surgery at S.M.S Medical College Jaipur. At Jaipur he got the privilege of working with one of the pillars of Spinal Surgery -Prof. R.S. Mittal under whom he trained for almost 2yrs. After completing his MCh in July 2009, he trained under Prof. S.R. Dharker one of the pioneers of Micro- Vascular Neurosurgery in Rajasthan and India. During this time he also assisted Dr S.K Basandani another eminent Spinal Surgeon at Jaipur. Before joining Ivy Hospital as consultant Neuro Spinal Surgeon, he headed Department of Neurosurgery at Adesh Medical College Bathinda for some time. He has special interest in Spinal Surgery and Skull-Based Micro Neurosurgery. Apart from many national and international publications on Spine Surgeries, he also has research publications on Head Injury to his credit .
Late onset jugular foramen syndrome following head traumaNeuro Surgeon
Recklinghausen's disease. Neurological examination revealed spastic quadriparesis, prominent in the left extremities. Posterior column sensations were lost in all four limbs. Deep tendon reflexes were exaggerated in all four limbs. A positive Hoffman s and Babinsky signs and sign were present bilaterally. Gait was broad-based due to spasticity. Difficulty in urination was present .MRI of cervical spine was done at some other institute revealed a large well defined homogenously enhancing intradural extramedullary mass at C1-2 level on left side markedly compressing the cord, there was associated cord edema at adjacent cervical levels(fig.1&2). A provisional diagnosis of schwannoma or neurofibroma was kept since there was no dural tail or broad based attachment of tumor to dura.
Patient was advised surgical removal of tumour . Tumor was approached via midline incision in neck and C-1 to C-3 laminectomy was done. Dura was opened under microscope and tumor was found on left side and whole of the tumor was intra arachnoidal. To our surprise though tumor was mainly extra medullary on left side ,it had an intra-medullary extension. Extramedullary component was completely removed followed by intatumoral decompression of intra medullary part.Capsule of intramedullary component was densely adherent to spinal cord and small amount of tumor tissue had to be left behind to avoid post operative neurological deficit(fig.4). Duraplasty was done. In the postoperative period the power of the patient improved gradually and by the end of the first week she could walk without support and at the end of one month power in all four limbs was 5/5 , though spasticity remained in all four limbs. Her gait remain broad based and there is clumsiness while walking.
DISCUSSION
Intramedullary schwannomas are rare tumors . The first surgical description of a spinal tumor was made in 1888 by Sir Victor Horsley(3). In 1907 Von Eiselberg published the successful resection of an intramedullary neurofibrosarcoma. First intramedullary schwannoma was reported by Kernohanin1952 though Penfield had already described an intramedullary lesion with schwannoma characteristics in 1932(4).
We found 52 cases in the literature, in addition to our case. Of these cases only three have been reported as having both intramedullary and extramedullary component . Gorman etal., have reported the extramedullary component to be an exophytic extension of the intramedullary tumor from the enlarged spinal cord(5).
Mean age at presentation of these lesions is 40-years . They are usually single lesions affecting the cervical spinal cord (63%), the thoracic spinal cord (26%) and the lumbar spinal cord (11%). They have a slow growth pattern and because of this the average interval between first symptoms and diagnosis is 28.2 months (from six months to 20 years)(6). The most described clinical manifestation is the pyramidal syndrome followed by sensitivity complaints and sphincter dysfunctio
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
8. Longitudinal fractures
80% of Temporal
Bone Fractures
Lateral Forces along
the petrosquamous
suture line
15-20% Facial Nerve
involvement
EAC laceration
9. Transverse fractures
20% of Temporal
Bone Fractures
Forces in the Antero-
Posterior direction
50% Facial Nerve
Involvement
EAC intact
10. Temporal Bone Trauma
Hearing Loss
Dizziness/Vertigo
CSF Otorrhea
Facial Nerve Injuries
11. Hearing Loss
Formal Audiometry
vs. Tuning Fork
71% of patients with
Temporal Bone
Trauma have hearing
loss
TM Perforations
CHL > 40db
suspicious for
ossicular discontinuity
12. Hearing Loss
Longitudinal Fractures
Conductive or mixed hearing loss
80% of CHL resolve spontaneously
Transverse Fractures
Sensorineural hearing loss
Less likely to improve
13. Hearing Loss
Tympanic Membrane Perforations
Ossicular fracture or discontinuity
Hemotympanum
Treatment:
Observation
Otic solutions may only mask CSF leaks
14. Dizziness
Fracture through the otic capsule or a
labyrinthine concussion
Difficult diagnosis- bed rest, obtundation,
sedation
Treatment: reserved for vomiting,
limitation of activity
Vestibular suppressants
Allow for maximal central compensation
15. Dizziness
Perilymphatic Fistulas
SCUBA diver with ETD
Fluctuating dizziness and/or hearing
loss
Tullio’s Phenomenon
Management
• Conservative treatment in first 10-14 days
• 40% spontaneously close
• Surgical management for persistent
vertigo or hearing loss
• Regardless of visualization of fistula site,
the majority of patients get better
16. Dizziness
Inner Ear
Decompression
Sickness
Too rapid an ascent
leads to percolation of
nitrogen bubbles within
the otic capsule.
