Temporal bone trauma can cause a wide range of clinical issues including hearing loss, dizziness, CSF leakage, and facial nerve injuries. Proper evaluation involves thorough physical examination, imaging such as CT or MRI, and audiometric testing. Most longitudinal fractures heal well with conservative treatment, while transverse fractures often cause sensorineural hearing loss. CSF otorrhea typically stops within 2 weeks but may require surgery if persistent. Facial nerve function is a key prognostic indicator, and early intervention can improve outcomes.

1. Temporal Bone Trauma
Temporal Bone Trauma
October 12, 2005
October 12, 2005
Steven T. Wright, M.D.
Steven T. Wright, M.D.
Matthew Ryan, M.D.
Matthew Ryan, M.D.

2. Temporal Bone Trauma
Temporal Bone Trauma
 Wide spectrum of
Wide spectrum of
clinical findings
clinical findings
 Knowledge of the
Knowledge of the
anatomy is vital to
anatomy is vital to
proper diagnosis and
proper diagnosis and
appropriate
appropriate
management
management

3. Incidence and Epidemiology
Incidence and Epidemiology
 Motorized Transportation
Motorized Transportation
 30-75% of blunt head trauma had associated
30-75% of blunt head trauma had associated
temporal bone trauma
temporal bone trauma
 Penetrating Trauma
Penetrating Trauma
 More dismal prognosis
More dismal prognosis
 Barotrauma
Barotrauma
 Inner ear decompression sickness
Inner ear decompression sickness
• The “bends”
The “bends”
 Perilymphatic fistula
Perilymphatic fistula
 Blast Injuries
Blast Injuries

4. Evaluation and Management
Evaluation and Management
 ATLS
ATLS
 Airway
Airway
 Breathing
Breathing
 Circulation
Circulation
 H & P
H & P
 Thorough head & neck
Thorough head & neck
examination
examination

5. Physical Examination
Physical Examination
 Basilar Skull
Basilar Skull
Fractures
Fractures
 Periorbital Ecchymosis
Periorbital Ecchymosis
(Raccoon’s Eyes)
(Raccoon’s Eyes)
 Mastoid Ecchymosis
Mastoid Ecchymosis
(Battle’s Sign)
(Battle’s Sign)
 Hemotympanum
Hemotympanum

6. Physical Examination
Physical Examination
 Tuning Fork exam
Tuning Fork exam
 Pneumatic Otoscopy
Pneumatic Otoscopy
 Flaccid TM
Flaccid TM
 Nystagmus
Nystagmus

7. Imaging
Imaging
 HRCT
HRCT
 MRI
MRI
 Angiography/ MRA
Angiography/ MRA

8. Longitudinal fractures
Longitudinal fractures
 80% of Temporal
80% of Temporal
Bone Fractures
Bone Fractures
 Lateral Forces along
Lateral Forces along
the petrosquamous
the petrosquamous
suture line
suture line
 15-20% Facial Nerve
15-20% Facial Nerve
involvement
involvement
 EAC laceration
EAC laceration

9. Transverse fractures
Transverse fractures
 20% of Temporal
20% of Temporal
Bone Fractures
Bone Fractures
 Forces in the Antero-
Forces in the Antero-
Posterior direction
Posterior direction
 50% Facial Nerve
50% Facial Nerve
Involvement
Involvement
 EAC intact
EAC intact

10. Temporal Bone Trauma
Temporal Bone Trauma
 Hearing Loss
Hearing Loss
 Dizziness/Vertigo
Dizziness/Vertigo
 CSF Otorrhea
CSF Otorrhea
 Facial Nerve Injuries
Facial Nerve Injuries

11. Hearing Loss
Hearing Loss
 Formal Audiometry
Formal Audiometry
vs. Tuning Fork
vs. Tuning Fork
 71% of patients with
71% of patients with
Temporal Bone
Temporal Bone
Trauma have hearing
Trauma have hearing
loss
loss
 TM Perforations
TM Perforations
 CHL > 40db
CHL > 40db
suspicious for
suspicious for
ossicular discontinuity
ossicular discontinuity

