Otolaryngology

Patient Stories | Ezra and Skull Fracture

Hospital Teams Pull Together for Ezra’s Care Following Serious Accident

Ezra Swartzentruber was in the crosswalk with his father and siblings when the driver of a car failed to yield. Ezra was struck, thrown to the ground, and left with numerous injuries, including fractures to his skull, pelvis, leg and collarbone.  

Thankfully, he is making a tremendous recovery at his home in northern Ohio, but at the time of the accident the situation was dire. When Ezra arrived at nearby Akron Children’s, he required an extensive care team, featuring specialists from across the hospital, including trauma service, orthopedics, neurosurgery, anesthesiology, and otolaryngology.

Plus, one doctor from Cincinnati Children’s, who was visiting from 230 miles away.  

Daniel Choo, MD, a neuro-otolaryngologist and director of Pediatric Otolaryngology – Head and Neck Surgery at Cincinnati Children’s, sees patients at Akron Children’s every week through a collaborative arrangement between the two children’s hospitals that began two years ago. 

The Akron team consulted with Dr. Choo as they worked to determine the best next steps for Ezra, who was diagnosed with a concussion and a fractured skull, specifically a horizonal temporal bone fracture.  

“Dr. Choo is renowned for complex neuro-otology procedures, including those involving the cranial nerves and middle ear. He was here and immediately saw Ezra,” explained Julie Wei, MD, division director of Ear, Nose and Throat at Akron Children’s.

“The fracture caused a significant leak of cerebrospinal fluid from his right ear,” Dr. Wei added. “Horizontal temporal bone fractures are relatively uncommon, resulting in immediate deafness and facial paralysis. Losing cerebrospinal fluid is also very dangerous because it increases the risk for meningitis.”  

Determining the Best Care Plan for Ezra

There are several ways to fix the spinal fluid leak and prevent infection (meningitis), which are determined by several related factors, explained Dr. Choo.

“The first option is to perform a combined surgical approach with neurosurgery in which the spinal fluid is ‘sealed from above’ via a craniotomy as well as ‘from below’ via the ear,” said Dr. Choo. “This combined approach is more involved but can be performed when there is still useful hearing in the patient’s ear.”

But because the injury resulted in complete deafness in Ezra’s right ear, Dr. Choo and the family agreed on an alternative approach that didn’t require a craniotomy. 

For Ezra’s surgery, Dr. Choo completely sealed up the right ear, including filling the inner ear with abdominal fat, removing the eardrum and sewing the ear canal closed so that there is no possible pathway for spinal fluid to leak through the fracture and the ear.

The surgery is not common, but Dr. Choo said he and his team perform it once or twice a year for patients who suffer catastrophic traumas. 

According to Dr. Choo, cases like Ezra’s—treating patients closer to their homes and helping elevate the care that is delivered to all patients—encapsulate the shared goal between Cincinnati Children’s and Akron Children’s.  

“The alignment between pediatric institutions that are over three hours apart, in diametrically opposite corners of the state, is what drives the collaborative,” said Dr. Choo. “Making the partnership ‘real’ requires concrete linkages between providers, programs, and care teams.”

Cincinnati Children’s and Akron Children’s: A Growing Collaborative 

Those linkages proved to be concrete strong for Ezra’s care. After meeting with Ezra’s parents, Karl and Joanna, Dr. Choo and the team implemented a coordinated plan for all the services Ezra needed. A hearing test was scheduled, and a lumbar drain was placed to clear away some of Ezra’s cerebrospinal fluid. Akron Children’s pediatric orthopedic surgeon Pat Riley, Jr., MD, repaired Ezra’s broken hip and leg. 

A week later, Dr. Choo performed the complex procedure to repair Ezra’s fractured skull and spinal fluid leak. 

Unfortunately, Ezra's temporal bone fracture also affected the facial nerve. As a result, Ezra lost the ability to wrinkle his forehead, fully close his right eye, or make facial expressions such as grimacing, smiling, or moving his lips on the right side.

Facial nerve injuries are graded on a scale of 1 to 6, with 1 being normal symmetric function and 6 being absolutely zero function. Ezra was a 5, which Dr. Choo described as both “unfortunate” and “fortunate." 

“Unfortunate, because it means there was a very significant nerve injury with obvious, almost complete, facial paresis (weakened muscle),” said Dr. Choo. “Fortunate, because a 5 still has dramatically better outcomes than a 6. This means that there are still some functional nerve fibers that are intact and can recover.” 

In fact, Ezra’s facial paralysis is showing signs of slow but steady improvement, with some movement returning around his mouth and his eye on the injured side, according to Dr. Choo.

Reflecting on the coordinated care that Ezra received, Dr. Wei is proud of the way everyone pulled together to ensure the best possible outcome. 

“Seeing how everyone came together on the day of surgery, understanding the impact we are making in the life of a single child made me most proud. In real-time, we saw two different hospital systems come together for this one patient,” Dr. Wei said. “This is the future of what’s to come from our collaborative, as we grow our multidisciplinary programs for complex ear, nose and throat conditions, with the expertise to keep kids close to home.”

These efforts have not been lost on Ezra’s parents, who are grateful for the care their son has received and continues to receive.

“Everyone has been amazing. We know there was a lot of coordination to provide that level of care to Ezra, yet everyone has been so humble. Their focus is on the kids,” Karl added. 

Ezra’s Road to Recovery 

As Ezra continues to recover, he still has a long road ahead. Once he’s out of the cast, he’ll need physical therapy. Although the hearing loss in his right ear is permanent, he was recently fitted with a hearing aid that will transmit sounds from the right side to his left ear, but his brain will recognize the sound as coming from his right. Coincidentally, Ezra’s best friend has hearing aids, so he’s already more familiar with them than a typical 11-year-old. 

Since Ezra's inner ear was completely non-functional, a traditional hearing aid (amplifying the sound and speech to make it louder) was not an option.

“Newer technologies have become dramatically more effective in what we call contralateral routing of sign (CROS),” said Dr. Choo. “With these devices, we take sound from the deaf ear and route it to the normal hearing ear. This restores the sound and speech awareness on the side that has become deaf.”

For now, Ezra and his parents are taking one day at a time, celebrating each positive step in his recovery. Ezra is looking forward to being out of the cast and walking again, and no longer having daily injections to prevent any complications from blood clots.

He’s also looking forward to going back to school. His favorite subject is science, and he wants to be a marine biologist when he grows up.

Joanna noted Ezra’s determination, confident her son will not let his injuries hold him back from achieving anything he sets out to do.

(Published May 2024)