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$Sinai Me#i%al "enter, &os Angeles, "aliornia
'(()*, +SA.
Abstract
BA"K,R-+.D/ Traumati% %ranioa%ial an# s0ull base in1uries re2uire a multi#is%iplinary team approa%h.
Trauma physi%ians must e!aluate %areully, triage properly, an# maintain a high in#e3 o suspi%ion to impro!e
sur!i!al an# enhan%e un%tional re%o!ery. 4re2uently, %ranioa%ial an# s0ull base in1uries are o!erloo0e# 5hile
treating more lie$threatening in1uries. +nnoti%e# %omple3 %ranioa%ial an# s0ull base ra%tures, %erebrospinal
lui# istulae, an# %ranial ner!e in1uries %an result in blin#ness, #iplopia, #eaness, a%ial paralysis, or
meningitis. Early re%ognition o spe%ii% %ranioa%ial an# s0ull base in1ury patterns %an lea# to i#entii%ation o
asso%iate# in1uries an# allo5 or more rapi# an# appropriate management. "-."&+S6-./ Early #ete%tion an#
treatment o %ranioa%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% %ranioa%ial an# s0ull base in1uries re2uire a multi#is%iplinary team approa%h. Trauma physi%ians
must e!aluate %areully, 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, %ranioa%ial an# s0ull base in1uries are o!erloo0e# 5hile treating more lie$
threatening in1uries. +nnoti%e# %omple3 %ranioa%ial an# s0ull base ra%tures, %erebrospinal lui# istulae, an#
%ranial ner!e in1uries %an result in blin#ness, #iplopia, #eaness, a%ial paralysis, or meningitis. Early
re%ognition o spe%ii% %ranioa%ial an# s0ull base in1ury patterns %an lea# to i#entii%ation o asso%iate# in1uries
an# allo5 or more rapi# an# appropriate management.
Abstract: Conclusion
Early #ete%tion an# treatment o %ranioa%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
%ranioa%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 %ranioa%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#. +nortunately,
#elaye# or misse# #iagnoses %an lea# to signii%ant morbi#ity =blin#ness, #iplopia, #eaness, 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 %areul history an# physi%al e3amination is paramount to a%%urately #iagnose %ranioa%ial in1ury. Ater
perorming the primary sur!ey outline# by a#!an%e# trauma lie support, a more thorough se%on#ary sur!ey
shoul# pro%ee# systemati%ally. The %lini%al e3amination o the %ranioa%ial s0eleton begins 5ith inspe%tion or
lo%alize# ten#erness, numbness, blee#ing, asymmetry, #eormity, e%%hymosis, periorbital e#ema, otorrhea, an#
rhinorrhea. All bony sura%es shoul# be palpate# in%lu#ing the superior an# inerior 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 perorme#. 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 #ii%ult an# relies on testing o brain
stem rele3es.B 6n the %omatose patient, assessing !ision %an be #ii%ult? e!en 5ith %omplete unilateral !isual
loss, pupils %an remain e2ually rea%ti!e as long as the eerent 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 aerent
". 66 path5ay an# an inta%t eerent ". 666 parasympatheti% path5ay.8 Testing patients 5ith unilateral aerent
". 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 reerre# 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> rele3. The %orneal rele3 %onsists o tou%hing the %ornea 5ith a
pie%e o %otton? aerent ibers o ". A sen# the message to the brain an# ". A66 respon#s by eyeli# %losure.
". A666 is assesse# 5ith the %ol#$5ater %alori% test, in 5hi%h i%e 5ater is in1e%te# into the ear an# eli%its
nystagmus. Testing o the gag rele3 e!aluates ". 6E an# ". E.
Ater %areul physi%al e3amination, the trauma surgeon shoul# o%us on spe%ii% areas o %ommon %ranioa%ial
in1uries.