12. Hearing Loss
Hearing Loss
Longitudinal Fractures
Longitudinal Fractures
 Conductive or mixed hearing loss
Conductive or mixed hearing loss
 80% of CHL resolve spontaneously
80% of CHL resolve spontaneously
 Transverse Fractures
Transverse Fractures
 Sensorineural hearing loss
Sensorineural hearing loss
 Less likely to improve
Less likely to improve

13. Hearing Loss
Hearing Loss
 Tympanic Membrane Perforations
Tympanic Membrane Perforations
 Ossicular fracture or discontinuity
Ossicular fracture or discontinuity
 Hemotympanum
Hemotympanum
 Treatment:
Treatment:
 Observation
Observation
 Otic solutions may only mask CSF leaks
Otic solutions may only mask CSF leaks

14. Dizziness
Dizziness
 Fracture through the otic capsule or a
Fracture through the otic capsule or a
labyrinthine concussion
labyrinthine concussion
 Difficult diagnosis- bed rest, obtundation,
Difficult diagnosis- bed rest, obtundation,
sedation
sedation
 Treatment: reserved for vomiting,
Treatment: reserved for vomiting,
limitation of activity
limitation of activity
 Vestibular suppressants
Vestibular suppressants
 Allow for maximal central compensation
Allow for maximal central compensation

15. Dizziness
Dizziness
 Perilymphatic Fistulas
Perilymphatic Fistulas
 SCUBA diver with ETD
SCUBA diver with ETD
 Fluctuating dizziness and/or hearing
Fluctuating dizziness and/or hearing
loss
loss
 Tullio’s Phenomenon
Tullio’s Phenomenon
 Management
Management
• Conservative treatment in first 10-14 days
Conservative treatment in first 10-14 days
• 40% spontaneously close
40% spontaneously close
• Surgical management for persistent
Surgical management for persistent
vertigo or hearing loss
vertigo or hearing loss
• Regardless of visualization of fistula site,
Regardless of visualization of fistula site,
the majority of patients get better
the majority of patients get better

16. Dizziness
Dizziness
 Inner Ear
Inner Ear
Decompression
Decompression
Sickness
Sickness
 Too rapid an ascent
Too rapid an ascent
leads to percolation of
leads to percolation of
nitrogen bubbles within
nitrogen bubbles within
the otic capsule.
the otic capsule.
 Greater than 30 ft….
Greater than 30 ft….
Decompression stages
Decompression stages
upon ascent are
upon ascent are
needed
needed

17. Dizziness
Dizziness
 BPPV
BPPV
 Acute, latent, and
Acute, latent, and
fatiguable vertigo
fatiguable vertigo
 Can occur any time
Can occur any time
following injury
following injury
 Dix Hallpike
Dix Hallpike
 Epley Maneuver
Epley Maneuver

18. CSF Otorrhea
CSF Otorrhea
 Acquired
Acquired
 Postoperative (58%)
Postoperative (58%)
 Trauma (32%)
Trauma (32%)
 Nontraumatic (11%)
Nontraumatic (11%)
 Spontaneous
Spontaneous
 Bony defect theory
Bony defect theory
 Arachnoid granulation theory
Arachnoid granulation theory

19. Temporal bone fractures
Temporal bone fractures
 Longitudinal
Longitudinal
 80% of Temp bone fx
80% of Temp bone fx
 Anterior to otic capsule
Anterior to otic capsule
 Involve the dura of the
Involve the dura of the
middle fossa
middle fossa

20. Temporal bone fractures
Temporal bone fractures
 Transverse
Transverse
 20% of Temp bone fx
20% of Temp bone fx
 High rate of SNHL due
High rate of SNHL due
to violation of the otic
to violation of the otic
capsule
capsule
 50% facial nerve
50% facial nerve
involvement
involvement

21. Testing of Nasal Secretions
Testing of Nasal Secretions
 Beta-2-transferrin is highly sensitive and
Beta-2-transferrin is highly sensitive and
specific
specific
 1/50
1/50th
th
of a drop
of a drop
 Gold top tube, may need to send a sample of
Gold top tube, may need to send a sample of
the patients serum also.
the patients serum also.
 Found in Vitreous Humor, Perilymph, CSF
Found in Vitreous Humor, Perilymph, CSF
 Electronic nose has shown early success
Electronic nose has shown early success
 Faster (<24hrs)
Faster (<24hrs)
 Very Accurate
Very Accurate

