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CranialNerveInjuriesAreAssociatedwithSpecificCraniofacial
FracturesafterBluntTrauma
Kampshoff,JesseL,MDCogbill,ThomasH,MDMathiason,MichelleA,MS
Kallies,KaraJ,BAMartin,LynnT,MD.TheAmericanSurgeon 76.11 (Nov2010):
12237.

Abstract(summary)
Identificationofcranialnerve(CN)injuriesafterblunttraumaisoftendelayedduetoconcomitantlife
threateningtrauma,alteredmentalstatus,andassociatedbonyorsofttissueinjuries.Wehypothesizedthat
specificcraniofacialfracture(FX)patternsareassociatedwithCNinjuries,permittingearlierdiagnosis.The
traumaregistryatasingleinstitutionwasqueriedforallCNinjuriesandcraniofacialFXs.Associationswere
determinedbyFisher'sexacttest.NinetyCNinjurieswereidentifiedin59patients.CNinjurieswere
diagnosedonthedayofadmissionin24(41%)patients.ThemostfrequentlyinjuredCNswereCNVII(22),
CNI(16),andCNVI(14).OccipitalFXswereassociatedwithCNIinjury(P=0.001).Sphenoidandethmoid
FXswerecorrelatedwithCNIIItrauma(P=0.019and0.04).TemporalboneFXswereassociatedwithCN
VIIinjuries(P=0.025).MaxillaryFXswereassociatedwithCNVinjuries(P=0.041).Completeorpartial
recoverywasdocumentedafter17percentand39percentofCNinjuries,respectively.Diagnosticdelaywas
documentedin59percentofpatients.SpecificcraniofacialFXswerecorrelatedwithcertainCNinjuries.
Partialorcompleterecoveryoffunctionoccurredafter56percentofCNinjuries.[PUBLICATIONABSTRACT]

FullText
Headnote
Identificationofcranialnerve(CN)injuriesafterblunttraumaisoftendelayedduetoconcomitantlife
threateningtrauma,alteredmentalstatus,andassociatedbonyorsofttissueinjuries.Wehypothesizedthat
specificcraniofacialfracture(FX)patternsareassociatedwithCNinjuries,permittingearlierdiagnosis.The
traumaregistryatasingleinstitutionwasqueriedforallCNinjuriesandcraniofacialFXs.Associationswere
determinedbyFisher'sexacttest.NinetyCNinjurieswereidentifiedin59patients.CNinjurieswere
diagnosedonthedayofadmissionin24(41%)patients.ThemostfrequentlyinjuredCNswereCNVII(22),
CNI(16),andCNVI(14).OccipitalFXswereassociatedwithCNIinjury(P=0.001).Sphenoidandethmoid
FXswerecorrelatedwithCNIIItrauma(P=0.019and0.04).TemporalboneFXswereassociatedwithCN
VIIinjuries(P=0.025).MaxillaryFXswereassociatedwithCNVinjuries(P=0.041).Completeorpartial
recoverywasdocumentedafter17percentand39percentofCNinjuries,respectively.Diagnosticdelaywas
documentedin59percentofpatients.SpecificcraniofacialFXswerecorrelatedwithcertainCNinjuries.
Partialorcompleterecoveryoffunctionoccurredafter56percentofCNinjuries.
LIFETHREATENINGTRAUMATICinjuriesoftenovershadowmoresubtledeficitscausedbycranialnerve(CN)
injury.Associatedheadtraumainthesepatientsalsomakesdiagnosisdifficultaspatientsareoftenunableto
cooperatewithexamination.ComamayobscureallbutIII,VI,andVIInervedamage.1Additionally,orbital
muscleinjurymaymimicocularmotornervetraumamiddleeardamagecanbemistakenforinjuryofCN
VIIIandobstructionofthenaresorearcanalcanconfoundthediagnosisofCNIorCNVIIIinjuries,
respectively.1DiagnosisandtreatmentoftheseCNinjuriesoftenrequirespecialiststosortoutthe
complicatedclinicalpresentation.Physicianstakingcareoftraumapatientsneedtobevigilantintheir
examinationstodiagnosetheseinjuriesasapatient'smentalstatuschanges.CNinjuriesafterblunttrauma
areuncommonbutmayresultinsignificantlongtermdisability.EarlierdiagnosisofsomeCNinjuriesmay
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allowformoretimelyinterventionandreduceddisability.AccuratediagnosisofCNinjurieshasimportant
prognosticimplications.WereviewedourexperiencewithtraumaticCNinjuriesinanefforttoidentifyfactors
thatpredictthepresenceandseverityoftheseunusualinjuries.Wehypothesizedthatspecificcraniofacial
fracture(FX)patternsareassociatedwithCNinjuriesafterblunttraumaandmayassistwithearlier
identification.