Craniofacial fractures
Orbital fractures
4or%eul impa%t to the s0ull %an %ause a ra%ture along the 5ea0 points o the orbit. The thinnest an# 5ea0est
area o the orbit is the loor. Typi%ally, the posterome#ial region o the orbital loor is ra%ture#. -ten, orbital
sot tissues herniate ineriorly into the ma3illary sinus an# be%ome entrappe#.* Entrapment o the inerior
obli2ue or inerior re%tus mus%le %an lea# to #iplopia an# restri%tion o globe mo!ement. A##itionally, the globe
is #ispla%e# posteriorly an# ineriorly, 5hi%h %auses enophthalmos an# urther #iplopia.
The #egree o orbital loor #ispla%ement is #iagnose# a%%urately 5ith a3ial an# espe%ially, %oronal "T s%ans o
the orbit an# a%ial bones. Surgi%al inter!ention is in#i%ate# 5hen there is signii%ant orbital loor #isruption,
persistent #iplopia, entrapment, or enophthalmos.' Surgi%al a%%ess to orbital loor ra%tures in!ol!es a
sub%iliary or trans%on1un%ti!al in%ision in the lo5er eyeli#. ' The in%ar%erate# orbital tissue is re#u%e# an# bony
#ee%ts are re%onstru%te# 5ith a !ariety o allograts or autograts har!este# rom assorte# sites.
4ra%tures o the superior, lateral, an# inerior orbital rims may o%%ur in isolation or in %on1un%tion 5ith other
%ranioa%ial ra%tures. Fhysi%al e3amination may re!eal step$os in the line o the ra%ture. "hee0 paresthesias
are %ommon #ue to inerior orbital rim ra%tures traumatizing the inraorbital 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%orontal suture. 6neriorly, 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 inerior, me#ial, an# posterior !e%tor. 7; Sub%on1un%ti!al
hematomas an# inraorbital 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$%omminute#,
posterior zygomati% ar%h ra%tures %an be treate# through a 7 %m temporal in%ision by simple re#u%tion, 5ithout
the nee# or internal i3ation.7; Ho5e!er, any other #ispla%e# zygomati% ra%ture re2uires open re#u%tion an#
internal i3ation.7@ Su%%essul re#u%tion relies on an a%%urate three$#imensional re#u%tion 5ith an emphasis on
%areul 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 %lassii%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 piriorm aperture an# e3ten# laterally abo!e the roots o the teeth, through the anterior ma3illary 5all, an#
posterior$laterally to in!ol!e the pterygoi# pro%esses. &e4ort 66 ra%tures are %entrally more %ephala# an# #ue to
their shape, are %alle# Cpyrami#al ra%turesC. &e4ort 66 ra%tures begin at the nasal bri#ge, e3ten# inerior$
laterally insi#e the me#ial orbit, e3it through the inraorbital 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 inraorbital rim, they progress laterally along the
entire orbital loor an# e3ten# to #isrupt the zygomati%orontal suture. &e4ort 666 ra%tures result in %omplete
%ranioa%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 perorme# 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 let 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. Thereore, &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 ater the in1ury, to
allo5 or #e%ease# e#ema an# intra$operati!e blee#ing. 6 there is any 2uestion as to the stability o a
man#ibular ra%ture, the patient shoul# be let in interma3illary i3ation or our to si3 5ee0s to ensure proper
bone healing.7*
Skull base fractures
4i!e bones orm the base o the s0ull. The bones in%lu#e the orbital plate o the rontal bone, %ribriorm plate o
the ethmoi# bone, sphenoi# bone, o%%ipital bone, an# the s2uamous an# petrous portions o the temporal bone.
+p to ;): o patients sustaining blunt hea# trauma ha!e a s0ull base ra%ture.;( Despite the %lini%al importan%e
o s0ull base ra%tures, many are un#iagnose#. Be%ause o the %omple3 anatomi% relationships o the s0ull base,
the ra%tures may #amage %riti%al neighboring stru%tures, in%lu#ing %ranial ner!es, internal %aroti# artery, an#
%a!ernous sinus. The ra%tures may la%erate the #ura an# %reate a potential "S4 istula.