22. Imaging CSF Otorrhea
Imaging CSF Otorrhea
 High resolution CT
High resolution CT
 Convenience
Convenience
 Speed
Speed
 CT Cisternography
CT Cisternography
 MRI
MRI
 Heavily weighted T2
Heavily weighted T2
 Slow flow MRI
Slow flow MRI
 MRI cisternography
MRI cisternography

23. Imaging
Imaging
 Slow flow MRI
Slow flow MRI
 Diffusion weighted
Diffusion weighted
MRI
MRI
 Fluid motion down to
Fluid motion down to
0.5mm/sec
0.5mm/sec
 Ex. MRA/MRV
Ex. MRA/MRV

24. Treatment of CSF Otorrhea
Treatment of CSF Otorrhea
 Conservative measures
Conservative measures
 Bed rest/Elev HOB>30
Bed rest/Elev HOB>30
 Stool softeners
Stool softeners
 No sneezing/coughing
No sneezing/coughing
 +/- lumbar drains
+/- lumbar drains
 Early failures
Early failures
 Assoc with hydrocephalus
Assoc with hydrocephalus
 Recurrent or persistent leaks
Recurrent or persistent leaks

25. Treatment of CSF Otorrhea
Treatment of CSF Otorrhea
 Brodie and Thompson et al.
Brodie and Thompson et al.
 820 T-bone fractures/122 CSF leaks
820 T-bone fractures/122 CSF leaks
 Spontaneous resolution with conservative
Spontaneous resolution with conservative
measures
measures
 95/122 (78%): within 7 days
95/122 (78%): within 7 days
 21/122(17%): between 7-14 days
21/122(17%): between 7-14 days
 5/122(4%): Persisted beyond 2 weeks
5/122(4%): Persisted beyond 2 weeks

26. Temporal bone fractures
Temporal bone fractures
 Meningitis
Meningitis
 9/121 (7%) developed meningitis. Found no
9/121 (7%) developed meningitis. Found no
significant difference in the rate of meningitis
significant difference in the rate of meningitis
in the ABX group versus no ABX group.
in the ABX group versus no ABX group.
 A later meta-analysis by the same author
A later meta-analysis by the same author
did reveal a statistically significant
did reveal a statistically significant
reduction in the incidence of meningitis
reduction in the incidence of meningitis
with the use of prophylactic antibiotics.
with the use of prophylactic antibiotics.

27. Pediatric temporal bone fractures
Pediatric temporal bone fractures
 Much lower incidence (10:1, adult:pedi)
Much lower incidence (10:1, adult:pedi)
 Undeveloped sinuses, skull flexibility
Undeveloped sinuses, skull flexibility
 otorrhea>> rhinorrhea
otorrhea>> rhinorrhea
 Prophylactic antibiotics did not influence
Prophylactic antibiotics did not influence
the development of meningitis.
the development of meningitis.

28. CSF Otorrhea Surgical
CSF Otorrhea Surgical
Management
Management
 Surgical approach
Surgical approach
 Status of hearing
Status of hearing
 Meningocele/encephalocele
Meningocele/encephalocele
 Fistula location
Fistula location
 Transmastoid
Transmastoid
 Middle Cranial Fossa
Middle Cranial Fossa

29. Overlay vs Underlay
Overlay vs Underlay
technique
technique
 Meta-analysis
Meta-analysis
showed that both
showed that both
techniques have
techniques have
similar success rates
similar success rates
 Onlay: adjacent
Onlay: adjacent
structures at risk, or if
structures at risk, or if
the underlay is not
the underlay is not
possible
possible

30. Technique of closure
Technique of closure
 Muscle, fascia, fat, cartilage, etc..
Muscle, fascia, fat, cartilage, etc..
 The success rate is significantly higher for
The success rate is significantly higher for
those patients who undergo primary
those patients who undergo primary
closure with a multi-layer technique versus
closure with a multi-layer technique versus
those patients who only get single-layer
those patients who only get single-layer
closure.
closure.
 Refractory cases may require closure of
Refractory cases may require closure of
the EAC and obliteration.
the EAC and obliteration.

