Craniofacial and skull base trauma.

Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK.

Source
Department o Surgery, Di!ision o Trauma Surgery, "e#ars$Sinai Me#i%al "enter, &os Angeles, "ali ornia '(()*, +SA.

Abstract
BA"K,R-+.D/ Traumati% %ranio a%ial an# s0ull base in1uries re2uire a multi#is%iplinary team approa%h. Trauma physi%ians must e!aluate %are ully, triage properly, an# maintain a high in#e3 o suspi%ion to impro!e sur!i!al an# enhan%e un%tional re%o!ery. 4re2uently, %ranio a%ial an# s0ull base in1uries are o!erloo0e# 5hile treating more li e$threatening in1uries. +nnoti%e# %omple3 %ranio a%ial an# s0ull base ra%tures, %erebrospinal lui# istulae, an# %ranial ner!e in1uries %an result in blin#ness, #iplopia, #ea ness, a%ial paralysis, or meningitis. Early re%ognition o spe%i i% %ranio a%ial an# s0ull base in1ury patterns %an lea# to i#enti i%ation o asso%iate# in1uries an# allo5 or more rapi# an# appropriate management. "-."&+S6-./ Early #ete%tion an# treatment o %ranio a%ial an# s0ull base traumati% in1uries shoul# lea# to #e%rease# morbi#ity an# mortality. This re!ie5 #is%usses the most %ommon o these in1uries, their possible %ompli%ations, an# treatment. Craniofacial and Skull Base Trauma By J. Timothy Katzen M.D., Reza Jarrahy M.D., Joseph B. Eby M.D., Ronal# A. Mathiasen M.D., Daniel R. Margulies M.D., 4A"S, Hrayr K. Shahinian M.D, 4A"S Abstract: Background Traumati% %ranio a%ial an# s0ull base in1uries re2uire a multi#is%iplinary team approa%h. Trauma physi%ians must e!aluate %are ully, triage properly, an# maintain a high in#e3 o suspi%ion to impro!e sur!i!al an# enhan%e un%tional re%o!ery. 4re2uently, %ranio a%ial an# s0ull base in1uries are o!erloo0e# 5hile treating more li e$threatening in1uries. +nnoti%e# %omple3 %ranio a%ial an# s0ull base ra%tures, %erebrospinal lui# istulae, an# %ranial ner!e in1uries %an result in blin#ness, #iplopia, #ea ness, a%ial paralysis, or meningitis. Early re%ognition o spe%i i% %ranio a%ial an# s0ull base in1ury patterns %an lea# to i#enti i%ation o asso%iate# in1uries an# allo5 or more rapi# an# appropriate management. Abstract: Conclusion Early #ete%tion an# treatment o %ranio a%ial an# s0ull base traumati% in1uries shoul# lea# to #e%rease# morbi#ity an# mortality. This re!ie5 #is%usses the most %ommon o these in1uries their possible %ompli%ations an# treatment. Keywords %ranio a%ial trauma, s0ull base trauma, a%ial ra%tures, temporal bone ra%tures, anosmia, #iplopia, otorrhea, rhinorrhea, "S4 lea0s, %ranial ner!e trauma, man#ible ra%tures, ma3illary ra%tures, &e4ort ra%tures, zygomati% ra%tures, orbital ra%tures Introduction 6n the +nite# States in 7''', there 5ere o!er si3 million automobile %rashes. -!er t5o million %rashes resulte# in in1uries 5ith o!er thirty$se!en thousan# #eaths.7 -!er 89: o these in1uries ha!e %ranio a%ial or %er!i%al spine in1ury.; <ith the a#!ent o e!er in%reasing sophisti%ation in %ompute# tomography ="T> imaging, trauma surgeons %an #iagnose rapi#ly small a%ial ra%tures an# intra%ranial hemorrhages. Ho5e!er, #espite imaging

impro!ements an# more thorough physi%al e3amination, subtle %omple3 a%ial ra%tures 5ith %erebrospinal lui# ="S4> lea0s, temporal bone ra%tures, an# %ranial ner!e in1uries %an remain un#iagnose#. +n ortunately, #elaye# or misse# #iagnoses %an lea# to signi i%ant morbi#ity =blin#ness, #iplopia, #ea ness, a%ial paralysis, an# meningitis> or #eath. ,reater a5areness o potential %ranial in1uries is nee#e# to a%ilitate more rapi# #iagnosis an# appropriate treatment. A %are ul history an# physi%al e3amination is paramount to a%%urately #iagnose %ranio a%ial in1ury. A ter per orming the primary sur!ey outline# by a#!an%e# trauma li e support, a more thorough se%on#ary sur!ey shoul# pro%ee# systemati%ally. The %lini%al e3amination o the %ranio a%ial s0eleton begins 5ith inspe%tion or lo%alize# ten#erness, numbness, blee#ing, asymmetry, #e ormity, e%%hymosis, periorbital e#ema, otorrhea, an# rhinorrhea. All bony sur a%es shoul# be palpate# in%lu#ing the superior an# in erior orbital rims, zygomati% ar%hes, nose, ma3illa, man#ible, an# both al!eolar ri#ges. E!en i the eye is s5ollen shut, both eyes shoul# be e3amine# %losely? e3amination shoul# in%lu#e !isual a%uity an# e3trao%ular mus%les. Mi# a%e stability shoul# be appraise#. Al!eolar ri#ges an# teeth shoul# be e3amine# or #ental trauma an# o%%lusion shoul# be assesse#.@, ) 6n the %ons%ious an# %ooperati!e patient, a #etaile# %ranial ner!e =".> e3amination shoul# be per orme#. The opti% ner!e, ". 66, is assesse# by !isual iel# a%uity. E3trao%ular mo!ements test the integrity o ". 666, 6A, an# A6.9 Hypoesthesia o the a%e suggests ". A in1ury. 4a%ial ner!e in1ury, ". A66, pro#u%es paresis or paralysis o the mus%les o a%ial e3pression. The %ranial ner!e e3amination o the %omatose patient is slightly more #i i%ult an# relies on testing o brain stem re le3es.B 6n the %omatose patient, assessing !ision %an be #i i%ult? e!en 5ith %omplete unilateral !isual loss, pupils %an remain e2ually rea%ti!e as long as the e erent path5ay o ". 666 is inta%t.8 The opti% an# o%ulomotor systems shoul# be e!aluate# by the Cs5inging lashlight testC. The test re2uires an inta%t a erent ". 66 path5ay an# an inta%t e erent ". 666 parasympatheti% path5ay.8 Testing patients 5ith unilateral a erent ". 66 #amage re!eals bilateral, e2ual pupillary %onstri%tion 5hen light is #ire%te# to5ar# the eye 5ith !ision. Ho5e!er, 5hen light is #ire%te# to5ar# the eye 5ith #iminishe# !ision, bilateral pupils 5ill #ilate. The phenomenon is re erre# to as the Mar%us ,unn pupil.8 6n the %omatose patient, e3trao%ular mo!ements %an be teste# 5ith the o%ulo%ephali% =or C#ollDs eyeC> re le3. The %orneal re le3 %onsists o tou%hing the %ornea 5ith a pie%e o %otton? a erent ibers o ". A sen# the message to the brain an# ". A66 respon#s by eyeli# %losure. ". A666 is assesse# 5ith the %ol#$5ater %alori% test, in 5hi%h i%e 5ater is in1e%te# into the ear an# eli%its nystagmus. Testing o the gag re le3 e!aluates ". 6E an# ". E. A ter %are ul physi%al e3amination, the trauma surgeon shoul# o%us on spe%i i% areas o %ommon %ranio a%ial in1uries. Craniofacial fractures Orbital fractures 4or%e ul impa%t to the s0ull %an %ause a ra%ture along the 5ea0 points o the orbit. The thinnest an# 5ea0est area o the orbit is the loor. Typi%ally, the posterome#ial region o the orbital loor is ra%ture#. - ten, orbital so t tissues herniate in eriorly into the ma3illary sinus an# be%ome entrappe#.* Entrapment o the in erior obli2ue or in erior re%tus mus%le %an lea# to #iplopia an# restri%tion o globe mo!ement. A##itionally, the globe is #ispla%e# posteriorly an# in eriorly, 5hi%h %auses enophthalmos an# urther #iplopia. The #egree o orbital loor #ispla%ement is #iagnose# a%%urately 5ith a3ial an# espe%ially, %oronal "T s%ans o the orbit an# a%ial bones. Surgi%al inter!ention is in#i%ate# 5hen there is signi i%ant orbital loor #isruption, persistent #iplopia, entrapment, or enophthalmos.' Surgi%al a%%ess to orbital loor ra%tures in!ol!es a sub%iliary or trans%on1un%ti!al in%ision in the lo5er eyeli#. ' The in%ar%erate# orbital tissue is re#u%e# an# bony #e e%ts are re%onstru%te# 5ith a !ariety o allogra ts or autogra ts har!este# rom assorte# sites. 4ra%tures o the superior, lateral, an# in erior orbital rims may o%%ur in isolation or in %on1un%tion 5ith other

