›Docusate sodium 100 mg PO twice daily
›Most CSF leaks resolve spontaneously within 7 to 10 days
›85 to 95% closure rate with conservative management
›No nasal packing in CSF rhinorrhea
›Escalation for persistent leak
›Lumbar drain if persistent beyond 7 to 14 days
›Target CSF drainage 5 to 10 mL per hour
›Neurosurgery supervised placement and management
›Surgical repair for refractory leaks
›Endonasal endoscopic approach for anterior fossa leaks
›Transmastoid approach for posterior fossa leaks
›Timing: after 2 weeks conservative trial
›Antibiotic prophylaxis for CSF leak
›Routine prophylactic antibiotics not recommended
›No strong evidence supports routine use
›Risk of selecting resistant organisms
›Treat meningitis if it develops
›Ceftriaxone 2 g IV every 12 hours for community-acquired meningitis
›Dexamethasone 0.15 mg/kg IV every 6 hours for 4 days if bacterial meningitis
Facial nerve injury management
›Delayed onset facial palsy (most common pattern)
›Corticosteroid therapy
›Prednisone 1 mg/kg per day orally (maximum 60 mg daily)
›Taper over 14 days
›Initiated within 72 hours of onset for best effect
›Prognosis
›Greater than 90% achieve spontaneous recovery
›House-Brackmann I-II in majority
›Contraindications to corticosteroids
›Significant concurrent intracranial injury: consult neurosurgery
›Uncontrolled diabetes or active infection
›Polytrauma with sepsis concern
›Immediate complete facial paralysis (House-Brackmann V-VI)
›Corticosteroids plus electrodiagnostic monitoring
›Same corticosteroid regimen as above if not contraindicated
›Electroneurography (ENoG) at 3 to 5 days post injury
›Repeat ENoG at 14 days
›ENoG interpretation and surgical threshold
›Greater than 90% degeneration on ENoG within 2 weeks suggests poor prognosis
›90% degeneration threshold: surgical decompression consideration
›EMG adds information at 2 to 3 weeks: voluntary potentials suggest recovering axons
›Surgical decompression
›Transmastoid approach for tympanic and mastoid segment
›Middle fossa approach for labyrinthine segment
›Ideally within 8 weeks of injury: 91.7% achieve House-Brackmann I-II
›Nerve grafting if transection confirmed
›Eye care for facial nerve palsy
›Lubricating eye drops
›Carboxymethylcellulose 0.5% drops hourly when awake
›Lacrilube or equivalent lubricating ointment at bedtime
›Eye protection
›Moisture chamber glasses during the day
›Eyelid taping at night to maintain closure
›Ophthalmology referral if incomplete eye closure persists
›Exposure keratopathy prevention
›Tarsorrhaphy if required
›Conductive hearing loss
›Hemotympanum: expectant management
›Typically resolves over 4 to 6 weeks as blood resorbs
›Formal audiogram after resolution
›Ossicular disruption
›Timing: ossiculoplasty deferred 3 to 6 months after fracture
›CT assessment of disruption type guides surgical approach
›Incudo-stapedial dislocation most common
›Sensorineural hearing loss from otic capsule violation
›No proven pharmacologic treatment
›High-dose corticosteroids sometimes used empirically
›Insufficient evidence for routine recommendation
›Hearing rehabilitation planning
›Hearing aid evaluation once stable
›Cochlear implantation for severe to profound SNHL
›Bone-anchored hearing aid option for appropriate anatomy
Vestibular symptom management
›Acute vestibular suppression (short-term only)
›Meclizine 25 mg PO every 8 hours
›Maximum 7 days of vestibular suppressant use
›Prolonged use delays central compensation
›Ondansetron 4 mg IV or PO every 8 hours for nausea
›Post-traumatic BPPV treatment
›Epley canalith repositioning maneuver
›Posterior canal BPPV most common after temporal trauma
›Repeat if initial maneuver incomplete
›Semont maneuver as alternative
›Vestibular rehabilitation referral
›Early mobilization encouraged
›Supervised balance and gait program
Anticoagulation management in vascular injury
›Carotid artery dissection
›Anticoagulation or antiplatelet therapy
›Heparin infusion initial if low hemorrhagic risk
›Unfractionated heparin adjusted to aPTT 60 to 100 seconds
›Transition to warfarin INR 2.0 to 3.0 for 3 to 6 months
›Aspirin 81 to 325 mg daily if anticoagulation contraindicated by intracranial hemorrhage
›Neurosurgery and vascular surgery co-decision
›Endovascular stenting for occlusive dissection refractory to medical therapy
›Sigmoid sinus thrombosis
›Anticoagulation if no contraindication
›Heparin bridge to therapeutic anticoagulation
›Interventional options if propagating despite anticoagulation