<hen a ra%ture o the s0ull base is suspe%te#, insertion o a nasogastri% tube =.,T> shoul# be a!oi#e#. The
orogastri% route is preerre# as there ha!e been %ases o intra%ranial .,T pla%ement in the presen%e o
%ribriorm plate ra%tures.;7
Temporal bone fractures
"lini%al signs o temporal bone ra%tures in%lu#e bloo# in the e3ternal au#itory %anal, hemotympanum,
e%%hymosis o!erlying the mastoi# bone, otorrhea, hearing loss, !estibular #ysun%tion, an# a%ial ner!e paresis
or paralysis. High$resolution non$%ontra%t "T s%an shoul# be perorme# in all suspe%te# temporal bone
in1uries.;; "oronal se%tions an# @D re%onstru%tions pro!i#e inormation about the a%ial ner!e %anal, %aroti#
%anal, an# oti% %apsule.
Temporal bone ra%tures are %lassiie# a%%or#ing to their relationship to the long a3is o the petrous pyrami#.
Though most temporal bone ra%tures are mi3e#, temporal bone ra%tures are %lassiie# as longitu#inal or
trans!erse.
Se!enty to ninety per%ent o temporal bone ra%tures are longitu#inal, an# o%%ur ater #ire%t lateral blo5s to the
temporoparietal s0ull.;;, ;@ These ra%tures usually begin in the 5ea0er s2uamous portion o the temporal bone
an# %ourse to5ar# the %aroti# an# 1ugular oramina. +sually, the tympani% membrane is torn an# the mi##le ear
ossi%les are #isrupte# resulting in a %on#u%ti!e hearing loss. Blee#ing rom the e3ternal au#itory %anal is
%ommon. Appro3imately ;9: o patients ha!e a%ial ner!e in1ury, 5hi%h usually o%%urs in the geni%ulate
ganglion or a%ial %anal.
Trans!erse temporal bone ra%tures are mu%h more rare an# o%%ur ollo5ing se!ere trauma to the o%%iput.;)
These ra%tures begin in the 1ugular oramen an# %ourse a%ross the petrous pyrami#, through the oramina
spinosum an# la%erum to the oramen magnum. Appro3imately 9(: o patients noti%e imme#iate a%ial
paralysis rom ".A66 in1ury.;9 +nless %orre%te# surgi%ally, a%ial paralysis may be permanent. Typi%ally,
".A66 is in1ure# in the internal au#itory meatus or on the me#ial 5all o the tympani% membrane. 6n a##ition,
#amage to the labyrinth, %o%hlea, or ".A666 %an result in sensorineural hearing loss an# !estibular #ysun%tion.
