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Basilar Skull Fractures
Leonel Martinez, M.D. Faculty Advisor: Farrah Siddiqui, M.D. The University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation December 11, 2013

Objectives

   

Incidence- overall Anatomy- Each section Evaluation Management

Disclosure for CME
 No drugs will cure skull base fractures.  I do not own stock in medical equipment.  However, I do drive a car, own a baseball bat and work at the TDC hospital.

Incidence
 In US, 2 million head injuries occur yearly.  Leading cause of death and disability of children.  Motor vehicle accidents are leading cause of head trauma in industrialized countries.  Up to 1/3 of motor vehicle injuries involve head and neck injuries and 28% of all fractures of involving MVA are of the head and neck region.

cElhaney JH, Hopper RH Jr, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma. 1995 Aug;12(4):669-78. PubMed PMID: 8683618.

"Initial CT findings in 753 patients with severe head injury: a report from the NIH Traumatic Coma Data Bank. Howard M.Incidence  Skull base fractures occur in 3.5-24 % of head injuries.. .” Journal of neurosurgery 73.5 (1990): 688-698.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-sanfrancisco/ Eisenberg.  Traumatic Coma Data Bank states 25% of severe head injuries They account for 2% of all traumas http://www. et al.

in Tuscon. .Incidence  Behbahani 2013.Retrospective study 1606 pt.

Otolaryngol Clin North Am . The Laryngoscope. Byrne. 102: 1247–1250 Temporal bone fracture: evaluation and management in the modern era. 41(3): 597-618 Gerbino G. and three or more facial fractures (33.Incidence with other fracture(s)  Skull base fracture incidence is increased with orbital wall/rim fractures (36%) and ZMC Fractures (29. G.  The incidence of skull base fracture was directly associated with the number of facial fractures per patient.9%). Benech A. one facial fracture (21. Association of skull base and facial fractures. J Craniomaxillofac Surg.28:133–139. Analysis of 158 frontal sinus fractures: current surgical management and complications. W. S. 2000. (1992).4%).7%) and mandible fractures (4. S. Slupchynskyj..0%). Roccia F. Johnson F . D.01-JUN-2008.  Temporal bone fractures are associated 18-40% of the time. O.  Frontal sinus fractures occur 15-20% of the time. . Berkower.0%). A.. Caldarelli C. two facial fractures (30. C. and Cayten.3%).  Infrequent with nasal bone (7.

Cattell.Anatomy Examination of the skull and brain: method of removing the brain after it is severed from the body Henry W. 1903 .

Anatomy .

Anatomy https://www2.jsp .org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjI wN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle= &showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.aofoundation.

aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjI wN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle= &showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.Anatomy https://www2.jsp .

Netter Images. . Used under NEOMED License.” ©2012 Icon Learning Systems. Plate # [11]. Accessed on [12 -11-2013].Anatomy Base of skull: above.

Anatomy .

. Used under NEOMED License.” ©2012 Icon Learning Systems.Anatomy Base of skull: above. Netter Images. Accessed on [12 -11-2013]. Plate # [11].

Anatomy .

Used under NEOMED License. .Anatomy Base of skull: above. Plate # [11]. Netter Images. Accessed on [12 -11-2013].” ©2012 Icon Learning Systems.

Anatomy: Fractures .

Anatomy: Fractures .

Anatomy: Fractures .

Anatomy: Fractures RK Jackler Atlas of Skull Base Surgery and Neurotology 2009 .

David BJ.Anatomy: Anterior Skull Base Fractures  This includes posterior frontal sinus. cribriform and orbital roof.Through the lateral frontal sinus to the superomedial wall of orbit.any combination of above.Lateral frontal fracture. J Neurosurg 1998.  Classification (Damianos):  Type 1. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair.  Type 3.  Type 4. Ameen AA. Damianos SA.88:471-477 .Mixed. roof of ethmoid.  Type 2.Frontoethmoid fracture.linear through cribriform.Cribriform fractures. et al.Ethmoids and medial frontal sinus walls.

Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg 1998. Ameen AA. et al.88:471-477 . David BJ.Anatomy: Anterior Skull Base Fractures Type I Fractures Damianos SA.

