A.Evaluation: cardiovascular and respiratory stability, neurological status, facial nerve function, direction of nystagmus, cerebrospinal fluid leak.
B. Radiological evaluation: high resolutin computer tomography, contrast CT,MRI if ontracranial injury is suspected, digital subtraction angiography, magnetic resonance angiography.
C. Nuclearmedicine evaluation: intrathecal injection of fluoresceine to visualize csf.
D. Audiologic evaluation: PTA, speech discrimination scres, acoustic reflex
E. Vestibular evaluation: electro-oculography
F. Facial nerve function evaluation
MANAGEMENT OF MIDDLE EAR AND TEMPORAL BONE TRAUMA
A.Laceration of external auditory canal:A pack should be placed to avoid stenosis of ear canal. If there is significant fracture dislocation, an infant nasal speculum can be placed upto the bony externsl canal.
B. CSF leak: spontaneous closure ususlly occur within 4-5 days. If there is no evidence of meningitis, a temporary lumbar subarachnoid drainage may be done. If leak persists, it requires surgical intervention.
C. Tympanic membrane perforation: slit like perforation heals spontaneously. If tyere is rotation flap of the ttmpanic membrane, it can be gently rotated back into its anatomical position and held in position by surrounding local blood. Nose blowing and instillation ofliquid drops should be avoided. Surgical repair is vonsidered after 3 months if the tympanic membrane perforation does not heal.
D. Ossicular injury: The most common ossicular injury is separation of the incudostapedial joint with or without dislocation of the body of incus from malleus head. For fracture dislocation of stapes, the remainder of stapes is extracted close to oval window, along with a tissue graft and prosthesis reconstruction is done.
E. Perilymph fistula: If the fistula is identified, the mucosa is denuded and autologos tissue graft (lobular ear fat, tragal perichondrium, temporalis fascia, vein) is applied over fistula. If the fistula from the round window is profuse, a tissue graft and cartilage strut from the tragal cartilage is used from the hypotympanum or bonny annulus into the window membrane. In an oval window fistula , tissue can be supported on crura of stapes or stapedectomy with prosthesis (if stapes is significantly injured). Fistula through the area of fossula of cochlear window is closed by using a small diamond burr, later covered by tissue graft.
F. Vestibular damage: vestibular neurectomy through retrolabyrinthine, retrosigmoid or middle fossa approach. If there is non functional hearing in the ear, postauricular labyrinthine with or without eighth nerve neurectomy can be done.
G. Stenosis of EAC: If stenosis is rescted 360 degrees, local skin flaps, full thickness post auricular skin grafts, split-thickness grafts can be used.