Temporal bone fractures: Three identical cases of lateral middle ear fractures with facial nerve injury and conductive hearing loss

During the past two years at Thomas Jefferson University Hospital the authors have encountered three identical cases of middle ear injuries and their treatment has been so alike that we believe they merit general discussion. These patients illustrate the basic pathology of middle ear fractures in association with skull trauma, and in addition, emphasize the transtympanic approach in the surgical repair. In the past there has been some hesitancy about operating on temporal bone fractures in the acute period. The authors wish to use the following three cases to illustrate the early surgical approach to temporal bone fractures with associated facial nerve injury. It is our belief that the transcanal route is an excellent one for isolated middle ear fractures with concomitant facial nerve palsy when there is normal tearing on the involved side. We also believe that these middle ear fractures should be explored at the earliest possible time, as soon as general status of the patient will allow. We have some hesitancy about performing the standard incus body‐to‐head transposition for ossicular chain reconstruction because of the close proximity of the exposed facial nerve to the repositioned incus. We worry about pressure of this incus should it become displaced postoperatively onto this bare facial nerve. There is also difficulty experienced with this approach if re‐exploration is indicated. The tympano‐meatal flap must be elevated off the facial nerve, a procedure not without its own inherent dangers.