Ameen AA. et al. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg 1998.88:471-477 . David BJ.Anatomy: Anterior Skull Base Fractures Type II fractures Damianos SA.

J Neurosurg 1998. et al. David BJ.Anatomy: Anterior Skull Base Fractures Type III fractures Damianos SA.88:471-477 . Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. Ameen AA.

Anatomy: Middle Skull Base .

Anatomy: Middle Skull Base: Temporal Bone .

Anatomy: Middle Skull Base: Temporal Bone .

Anatomy: Middle Skull Base: Temporal Bone Collins JM. Semin Ultrasound CT MR. 2012 Oct. Krishnamoorthy AK. Kubal WS. Johnson MH. Multidetector CT of temporal bone fractures. Poon CS.33(5):418-31 .

Anatomy: Middle Skull Base: Temporal Bone Collins JM. Johnson MH. Semin Ultrasound CT MR.33(5):418-31 . 2012 Oct. Krishnamoorthy AK. Poon CS. Kubal WS. Multidetector CT of temporal bone fractures.

with 18 (26. Kim MG. Kim KH. Lee SK. Boo SH. 2012 Aug.1%) having SNHL.  Hearing loss noted 78 pt. Eur Arch Otorhinolaryngol. Kang HM.  68 otic sparing.Anatomy: Middle Skull Base: Temporal Bone  2011-Kang-Seoul 128 patients 2003-2010.9%) having SNHL.269(8):1893-9 .with 8 (88. Yeo SG. Yeo EK.  9 otic violating. Comparison of the clinical relevance of traditional and new classification systems of temporal bone fractures.

.Anatomy: Middle Skull Base: Temporal Bone  Little and Kesser 2006.6%.Showed 5 fold increase in facial nerve injury.  They also showed a correlation among OCV fracture and facial nerve paresis or paralysis. 25 fold increase in SNHL and 8 fold increase in CSF leaks with otic capsule violating fractures. In a large series of 820 temporal bone fractures facial nerve paralysis occurred in 48% of OCV fractures versus only 6% in OCS fractures.5% to 5.  The incidence of otic capsule violating fracture is 2.

Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194–198 DOI 10. III.  Transverse had 1 out of 4 die from carotid artery injury. V.  Longitudinal fractures have worse prognosis.39%) recorded in one case series over 5 years. 9/25000 (0. IV. with 3 out of 5 patients died from verebrobasilar injury. with VI and VII most common (66%). VII).Posterior Fossa: Clivus fractures  Uncommon. VII.1007/s10143-004-0320- .  All patients had cranial nerve defects (II. VI.

1007/s10143-004-0320- 2 .Posterior Fossa: Clivus fractures Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194–198 DOI 10.

Posterior Fossa: Clivus fractures Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194–198 DOI 10.1007/s10143-004-0320- 2 .

intact alar ligaments. .Posterior Fossa: Occipital condylar fracture  High energy blunt trauma with compression.  Type III.  Type II.  Type I.Axial compression with comminution of occipital condyle-stable injury with no displacement.Direct blow that occurs with skull base and occipital condyle.Avulsion with lateral or rotational forces with torn alar ligaments and fractures. rotational or lateral bending injuries to head.

Posterior Fossa: Occipital condylar fracture .

Posterior Fossa: Occipital condylar fracture .

Posterior Fossa: Occipital condylar fracture .

net/?p=2460 .Evaluation http://www.missmassacre.

Physical Exam           Periorbital ecchymosis (raccoon eyes) Conjunctival hemorrhage Anosmia Mastoid ecchymosis (Battles sign) Vision changes CSF rhinorrhea or otorrhea Step off of supraorbital ridge Hearing loss Facial paralysis Facial numbness .

PPV for intracranial lesions was (78%) periorbital ecchymosis.  Battle’s sign (100%) and unilateral Periorbital ecchymosis (90%). (PMID:11105835) Pretto Flores L. bloody otorrhea (70%) are highest predictive value for skull base fracture. Positive predictive values of selected clinical signs associated with skull base fractures. discussion 82-3] . De Almeida CS. (66%) Battle’s sign and (41%) bloody otorrhea.Clinical signs  Frontal bone fractures had the most clinical signs.  Patients with GCS of 13-15. Casulari LA Journal of Neurosurgical Sciences [2000. 44(2):77-82.