%ranio a%ial ra%tures. Fhysi%al e3amination may re!eal step$o s in the line o the ra%ture. "hee0 paresthesias are %ommon #ue to in erior orbital rim ra%tures traumatizing the in raorbital ner!e. -rbital ra%tures are repaire# by realignment an# i3ation 5ith miniplates. 7( Zygomatic fractures The zygoma orms the malar eminen%e, #etermines anterior an# lateral %hee0 pro1e%tion, an# supports the lateral orbital 5all an# loor. The zygoma has our pro%esses. Superiorly, the rontal pro%ess arti%ulates 5ith the rontal bone at the zygomati%o rontal suture. 6n eriorly, the ma3illary pro%ess arti%ulates 5ith the ma3illa at the zygomati%oma3illary suture. &aterally, the temporal pro%ess 1oins the temporal bone, anterior to the e3ternal au#itory %anal. Me#ially, the orbital pro%ess arti%ulates 5ith the greater 5ing o the sphenoi#. Due to the pro1e%tion o the zygoma, traumati% in1ury is %ommon. Most zygomati% ra%tures o%%ur in the ar%h an# in%lu#e a portion o the lateral orbital 5all.77, 7; Gygomati% ar%h ra%tures %ause #epression o the %hee0 #ue to the pull o the masseteri% mus%le in an in erior, me#ial, an# posterior !e%tor. 7; Sub%on1un%ti!al hematomas an# in raorbital ner!e paresthesias are so %ommon, that their absen%e ma0es the #iagnosis o zygomati% ra%ture 2uestionable.7@ Many zygomati% ra%tures are minimally #ispla%e# an# #o not re2uire surgi%al %orre%tion. .on$%omminute#, posterior zygomati% ar%h ra%tures %an be treate# through a 7 %m temporal in%ision by simple re#u%tion, 5ithout the nee# or internal i3ation.7; Ho5e!er, any other #ispla%e# zygomati% ra%ture re2uires open re#u%tion an# internal i3ation.7@ Su%%ess ul re#u%tion relies on an a%%urate three$#imensional re#u%tion 5ith an emphasis on %are ul realignment o the lateral orbital 5all.7) 4ra%tures are re#u%e# an# se%ure# 5ith miniplates. Maxillary fractures Ma3illary ra%tures result rom #ire%t blo5s. Transmitte# or%es ollo5 a pre#i%table path along the thinner portions o the ma3illa. The pre#i%table patterns orm the basis o the &e4ort %lassi i%ation o ma3illary ra%tures.79 &e4ort 6 ra%tures are the most %au#al o ma3illary ra%tures. &e4ort 6 begin in the lo5er margin o the piri orm aperture an# e3ten# laterally abo!e the roots o the teeth, through the anterior ma3illary 5all, an# posterior$laterally to in!ol!e the pterygoi# pro%esses. &e4ort 66 ra%tures are %entrally more %ephala# an# #ue to their shape, are %alle# Cpyrami#al ra%turesC. &e4ort 66 ra%tures begin at the nasal bri#ge, e3ten# in erior$ laterally insi#e the me#ial orbit, e3it through the in raorbital oramen, tra!el through the zygomati%oma3illary suture, an# e3ten# posteriorly to in!ol!e the pterygoi# pro%esses. &e4ort 666 ra%tures begin me#ially as &e4ort 66 ra%tures? ho5e!er, instea# o e3iting the orbit o!er the in raorbital rim, they progress laterally along the entire orbital loor an# e3ten# to #isrupt the zygomati%o rontal suture. &e4ort 666 ra%tures result in %omplete %ranio a%ial #ys1un%tion be%ause the a%ial bones an# stru%tures o the mi##le thir# o the a%e be%ome totally separate# rom the %ranium. The original a%ial ra%ture stu#ies #one by Dr. Rene &e4ort 5ere per orme# on %a#a!ers sustaining #ire%t blo5s to the %enter on the a%e.7B Sin%e most a%ial trauma %onsists o blo5s rom the si#e or slightly o %enter, i#eal, symmetri% &e4ort 6, 66, an# 666 patterns are rarely ollo5e#.7) Most ma3illary ra%tures are more %omminute# on one si#e than the other. Thus, &e4ort ra%tures may be seen in any %ombination/ a right ChemiC &e4ort 66 ra%ture %an %oe3ist 5ith a le t ChemiC &e4ort 666 ra%ture.7) Frolonge# #elay in the operati!e repair o ma3illary ra%tures results in poor healing an# shoul# be #is%ourage#.7; -ne o the ma1or goals in the treatment o &e4ort ra%tures shoul# be reestablishment o pre$ in1ury #ental o%%lusion. There ore, &e4ort ra%ture patients shoul# al5ays be pla%e# in interma3illary i3ation, prior to open re#u%tion an# internal i3ation. A se%on#, but e2ually important goal in the treatment o &e4ort ra%tures shoul# be re%onstru%tion o the orbital loor =see Orbital fractures abo!e>. A thir# goal shoul# be reestablishment o the patientDs a%ial height an# pro1e%tion? pre$traumati% a%ial orm %an be a%hie!e# by a%%urate open re#u%tion an# internal i3ation. Mandibular fractures

Along 5ith the zygoma, the man#ible is one o the most re2uently ra%ture# a%ial bones an# %onstitutes appro3imately ;(: o all a%ial ra%tures.7* Areas o man#ibular 5ea0ness are the most li0ely to ra%ture an# in%lu#e the man#ibular ne%0, sub%on#ylar region, an# angle.7* Sin%e greater than 9(: o man#ibular ra%ture in t5o or more lo%ations, a se%on# ra%ture site most al5ays be suspe%te# 5hen e3amining a patient.7* Fresen%e o teeth, position o man#ibular ra%ture, an# pull o man#ibular mus%ulature all #etermine presenting symptomatology. Man#ibular ra%tures re2uently present 5ith malo%%lusion an# asymmetry.7* The most important goal in the treatment o man#ibular ra%tures is to reestablish the patientDs pre$in1ury #ental o%%lusion.7* Most man#ibular ra%tures re2uire open re#u%tion an# internal i3ation. Due to the ba%terial loa# o the mouth, open man#ibular ra%tures shoul# be irrigate# imme#iately, re#u%e# an# i3ate#. "lose# man#ibular ra%tures shoul# be openly re#u%e# an# internally i3ate# 5ithin three to i!e #ays a ter the in1ury, to allo5 or #e%ease# e#ema an# intra$operati!e blee#ing. 6 there is any 2uestion as to the stability o a man#ibular ra%ture, the patient shoul# be le t in interma3illary i3ation or our to si3 5ee0s to ensure proper bone healing.7* Skull base fractures 4i!e bones orm the base o the s0ull. The bones in%lu#e the orbital plate o the rontal bone, %ribri orm plate o the ethmoi# bone, sphenoi# bone, o%%ipital bone, an# the s2uamous an# petrous portions o the temporal bone. +p to ;): o patients sustaining blunt hea# trauma ha!e a s0ull base ra%ture.;( Despite the %lini%al importan%e o s0ull base ra%tures, many are un#iagnose#. Be%ause o the %omple3 anatomi% relationships o the s0ull base, the ra%tures may #amage %riti%al neighboring stru%tures, in%lu#ing %ranial ner!es, internal %aroti# artery, an# %a!ernous sinus. The ra%tures may la%erate the #ura an# %reate a potential "S4 istula. <hen a ra%ture o the s0ull base is suspe%te#, insertion o a nasogastri% tube =.,T> shoul# be a!oi#e#. The orogastri% route is pre erre# as there ha!e been %ases o intra%ranial .,T pla%ement in the presen%e o %ribri orm plate ra%tures.;7 Temporal bone fractures "lini%al signs o temporal bone ra%tures in%lu#e bloo# in the e3ternal au#itory %anal, hemotympanum, e%%hymosis o!erlying the mastoi# bone, otorrhea, hearing loss, !estibular #ys un%tion, an# a%ial ner!e paresis or paralysis. High$resolution non$%ontra%t "T s%an shoul# be per orme# in all suspe%te# temporal bone in1uries.;; "oronal se%tions an# @D re%onstru%tions pro!i#e in ormation about the a%ial ner!e %anal, %aroti# %anal, an# oti% %apsule. Temporal bone ra%tures are %lassi ie# a%%or#ing to their relationship to the long a3is o the petrous pyrami#. Though most temporal bone ra%tures are mi3e#, temporal bone ra%tures are %lassi ie# as longitu#inal or trans!erse. Se!enty to ninety per%ent o temporal bone ra%tures are longitu#inal, an# o%%ur a ter #ire%t lateral blo5s to the temporoparietal s0ull.;;, ;@ These ra%tures usually begin in the 5ea0er s2uamous portion o the temporal bone an# %ourse to5ar# the %aroti# an# 1ugular oramina. +sually, the tympani% membrane is torn an# the mi##le ear ossi%les are #isrupte# resulting in a %on#u%ti!e hearing loss. Blee#ing rom the e3ternal au#itory %anal is %ommon. Appro3imately ;9: o patients ha!e a%ial ner!e in1ury, 5hi%h usually o%%urs in the geni%ulate ganglion or a%ial %anal. Trans!erse temporal bone ra%tures are mu%h more rare an# o%%ur ollo5ing se!ere trauma to the o%%iput.;) These ra%tures begin in the 1ugular oramen an# %ourse a%ross the petrous pyrami#, through the oramina spinosum an# la%erum to the oramen magnum. Appro3imately 9(: o patients noti%e imme#iate a%ial paralysis rom ".A66 in1ury.;9 +nless %orre%te# surgi%ally, a%ial paralysis may be permanent. Typi%ally, ".A66 is in1ure# in the internal au#itory meatus or on the me#ial 5all o the tympani% membrane. 6n a##ition, #amage to the labyrinth, %o%hlea, or ".A666 %an result in sensorineural hearing loss an# !estibular #ys un%tion.