Trans!erse temporal bone ra%tures oten %ourse through the oti% %apsule. Be%ause the oti% %apsule heals by
ibrous union rather than bony %allus ormation, patients ha!e a lielong ris0 or #e!eloping meningitis.;B
Penetrating temporal bone trauma
Fenetrating trauma to the temporal bone usually results rom sel$inli%te# gun shot 5oun#s.;8 Ater initial
stabilization, a %omplete !as%ular an# neurologi% e!aluation shoul# be perorme#. 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% #ei%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$traumati% "S4 istulae 5ith meningitis, trans!erse petrous ra%tures
5ith oti% %apsule in!ol!ement, temporal bone ra%tures 5ith %omplete a%ial paralysis, an# ballisti% in1ury to the
temporal bone.;' Treatment in%lu#es a subtotal petrose%tomy. The operation %onsists o %omplete e3enteration
o temporal bone air %ell tra%ts an# obliteration o the eusta%hian tube.;B Ater the in1ure# stru%tures are
repaire# =e.g., the a%ial ner!e or %aroti# artery> or e3enterate# =e.g., the oti% %apsule>, the resulting %a!ity is
obliterate# 5ith an en#ogenous at grat an# temporalis mus%le lap
CSF Fistulae
Appro3imately ;(: o s0ull base ra%tures 5ill #e!elop a "S4 istula 5ith *(: o%%urring 5ithin )* hours o
in1ury.@(, @7 Maniestations in%lu#e rhinorrhea an# otorrhea. The #rainage is usually %lear an# nonmu%oi# an#
may be #ii%ult to #ete%t 5hen mi3e# 5ith bloo#. To a%ilitate the #iagnosis o "S4 lea0, a e5 #rops o the
lui# are pla%e# on a tissue paper. "S4 has a more rapi# #iusion pattern than bloo#, an# 5hen the #is%harge is
mi3e# 5ith bloo#, a larger, %learer "S4 ring 5ill surroun# the sanguineous %entral ring. The %lini%al in#ing is
terme# the C#ouble$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$;$transerrin. Fresen%e o beta$;$transerrin %onirms a "S4 lea0.
Rhinorrhea
"S4 #raining rom the nose results rom ra%tures through the %ribriorm 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# ater 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.
Ater 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 #eerring surgery or at least i!e #ays.;(, @7, @8 Surgi%al inter!ention shoul# be reser!e# or patients
5ith meningitis, large #ee%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# perorates 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$resolution "T s%anning 5ith %oronal
se%tioning shoul# be perorme# to lo%alize the site o the ra%ture. Detaile# au#itory an# !estibular testing
shoul# be perorme# at si3 to eight 5ee0s to #iagnose abnormalities.
-perati!e inter!ention %onsists o a mi##le or posterior ossa %raniotomy, ashioning a bone lap to e3pose the
#ura o!erlying the petrous bone.@9 Frimary repair is attempte#, but i not possible, a grat o peri%ar#ium or
as%ia lata is use#. -%%asionally, en#ogenous at or mus%le is use# to pa%0 the #ee%t.
Cranial nerve injuries
+pon e3iting the s0ull, %ranial ner!es are espe%ially prone to #amage. S0ull base ra%tures parti%ularly
pre#ispose patients to %ranial ner!e #amage. Table 7 lists the t5el!e %ranial ner!es an# the %ommon neurologi%
#ei%its ollo5ing in1ury.
Olfactory nere !C" I# in$ury
6n1ury to the ola%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 ola%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. Thereore, 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 rele3.);
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 birontal %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 ineriorly.
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, inerior re%tus, inerior 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 ae%te# eye. Spontaneous re%o!ery o
o%ular mo!ement usually o%%urs in our to si3 5ee0s.
Troc%lear nere !C" I&# in$ury
The tro%hlear ner!e is the least re2uently in1ure# %ranial ner!e. Damage to %ranial ner!e 6A results rom
stret%hing near the e3it rom the #orsal mi#brain. &ateral re%tus 5ea0ness results. Treatment is %onser!ati!e an#
in!ol!es an eye pat%h to pre!ent #iplopia. 4un%tion usually returns by our to si3 5ee0s.
Trigeminal nere !C" &# in$ury
6n1ury to the trigeminal ner!e %auses sensory #ei%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
ma3illoa%ial ra%tures 5ith resultant sensory #ee%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#$%a!ernous istula.)B The ner!e is espe%ially !ulnerable %oursing through the #ura, pro3imal to
Me%0elDs %a!e.
6n%omplete transe%tion or s%arring o the bran%hes o ". A may result in intra%table a%ial pain an# neuroma
ormation. "orti%osteroi# in1e%tions, en#os%opi% #e%ompression, or en#os%opi% #i!ision may be re2uire# or
relie o symptoms.)8
Abducens nere !C" &I# in$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 ae%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 ater our 5ee0s.