Periorbital Ecchymosis http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.html .

net/OMFS/ .Think Basilar Skull Fracture http://www.Battle sign  Battle sign .dooey.

sg/a-runny-nose-may-not-just-be-a-runny-nose/ .CSF Rhinorrhea http://amandela.

 50% appear in first 2 days. M>F.  Occur in 2% of all head traumas. and 12% to 30% of all basilar skull fractures. and almost all seen in 3 months.CSF Rhinorrhea  Eighty percent of cerebrospinal fluid (CSF) leaks occur following nonsurgical trauma (16% surgical). . 70% in one week.

ComPLiCAtioNS. Md.CSF Rhinorrhea REtRoSPECtivE StuDY oF SKuLL BASE FRACtuRE: A StuDY oF iNCiDENtS. mANAgEmENt. Ba (presenter). university of arizona college of Medicine . Mandana Behbahani. AND outComE ovERviEW FRom tRAumA-oNE-LEvEL iNStitutE ovER FivE YEARS – Michael lemole.

Cranial nerve injuries http://kevinpremed.wordpress.com/2009/02/cranial-nerves.files.jpg .

Gjerris F. New York: Elsevier. In: Vinken PJ. Sense of smell may return over several months. Sphenoid body with sella turcica damage can cause injury to the optic chiasm. Swaid SN.anosmia. Handbook of Neurology. Neurosurgery. Kline LB. Indirect injury of the optic nerve. Workup is limited with CT scan. eds. 1984. Morawetz RB.  CN II.Cranial nerve injuries: Anterior Cranial Fossa  CN I. Traumatic lesions of the visual pathways.from damage to the optic canal or orbit. . Vol 24. 1976:27–57.from anterior fossa injuries (cribriform).14:756–764. Bruyn GW.Blindness worst outcome. causing bitemporal blindness.

. or inferiorly (down and out). Bruyn GW. New York: Elsevier. Morawetz RB.Diplopia.  Noted dilated pupil. Gjerris F.Cranial nerve injuries: Middle Cranial Fossa  CN III. Swaid SN. Handbook of Neurology. Kline LB. inability to move eye medially. 1976:27–57. Usually from direct frontal blow. 1984. In: Vinken PJ. superiorly. impaired EOM. eds. as spontaneous recovery usually occurs in 4-6 weeks.14:756–764. Traumatic lesions of the visual pathways. which stretches the nerve at the posterior cavernous sinus as it enters the brain.  Treatment consists of wearing a patch over the affected eye. Neurosurgery. Vol 24. Indirect injury of the optic nerve.

 V1 most commonly damaged portion. V3-mandibular. with injury at supraorbital notch.Cranial nerve injuries: Middle Cranial Fossa  CN IV. with patch and spontaneous recovery. V2maxillary. V1-supraorbital.diplopia Least common injury site. .  CN V.Sensory deficits to the face.  Treatment same as CN III. Cause from stretching of nerve as it exits from the dorsal midbrain.

Also stretched or avulsed when leaving the pons. When accompanied by blindness. Damage to the clivus. Kline LB. Neurosurgery. Handbook of Neurology. Traumatic lesions of the visual pathways. VI and V1. Vol 24. Gjerris F.known as superior orbital fissure syndrome. Swaid SN. IV. Unable to abduct. . eds. 1984. In: Vinken PJ. it is known as orbital apex syndrome and involves optic foramen.Cranial nerve injuries: Middle Cranial Fossa  CN VI. 1976:27–57. Bruyn GW.  Superior orbital fissure fractures can damage CN III. Indirect injury of the optic nerve.diplopia. Conservative treatment with spontaneous recovery. New York: Elsevier.14:756–764. Morawetz RB.