Trans!erse temporal bone ra%tures o ten %ourse through the oti% %apsule. Be%ause the oti% %apsule heals by ibrous union rather than bony %allus ormation, patients ha!e a li elong ris0 or #e!eloping meningitis.;B Penetrating temporal bone trauma Fenetrating trauma to the temporal bone usually results rom sel $in li%te# gun shot 5oun#s.;8 A ter initial stabilization, a %omplete !as%ular an# neurologi% e!aluation shoul# be per orme#. Aas%ular e3amination shoul# in%lu#e #igital subtra%tion angiography 5ith !enous phasing or magneti% resonan%e angiography.;* "omplete neurologi% e3amination shoul# pla%e spe%ial emphasis on %ranial ner!es e3amination. Due to the %lose pro3imity o !ital stru%tures, one neurologi% #e i%it may point to5ar#s another in1ury. 4or e3ample, !o%al %or# paralysis rom an in1ure# !agus ner!e may be asso%iate# 5ith a %aroti# artery or 1ugular !ein in1ury. Skull base fracture treatment 6n the absen%e o a "S4 istula, temporal bone ra%ture, a%ial paralysis, hearing loss, or blin#ness, the management o s0ull base ra%tures is nonoperati!e an# e3pe%tant. "onser!ati!e treatment in%lu#es a i!e #ays %ourse o intra!enous antibioti%s to allo5 potential #ural tears to heal.;( -perati!e treatment is in#i%ate# or post$traumati% "S4 istulae 5ith meningitis, trans!erse petrous ra%tures 5ith oti% %apsule in!ol!ement, temporal bone ra%tures 5ith %omplete a%ial paralysis, an# ballisti% in1ury to the temporal bone.;' Treatment in%lu#es a subtotal petrose%tomy. The operation %onsists o %omplete e3enteration o temporal bone air %ell tra%ts an# obliteration o the eusta%hian tube.;B A ter the in1ure# stru%tures are repaire# =e.g., the a%ial ner!e or %aroti# artery> or e3enterate# =e.g., the oti% %apsule>, the resulting %a!ity is obliterate# 5ith an en#ogenous at gra t an# temporalis mus%le lap CSF Fistulae Appro3imately ;(: o s0ull base ra%tures 5ill #e!elop a "S4 istula 5ith *(: o%%urring 5ithin )* hours o in1ury.@(, @7 Mani estations in%lu#e rhinorrhea an# otorrhea. The #rainage is usually %lear an# nonmu%oi# an# may be #i i%ult to #ete%t 5hen mi3e# 5ith bloo#. To a%ilitate the #iagnosis o "S4 lea0, a e5 #rops o the lui# are pla%e# on a tissue paper. "S4 has a more rapi# #i usion pattern than bloo#, an# 5hen the #is%harge is mi3e# 5ith bloo#, a larger, %learer "S4 ring 5ill surroun# the sanguineous %entral ring. The %lini%al in#ing is terme# the C#ouble$ringC sign. Alternati!ely, the lui# glu%ose %on%entration %an be measure#. Aalues shoul# be %ompare# to serum glu%ose le!els an# 2uantities greater than @( mgH#l are usually %onsistent 5ith "S4.@; 6n a##ition, the lui# shoul# be sent or beta$;$trans errin. Fresen%e o beta$;$trans errin %on irms a "S4 lea0. Rhinorrhea "S4 #raining rom the nose results rom ra%tures through the %ribri orm plate, ethmoi#, sphenoi#, petrous portion o the temporal bone, or orbital plate o the rontal bone.@@ 6nitially, patients are manage# %onser!ati!ely. Fatients are maintaine# at total be# rest 5ith the hea# o be# ele!ate#, to re#u%e the lo5 o "S4 #rainage. 6 #rainage has not %ease# a ter 8; hours o %onser!ati!e therapy, a lumbar #rain shoul# be inserte# to #rain 79(ml o "S4 per #ay or three to our #ays. Di!ersion o "S4 rom the site o the #ural tear a%ilitates spontaneous %losure. "urrent #ata support pla%ing patients on 7 to ; million units o peni%illin per #ay in the presen%e o a "S4 istula.@), @9 .asal an# throat %ultures shoul# be ta0en, an# antibioti%s shoul# be sele%te# upon %ulture results. The "S4 istula is lo%alize# 5ith "T s%ans using @.( mm %oronal se%tions. T5o other stu#ies may help lo%alize the istula/ an in#ium$777 DTFA or metrizami#e "T %isternogram. An 6n#ium$777 %isternogram begins 5ith the pla%ement o %otton ple#gets in the anterior an# posterior roo o the nose, sphenoethmoi#al re%ess, an# mi##le meatus.@B 6n#ium$777 DTFA is intro#u%e# into the spinal subara%hnoi# spa%e !ia lumbar pun%ture. The patientDs hea# is le3e#, %ausing an in%rease in intra%ranial pressure an# thereby in%reasing the lo5 o "S4 through the #ural tear. The ra#ioa%ti!ity o the %otton ple#gets is measure# an# use# as a gui#e to the site o the lea0. A metrizami#e "T %isternogram begins by intro#u%ing metrizami#e into the lumbar subara%hnoi# spa%e. Then the patient un#ergoes a %oronal "T s%an. "ontrast material 5ill be seen in the paranasal sinuses near the istulous tra%t. An a%ti!ely #raining istula is re2uire# or the te%hni2ue. Sin%e most istulae #rain only

intermittently, alse$negati!e stu#ies are %ommon. A ter lo%alizing the site o the "S4 istula, operati!e repair may be un#erta0en. Ho5e!er, there is no %onsensus regar#ing the timing o operati!e repair. "urrent re%ommen#ations or patients 5ith an isolate# "S4 istula in%lu#e #e erring surgery or at least i!e #ays.;(, @7, @8 Surgi%al inter!ention shoul# be reser!e# or patients 5ith meningitis, large #e e%ts 5ith brain herniation into paranasal sinuses, pneumo%ephalus, or persistent "S4 lea0 o!er i!e #ays.@7, @8 Re%ent a#!an%es in en#os%opy allo5 or a minimally in!asi!e ully en#os%opi% transethmoi#al or transsphenoi#al approa%h to repair "S4 istulae.@* The te%hni2ue is best utilize# to a%%ess lea0s through the sphenoi# an# ethmoi# sinuses an# the sella tur%i%a.@9 Otorrhea Drainage o "S4 rom the ear results 5hen a ra%ture o the petrous portion o the temporal bone both tears the #ura mater an# per orates the tympani% membrane. "S4 #rainage %an also o%%ur rom ra%ture# mastoi# air %ells %ausing a la%eration o the e3ternal au#itory %anal. As 5ith rhinorrhea, the initial management o otorrhea is %onser!ati!e. The patient shoul# be positione# to minimize istula #rainage. 6rrigation an# probing o the ear in%rease the ris0 o meningitis an# shoul# be #is%ourage#. Most patients 5ill stop #raining spontaneously 5ithin se!eral #ays. Rarely, otorrhea persists beyon# i!e to se!en #ays. <hen otorrhea lasts beyon# se!en #ays, high$resolution "T s%anning 5ith %oronal se%tioning shoul# be per orme# to lo%alize the site o the ra%ture. Detaile# au#itory an# !estibular testing shoul# be per orme# at si3 to eight 5ee0s to #iagnose abnormalities. -perati!e inter!ention %onsists o a mi##le or posterior ossa %raniotomy, ashioning a bone lap to e3pose the #ura o!erlying the petrous bone.@9 Frimary repair is attempte#, but i not possible, a gra t o peri%ar#ium or as%ia lata is use#. -%%asionally, en#ogenous at or mus%le is use# to pa%0 the #e e%t. Cranial nerve injuries +pon e3iting the s0ull, %ranial ner!es are espe%ially prone to #amage. S0ull base ra%tures parti%ularly pre#ispose patients to %ranial ner!e #amage. Table 7 lists the t5el!e %ranial ner!es an# the %ommon neurologi% #e i%its ollo5ing in1ury. Olfactory ner e !C" I# in$ury 6n1ury to the ol a%tory ner!e results in anosmia. Typi%ally, anosmia o%%urs rom anterior ossa loor ra%tures. 6n almost hal o the %ases, a patientDs sense o smell returns in se!eral months.@' 6n a##ition to a "T s%an, 5or0$ up may re2uire an ol a%tory ele%troen%ephalogram. Most o ".6 in1uries %an be manage# %onser!ati!ely. Optic nerve (CN ! injur" -pti% ner!e in1ury %an result in blin#ness. -pti% ner!e in1uries are usually #ue to isolate# ra%tures o the opti% %anal or orbit or e3tensions o s0ull base ra%tures.)( S0ull base ra%tures in!ol!ing the sphenoi# bo#y an# e3ten#ing through the sella tur%i%a an# pars petrosa %an #amage the opti% %hiasm, pro#u%ing blin#ness or bitemporal hemianopsia.)7 The opti% ner!e is uni2ue an# not a true %ranial ner!e. The opti% ner!e is a #ire%t e3tension o the brain an# thus, the a3ons o the opti% ner!e #o not regenerate. There ore, prognosis is poor ollo5ing opti% ner!e in1ury. <ith %omplete opti% ner!e transe%tion #istal to the opti% %hiasm, there is mono%ular blin#ness, a #ilate# pupil, an# an absent pupillary re le3.); Results o surgi%al #e%ompression o the opti% ner!e in the opti% %anal are similar to rates o spontaneous re%o!ery.)@ Surgi%al #e%ompression is reser!e# or %ases o a narro5e# opti% %anal, bony ragment in the opti% %anal, or #eterioration o pre!iously goo# !ision ollo5ing hea# trauma.);