Facial nerve (CN #! injur"
Temporal bone ra%tures are the most %ommon %ause o a%ial ner!e in1uries.;;, ;9 4ity 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
#ieren%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 #eaness an# labyrinthine #ysun%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 #ysun%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 rele3. 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 %ranioa%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 reerral 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%%essul 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 Trai% Saety 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$77)7.
). S%hultz R". Sot tissure in1uries o the a%e. 6n/ Aston SJ, Beasley R<, Thorne "HM, e#s. Plastic
Surger") 9 e#. Fhila#elphia, FA/ &ippin%ott$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 inraorbital rim an# orbital loor/ a retrospe%ti!e stu#y. Plast Reconstr Surg)
7'';?'(/9*9$9'7.
7(. Tessier F. The %on1un%ti!al approa%h to the orbital loor an# ma3illa in %ongenital malormation an#
trauma. - Ma,illofac Surg) 7'8@?7/@$*.
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$);*.
7;. ,russ JS, Aan <y%0 &, Fhillips JH, an# Antonyshyn -. The importan%e o the zygomati% ar%h in
%omple3 mi#a%ial ra%ture repair an# %orre%tion o posttraumati% orbitozygomati% #eormities. Plast
Reconstr Surg) 7''(?*9/*8*$*'(.
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)$B;.
79. Manson F.. Some thoughts on the %lassii%ation an# treatment o &e 4ort ra%tures. +nn Plast Surg)
7'*B?78/@9B$@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# pana%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 ater 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 ater 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;$7BB.
;@. "annon "R, an# Jahrs#oerer RA. Temporal bone ra%tures. Re!ie5 o '( %ases. +rch Otolar"ngol)
7'*@?7('/;*9$;**.
;). 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, Khaagy 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# %let 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.
"ere (eficit
=7> Olfactory Anosmia
=;> Optic Blin#ness? Aisual iel# #ei%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 rele3? 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 #ysun%tion? .ystagmus? Hearing loss
='> *lossop%aryngeal &oss o gag rele3? 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
oten 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 ater in1ury.
7B: o %ases are Ko%%ultK, being oun# ater re%urrent meningitis.
Anatomy
Introduction
<e %onsi#er the en#o%ranial =inner> sura%e o the s0ull base, 5hi%h %onsists o the %ranial %a!ity on 5hi%h the
brain rests, an# the e3o%ranial =e3ternal> sura%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 sura%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 sura%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 %ribriorm 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 =let an# right>
Thereby, the inner sura%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 neres and related skull base foramina
<hen ra%tures in!ol!e some spe%ii% 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 -la%tory ner!e/ orme# by many sensory ner!e ibers that e3ten# rom the ola%tory epithelium to the
ola%tory bulbs passing through the openings o the %ribriorm 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 sura%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 sura%e is orme# by/
-%%ipital bones
Temporal bones
Sphenoi# bones
Falatine bones
Gygomati% bones
The spe%ii% stru%tures that %an be in!ol!e# in ra%tures o the e3tra%ranial sura%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$ury
The s0ull base is parti%ularly sus%eptible to the ee%ts o blunt trauma. S0ull base ra%tures are oten asso%iate#
5ith %ranial !ault or mi#a%e ra%tures.
The most !ulnerable regions o the s0ull base are the petrous bone, the sphenoi# sinus, an# the oramen
magnum.
Clinical presentation
Sin%e s0ull base ra%tures are the results o high or%e impa%ts an# are oten asso%iate# 5ith other intra%ranial
in1uries. Thereore, patients may be un%ons%ious or re2uire inter!ention or other more lie$threatening in1uries.
As a result, the %lini%al signs an# symptoms o s0ull base ra%tures may not be re%ognize# imme#iately.
Fatients ae%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#entiie# 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 useul. -ther useul test %an be/
Double ring sign
,lu%ose test strip
Beta$;$transerrin 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#entiy 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%ii%, !ery useul "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$%isternography
Classification
Single !linear and/or branc%ed# and multiple
The ra%tures %an be single, %rossing more bones, or multiple, in the same bone or in #ierent bones. The
ra%ture %an be linear or bran%he#.