Methods
AretrospectivereviewoftheprospectivetraumaregistryatGundersenLutheranHealthSystemfrom
January2000toMarch2007wasconducted.GundersenLutheranHealthSystemhasanAmericanCollege
ofSurgeons(ACS)verifiedLevelIItraumacenterandisthereferralcenterfor19ruralcountiesof
southwesternWisconsin,southeasternMinnesota,andnortheasternIowa.Thedatabasecontainedover
3800patients,26ofwhomwereidentifiedashavingCNtrauma.Ofthese26patients,onehada
penetratingmechanismofinjuryandwasexcludedfromtheanalysis.Initialreviewrevealedthat65percent
ofthesepatientshadcraniofacialFXs.TheregistrywasthenqueriedforallpatientswithbasilarskullFXsand
facialFXs.ThreehundredandfiftyeightpatientshadsustainedfacialFXsand320patientshadbasilarskull
FXs.Electronicmedicalrecordswerethenindividuallyreviewedforeachofthesepatients,identifyingan
additional33patientswithCNtrauma.DatawerecollectedonallpatientswithdocumentedCNinjury
includingdemographics,mechanismofinjury,locationofcraniofacialFXs,intracranialhemorrhage,
associatedinjuries,injuryseverityscores,proceduresperformed,andoutcomes.Associationsbetweeneach
CNinjuredandspecificcraniofacialFXsweredeterminedbyFisher'sexacttest.Levelofconfidencewas
definedasP<0.05.
Results
CNinjurieswereidentifiedin59patientsafterblunttrauma.MultipleCNinjurieswerefoundin11patients,
givingatotalof90CNinjuries.Averagepatientagewas36.7years(range787years).Themajorityof
patientsweremale(n=4373%).Themostfrequentmechanismofinjurywasmotorvehiclecollision
(31%),followedbyfalls(27%)andmotorcyclecollisions(12%)(Table1).Themostcommonassociated
injurynotinvolvingtheheadorfacewasextremitytrauma,occurringin41percentofpatients(Table2).
Themeaninjuryseverityscorewas22.9(range566).MeanAbbreviatedInjuryScoreforheadwas3.5and
forfacewas1.9.SeverityofheadinjurywasbasedonadmissionGlasgowComaScoreasfollows:severe(3
8),moderate(912),andmild(1315).Therewere18(30%)patientswithsevere,four(7%)with
moderate,and32(54%)withmildheadinjuries.Meanlengthofhospitalstaywas10days(range177).
Mortalitywasnil.
CNinjurieswerediagnosedonthedayofadmissionin41percentofpatients(24).Diagnosiswasdelayed
morethan1weekin21(36%)patientsandmorethan1monthinnine(15%).CNIinjurieswerethemost
likelytobediscoveredlatewithfiveCNIinjuriesdocumentedmorethan30daysafterinjury.ThreeCNVII,
oneCNVIII,andoneCNXinjurieswerealsofirstidentifiedmorethan30daysafterinjury.Presenting
symptomsorsignsforeachCNinjurywereasfollows:CNIanosmia,dysosmia,orparosmiaCNII
blindness,diminishedvision,andabnormalpupillaryreflexCNIIIptosis,esotropia,anddilatedorfixed
pupilCNIVverticaldiplopiaCNVfacialparesthesiaCNVIdiplopiaCNVIIfacialparalysis,facial
paresis,andincompleteeyelidclosureCNVIIIhearinglossandCNXhoarseness.Table3showsthe
numberandfrequencyofCNinjuries.ThemostfrequentlyinjuredCNwasVIIwith22injuries,followedby
CNIwith16,andCNVIwith14.NoCNIX,XI,orXIIinjuriesweredetected.