<hen in#i%ate#, a%ute #e%ompression is %on#u%te# through a bi rontal %raniotomy. A##itionally, opti% %hiasm #e%ompression may be a%%omplishe# using an en#os%opi% transsphenoi#al approa%h. Oculomotor nerve (CN ! injur" 6n1ury to ".666 is typi%ally rom a #ire%t, rontal blo5. Trauma stret%hes an# %ontuses ".666 upon entry into the brain, at the posterior aspe%t o the %a!ernous sinus. "lini%ally, patients %omplain o #iplopia resulting rom impaire# e3trao%ular mo!ements. E3amination re!eals an ipsilateral #ilate# pupil an# an inability to mo!e the eye me#ially, superiorly, or in eriorly. 4ra%tures through the superior orbital issure %ause #amage to ". 666, 6A, A6, an# the ophthalmi% #i!ision o A.)) The %lini%al result is the superior orbital issure syn#rome. Fatients may present 5ith paralysis o the le!ator, superior re%tus, in erior re%tus, in erior obli2ue, superior obli2ue, an# lateral obli2ue mus%les an# anesthesia o the bro5, upper li#, an# orehea#. <hen superior orbital issure syn#rome symptoms are a%%ompanie# by blin#ness, the %omple3 is %alle# the orbital ape3 syn#rome an# in#i%ates in!ol!ement o the opti% oramen. Treatment o o%ular ner!e palsies %onsists o 5earing a pat%h o!er the a e%te# eye. Spontaneous re%o!ery o o%ular mo!ement usually o%%urs in our to si3 5ee0s. Troc%lear ner e !C" I&# in$ury The tro%hlear ner!e is the least re2uently in1ure# %ranial ner!e. Damage to %ranial ner!e 6A results rom stret%hing near the e3it rom the #orsal mi#brain. &ateral re%tus 5ea0ness results. Treatment is %onser!ati!e an# in!ol!es an eye pat%h to pre!ent #iplopia. 4un%tion usually returns by our to si3 5ee0s. Trigeminal ner e !C" &# in$ury 6n1ury to the trigeminal ner!e %auses sensory #e i%its to the a%e. The three bran%hes o the trigeminal ner!e are the supraorbital ner!e =A7>, the ma3illary bran%h =A;>, an# the man#ibular bran%h =A@>. A7 is #amage# most %ommonly. The bran%h is parti%ularly sus%eptible to in1ury at the supraorbital not%h. "omplete transe%tion may result in anesthesia o the nose, eyebro5, an# orehea#.)9 Typi%ally, A; is in1ure# by ma3illo a%ial ra%tures 5ith resultant sensory #e e%ts o the ipsilateral %hee0, upper lip, gums, an# har# palate. Typi%ally, A@ is in1ure# by man#ibular ra%tures an# results in anesthesia o the %hin. "entrally, the trigeminal ganglion %an be #amage# by a penetrating hea# in1ury. This is asso%iate# 5ith ". 666, ". 6A, or %aroti#$%a!ernous istula.)B The ner!e is espe%ially !ulnerable %oursing through the #ura, pro3imal to Me%0elDs %a!e. 6n%omplete transe%tion or s%arring o the bran%hes o ". A may result in intra%table a%ial pain an# neuroma ormation. "orti%osteroi# in1e%tions, en#os%opi% #e%ompression, or en#os%opi% #i!ision may be re2uire# or relie o symptoms.)8 Abducens ner e !C" &I# in$ury 6n1ury to the ". A6 results rom ra%tures in the %li!us. Aerti%al mo!ement o the brainstem #uring trauma may stret%h or a!ulse the ner!e upon lea!ing the pons =4igure '>. As mentione# abo!e, ". A6 may be #amage# in the superior orbital issure an# is %lassi%ally a%%ompanie# by ". 666 an# ". 6A palsies. The #iagnosis o ab#u%ens palsy in the un%ons%ious patient %an be ma#e 5hen the a e%te# eye ails to ab#u%t as the hea# is passi!ely turne# a5ay rom the si#e o in1ury. Treatment is %onser!ati!e an# most %ases o ab#u%ens ner!e in1ury re%o!er spontaneously a ter our 5ee0s.

Facial nerve (CN # ! injur" Temporal bone ra%tures are the most %ommon %ause o a%ial ner!e in1uries.;;, ;9 4i ty per%ent o patients 5ith trans!erse ra%tures o the temporal bone an# ;9: o patients 5ith longitu#inal ra%tures 5ill ha!e asso%iate# a%ial ner!e in1ury %ausing ipsilateral a%ial paralysis.)* Although a%ial ner!e in1ury 5ithin the temporal bone is the most %ommon site, ". A66 %an be #amage# any5here along its %ourse.)' 6n trans!erse temporal ra%tures, the ner!e may be in1ure# at the internal au#itory meatus or in the horizontal portion o the allopian %anal. 6n longitu#inal temporal ra%tures, the ner!e may be #amage# at the geni%ulate ganglion. 4ollo5ing a #etaile# %lini%al e3amination, all patients suspe%te# to ha!e a a%ial ner!e in1ury shoul# ha!e a "T s%an an# be e!aluate# 5ith trans%utaneous ner!e e3%itability tests an# ele%troneurography. Trans%utaneous ner!e e3%itability tests pre#i%t irre!ersible ner!e in1ury by %omparing the normal an# in1ure# si#e. <hen the #i eren%e is greater than @.9mA, surgi%al inter!ention is usually re2uire#.9( -perati!e inter!ention is also in#i%ate# 5hen there is %omplete, imme#iate, a%ial paralysis 5ith greater than '(: #ener!ation #o%umente# by ele%troneurography.97 Mi%rosurgi%al te%hni2ues are utilize# to e3plore, #e%ompress, or #ire%tly repair the ner!e. A subtotal petrose%tomy approa%h is utilize#. The se!ere# ner!e as%i%les are suture# together un#er a mi%ros%ope. Most patients 5ith traumati% a%ial paralysis re%o!er 5ell 5ithout surgi%al inter!ention? ho5e!er, the eye must be guar#e# against e3posure 0eratitis #uring the re%o!ery perio#.;9 #estibulocochlear nerve (CN # ! injur" Damage to the ". A666 is %ommon ollo5ing trans!erse ra%tures o the temporal bone rom rontal or o%%ipital impa%t. "o%hlear an# !estibular #amage %an result 5ith #ea ness an# labyrinthine #ys un%tion. 6n a##ition, ra%tures in!ol!ing the oti% %apsule %an lea# to total #egeneration o the %o%hlear an# !estibular organs. A baseline neuro$otologi% e!aluation shoul# be #one in all patients 5ith hea# in1ury to #ete%t hearing loss an# !estibular #ys un%tion. Ele%tronystagmography %an be use# to assess labyrinthine un%tion. Au#itometry an# brainstem e!o0e# potentials are use# to e!aluate hearing loss. Fre!iously, the prognosis o sensorineural hearing loss 5as poor. Ho5e!er, re%ent a#!an%es in %o%hlear implantation ha!e allo5e# a return to spee%h un#erstan#ing in *): o patients ollo5ing an intensi!e rehabilitation program.9; $lossophar"ngeal (CN %! #agus (CN %! Spinal accessor" (CN % ! &"poglossal (CN % ! nerve injur" The glossopharyngeal, !agus, an# spinal a%%essory ner!es e3it the s0ull base in the 1ugular oramen. The hypoglossal ner!e passes though the hypoglossal oramen 1ust me#ial to the 1ugular oramen. 6n1ury to glossopharyngeal ner!e pro#u%es #ysphagia an# loss o gag re le3. Aagus ner!e in1ury results in paralysis o the ipsilateral !o%al %or# an# resultant !oi%e hoarseness. Spinal a%%essory ner!e in1ury results in paralysis o the sterno%lei#omastoi# mus%le an# 5ea0ness o the trapezius mus%le? the result is 5ea0ness in %ontralateral hea# rotation an# shoul#er ele!ation. Hypoglossal ner!e in1ury %auses hemiatrophy o the tongue an# ipsilateral tongue #e!iation. Treatment is usually supporti!e, employing physi%al, o%%upational, an# spee%h therapy. Conclusion