Single ra%ture line
Bran%he# ra%ture lines.
Multiple separate# ra%ture lines.
Comminuted
A ra%ture is %omminute# 5hen the bone is shattere# into many ragments.
Contiguous
The ra%ture is %ontiguous 5hen it %rosses anatomi%al boun#aries.
(epressed
The ra%ture# segments are #ispla%e# in5ar#, to5ar# the meninges an# brain or more than @ mm.
(iastatic suture
Horizontal #ispla%ement along the %ranial sutures =M@ mm>.
(iastatic fracture
Horizontal #ispla%ement o the bones at the margin o the ra%ture =M@ mm>.
Cranial Vault & Skull Base
Authors
Oeriew
0acerations
Sot$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#entii%ation o the #ee%t
Repair o the #ee%t
6. )luorescein in$ection
6n the ma1ority o %ases beore surgery a lumbar #rainage is inserte# 5hi%h allo5s the in1e%tion o 7 ml so#ium
luores%ein =(.9:>. +sing a lumbar #rainage oers the a#!antage to re$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 $7(N up to O)9N. The
hea# %an be rotate# to5ar# the surgeon i ne%essary. The en#os%ope is inserte# in the nostril =right, let, or both>
an# the anatomi%al lan#mar0s are !isualize#.
The use o na!igational #e!i%es =usion #ata sets, "T, an# MR6> is helpul.
8. Identification of t%e anatomical landmarks
4or the en#os%opi% anatomi%al orientation the ollo5ing stru%tures shoul# be i#entiie#/
.asal septum =.S>
Mi##le turbinate =MT>
"hoana =">
Sphenoi# ostium =-S>
9. .et%ods of approac%
En#onasal en#os%opy %an be perorme# by se!eral metho#s #epen#ing on the type o lesion an# its lo%ation.
The %lassi% approa%h to the ola%tory ossa is the #ire%t paraseptal one =5ith or 5ithout remo!ing any ethmoi#al
stru%tures a%%or#ing to the anatomi%al !ariations o the patient>.
:. Identification of t%e lesion
The use o a luores%ein blue$light ilter system an# the luores%ein barrier ilter mounte# to the eyepie%e o the
en#os%ope might be helpul to !isualize the lo%alization o the #ural #ee%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 #ee%t an# #ierent grats %an be use# in%lu#ing autologous nasal,
e3tra$nasal, an# heterologous grats. The bone #ee%ts %an be repaire# using septal %artilages, parts rom the
mi##le nasal turbinates, e!entually the !omer, et%. The most use# autologous e3tranasal grat is the ab#ominal
at or the as%ia lata. 6n larger #ee%ts, a !as%ularize# nasoseptal lap %an be use#.
The %losure te%hni2ue is a stri%tly relate# to the in#i!i#ual patientPs anatomy, the size o the lea0, an# its
anatomi%al lo%ation. +n#erlay, o!erlay, %ombine#, an# obliterati!e te%hni2ues ha!e been #es%ribe#.
The illustration sho5s a %ombine# three layer te%hni2ue in 5hi%h are e!i#ent/
Sub#ural intra%ranial un#erlay grat =#ar0 green>
E3tra#ural intra%ranial un#erlay grat =blue>
E3tra%ranial o!erlay grat =purple>
4ibrin glue %an be use# to 0eep the layers together or to ill the #ea#$spa%e.
2<. Confirmation of proper closure
Ater %losing the #ee%t, its ei%a%y an# reliability is %he%0e# using a Aalsal!a maneu!er an# in spe%ial %ases,
intraoperati!e luores%ein test.