Cranial nerve injuries: Middle Cranial Fossa
 CN VII- facial paralysis. Most common temporal bone, 50% of transverse and 25% of longitudinal fractures as injuries. ENoG of 90% denervation should undergo surgery.  CN VIII- Hearing loss, vestibular damage. Cochlear and vestibular nerve damage, or damage to otic capsule can lead to total degeneration with deafness and labyrinthine dysfunction. Workup with Audiogram, ABR, and ENG. Cochlear implants have 84% success rate of return to speech understanding.
Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New York: Elsevier; 1976:27–57. Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756–764.

Cranial nerve injuries: Posterior Cranial Fossa
 CN IX, X, XI- exit out of jugular foramen and CN XII exit out of hypoglossal foramen.  Glossopharyngeal injury leads to dysphagia and loss of gag  Vagus nerve results in ipsilateral cord or palate weakness with hoarseness.  Spinal accessory nerve causes weakness with head rotation and shoulder elevation. Hypoglossal nerve injury causes atrophy of ipsilateral tongue.  Treatment is usually supportive with therapy.
Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New York: Elsevier; 1976:27–57. Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756–764.

Evaluation: Imaging
 New Orleans criteria
 CT required for minor head trauma (Loss of consciousness with normal neurologic exam) if the following apply:  Headache, vomit, >60 yo, Drug/alcohol, seizure witness, anterograde amnesia, soft tissue injury

Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519-25. PubMed PMID: 16189365.

Evaluation: Imaging
 X-Ray skull: Not recommended; delays diagnosis of intracranial injury.  It is not recommended for most head traumas. It has some benefit for non accidental trauma in children.

hornbury JR, Masters SJ, Campbell JA. Imaging recommendations for head trauma: a new comprehensive strategy. AJR Am J Roentgenol. Oct 1987;149(4):781-3

Evaluation: Imaging: CT  HRCT scan is the gold standard for skull base injury.  CT Angiography is an excellent.  Helical CT scans are useful in the evaluation of occipital condylar fractures.  The slices should be 1-1. It has the best modality to evaluate bony fractures.5 mm thick at the most. non-invasive technique for the assessment of cerebral vasculature. . quick.

gif&IID=238&isPDF=NO .com/eJournals/ShowText.jaypeejournals.Evaluation: Imaging: CT http://www.aspx?ID=3093&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.

Imaging: CT .

K. 2012 . A.Imaging: CT  Textbook of Head Injury Raj Kumar. Mahapatra JP Medical Ltd.320 pages .Medical .

Colin S. CT. Kubal. Collins. Michele H. Johnson . Wayne S.Imaging: CT Multidetector CT of Temporal Bone Fractures John M. Aswin K. Krishnamoorthy. and MR 1 October 2012 (volume 33 issue 5 Pages 418-431 . Poon Seminars in ultrasound.

Krishnamoorthy. Johnson . Poon Seminars in ultrasound. Wayne S.Imaging: CT Multidetector CT of Temporal Bone Fractures John M. and MR 1 October 2012 (volume 33 issue 5 Pages 418-431 . CT. Michele H. Collins. Aswin K. Colin S. Kubal.

Krishnamoorthy. Aswin K. CT. Michele H. Collins. and MR 1 October 2012 (volume 33 issue 5 Pages 418-431 . Poon Seminars in ultrasound. Johnson .Imaging: CT Multidetector CT of Temporal Bone Fractures John M. Colin S. Wayne S. Kubal.

Carotid injuries include carotid disruption. Tatagiba M. and occlusion. compression by fracture fragments or associated hematoma. but no carotid injures noted on angiographic studies. carotid cavernous fistula. arterial dissection.Evaluation: Vascular injuries Approximately 50% of patients with skull base fractures present with delayed ischemic brain damage. Samii M.24:147-156 . Behbahani 2013. arterial wall contusion or hematoma. 16 patients had fractures extending to carotid canal.Retrospective study 1606 pt. in Tuscan. Skull base trauma: diagnosis and management. Neurol Res 2002.