Be%ause o the pro3imity o !ital stru%tures in the %ranio a%ial an# s0ull base region, lo%alize# trauma %an result in unre%ognize# in1uries. "S4 istulae an# %ranial ner!e in1uries in %omple3 ra%tures %an %arry #e!astating %onse2uen%es. A%%or#ingly, appropriate surgi%al re erral shoul# be ma#e 5hene!er the in1uries are suspe%te#. Re%ent a#!an%es in s0ull base approa%hes ha!e allo5e# or highly su%%ess ul surgi%al %orre%tion o these potentially #e!astating in1uries. 'eferences: 7. A#ministration .HTS. .ational Motor Aehi%le A%%i#ent Statisti%s, "orrespon#en%e/ Katzen JT, <ashington, D", .ational High5ay Tra i% Sa ety A#ministration? ;(((. ;. Kazan1ian AH, an# "on!erse JM. The surgi%al treatment o a%ial in1uries., @ e#. Baltimore, MD, <illiams I <ill0ins? 7'8). @. Manson F.. 4a%ial in1uries. 6n/ M%"arthy J,, e#. Plastic Surger"' (he Face) !ol ;. Fhila#elphia, FA/ <.B. Saun#ers? 7'''/*B8$77)7. ). S%hultz R". So t tissure in1uries o the a%e. 6n/ Aston SJ, Beasley R<, Thorne "HM, e#s. Plastic Surger") 9 e#. Fhila#elphia, FA/ &ippin%ott$Ra!en? 7''8/@87$@*;. 9. Barton 4E, an# Berry <&. E!aluation o the a%utely in1ure# orbit. 6n/ Aston SJ, Hornblass A, Meltzer MA, Rees TD, e#s. (hird nternational S"mposium of Plastic and Reconstructive Surger" of the *"e and +dne,a. Baltimore, MD/ <illiam I <il0ins? 7'*;/@). B. Turner D, A,. .eurologi%al e!aluation o a patient 5ith hea# trauma/ "oma s%ales. 6n/ <il0ins RH, Renga%hary SS, e#s. Neurosurger") ; e#. .e5 Jor0, .J/ M%,ro5$Hill? 7''B/;BB'. 8. <eisman RA, an# Sa!ino FJ. Management o patients 5ith a%ial trauma an# asso%iate# o%ularHorbital in1uries. Otolar"ngol Clin North +m) 7''7?;)/@8$98. *. Jones DE, an# E!ans J.. CBlo5$outC ra%tures o the orbit/ an in!estigation into their anatomi%al basis. - .ar"ngol Otol) 7'B8?*7/77('$77;(. '. Bahr <, Bagambisa 4B, S%hlegel ,, an# S%hilli <. "omparison o trans%utaneous in%isions use# or e3posure o the in raorbital rim an# orbital loor/ a retrospe%ti!e stu#y. Plast Reconstr Surg) 7'';?'(/9*9$9'7. 7(. Tessier F. The %on1un%ti!al approa%h to the orbital loor an# ma3illa in %ongenital mal ormation an# trauma. - Ma,illofac Surg) 7'8@?7/@$*. 77. Ellis E#, el$Attar A, an# Moos K4. An analysis o ;,(B8 %ases o zygomati%o$orbital ra%ture. - Oral Ma,illofac Surg) 7'*9?)@/)78$);*. 7;. ,russ JS, Aan <y%0 &, Fhillips JH, an# Antonyshyn -. The importan%e o the zygomati% ar%h in %omple3 mi# a%ial ra%ture repair an# %orre%tion o posttraumati% orbitozygomati% #e ormities. Plast Reconstr Surg) 7''(?*9/*8*$*'(. 7@. Manson F.. 4a%ial ra%tures. 6n/ Aston SJ, Beasley R<, Thorne "HM, e#s. Plastic Surger") 9 e#. Fhila#elphia, FA/ &ippin%ott$Ra!en? 7''8/@*@$)7;. 7). Manson F., Hoopes JE, an# Su "T. Stru%tural pillars o the a%ial s0eleton/ an approa%h to the management o &e 4ort ra%tures. Plastic / Reconstructive Surger") 7'*(?BB/9)$B;. 79. Manson F.. Some thoughts on the %lassi i%ation an# treatment o &e 4ort ra%tures. +nn Plast Surg) 7'*B?78/@9B$@B@. 7B. &e 4ort R. Etu#e e3perimentale sur les ra%tures #e la ma%hoire superieure. Rev Chir Paris) 7'(7?;@/;(*, @B(, )8'. 78. "ra5ley <A, an# Aas%onez H". Mi# a%e, upper a%e, an# pan a%ial ra%tures. 6n/ 4erraro J<, e#. Fundamentals of Ma,illofacial Surger") .e5 Jor0, .J/ Springer$Aerlag? 7''8/;(@$;7). 7*. "ra5ley <A, an# San#el AJ. 4ra%tures o the man#ible. 6n/ 4erraro J<, e#. Fundamentals of Ma,illofacial Surger") .e5 Jor0, .J/ Springer$Aerlag? 7''8/7';$;(;. 7'. 6izu0a T, &in#2!ist ", Halli0ainen D, Mi00onen F, an# Fau00u F. Se!ere bone resorption an# osteoarthrosis a ter miniplate i3ation o high %on#ylar ra%tures. A %lini%al an# ra#iologi% stu#y o thirteen patients. Oral Surg Oral Med Oral Pathol) 7''7?8;/)(($)(8. ;(. Bra5ley B<, an# Kelly <A. Treatment o basal s0ull ra%tures 5ith an# 5ithout %erebrospinal lui# istulae. - Neurosurg) 7'B8?;B/98$B7. ;7. 4remsta# JD, an# Martin SH. &ethal %ompli%ation rom insertion o nasogastri% tube a ter se!ere basilar s0ull ra%ture. - (rauma) 7'8*?7*/*;($*;;.

;;. Aguilar EA#, Jea0ley J<, ,horayeb BJ, et al. High resolution "T s%an o temporal bone ra%tures/ asso%iation o a%ial ner!e paralysis 5ith temporal bone ra%tures. &ead Neck Surg) 7'*8?'/7B;$7BB. ;@. "annon "R, an# Jahrs#oer er RA. Temporal bone ra%tures. Re!ie5 o '( %ases. +rch Otolar"ngol) 7'*@?7('/;*9$;**. ;). Dolan KD. Temporal bone ra%tures. Semin 0ltrasound C( MR) 7'*'?7(/;B;$;8'. ;9. 4eli3 H, Eby T&, an# 4is%h +. .e5 aspe%ts o a%ial ner!e pathology in temporal bone ra%tures. +cta Otolar"ngol) 7''7?777/@@;$@@B. ;B. 4is%h +, an# Matto3 D. Mi%rosurgery o the S0ull Base. .e5 Jor0, .J, Thieme? 7'**/)$9@. ;8. Dun%an .o#, "o0er .J, Jen0ins HA, an# "analis R4. ,unshot in1uries o the temporal bone. Otolar"ngol &ead Neck Surg) 7'*B?')/)8$99. ;*. Haber0amp TJ, M%4a##en E, Kha agy J, an# Har!ey SA. ,unshot in1uries o the temporal bone. .ar"ngoscope) 7''9?7(9/7(9@$7(98. ;'. "o0er .J, Jen0ins HA, an# 4is%h +. -bliteration o the mi##le ear an# mastoi# %le t in subtotal petrose%tomy/ in#i%ations, te%hni2ue, an# results. +nn Otol Rhinol .ar"ngol) 7'*B?'9/9$77. +m - *merg Med) 123451'6278623)9 4:) Park - ; Strel<o= ##; and Friedman >&) Current management of cerebrospinal fluid rhinorrhea) .ar"ngoscope) 1234524'162?814::) 41) Calcaterra (C) *,tracranial surgical repair of cerebrospinal rhinorrhea) +nn Otol Rhinol .ar"ngol) 123:532'1:3811@) 46) &enr" RC; and (a"lor P&) Cerebrospinal fluid otorrhoea and otorhinorrhoea follo=ing closed head injur") - .ar"ngol Otol) 12A3526'A?48A7@) 44) Brodie &+) Proph"lactic antibiotics for posttraumatic cerebrospinal fluid fistulae) + meta8anal"sis) +rch Otolar"ngol &ead Neck Surg) 122A5164'A?28A76) 4?) Omma"a +C) Cerebrospinal fluid fistula and pneumocephalus) n' >ilkins R&; Rengachar" SS; eds) Neurosurger") vol 6) Ne= Dork; ND' Mc$ra= &ill5 122@'6A3:) 47) Oberson R) Radioisotopic diagnosis of rhinorrhea) Radiol Clin Biol) 12A65?1'63847) 4@) Minc" -*) Posttraumatic cerebrospinal fluid fistula of the frontal fossa) - (rauma) 12@@5@'@138@66) 4A) +ust MR; McCaffre" (#; and +tkinson -) (ransnasal endoscopic approach to the sella turcica) +m Rhinol) 1223516'634863A) 43) Sumner E) Post8traumatic anosmia) Brain) 12@?53A'1:A816:) 42) +nderson R.; Panje >R; and $ross C*) Optic nerve blindness follo=ing blunt forehead trauma) Ophthalmolog") 1236532'??78?77) ?:) *lisevich C#; Ford RM; +nderson EP; Stratford -$; and Richardson PM) #isual abnormalities =ith multiple trauma) Surg Neurol) 123?566'7@787A7) ?1) $jerris F) (raumatic lesions of the visual path=a"s) n' #inken P-; Bru"n $>; eds) &andbook of Neurolog") vol 6?) Ne= Dork; ND' *lservier Pub5 12A@'6A87A) ?6) Cline .B; Mora=et< RB; and S=aid SN) ndirect injur" of the optic nerve) Neurosurger") 123?51?'A7@8 A@?) ?4) Cur<er +; and Patel MP) Superior orbital fissure s"ndrome associated =ith fractures of the <"goma and orbit) Plast Reconstr Surg) 12A25@?'A178A12) ??) -efferson $; and Schorstein -) njuries of the trigeminal nerve; its ganglion; and its divisions) Brithish -ournal of Surger") 12775?6'7@18731) ?7) Cahill E>; Rao CC; and Eucker (B) Eela"ed carotid8cavernous fistula and multiple cranial neuropath" follo=ing basal skull fracture) Surg Neurol) 123151@'1A866) ?@) Patak" P*; $raham >PE; and Munger B.) (erminal neuromas treated =ith triamcinolone acetonide) Surg Res) 12A451?'4@8?7) ?A) $robman .R; Pollak +; and Fisch 0) *ntrapment injur" of the facial nerve resulting from longitudinal fracture of the temporal bone) Otolar"ngol &ead Neck Surg) 123251:1'?:?8?:3) ?3) Fisch 0) Facial paral"sis in fractures of the petrous bone) .ar"ngoscope) 12A?53?'61?18617?) ?2) Nelson -R) Neuro8otologic aspects of head injur") n' (hompson R+; $reen -R; eds) +dvancement of Neurolog") Ne= Dork; ND' Raven Press5 12A2)

7:) Coker N-) Management of traumatic injuries to the facial nerve) Otolar"ngol Clin North +m) 122156?'617866A) 71) Mack CF; Cempf &$; and .enar< () Patients =ith trauma8induced deafness88rehabilitation using a cochlear implant) >ien Med >ochenschr) 122A51?A'6?28671)