Greater than 30 ft….
Decompression stages
upon ascent are
needed
17. Dizziness
BPPV
Acute, latent, and
fatiguable vertigo
Can occur any time
following injury
Dix Hallpike
Epley Maneuver
19. Temporal bone fractures
Longitudinal
80% of Temp bone fx
Anterior to otic capsule
Involve the dura of the
middle fossa
20. Temporal bone fractures
Transverse
20% of Temp bone fx
High rate of SNHL due
to violation of the otic
capsule
50% facial nerve
involvement
21. Testing of Nasal Secretions
Beta-2-transferrin is highly sensitive and
specific
1/50th of a drop
Gold top tube, may need to send a sample of
the patients serum also.
Found in Vitreous Humor, Perilymph, CSF
Electronic nose has shown early success
Faster (<24hrs)
Very Accurate
23. Imaging
Slow flow MRI
Diffusion weighted
MRI
Fluid motion down to
0.5mm/sec
Ex. MRA/MRV
24. Treatment of CSF Otorrhea
Conservative measures
Bed rest/Elev HOB>30
Stool softeners
No sneezing/coughing
+/- lumbar drains
Early failures
Assoc with hydrocephalus
Recurrent or persistent leaks
25. Treatment of CSF Otorrhea
Brodie and Thompson et al.
820 T-bone fractures/122 CSF leaks
Spontaneous resolution with conservative
measures
95/122 (78%): within 7 days
21/122(17%): between 7-14 days
5/122(4%): Persisted beyond 2 weeks
26. Temporal bone fractures
Meningitis
9/121 (7%) developed meningitis. Found no
significant difference in the rate of meningitis
in the ABX group versus no ABX group.
A later meta-analysis by the same author
did reveal a statistically significant
reduction in the incidence of meningitis
with the use of prophylactic antibiotics.
27. Pediatric temporal bone fractures
Much lower incidence (10:1, adult:pedi)
Undeveloped sinuses, skull flexibility
otorrhea>> rhinorrhea
Prophylactic antibiotics did not influence
the development of meningitis.
29. Overlay vs Underlay
technique
Meta-analysis
showed that both
techniques have
similar success rates
Onlay: adjacent
structures at risk, or if
the underlay is not
possible
30. Technique of closure
Muscle, fascia, fat, cartilage, etc..
The success rate is significantly higher for
those patients who undergo primary
closure with a multi-layer technique versus
those patients who only get single-layer
closure.
Refractory cases may require closure of
the EAC and obliteration.
31. Facial Nerve Injuries
Loss of forehead wrinkles
Bell’s Phenomenon
Nasal tip pointing away
Flattened Nasofacial groove
33. Facial Nerve Injuries
Initial Evaluation is the most important
prognostic factor
Previous status
Time
Onset and progression
Complete vs. Incomplete
34. House Brackman Scale
No movement
Total
VI
Assymetry at rest, barely
noticeable motion
Severe
V
Incomplete eye closure, symmetry
at rest, no forehead movement,
dysfiguring synkinesis
Moderatel
y Severe
IV
Complete eye closure, noticeable
synkinesis, slight forehead
movement
Moderate
III
II
Normal Normal facial function
Mild Slight synkinesis/weakness
I
35. Electrophysiologic Testing
NET: Nerve Excitability Test
MST: Maximal Stimulation Test
ENoG: Electroneurography
Goal is to determine whether the lesion is partial
or complete?
Neuropraxia: Transient block of axoplasmic flow ( no
neural atrophy/damage)
Axonotmesis: damage to nerve axon with
preservation of the epineurium (regrowth)
Neurotmesis: Complete disruption of the nerve ( no
chance of organized regrowth)
36. Nerve Excitability Test
Maximal Stimulation Test
Stimulating electrodes are placed and a
gross movement is recorded
Not as objective and reliable
>3.5mA difference suggests a poor
prognosis for return of facial function.