Optimizing screening for blunt cerebrovascular injuries. Having one of these factors in the setting of a highrisk mechanism was associated with 41% risk of injury. Offner PJ.  Independent predictors of carotid arterial injury were: Glasgow coma score ≤6. and LeFort II or III fracture. Franciose RJ. petrous bone fracture. Am J Surg. Moore EE. Biffl WL. 85 (34%) had injuries.Evaluation: Vascular injuries  Biffl et all (1999)  A total of 249 patients underwent arteriography. Burch JM. Elliott JP. 1999 . Brega KE. diffuse axonal brain injury.

RadioGraphics 2008.28(6):1689–1708. discussion 1709–1710 . Blunt cerebrovascular injuries: imaging with multidetector CT angiography.Evaluation: Vascular injuries Sliker CW.

Evaluation: Vascular injuries .

 T2 weighted thin sliced images (FIESTA) is used to evaluate cranial nerves. Temporal Bone.Imaging: MRI  Provides greater soft tissue detail but less bony detail compared to CT.mric. Skull Base.2011.  T-2 fat suppression with image reversal is used to highlight CSF.1016/j.006 . Orbits.  FSE T-1 or T-2 with post contrast enhancement are preferred methods to evaluate skull base.05. and Cranial Nerves: Anatomy on MR Imaging Magn Reson Imaging Clin N Am 19 (2011) 439–456doi:10.

Imaging: MRI .

DJ. 1993. and other mucus will also produce a ring sign. MD and Fales.Evaluation: CSF Rhinorrhea/Otorrhea  CSF evaluation  Halo or Ring Sign  Bloody CSF placed on a piece of filter paper  Blood will separate out from the CSF (central blood with clear ring). The 'Ring Sign': Is It a Reliable Indicator for Cerebral Spinal Fluid? Annals of Emergency Medicine. MD.  The ring sign is not specific to bloody CSF  Blood mixed with water. F.22:718-720 . saline. Dula.

Evaluation: CSF Rhinorrhea/Otorrhea .

Beta-trace protein  Found in CSF. P. and serum.Evaluation: CSF Rhinorrhea/Otorrhea  Beta-2-transferrin  Protein produced by enzymes only in CNS.  Test requires 0. 2002 .5cc of fluid. multiple sclerosis.com/dg. ○ Elevated with renal insufficiency. heart.  Not routinely ordered as it may be altered in many cases. Beta-Trace Protein Shows Promise as a Marker for Diagnosing CSF Leaks. Moyer.nsf/PrintPrint/5DF097A1EB04B3FA85256C3E00731E65.  Highly sensitive and specific for CSF. Online[Available]: http://www. and some CNS tumors.docguide. cerebral infarctions. Doctor’s Guide.

 Involve intrathecal administration of radiopaque contrast (metrizamide.  Up to 80% sensitivity.129:508–17 . Otolaryngol Head Neck Surg 2003. iohexol. Oberascher G. Arrer E. Beta-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula. or iopamido) followed by CT scan.Imaging: CT cisternograms  Useful in detection of CSF leaks. et al.  However results vary with intermittent leaks. Meco C. and contrast may obscure visualization of leak site.

CSF Rhinorrhea .

com/featuredcases.chatrath.CSF Rhinorrhea http://www.html .

CSF Rhinorrhea .

after two separate meta-analysis showed conflicting data.(1): CD004884.  Currently.CSF Rhinorrhea  Treatment begins with conservative management of strict bed rest. Sampaio C. straining. no cough. sneezing. Cochrane Database Syst Rev 2006.  The analysis concluded that the evidence does not support the use of prophylactic antibiotics to reduce the risk of meningitis in patients with basilar skull fractures or basilar skull fractures with active CSF leak. a Cochrane review was done for evaluation of prophylactic antibiotics for CSF leaks. Ratilal BO. Costa J. HOB >30 degrees. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. .

Dierks EJ. J Oral Maxillofac Surg 2004.CSF Rhinorrhea  Conservative management for 7 days has resolutions rate of 85%. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.  Continued leakage is then treated with lumbar drainage of 10 ml/hr. et al.  Therefore. Bell RB. surgical intervention is reserved for patients who do not resolve with the above measures. . Homer L.62(6):676–84. This increases resolution rate to 90%.