Table 1. The 12 cranial nerves and the respective deficits following injury. "er e (eficit =7> Olfactory Anosmia =;> Optic Blin#ness? Aisual iel# #e i%its =@> Oculomotor Fupillary enlargement? Diplopia =paralysis o e3trao%ular mus%les> =)> Troc%lear Faralysis o superior obli2ue mus%le %ausing #iplopia =9> Trigeminal &oss o %orneal re le3? 4a%ial numbness? <ea0 mus%les o masti%ation =B> Abducens 6nability to mo!e the eye laterally %ausing #iplopia on lateral gaze =8> )acial Faralysis o mus%les o a%ial e3pression =*> &estibulococ%lear Aestibular #ys un%tion? .ystagmus? Hearing loss ='> *lossop%aryngeal &oss o gag re le3? Dysphagia =7(> &agus Ao%al %or# paralysis? Ta%hy%ar#ia =77> Spinal Accessory Faralysis o sterno%lei#omastoi# =7;> +ypoglossal 6psilateral tongue #e!iation an# atrophy

Skull base fractures

Introduction

S0ull base ra%tures are o high importan%e in neurotrauma. They o%%ur in @.9 $ ;): o hea# in1uries an# are o ten relate# to brain in1ury =in 9(: o the %ases>. 8(: o the s0ull base ra%tures o%%ur in the anterior ossa, ;(: in the mi##le %entral s0ull base an# 9: in the mi##le an# posterior ossa.

Traumatic !CS)# leakage The most rele!ant %lini%al sign relate# to s0ull base ra%tures is "S4 lea0age. 6t o%%urs in ;: o all hea# trauma an# %an rea%h @(: o all s0ull base ra%ture %ases. *(: o the traumati% "S4 lea0age o%%urs 5ithin )* hours a ter in1ury. 7B: o %ases are Ko%%ultK, being oun# a ter re%urrent meningitis.

Anatomy

Introduction <e %onsi#er the en#o%ranial =inner> sur a%e o the s0ull base, 5hi%h %onsists o the %ranial %a!ity on 5hi%h the brain rests, an# the e3o%ranial =e3ternal> sur a%e. The bones 5hi%h orm the s0ull base are/

4rontal bone Sphenoi# bone Temporal bone -%%ipital bone

The anterior part o the e3o%ranial sur a%e is also orme# by the/

Gygomati% bone Ma3illary bone Falatine bones

The bones o the s0ull base %ontain se!eral oramina through 5hi%h ner!es, arteries, an# !eins pass.

Anatomi%ally, the inner sur a%e o the s0ull base is orme# by/

Anterior ossa Mi##le ossa Fosterior ossa

Anterior fossa The anterior ossa is orme# by the ethmoi# bone, sphenoi# bone an# rontal bone. 6t is limite# anteriorly by the rontal bone an# the posterior 5all o the rontal sinus, posteriorly by the limen o the lesser 5ing o the sphenoi# bone. The lateral parts orm the roo o the orbits. The me#ian =%entral> part is orme# by the %rista galli, the %ribri orm plate o the ethmoi# plane an# the planum o the sphenoi# bone.

Middle fossa The mi##le ossa is orme# by the sphenoi# an# temporal bones. 6t is limite# anteriorly by the lesser 5ings o the sphenoi# bones, posteriorly by the petrous bones.

osterior fossa The posterior ossa is orme# by the o%%ipital bones. 6t is limite# anteriorly by the posterior 5alls o the petrous bones an# posteriorly by the groo!es o the trans!erse sinuses.

,-tension of anatomical classification By #ra5ing t5o horizontal lines 5hi%h rea%h the lateral margins o the opti% %anals, the s0ull base %an be #i!i#e# into three longitu#inal regions/

"entral s0ull base &ateral s0ull base =le t an# right>

Thereby, the inner sur a%e o the s0ull base is #i!i#e# into ' 2ua#rants.

!entral s"ull base The anterior %entral s0ull base =a "SB> %o!ers the upper nasal %a!ity an# the sphenoi# sinus. The mi##le %entral s0ull base =m "SB> %ontains laterally the %a!ernous sinuses 5ith the %aroti# arteries insi#e =parasellar %ompartments>. The posterior %entral s0ull base =p "SB> in%lu#es the %li!us rea%hing the anterior margin o the great o%%ipital oramen.

Cranial ner es and related skull base foramina <hen ra%tures in!ol!e some spe%i i% anatomi%al regions the in!ol!ement o ner!es passing through a oramen in the respe%ti!e region shoul# be al5ays %onsi#ere#. 6 -l a%tory ner!e/ orme# by many sensory ner!e ibers that e3ten# rom the ol a%tory epithelium to the ol a%tory bulbs passing through the openings o the %ribri orm plates o the ethmoi# bone =in the anterior %entral s0ull base>. 66 -pti% ner!e/ passes rom the retina to the brain in the opti% %anal in %lose relationship 5ith the anterior %linoi# pro%ess =mi##le %entral s0ull base>. 666 -%ulomotor ner!e/ enters the orbit through the superior orbital issure bet5een the mi##le an# anterior ossae. 6A Tro%hlear ner!e/ enters the orbit through the superior orbital issure bet5een the mi##le an# anterior ossae. A Trigeminal ner!e/ is ma#e up o three #i!isions/

-phthalmi% bran%h 5hi%h passes through the superior orbital issure Ma3illary bran%h 5hi%h passes through the oramen rotun#um

Man#ibular bran%h 5hi%h passes through the oramen o!ale

A6 Ab#u%ens ner!e/ enters the orbit through the superior orbital issure bet5een the mi##le an# anterior ossae. A66 4a%ial ner!e/ enters the petrous temporal bone !ia the internal au#itory meatus an# emerges rom the e3ternal sur a%e o the s0ull base through the stylomastoi# oramen =lateral posterior s0ull base> A666 Aestibulo%o%hlear ner!e/ enters the internal a%ousti% meatus. 6E ,lossopharyngeal ner!e/ passes the through the 1ugular oramen. E Aagus ner!e/ passes the through the 1ugular oramen. E6 A%%essory ner!e/ starts outsi#e the s0ull, enters the s0ull through the oramen magnum an# e3its again 5ith the 6E an# E ner!e through the 1ugular oramen. E66 Hypoglossal ner!e/ passes through the hypoglossal %anal in the o%%ipital bone.

,-tracranial surface The e3tra%ranial sur a%e is orme# by/

-%%ipital bones Temporal bones Sphenoi# bones Falatine bones Gygomati% bones

The spe%i i% stru%tures that %an be in!ol!e# in ra%tures o the e3tra%ranial sur a%e o the s0ull base are the/

Styloi# pro%esses o the temporal bone

Tips o the mastoi# bones -%%ipital %on#ylar pro%esses

.ec%anism of t%e in$ury

The s0ull base is parti%ularly sus%eptible to the e e%ts o blunt trauma. S0ull base ra%tures are o ten asso%iate# 5ith %ranial !ault or mi# a%e ra%tures. The most !ulnerable regions o the s0ull base are the petrous bone, the sphenoi# sinus, an# the oramen magnum.

Clinical presentation
Sin%e s0ull base ra%tures are the results o high or%e impa%ts an# are o ten asso%iate# 5ith other intra%ranial in1uries. There ore, patients may be un%ons%ious or re2uire inter!ention or other more li e$threatening in1uries. As a result, the %lini%al signs an# symptoms o s0ull base ra%tures may not be re%ognize# imme#iately. Fatients a e%te# by s0ull base ra%tures %an present any5here rom a5a0e an# asymptomati% to %omatose or e!en moribun#.

The irst %lini%al assessment is the e!aluation o the ,lasgo5 %oma s%ale =,"S>.

6t is important to re%ognize the bloo# an#Hor "S4 %oming rom the ear =otorrhea>, the nose =rhinorrhea>, or some %al!arial 5oun#s. "S4 lea0age must be i#enti ie# sin%e it poses high ris0 or meningitis. 4or suspe%te# but not e!i#ent rhinorrhea a pro!o%ation test =Aalsal!a maneu!er> %an be use ul. -ther use ul test %an be/

Double ring sign ,lu%ose test strip Beta$;$trans errin test

The presen%e o sub%utaneous e%%hymosis in the mastoi# region =BattlesL sign> or ...

... aroun# the eyes =ra%%oonLs eyes> is !ery highly suspi%ious or s0ull base ra%tures. 6n a5a0e patients it is important to i#enti y the presen%e o %ranial ner!e in1ury as soon as possible espe%ially o the opti% an# a%ial ner!es. A %omplete neurologi%al e3amination has to be #one in all %ases.

Imaging
The gol# stan#ar# or the ra#iographi% #ete%tion o s0ull base ra%tures is %ompute# tomography. Spe%i i%, !ery use ul "T se2uen%es are/

.on %ontrast high resolution bone 5in#o5 ""T =thin sli%es 7mm, a3ial an# %oronal> Multiplanar re%onstru%tions

Spe%ial mo#alities in%lu#e/

MR6 "erebral angiography "T$%isternography

Classification

Single !linear and/or branc%ed# and multiple The ra%tures %an be single, %rossing more bones, or multiple, in the same bone or in #i erent bones. The ra%ture %an be linear or bran%he#. Single ra%ture line

Bran%he# ra%ture lines.

Multiple separate# ra%ture lines.

Comminuted A ra%ture is %omminute# 5hen the bone is shattere# into many ragments.

Contiguous The ra%ture is %ontiguous 5hen it %rosses anatomi%al boun#aries.