SpecificcraniofacialfracturefrequenciesareshowninTable4.TemporalandorbitalFXswerethemost
commonat42percentand41percent,respectively.Thesewerefollowedbymaxillary,zygomatic,and
sphenoidFXsat34percent,27percent,and22percent,respectively.Table5showssignificant
associationsbetweendocumentedCNinjuriesandspecificcraniofacialFXs.OccipitalFXwasassociatedwith
CNIinjuries(P=0.001).Frontal(P=0.002),maxillary(P=0.023),nasal(P=0.014),orbital(P=0.011),
ethmoid(P=0.006),andsphenoid(P=0.033)FXswereallassociatedwithCNIIinjuries.Sphenoidand
ethmoidFXswereassociatedwithCNIIIinjuries(P=0.019andP=0.04,respectively).MaxillaryFXwas
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associatedwithCNVinjuries(P=0.041).TemporalFXwasassociatedwithCNVIIinjuries(P=0.025).
TherewerenocraniofacialFXsineightpatientswithnineCNinjuries(CNII1,CNIII2,CNIV1,CNVI2,
CNVII3).Insixoftheseeightpatients,theCNinjurywasidentifiedonthedayofadmission.The
proportionofpatientswithdelayeddiagnosisofCNinjurywasnotdifferentinthissubgroupwhencompared
withtheentirestudypopulation(P=0.53).
Followupwasdocumentedin57patientsatamedianof169days(12970).ThemajorityofCNinjuries
weremanagednonoperatively.Fourpatientsweretreatedwithsteroidadministration.FourCNVIIinjuries
requiredoperativerepair.Followupdatawereavailableon77CNinjuriesatamedianof169days.Recovery
offunctionwasassessedbyreviewingnotesfromthepatients'mostrecentoutpatientfollowupvisit.
Completerecoverywasdocumentedafter13(17%)injuries.Partialrecoveryoccurredwith30(39%)
injuries,whereasnorecoverywasobservedafter34(44%)CNinjuries.AlloftheCNVIIinjuriesrepaired
surgicallydemonstratedpartialrecoveryoffunction.Specificnervesanddegreeofrecoveryareshownin
Table6.ThedegreeofCNrecoverywassimilarinthegroupofpatientswithoutcraniofacialFXwhen
comparedwiththosewithcraniofacialFX.Wewereunabletodemonstrateadifferenceinoutcomebetween
thegroupofpatientswithdiagnosismadeonthedayofadmissionversusthosewithdelayeddiagnosis.
Discussion
OursingleinstitutionexperiencerevealedlargedifferencesintherelativeriskofinjurytoeachCN.CNsIand
VIIwerethemostfrequentlyinjured,with16and22injuries,respectively.InjuriestothesetwoCNs
accountedformorethan40percentofthetotalinourseries.ThisisconsistentwithotherstudiesofCN
trauma.12WedetectedonlytwoCNXinjuriesandnoCNIX,XI,orXIIinjuries.