 Radiographic evaluation is important.Conclusion  Skull base injuries offer complex fractures that require thorough evaluations. along with history and physical exam.  Division in 3 cranial vaults provides a reasonable way for evaluation.  Treatment measure typically begin with conservative treatment. with surgical intervention saved for severe or persistent disease. .

O. K. Plate # [11]. PubMed PMID: 17544690. "Initial CT findings in 753 patients with severe head injury: a report from the NIH Traumatic Coma Data Bank.320 pages Driscoll CL. D.5 (1990): 688-698. 44(2):77-82.nelsonbarry. http://www. discussion 82-3] http://rlbatesmd. New York: Elsevier.on. Bruyn GW. Casulari LA Journal of Neurosurgical Sciences [2000. Netter Images. Byrne. Swaid SN. Used under NEOMED License. Morawetz RB. 1995 Aug. eds. Accessed on [12-11-2013]..com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/ Positive predictive values of selected clinical signs associated with skull base fractures. 102: 1247–1250 Eisenberg. A. 2007 Jun.html https://www2. G.blogspot. http://www. A.. Mechanisms of basilar skull fracture. Review.12(4):669-78. Otolaryngol Clin North Am. Traumatic lesions of the visual pathways. Myers BS. Lane JI. et al.14:756–764.40(3) cElhaney JH. Kline LB. Advances in skull base imaging. and Cayten. (1992). Berkower.:439-54.” ©2012 Icon Learning Systems. 1976:27–57. The Laryngoscope.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMD A08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01Diagnosis/skull_base-skull_base.lhsc.com/2010/07/blepharoplasty-complications-article. Howard M.jsp Textbook of Head Injury Raj Kumar. vii. Indirect injury of the optic nerve. In: Vinken PJ. Association of skull base and facial fractures.htm Gjerris F. De Almeida CS. Mahapatra JP Medical Ltd. Hopper RH Jr. W. Base of skull: above. J Neurotrauma. Handbook of Neurology.References        Slupchynskyj. 1984." Journal of neurosurgery 73. S. Neurosurgery.ca/Health_Professionals/CCTC/edubriefs/baseskull. C. Vol 24.. Nightingale RW.aofoundation. (PMID:11105835) Pretto Flores L. S. 2012 . PubMed PMID: 8683618.Medical .        .

Michele H. Analysis of 158 frontal sinus fractures: current surgical management and complications.References              Temporal bone fracture: evaluation and management in the modern era. Boo SH. Ba (presenter). Kim KH. Mandana Behbahani. Wayne S. et al. Collins. and MR 1 October 2012 (volume 33 issue 5 Pages 418-431 The analysis concluded that the evidence does not support the use of prophylactic antibiotics to reduce the risk of meningitis in patients with basilar skull fractures or basilar skull fractures with active CSF leak Bell RB. Johnson.62(6):676–84.Otolaryngol Clin North Am . J Oral Maxillofac Surg 2004.269(8):1893-9 Multidetector CT of Temporal Bone Fractures John M. discussion 1709–1710 Kang HM. Aswin K. ComPLiCAtioNS.132(12):1300–4 Sliker CW. Caldarelli C. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. Colin S. . Yeo SG. Kesser BW. Kim MG. 41(3): 597-618 Gerbino G. Roccia F.28:133–139. Eur Arch Otorhinolaryngol. J Craniomaxillofac Surg. Krishnamoorthy. Comparison of the clinical relevance of traditional and new classification systems of temporal bone fractures. Md. Arch Otolaryngol Head Neck Surg 2006.28(6):1689–1708. Kubal. Dierks EJ. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. REtRoSPECtivE StuDY oF SKuLL BASE FRACtuRE: A StuDY oF iNCiDENtS. Radiographic classification of temporal bone fractures: clinical predictability using a new system. Homer L. Johnson F . Lee SK. university of arizona college of Medicine Little SC. RadioGraphics 2008. Yeo EK. CT. mANAgEmENt. 2000.01-JUN-2008. 2012 Aug. Poon Seminars in ultrasound. Benech A. AND outComE ovERviEW FRom tRAumA-oNE-LEvEL iNStitutE ovER FivE YEARS – Michael lemole.