(epressed The ra%ture# segments are #ispla%e# in5ar#, to5ar# the meninges an# brain or more than @ mm.

(iastatic suture Horizontal #ispla%ement along the %ranial sutures =M@ mm>.

(iastatic fracture Horizontal #ispla%ement o the bones at the margin o the ra%ture =M@ mm>.

Cranial Vault & Skull Base

Authors

O er iew

0acerations

So t$tissue in1uries %an be use# to #ire%tly a%%ess ra%ture sites or ra%ture management.

Coronal approac%

The %oronal or bi$temporal approa%h is use# to e3pose the anterior %ranial !ault, the orehea#, an# the upper an# mi##le regions o the a%ial s0eleton.

0ateral skull base approac%

<ith the lateral s0ull base approa%h the lateral anterior an# the mi##le %ranial ossae %an be rea%he#.

1osterior skull base approac%

<hen 5i#e !isualization o the me#ial %anthal area, la%rimal sa%, an# me#ial orbital 5all is nee#e# an e3ten#e# glabellar approa%h is a#!antageous.

Transmastoid approac%

The transmastoi# approa%h is use# or a%ial ner!e #e%ompression. A postauri%ular in%ision is %ommonly use# to a%%ess the mastoi#.

,ndoscopy: Transnasal

En#os%opi% sinus surgery te%hni2ues %an be use# to open the rontal re%ess rom belo5.

,ndoscopy: Central skull base

The 5hole %entral %ompartment o the s0ull base, rom the %rista galli to the %li!us an# anterior %ranio%er!i%al 1un%tion, %an be a%%esse# by means o the en#onasal transsphenoi#al en#os%opi% approa%h.

,ndoscopy: Anterior table

En#os%opy has a !ariety o potential uses or rontal sinus ra%tures. En#os%opi% a%%ess is most a!orable in the upper portion o the rontal sinus.

,ndoscopic repair of CS) leak

2. Introduction

Traumati% "S4 rhinorrhea o%%urring in the anterior an#Hor mi##le %ranial ossa %an be treate# by en#os%opi% te%hni2ues asso%iate# 5ith lumbar intrathe%al a#ministration o luores%ein.

The illustration sho5s the region that %an be rea%he# en#os%opi%ally.

3. Tools re4uired

Tool re2uire# or the en#onasal en#os%opi% repair are/

En#os%opi% set =(N, @(N, an# )9N en#os%opes> 4luores%ein blue$light ilter system %ouple# to the light sour%e 4luores%ein

5. Se4uence of procedure
The steps or the surgi%al pro%e#ure are/

&umbar intrathe%al luores%ein in1e%tion En#onasal en#os%opy an# i#enti i%ation o the #e e%t Repair o the #e e%t

6. )luorescein in$ection
6n the ma1ority o %ases be ore surgery a lumbar #rainage is inserte# 5hi%h allo5s the in1e%tion o 7 ml so#ium luores%ein =(.9:>. +sing a lumbar #rainage o ers the a#!antage to re$in1e%t luores%ein #uring the surgi%al pro%e#ure i nee#e#.

7. ,ndonasal endoscopy and identification of t%e defect

The patient %an be positione# supine on the operating table 5ith the trun0 raise# bet5een $7(N up to O)9N. The hea# %an be rotate# to5ar# the surgeon i ne%essary. The en#os%ope is inserte# in the nostril =right, le t, or both> an# the anatomi%al lan#mar0s are !isualize#. The use o na!igational #e!i%es = usion #ata sets, "T, an# MR6> is help ul.

8. Identification of t%e anatomical landmarks

4or the en#os%opi% anatomi%al orientation the ollo5ing stru%tures shoul# be i#enti ie#/

.asal septum =.S> Mi##le turbinate =MT> "hoana ="> Sphenoi# ostium =-S>

9. .et%ods of approac%

En#onasal en#os%opy %an be per orme# by se!eral metho#s #epen#ing on the type o lesion an# its lo%ation. The %lassi% approa%h to the ol a%tory ossa is the #ire%t paraseptal one =5ith or 5ithout remo!ing any ethmoi#al stru%tures a%%or#ing to the anatomi%al !ariations o the patient>.

:. Identification of t%e lesion

The use o a luores%ein blue$light ilter system an# the luores%ein barrier ilter mounte# to the eyepie%e o the en#os%ope might be help ul to !isualize the lo%alization o the #ural #e e%t. A "S4 istula, i present, is seen 5ith a %hara%teristi% green glo5. "li%0 here to see !i#eo #emonstrating this.

;. 'epair of t%e defect

Se!eral te%hni2ues e3ist or the repair o the #e e%t an# #i erent gra ts %an be use# in%lu#ing autologous nasal, e3tra$nasal, an# heterologous gra ts. The bone #e e%ts %an be repaire# using septal %artilages, parts rom the mi##le nasal turbinates, e!entually the !omer, et%. The most use# autologous e3tranasal gra t is the ab#ominal at or the as%ia lata. 6n larger #e e%ts, a !as%ularize# nasoseptal lap %an be use#.

The %losure te%hni2ue is a stri%tly relate# to the in#i!i#ual patientPs anatomy, the size o the lea0, an# its anatomi%al lo%ation. +n#erlay, o!erlay, %ombine#, an# obliterati!e te%hni2ues ha!e been #es%ribe#. The illustration sho5s a %ombine# three layer te%hni2ue in 5hi%h are e!i#ent/

Sub#ural intra%ranial un#erlay gra t =#ar0 green> E3tra#ural intra%ranial un#erlay gra t =blue> E3tra%ranial o!erlay gra t =purple>

4ibrin glue %an be use# to 0eep the layers together or to ill the #ea#$spa%e.

2<. Confirmation of proper closure

A ter %losing the #e e%t, its e i%a%y an# reliability is %he%0e# using a Aalsal!a maneu!er an# in spe%ial %ases, intraoperati!e luores%ein test.

Appendi0ate se4uelae

2. Introduction

"ompli%ations an# late se2uela o %ranial !aultHanterior s0ull base ra%tures typi%ally in%lu#e/ Mu%o%eleHMu%opyo%ele o the rontal sinus -steomyelitis "ontour #e ormities 6n e%tion o =allogenei%> gra ts &ate "S4 lea0 Meningitis

These se2uela may o%%ur e!en #e%a#es a ter the initial in1ury an# o ten re2uire surgi%al management. The ris0 or late se2uela %an be minimize# by meti%ulously ensuring a#e2uate #rainage i the rontal sinus is preser!e# or meti%ulous remo!al o mu%osa i it is obliterate#. Fatients 5ith rontal sinusHanterior s0ull base ra%tures shoul# be ollo5e# up or years.

Mucocele# yocele
Mu%o%eleHpyo%ele is the most re2uent late se2uela a ter rontal sinus ra%tures an# may o%%ur many years a ter the a%%i#ent. These %ompli%ations are the result o mu%osal proli eration a ter in%omplete remo!al o the mu%osa or ina#e2uate #rainage. Typi%al symptoms in%lu#e pain, s5elling, an# globe #ispla%ement. Treatment 5ith antibioti%s may temporarily relie!e the symptoms. Ho5e!er, #ue to the potentially serious %ompli%ations =eg, meningitis, !isual #ys un%tion> operati!e treatment shoul# not be #elaye# or a long time. 6 the mu%o%ele is a%%essible an# limite# a transnasal en#os%opi% approa%h may be employe#. -ther5ise an open pro%e#ure shoul# be per orme#.

3. Operati e tec%ni4ues: Open approac%

$ndications and limitations
The open approa%h is in#i%ate# 5hene!er the pathology in!ol!es regions o the rontal sinus 5hi%h %an not be a##resse# transnasally or i re%onstru%tion o sinus 5alls or rontal bone is ne%essary. The %oronal approa%h allo5s 5i#e e3posure o the sinus an# naso$orbital$ethmoi#al region an# it allo5s or %raniotomy i ne%essary. 6n a##ition, har!esting o %ranial bone gra ts %an be #one 5ithout an a##itional in%ision.

Techni%ue

"oronal approa%h E3posure o the rontal sinus -steotomy o anterior table o rontal sinus Remo!al o in e%te# material Meti%ulous remo!al o mu%osa Re%onstru%tion or obliteration o the rontal sinus/ The te%hni2ue o re%onstru%tion may %onsi#erably %hange #epen#ing on the spe%i i% problem. This is illustrate# by the ollo5ing %olle%tion o %ases.

5. Case e-ample: .ucocele wit% globe displacement

&arge mu%o%ele o the le t rontal sinus %ausing Q

Q %au#alHlateral #ispla%ement o the globe.

Fostoperati!e s%an sho5ing the osteotomy use# or a%%ess an# repair o the mu%o%ele. The #e e%t in the orbital roo 5as re%onstru%te# 5ith a %ranial bone gra t =arro5>. E!en though this mu%o%ele %oul# ha!e been approa%he# en#onasally, re%onstru%tion o the orbital roo 5oul# not ha!e been possible.

6. Case e-ample: 1artial obliteration of t%e frontal sinus

Mu%o%ele a e%ting only the lateral t5o thir#s o the right rontal sinus in a patient 5ith pre!ious titanium mesh re%onstru%tion o the anterior table o the rontal sinus an# re%urrent in e%tions. The #rainage o the me#ial one thir# an# o the le t rontal sinus is inta%t.

Mu%o%ele has resorbe# the orbital roo %ausing re%urrent orbital %ellulitis.

6nitial repair o the rontal sinus ra%ture ha# been a%hie!e# 5ith a titanium mesh, re%onstru%ting the anterior table #e e%t.

A ter remo!al o the mesh, the rontal sinus %an be inspe%te#.