31. Facial Nerve Injuries
Facial Nerve Injuries
 Loss of forehead wrinkles
Loss of forehead wrinkles
 Bell’s Phenomenon
Bell’s Phenomenon
 Nasal tip pointing away
Nasal tip pointing away
 Flattened Nasofacial groove
Flattened Nasofacial groove

32. Facial Nerve Anatomy
Facial Nerve Anatomy

33. Facial Nerve Injuries
Facial Nerve Injuries
 Initial Evaluation is the most important
Initial Evaluation is the most important
prognostic factor
prognostic factor
 Previous status
Previous status
 Time
Time
 Onset and progression
Onset and progression
 Complete vs. Incomplete
Complete vs. Incomplete

34. House Brackman Scale
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
Slight synkinesis/weakness
Mild
II
Normal facial function
Normal
I

35. Electrophysiologic Testing
Electrophysiologic Testing
 NET: Nerve Excitability Test
NET: Nerve Excitability Test
 MST: Maximal Stimulation Test
MST: Maximal Stimulation Test
 ENoG: Electroneurography
ENoG: Electroneurography
 Goal is to determine whether the lesion is partial
Goal is to determine whether the lesion is partial
or complete?
or complete?
 Neuropraxia: Transient block of axoplasmic flow ( no
Neuropraxia: Transient block of axoplasmic flow ( no
neural atrophy/damage)
neural atrophy/damage)
 Axonotmesis: damage to nerve axon with
Axonotmesis: damage to nerve axon with
preservation of the epineurium (regrowth)
preservation of the epineurium (regrowth)
 Neurotmesis: Complete disruption of the nerve ( no
Neurotmesis: Complete disruption of the nerve ( no
chance of organized regrowth)
chance of organized regrowth)

36. Nerve Excitability Test
Nerve Excitability Test
Maximal Stimulation Test
Maximal Stimulation Test
 Stimulating electrodes are placed and a
Stimulating electrodes are placed and a
gross movement is recorded
gross movement is recorded
 Not as objective and reliable
Not as objective and reliable
 >3.5mA difference suggests a poor
>3.5mA difference suggests a poor
prognosis for return of facial function.
prognosis for return of facial function.
 Correlates with >90% degeneration on ENoG
Correlates with >90% degeneration on ENoG

37. Electroneuronography
Electroneuronography
 Most accurate, qualitative measurement
Most accurate, qualitative measurement
 Sensing electrodes are placed, a voluntary
Sensing electrodes are placed, a voluntary
response is recorded
response is recorded
 Accurate after 3 days
Accurate after 3 days
 Requires an intact side to compare to
Requires an intact side to compare to
 Reduction of >90% amplitude correlates
Reduction of >90% amplitude correlates
with a poor prognosis for spontaneous
with a poor prognosis for spontaneous
recovery
recovery

38. Electromyography
Electromyography
 Electrode is placed within the muscle and
Electrode is placed within the muscle and
voluntary movement is attempted.
voluntary movement is attempted.
 Normal Muscle is electrically silent.
Normal Muscle is electrically silent.
 After 10-14 days, the denervated muscle
After 10-14 days, the denervated muscle
begins to spontaneously fire:
begins to spontaneously fire:
 Diphasic/Polyphasic potentials: Good
Diphasic/Polyphasic potentials: Good
 Loss of voluntary potentials: Bad
Loss of voluntary potentials: Bad

39. Facial Nerve Injuries
Facial Nerve Injuries
WHO GETS TREATMENT?
WHO GETS TREATMENT?
 Conservative treatment candidates
Conservative treatment candidates
 Surgical treatment candidates
Surgical treatment candidates

40. Facial Nerve Injuries
Facial Nerve Injuries
 Chang & Cass
Chang & Cass
 Medline search back to 1966
Medline search back to 1966
 Individually reviewed each article
Individually reviewed each article
 1) Understand the pathophysiology of facial
1) Understand the pathophysiology of facial
nerve damage in temporal bone trauma.
nerve damage in temporal bone trauma.
 2) What is the effect of surgical intervention
2) What is the effect of surgical intervention
on the ultimate outcome of the facial nerve.
on the ultimate outcome of the facial nerve.
 3) Propose a rational course for evaluation
3) Propose a rational course for evaluation
and treatment.
and treatment.