Correlates with >90% degeneration on ENoG
37. Electroneuronography
Most accurate, qualitative measurement
Sensing electrodes are placed, a voluntary
response is recorded
Accurate after 3 days
Requires an intact side to compare to
Reduction of >90% amplitude correlates
with a poor prognosis for spontaneous
recovery
38. Electromyography
Electrode is placed within the muscle and
voluntary movement is attempted.
Normal Muscle is electrically silent.
After 10-14 days, the denervated muscle
begins to spontaneously fire:
Diphasic/Polyphasic potentials: Good
Loss of voluntary potentials: Bad
40. Facial Nerve Injuries
Chang & Cass
Medline search back to 1966
Individually reviewed each article
1)Understand the pathophysiology of facial
nerve damage in temporal bone trauma.
2) What is the effect of surgical intervention
on the ultimate outcome of the facial nerve.
3) Propose a rational course for evaluation
and treatment.
41. Facial Nerve Injuries
Chang & Cass
Pathophysiology based on findings by Fisch and
Lambert and Brackmann:
Where?
Perigeniculate, Labyrinthine, and meatal segments
Concern over findings of endoneural fibrosis and neural atrophy
proximal to the lesions
In an untreated human specimen found intraneural edema and
demyelinization that extended proximally to the meatal foramen
How?
Longitudinal Fractures
• 15% transection
• 33% bony impingement, 43% hematoma
Transverse Fractures
• 92% transection
42. Does Facial Nerve decompression result in
superior functional outcomes compared with
no treatment?
Not enough human data!
Boyle-monkey: prophylactic epineural decompression in
complete paralysis did not improve recovery of facial
nerve function after induced complete paralysis
Kartush: Prophylactic decompression of the meatal
segment during acoustic neuroma decreased the
incidence of delayed paralysis
Adour: compared patients with complete paralysis found:
Equal outcome with observation vs. decompression without
nerve slitting
Worse outcome with decompression with nerve slitting
43. Does Facial Nerve decompression result in
superior functional outcomes compared with
no treatment?
Many difficulties in Study designs,
controls, etc, but they made some rough
estimates:
50% of patients who undergo facial nerve
decompression obtain excellent outcomes
The true efficacy of facial nerve
decompression surgery for trauma
remains uncertain
44. Conservative Treatment
Candidates
Chang and Cass
Present with Normal Facial Function
regardless of progression
Incomplete paralysis and no
progression to complete paralysis
Less than 95% degeneration by ENoG
• Most data comes from Bell’s palsy/tumor studies
by Fisch.
45. Conservative Treatment
Candidates
Brodie and Thompson
All patients that presented with normal facial
nerve function initially that progressed to
complete paralysis recovered to a HB
1 or 2.
46. Surgical Candidates
Critical Prognostic factors
Immediate vs. Delayed
Complete vs. Incomplete paralysis
ENoG criteria
48. Facial Nerve Injuries
Chang & Cass
What time frame is best to operate?
Fisch-cats: Decompression of the nerve within
a 12 day period resulted in “excellent”
functional recovery. Presumption was that it
preserved endoneural tubules. (limits the
damage to axonotmesis at worst)
Limits the accuracy of your patient selection
because EMG is not reliable until day 10-14.
49. Surgical Approach
Medial to the Geniculate Ganglion
No useful hearing
• Transmastoid-translabyrinthine
Intact hearing
• Transmastoid-trans-epitympanic
• Middle Cranial Fossa
Lateral to Geniculate Ganglion
Transmastoid
50. Surgical Approach
Chang & Cass
l
l
Histopathologic study
Severe facial nerve
injury results in
retrograde axonal
degeneration to the leve
of the labyrinthine and
probably meatal
segments
51. Surgical findings of greater than
50% nerve transection/damage
Nerve repair via primary anastamosis or
cable graft repair
HB 1 or 2: 0%
HB 3 or 4: 82%
HB 5 or 6: 18%
52. Iatrogenic Facial Nerve Injuries
Mastoidectomy (55%)
Tympanoplasty (14%)
Bony Exostoses (14%)
Lower tympanic segment is the most
common location injury
79% were not identified at the time of
surgery
53. Management of Iatrogenic
Facial Nerve Injuries
Green, et al.
<50% damage: perform decompression
75% had HB of 3 or better!
>50% damage: perform nerve repair
No patients had better than a HB 3
Beware of local anesthetics
General consensus: acute, complete,
postoperative paralysis should be
explored as soon as possible.
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