ThediagnosisofCNinjuryisdifficultinthetraumapatientduetoalteredmentalstatus,associatedbonyor
softtissueinjuries,andthefactthatlifethreateninginjuriesdistracttheclinicianfromthemoresubtleCN
deficits.CNinjuriesareexceedinglydifficulttodiagnoseinthispatientpopulationunlessdetailedand
repetitiveexaminationsareperformed.Foroptimaltreatmentanddegreeofrecovery,injuriesshouldbe
identifiedimmediately,butidentificationofCNtraumaonthedayofadmissionwasdocumentedinlessthan
halfofthepatientsinourseries.OtherauthorshavereportedlongdelaysinthediagnosisofCNinjuryin
patientswithclosedheadinjury.3
OuranalysisdemonstratesthattherearesignificantassociationsbetweenspecificcraniofacialFXsandCN
injuries.Themajorityoftheassociationsseemtomakeanatomicsense.However,thereareothersthatmay
notberelatedtoadirectblowtothenervebutinsteaddueto"contracoup"phenomenonoranother
mechanism.ThisobservationmakestheseassociatedFXdataevenmoreimportantfordiagnosisofwhat
wouldseemtobeunexpectedCNinjuries.Althoughmanypreviousstudieshavedocumentedavarietyof
craniofacialandbasilarskullFXsfoundinconjunctionwithCNinjuries,nonehaveanalyzedthespecific
associations.1,2,46TheanatomiccorrelationsbetweentemporalboneFXsandCNVIIandCNVIIIinjuries
aswellasbetweenorbitalFXsandCNII,CNIII,CNIV,andCNVIinjurieshavebeendescribed.2,7Several
authorshavenotedtheassociationofanteriorfossaFXsandCNIinjuries.1,7Also,CNVinjurieshavebeen
observedinpatientswithorbital,maxillary,andmandibularFXs.7Ourstudyisthefirsttostatisticallyanalyze
therelationshipbetweenspecificcraniofacialFXsandcertainCNinjuries.OurdataprovidealookatallCN
injuriesandassociatedFXsandgivethetraumaphysicianinsightintothepossibilityofunderlyingCN
trauma.AdvancesinimagingtechnologyhavemadethediagnosisofcraniofacialFXsinthetraumapatient
moreprecisethandiagnosingCNinjuries.WiththeabilitytodefineassociatedFXs,injuriessuspiciousforCN
injurycanbeidentifiedmorepromptlyandmoretimelytreatmentcanbeinitiated.
Recoveryoffunctionwasseenafter56percentofCNinjuriesforwhichfollowupdatawereavailable.
Nonoperativemethodswereusedin55patients.Partialorcompleterecoverywasseenin51percentof
patients.Surgicaltreatmentwasperformedinfourpatients,allofwhomhadsustainedCNVIIinjury.Partial
recoveryoffunctionwasobservedafterallfourCNVIIoperativerepairs.Betterfunctionalrecoverywas
observedaftercertainCNinjuries.AllpatientswithCNIVinjuriesforwhomfollowupwasavailablehadsome
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degreeofrecovery.Over80percentofpatientswithCNVII,VI,andIIIexperiencedatleastpartialrecovery.
ThisisincontrasttopatientswithCNI,II,VIII,andXinjuriesinwhomrecoveryoccurred<20percentof
thetime.RatesofrecoveryforspecificCNinjurieshavebeenpreviouslyreported.CNIfunctionhasbeen
documentedtorecoveroverseveralmonthsin33to50percentofpatients.1,2,7Thirtyto56percentof
patientswithCNIIinjurieshaveexperiencedrecoveryoffunction,withthemostdramaticimprovement
documentedwithin4weeksofinjury.1,5RecoveryofCNIIIfunctionhasbeenobservedin40percentof
patientsfrom4to12weeksafterinjury.1,2,7Seventeen(71%)of24patientswithCNVItraumainone
serieshadfunctionalrecoveryfrom3weeksto6monthsafterinjury.2CNVIIinjuriescarrythebest
prognosisofallCNinjuries,withrecoveryinthevastmajorityofpatients.1,2,68Inonestudyof36patients
withCNVIIinjuries,all36demonstratedsomedegreeofrecovery,with19experiencingnearlynormal
functionwithin12weeksofinjury.2Inanotherstudyof22CNVIIinjuries,fullrecoveryoccurredin19
(86%).6AlthoughtheprognosisafterCNVIIIinjurieshasbeenreportedtobepoor,theuseofcochlear
implantshasresultedinenoughhearingtoallowspeechunderstandingin84percentofpatients.7Asecond
studyfoundthatfive(42%)of12patientswithCNVIIIinjuriesexperiencedsomehearingimprovement
withinseveralmonthsofinjury.2RecoveryratesafterCNIX,CNX,CNIX,andCNXIItraumahavenotbeen
detailed,presumablyduetotherarityoftheseinjuries.