41. Facial Nerve Injuries
Facial Nerve Injuries
Chang & Cass
Chang & Cass
 Pathophysiology based on findings by Fisch and
Pathophysiology based on findings by Fisch and
Lambert and Brackmann:
Lambert and Brackmann:
 Where?
Where?
 Perigeniculate, Labyrinthine, and meatal segments
Perigeniculate, Labyrinthine, and meatal segments
 Concern over findings of endoneural fibrosis and neural atrophy
Concern over findings of endoneural fibrosis and neural atrophy
proximal to the lesions
proximal to the lesions
 In an untreated human specimen found intraneural edema and
In an untreated human specimen found intraneural edema and
demyelinization that extended proximally to the meatal foramen
demyelinization that extended proximally to the meatal foramen
 How?
How?
 Longitudinal Fractures
Longitudinal Fractures
• 15% transection
15% transection
• 33% bony impingement, 43% hematoma
33% bony impingement, 43% hematoma
 Transverse Fractures
Transverse Fractures
• 92% transection
92% transection

42. Does Facial Nerve decompression result in
Does Facial Nerve decompression result in
superior functional outcomes compared with
superior functional outcomes compared with
no treatment?
no treatment?
 Not enough human data!
Not enough human data!
 Boyle-monkey: prophylactic epineural decompression in
Boyle-monkey: prophylactic epineural decompression in
complete paralysis did not improve recovery of facial
complete paralysis did not improve recovery of facial
nerve function after induced complete paralysis
nerve function after induced complete paralysis
 Kartush: Prophylactic decompression of the meatal
Kartush: Prophylactic decompression of the meatal
segment during acoustic neuroma decreased the
segment during acoustic neuroma decreased the
incidence of delayed paralysis
incidence of delayed paralysis
 Adour: compared patients with complete paralysis found:
Adour: compared patients with complete paralysis found:
 Equal outcome with observation vs. decompression without
Equal outcome with observation vs. decompression without
nerve slitting
nerve slitting
 Worse outcome with decompression with nerve slitting
Worse outcome with decompression with nerve slitting

43. Does Facial Nerve decompression result in
Does Facial Nerve decompression result in
superior functional outcomes compared with
superior functional outcomes compared with
no treatment?
no treatment?
 Many difficulties in Study designs,
Many difficulties in Study designs,
controls, etc, but they made some rough
controls, etc, but they made some rough
estimates:
estimates:
 50% of patients who undergo facial nerve
50% of patients who undergo facial nerve
decompression obtain excellent outcomes
decompression obtain excellent outcomes
 The true efficacy of facial nerve
The true efficacy of facial nerve
decompression surgery for trauma
decompression surgery for trauma
remains uncertain
remains uncertain

44. Conservative Treatment
Conservative Treatment
Candidates
Candidates
 Chang and Cass
Chang and Cass

Present with
Present with Normal Facial Function
Normal Facial Function
regardless of progression
regardless of progression
 Incomplete paralysis and no
Incomplete paralysis and no
progression
progression to complete paralysis
to complete paralysis

Less than
Less than 95%
95% degeneration by ENoG
degeneration by ENoG
• Most data comes from Bell’s palsy/tumor studies
Most data comes from Bell’s palsy/tumor studies
by Fisch.
by Fisch.

45. Conservative Treatment
Conservative Treatment
Candidates
Candidates
 Brodie and Thompson
Brodie and Thompson
 All patients that presented with normal facial
All patients that presented with normal facial
nerve function initially that progressed to
nerve function initially that progressed to
complete paralysis
complete paralysis recovered to a
recovered to a HB
HB
1 or 2.
1 or 2.

46. Surgical Candidates
Surgical Candidates
 Critical Prognostic factors
Critical Prognostic factors
 Immediate
Immediate vs. Delayed
vs. Delayed
 Complete
Complete vs. Incomplete paralysis
vs. Incomplete paralysis
 ENoG criteria
ENoG criteria

47. Algorithm for Facial Nerve Injury
Algorithm for Facial Nerve Injury

48. Facial Nerve Injuries
Facial Nerve Injuries
Chang & Cass
Chang & Cass
 What time frame is best to operate?
What time frame is best to operate?
 Fisch-cats: Decompression of the nerve within
Fisch-cats: Decompression of the nerve within
a 12 day period resulted in “excellent”
a 12 day period resulted in “excellent”
functional recovery. Presumption was that it
functional recovery. Presumption was that it
preserved endoneural tubules. (limits the
preserved endoneural tubules. (limits the
damage to axonotmesis at worst)
damage to axonotmesis at worst)
 Limits the accuracy of your patient selection
Limits the accuracy of your patient selection
because EMG is not reliable until day 10-14.
because EMG is not reliable until day 10-14.