Re%onstru%tion o the anterior table #e e%t 5ith bone.

6n this %ase, only partial obliteration o the rontal sinus 5as #one 5ith at an# as%ia, 5hile the #e e%t in the orbital roo an# in the anterior table 5as re%onstru%te# 5ith %ranial bone. "onsi#ering the large %ommuni%ation bet5een the rontal sinus an# the ethmoi#al sinus, partial obliteration 5as %onsi#ere# to be te%hni%ally less #i i%ult.

7. Case e-ample: Infection of a %ydro-yapatite graft

"hroni% in e%tion 5ith re%urrent istulae 9 years a ter obliteration o the rontal sinus 5ith hy#ro3yapatite %ement. The use o hy#ro3yapatite %ement in #ire%t %ommuni%ation 5ith the nasal %a!ity is not re%ommen#e# #ue to the high %ompli%ation rate.

E3posure o the %ement to the nasal %a!ity resulte# in %ontamination an# in e%tion o the alloplasti% gra t.

6 hy#ro3yapatite is %hosen or obliteration o the rontal sinus, %onta%t to the nasal %a!ity must be a!oi#e#.

Dissolution o the gra t by granulation tissue.

A ter remo!al o the gra t the nasal root =see arro5> is mobile.

Stabilization o the nasal root an# re%onstru%tion o the supraorbital rim 5ith %ranial bone.

"ommuni%ation to the nasal %a!ity is seale# 5ith as%ia =arro5>.

The rontal sinus %a!ity is obliterate# 5ith at an# the anterior table is re%onstru%te# 5ith titanium mesh.

8. Case e-ample: Infection of a 1..A graft causing recurrent fistulae

Fatient ;( years a ter e3ten#e# rontal sinus ra%ture. 6n the initial repair, obliteration o #e e%ts 5as a%hie!e# 5ith FMMA. Ten years a ter the a%%i#ent, re%urrent istulization o%%urre#. Repeate# lo%al e3%isions 5ere unsu%%ess ul.

MR6 sho5s a #e e%t in rontal bone %ommuni%ating 5ith the istula.

6ntraoperati!e !ie5 sho5ing the FMMA gra t embe##e# into granulation tissue.

A ter #ebri#ement the %ontour o the bone is restore# 5ith a titanium mesh an# the #e e%t is ille# 5ith at.

The istula is %lose# rom the insi#e 5ith a rotational peri%ranial lap.

+ne!ent ul healing 5ith a slightly #epresse# s%ar a ter B months.

9. Case e-ample: Infection of allogenic graft= causing swelling and c%ronic %eadac%e

"hroni% in e%tion o the le t rontal sinus a ter obliteration 5ith a polymeri% inlay %ausing s5elling an# %hroni% hea#a%he.

E3posure sho5s that the gra t is embe##e# in granulation tissue.

A ter e3plantation an# %leaning, the supraorbital rim is missing =arro5> an# 5ill be repla%e# 5ith %ranial bone.

The supraorbital rim 5as re%onstru%te# 5ith %ranial bone an# the #e e%t obliterate# 5ith %orti%al %an%ellous bone %hips.

The anterior table is repla%e# 5ith a titanium mesh. Alternati!ely, the anterior table %an also be re%onstru%te# 5ith %ranial bone. See %ase Kpartial obliterationR

:. Case e-ample: ,-posure of a titanium mes% t%roug% t%e skin

This patient ell rom a horse resulting in a e3ten#e# rontal sinus an# rontal bone ra%ture. 6nitial repair 5as #one 5ith FMMA 5hi%h ha# to be remo!e# #ue to an in e%tion a ter one year. Se%on#ary repair 5as #one 5ith a titanium mesh 5hi%h 5as 1ust lai# onto the bone 5ithout i3ation. A ter t5o years, the mesh began to per orate through the s0in =arro5>.

<i#e$meshe# titanium mesh loating on the #e e%t 5ithout i3ation.

Dea# spa%e belo5 the mesh resulte# in in#entation o the s0in =see also pre!ious %lini%al photograph>.

The #e e%t in the rontal bone a ter remo!al o the mesh. The un#erlying #ura =see arro5> is %o!ere# by thi%0 s%ar.

Re%onstru%tion o the #e e%t 5as #one 5ith split %ranial bone =outer table> ta0en as a ull$thi%0ness gra t rom the posterior hal o the s0ull. The #onor site #e e%t 5as re%onstru%te# 5ith internal table.

+ne!ent ul healing a ter @ months. .ote the thinning o the s0in o the right orehea# #ue to the ta0ing o peri%ranial lap #uring initial repair.

;. Case e-ample: Osteomyelitis of t%e supraorbital rim wit% fistuli>ation

This patient sustaine# a motor !ehi%le a%%i#ent 5ith a right rontal sinus an# %ranial base ra%ture re2uiring %ranialization o the rontal sinus. Ten years a ter the a%%i#ent, re%urrent istulization in the area o the glabella o%%urre#. Despite se!eral re!isions using a lo%al in%ision istulization #i# not stop.

"T sho5s osteomyelitis an# partial resorption Q

Q o the right supraorbital rim.

6ntraoperati!e !ie5 a ter rese%tion o the a e%te# supraorbital rim. Due to pre!ious %ranialization o the rontal sinus, a ormal %raniotomy 5as #one to prote%t the #ura.

The supraorbital rim 5as re%onstru%te# 5ith ull thi%0ness %ranial bone ta0en rom the posterior part o the s0ull.

Fostoperati!e 3$rays #emonstrating Q

Q anatomi%al re%onstru%tion o the supraorbital rim.

Fostoperati!e %lini%al !ie5. Elimination o the osteomyelitis allo5s or spontaneous healing o the istula.

2<. Operati e tec%ni4ues: Transnasal endoscopic approac%

$ndications
Re%ent a#!an%es in en#os%opi% e2uipment an# te%hni2ues = rontal sinus instrumentation, na!igation, intraoperati!e "T> has greatly e3pan#e# the s%ope o a%%ess or en#os%opi% sinus surgeons. The pre erre# te%hni2ue or treatment o paranasal sinus mu%o%eles is en#os%opi% #rainage into the nasal %a!ity. 6 a mu%o%ele %an be #raine# into the nasal %a!ity there is no nee# or any urther inter!ention. The mu%o%ele simply be%omes an a%%essory sinus. This a!oi#s the nee# or e3ternal in%isions, har#5are appli%ation, or bone gra ting. 4rontal sinus en#os%opi% surgi%al te%hni2ues are among the most #i i%ult en#os%opi% sinus pro%e#ures an# shoul# only be attempte# by those %om ortable #oing them.

&imitations
Mu%o%eles ina%%essible through the paranasal sinuses %an not be a%%esse# !ia an en#onasal approa%h. 4urthermore, mu%o%eles asso%iate# 5ith %ontaminate# har#5areHimplants generally %an not be manage# en#os%opi%ally.

Techni%ue

A %omplete re!ie5 o en#os%opi% surgi%al te%hni2ue is beyon# the s%ope o the Surgery Re eren%e. Ho5e!er, general prin%iples or en#os%opi% #rainage o paranasal sinus mu%o%eles 5ill be %o!ere#. Most patients 5ill re2uire an en#os%opi% ethmoi#e%tomy an# possible ma3illary antrostomy. Mu%o%eles emanating rom the rontal sinus usually enlarge the sinus ostia ma0ing a%%ess less %hallenging. This illustration #emonstrates a rontoethmoi# mu%o%ele #ispla%ing the orbital %ontent in eriorly. Dehis%en%e into the anterior ossa is not a %ontrain#i%ation or transnasal en#os%opi% #rainage.

A %omplete ethmoi#e%tomy has been per orme# to allo5 or #rainage o the mu%o%ele. 6t is important to %ompletely remo!e all ethmoi# air %ells. This minimizes the ris0 o re%urrent obstru%tion an# mu%o%ele ormation.

Rese%tion o the bone on the in erome#ial aspe%t o the mu%o%ele pro!i#es a path5ay or #rainage o the mu%o%ele into the nose. 6ntraoperati!e na!igation assists the surgeon to more sa ely enlarge the opening 5ithout !iolating the orbital or intra%ranial %a!ities. The opening shoul# be ma#e as large as possible to minimize the ris0 o postoperati!e stenosis an# obstru%tion, 5hi%h %an result in re%urrent mu%o%ele ormation.

!ase example $

A B( year ol# emale 5ith rontoethmoi# mu%o%ele 5ith proptosis, hypophthalmos, in an only seeing eye. The mu%o%ele has also resulte# in/

A bony orbital #e ormity

,lobe %ompression an# #e ormity

<hile there appears to be !ery limite# a%%ess rom the nasal %a!ity, this is 2uite a#e2uate or transnasal en#os%opi% #rainage o the mu%o%ele.

En#os%opi% photograph #emonstrating #e%ompression o the mu%o%ele an# su%tioning o its %ontents.

En#os%opi% transnasal !ie5 rom the nose into the mu%o%ele.

T5o years postoperati!ely, the mu%o%ele %a!ity %ontinues to #rain an# be 5ell aerate#. The bony #e ormity has also impro!e# signi i%antly.

The hypophthalmos an# proptosis ha!e resol!e#.

!ase example $$

8( year ol# male 5ith posttraumati% rontoethmoi# mu%o%ele, hypophthalmos an# e3ophthalmos.

"oronal "T s%an o the same patient.

Fostoperati!e "T s%an #emonstrating %omplete le t ethmoi#e%tomy an# #rainage o the mu%o%ele. =.ote/ Septal per oration seen on "T s%an 5as present prior to en#os%opi% mu%o%ele #e%ompression.