Weconcedethatretrospectivecollectionofdataisaninherentweaknessofourstudy.Nospecificalgorithm
forexaminingCNswasusedduringthestudyperiodatourinstitution.Therefore,identificationofinjurywas
dependentuponindividualclinicianexamination,andwiththedifficultcircumstancesinwhichthesepatients
present,injurieswerelikelytohavebeenmissed.Sincethecompletionofthisstudy,wehaveinitiateda
protocolfortheexaminationanddocumentationofCNinjuriesonallblunttraumaadmissions.Atadmission,
thefunctionofeachCNisassessedanddocumentedonthetraumaintakeform.PatientswithorbitalFXare
scrutinizedfurtherforCNII,III,IV,andVIinjuries.ThosewithmaxillaryFXortemporalFXarereassessed
forCNVorVIIinjuries,respectively.ThefunctionofeachCNisagaintestedat24hoursorwhenareliable
examinationisfirstpossibleaspartofacompletetertiarysurvey.Earlyreferraltotheappropriateconsult
serviceisinitiatedforpatientswithanysuspicionofCNinjury.Additionally,thenumberofinjuriesinour
seriesisrelativelysmall,especiallyforeachindividualnerve.NoinjuriestoCNsIX,XI,andXIIwere
identified,sonoinsightcanbegainedintotheseCNinjuriesexceptthattheyseemtoberareafterblunt
trauma.Lackofconsistentfollowupintraumapatientsandthedurationoffollowupwereotherfactorsthat
affectedourabilitytoaccuratelyevaluateshortandlongtermoutcomes.
MostCNinjuriesinourseriesweremanagednonoperativelyanditisnotlikelythatearlierdiagnosiswould
havechangedeithertreatmentoroutcome.However,earlydiagnosishassignificantramificationsforCNVII,
andpossiblyCNVIIIinjuries,toachievetimelynervedecompressionorrepair.8Operativeinterventionhas
beenrecommendedtoimproveoutcomeswithimmediatefacialparalysisduetoCNVIIinjuries.7,8Ina
recentstudyof19patientswhounderwentfacialnervedecompressionforfacialparalysiswithtemporalbone
FXs,followupelectromyographydemonstratednormalornearnormalnervefunctionin14of17patients
testedaftersurgery.8Lessimprovementwasdocumentedinthethreeremainingpatients.Knowledgethat
specificcraniofacialFXsareassociatedwithCNVIIandCNVIIIinjuriesmayheightentheclinician'ssuspicion
ofCNtrauma.ThiswouldresultinmorecarefulCNexaminationincooperativepatientsortheuseof
adjunctivetechniquessuchasnervestimulationforpatientswithsignificantheadinjuryoralteredmental
status.ConfirmationoftheseCNinjuriesmightthenleadtomoretimelynervedecompressionorsurgical
repairwithimprovedfunctionaloutcome.
Conclusion
Diagnosticdelaywasdocumentedin59percentofpatientswithCNinjuries.SpecificcraniofacialFXpatterns
werecorrelatedwithcertainCNinjuries.Theseassociationsmayassistcliniciansinmakingearlier,more
accuratediagnosesofCNinjurieswithimplicationsfortreatmentandprognosis.ThemajorityofCNinjuries
didnotrequireoperativeintervention.Partialorcompleterecoveryoffunctionoccurredwith56percentof
injuries.
References
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REFERENCES
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AuthorAffiliation
JESSEL.KAMPSHOFF,M.D.,*THOMASH.COGBILL,M.D.,[dagger]MICHELLEA.MATHIASON,M.S.,[double
dagger]
KARAJ.RALLIES,B.A.4LYNNT.MARTIN,M.D.
FromtheDepartmentsof*MedicalEducationand[doubledagger]Research,GundersenLutheranMedical
Foundation,
LaCrosse,WisconsinandtheDepartmentsoffGeneral&VascularSurgeryandPlasticandReconstructive
Surgery,GundersenLutheranHealthSystem,LaCrosse,Wisconsin
AuthorAffiliation
AddresscorrespondenceandreprintrequeststoThomasH.Cogbill,M.D.,GundersenLutheranHealth
System,DepartmentofSurgery,1900SouthAvenue,C05001,LaCrosse,Wisconsin54601.Email:
THCogbil@gundluth.org.
CopyrightSoutheasternSurgicalCongressNov2010

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