Anterior skull base fractures: guidelines for treatment

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks

ABSTRACT

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Decreased Incidence of CSF Leaks after Skull Base Fractures in the 21st Century: An Institutional Report

Objectives Cerebrospinal fluid (CSF) leaks are a possible complication in patients with skull base fractures (SBFs). The widely cited incidence of CSF leaks is 10 to 30% in SBF patients; however, this estimate is based only on a few outdated studies. A recent report found CSF leaks in <2% SBF patients, suggesting the incidence may be lower now. To investigate this, we report here our institutional series.

Design This study is a retrospective chart review.

Setting The study was conducted at two major academic medical centers (2000–2018).

Participants Adult patients with SBF were included in this study.

Main Outcome Measures Variables included age, gender, CSF leak within 90 days, management regimen, meningitis within 90 days, and 1-year mortality.

Results Among 4,944 patients with SBF, 199 (4%) developed a CSF leak. SBF incidence was positively correlated with year of clinical presentation (r-squared 0.78, p < 0.001). Among CSF leaks, 42% were conservatively managed, 52% were treated with lumbar drain, and 7% required surgical repair. Meningitis developed in 28% CSF leak patients. The 1-year mortality for all SBF patients was 11%, for patients with CSF leaks was 12%, and for patients with meningitis was 16%.

Conclusion In the largest institutional review of SBF patients in the 21st century, we found CSF leak incidence to be 4%. This is lower than the widely cited range of 10 to 30%. Nevertheless, morbidity and mortality associated with this complication remains clinically significant, and SBF patients should continue to be monitored for CSF leaks. We provide here our institutional treatment algorithm for these patients that may help to inform the treatment strategy at other institutions.

Diagnosis and Management of Cerebrospinal Fluid Leak in a Panfacial Fracture

Cerebrospinal fluid fistula caused by head trauma is a potentially dangerous problem and precise localization and radical treatment are necessary. We present a case of a patient with Panfacial fracture caused by a motorcycle accident, resulting in a cerebrospinal fluid leakage. The correct diagnosis was realized by computed tomography and auxiliary tests. The successful treatment can be confirmed with the support of radionuclide cisternography examination.

Clinical significance of skull base fracture in patients after traumatic brain injury

About 4% of all head injuries include skull base fractures. Most of these fractures (90%) are secondary to closed head trauma; the remainder are due to penetrating trauma. We reviewed the records from January 2006 through December 2008 of all patients older than 18 years of age who arrived at Soroka Medical Center in Be'er-Sheva, Israel, with skull base fractures following a traumatic brain injury (TBI). We identified 107 patients with a mean age of 42 years at the time of TBI. Glasgow Coma score on arrival predicted the clinical outcome. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. Cerebrospinal fluid (CSF) leak was observed in 16 patients (15%). Of the patients experiencing CSF leaks, otorrhea occurred in 10 (62%) and rhinorrhea occurred in six (37%). Three patients required surgical intervention to repair the leak. Meningitis occurred in four patients with clinically evident CSF leak. Multiple skull base fractures are associated with poor neurological outcome. The low rate of meningitis in this patient sample implies that there is no indication to administer prophylactic antibiotics to patients with skull base fractures.

[Dysosmia : current aspects of diagnostics and therapy]

Olfactory dysfunction is a common disorder, especially in elderly people. From the etiological point of view a differentiation is made between sinunasal, traumatic and non-sinunasal causes of dysosmia. Olfactory disorders are often observed in neurodegenerative diseases, especially in patients with Parkinson's disease or Alzheimer's disease. Apart from an extensive medical history important diagnostic tools are a complete ear nose and throat (ENT) examination including nasal endoscopy and olfactory testing, for example, with "sniffin' sticks". For diagnostic purposes modern imaging procedures, such as magnetic resonance imaging (MRI) are becoming more and more important. For testing children, olfactory testing needs to be adapted and depending on the etiology, olfactory training, antiphlogistic and surgical procedures are the most promising therapeutic approaches. In cases of intracranial causes of dysosmia neurosurgeons should know and respect the anatomical structures of the olfactory signal pathway, not least for the long-term prognosis.

Microsurgical anatomy for intraoperative preservation of the olfactory bulb and tract

Damage to the olfactory bulb and tract is a frequently described complication of brain surgery in the frontal region, and it seems to be influenced by the surgical approaches. Eighty cerebral hemispheres and 5 formalin-fixed cadavers filled with colored latex were used. Parameters were directly measured, and after olfactory bulb and tract were mobilized with careful dissections, retraction of the frontal lobe was noted. The anterior border of the olfactory bulb is 22.21 (SD, 5.45) mm posterior to the frontomarginal sulcus, and arachnoidal dissection should be performed parallel to olfactory structures using sharp instruments to allow early visualization. Overall mobilization of the olfactory bulb and tract as 29.3 (SD, 6.4) mm in length is possible without disrupting the structures and enables a greater degree of the frontal-lobe elevation window up to 13.1 (SD, 3.2) mm. Using the morphometric data and anatomic knowledge may prevent unwanted anosmia complication during surgical approaches.

Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma

INTRODUCTION

Post-traumatic cerebrospinal fluid leak from the anterior cranial fossa in children may be isolated or combined with severe facial and calvarial injury. Untreated leak may result with meningitis, hydrocephalus, and abnormal neurocognitive development.

PATIENTS AND METHODS

We present nine children, ages 4-16 years, with complicated craniofacial injury treated by a combined subcranial and intracranial approach. A continuous lumbar drainage was kept for several days, and prophylactic antibiotics and anti-convulsive medications were routinely given. A multidisciplinary approach including discussion before surgery about other surgical options (endoscopic extracranial and intracranial alone) were performed.

RESULTS

None of the operated children had episodes of meningitis/leak after the combined approach, suggesting that appropriate sealing of the base of the skull has been achieved. There was no mortality, and the long-term follow-up showed good developmental and cosmetic results. Most of the children had significant brain contusions prior to surgery; however, these did not progress as minimal retraction was enabled by the extensive subcranial and intracranial approach.

CONCLUSIONS

Child's age, anatomy of the bone, extent of cranial injury, and clinical parameters should be seriously considered when choosing the technical methods as for sealing base of skull and reconstruction of facial/cranial bones. Young age does not seem to be a contraindication to the combined approach, thus, we recommend considering it in extensive base of skull fractures when concomitant cranial, maxillofacial, and orbital fractures coexist, as alternative options may not suffice in these cases.