49. Surgical Approach
Surgical Approach
 Medial to the Geniculate Ganglion
Medial to the Geniculate Ganglion
 No useful hearing
No useful hearing
• Transmastoid-translabyrinthine
Transmastoid-translabyrinthine
 Intact hearing
Intact hearing
• Transmastoid-trans-epitympanic
Transmastoid-trans-epitympanic
• Middle Cranial Fossa
Middle Cranial Fossa
 Lateral to Geniculate Ganglion
Lateral to Geniculate Ganglion
 Transmastoid
Transmastoid

50. Surgical Approach
Surgical Approach
 Chang & Cass
Chang & Cass
 Histopathologic study
Histopathologic study
 Severe facial nerve
Severe facial nerve
injury results in
injury results in
retrograde axonal
retrograde axonal
degeneration to the level
degeneration to the level
of the labyrinthine and
of the labyrinthine and
probably meatal
probably meatal
segments
segments

51. Surgical findings of
Surgical findings of greater than
greater than
50%
50% nerve transection/damage
nerve transection/damage
 Nerve repair via primary anastamosis or
Nerve repair via primary anastamosis or
cable graft repair
cable graft repair
 HB 1 or 2: 0%
HB 1 or 2: 0%
 HB 3 or 4: 82%
HB 3 or 4: 82%
 HB 5 or 6: 18%
HB 5 or 6: 18%

52. Iatrogenic Facial Nerve Injuries
Iatrogenic Facial Nerve Injuries
 Mastoidectomy (55%)
Mastoidectomy (55%)
 Tympanoplasty (14%)
Tympanoplasty (14%)
 Bony Exostoses (14%)
Bony Exostoses (14%)
 Lower tympanic segment is the most
Lower tympanic segment is the most
common location injury
common location injury
 79% were not identified at the time of
79% were not identified at the time of
surgery
surgery

53. Management of Iatrogenic
Management of Iatrogenic
Facial Nerve Injuries
Facial Nerve Injuries
 Green, et al.
Green, et al.
 <50% damage: perform decompression
<50% damage: perform decompression
 75% had HB of 3 or better!
75% had HB of 3 or better!
 >50% damage: perform nerve repair
>50% damage: perform nerve repair
 No patients had better than a HB 3
No patients had better than a HB 3
 Beware of local anesthetics
Beware of local anesthetics
 General consensus: acute, complete,
General consensus: acute, complete,
postoperative paralysis should be
postoperative paralysis should be
explored as soon as possible.
explored as soon as possible.

54. Emergencies
Emergencies
 Brain Herniation
Brain Herniation
 Massive Hemorrhage
Massive Hemorrhage
 Pack the EAC
Pack the EAC
 Carotid arteriography with embolization
Carotid arteriography with embolization

55. Bibliography
Bibliography
 Bailey, Byron J., ed. Head and Neck surgery- Otolaryngology. Philadelphia, P.A. J.B. Lippincott Co., 1993.
Bailey, Byron J., ed. Head and Neck surgery- Otolaryngology. Philadelphia, P.A. J.B. Lippincott Co., 1993.
 Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. American
Brodie, HA, Thompson TC. Management of Complications from 820 Temporal Bone Fractures. American
Journal of Otology; 18: 188-197, 1997.
Journal of Otology; 18: 188-197, 1997.
 Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and Neck
Brodie HA, Prophylactic Antibiotic for Posttraumatic CSF Fistulas. Arch of Otolaryngology- Head and Neck
Surgery; 123; 749-752, 1997.
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Otology; 3: 254-261, 1992.
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Chang CY, Cass SP. Management of Facial Nerve Injury Due to Temporal Bone Trauma. The American Journal
of Otology; 20: 96-114, 1999.
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 Coker N, Traumatic Intratemporal Facial Nerve Injuries: Management Rationale for Preservation of Function.
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