Appendi-
0ate 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 #eormities
6ne%tion o =allogenei%> grats
&ate "S4 lea0
Meningitis
These se2uela may o%%ur e!en #e%a#es ater the initial in1ury an# oten 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 ater rontal sinus ra%tures an# may o%%ur many years ater
the a%%i#ent. These %ompli%ations are the result o mu%osal prolieration ater 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 #ysun%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 perorme#.
3. Operatie 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 grats %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 ine%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%ii% 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 let 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 #ee%t in the orbital
roo 5as re%onstru%te# 5ith a %ranial bone grat =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 ae%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 ine%tions. The #rainage o the me#ial one
thir# an# o the let 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 #ee%t.
Ater remo!al o the mesh, the rontal sinus %an be inspe%te#.
Re%onstru%tion o the anterior table #ee%t 5ith bone.
6n this %ase, only partial obliteration o the rontal sinus 5as #one 5ith at an# as%ia, 5hile the #ee%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 #ii%ult.
7. Case e-ample: Infection of a %ydro-yapatite graft
"hroni% ine%tion 5ith re%urrent istulae 9 years ater 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# ine%tion o the alloplasti% grat.
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 grat by granulation tissue.
Ater remo!al o the grat 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 ater e3ten#e# rontal sinus ra%ture. 6n the initial repair, obliteration o #ee%ts 5as a%hie!e#
5ith FMMA. Ten years ater the a%%i#ent, re%urrent istulization o%%urre#. Repeate# lo%al e3%isions 5ere
unsu%%essul.
MR6 sho5s a #ee%t in rontal bone %ommuni%ating 5ith the istula.
6ntraoperati!e !ie5 sho5ing the FMMA grat embe##e# into granulation tissue.
Ater #ebri#ement the %ontour o the bone is restore# 5ith a titanium mesh an# the #ee%t is ille# 5ith at.
The istula is %lose# rom the insi#e 5ith a rotational peri%ranial lap.
+ne!entul healing 5ith a slightly #epresse# s%ar ater B months.
9. Case e-ample: Infection of allogenic graft= causing swelling and c%ronic %eadac%e
"hroni% ine%tion o the let rontal sinus ater obliteration 5ith a polymeri% inlay %ausing s5elling an# %hroni%
hea#a%he.
E3posure sho5s that the grat is embe##e# in granulation tissue.
Ater 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 #ee%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 ine%tion ater one year. Se%on#ary repair 5as #one 5ith
a titanium mesh 5hi%h 5as 1ust lai# onto the bone 5ithout i3ation. Ater t5o years, the mesh began to perorate
through the s0in =arro5>.
<i#e$meshe# titanium mesh loating on the #ee%t 5ithout i3ation.
Dea# spa%e belo5 the mesh resulte# in in#entation o the s0in =see also pre!ious %lini%al photograph>.
The #ee%t in the rontal bone ater remo!al o the mesh. The un#erlying #ura =see arro5> is %o!ere# by thi%0
s%ar.
Re%onstru%tion o the #ee%t 5as #one 5ith split %ranial bone =outer table> ta0en as a ull$thi%0ness grat rom
the posterior hal o the s0ull. The #onor site #ee%t 5as re%onstru%te# 5ith internal table.
+ne!entul healing ater @ months. .ote the thinning o the s0in o the right orehea# #ue to the ta0ing o
peri%ranial lap #uring initial repair.
;. Case e-ample: Osteomyelitis of t%e supraorbital rim wit% fistuli>ation
This patient sustaine# a motor !ehi%le a%%i#ent 5ith a right rontal sinus an# %ranial base ra%ture re2uiring
%ranialization o the rontal sinus. Ten years ater the a%%i#ent, re%urrent istulization in the area o the glabella
o%%urre#. Despite se!eral re!isions using a lo%al in%ision istulization #i# not stop.
"T sho5s osteomyelitis an# partial resorption Q
Q o the right supraorbital rim.
6ntraoperati!e !ie5 ater rese%tion o the ae%te# supraorbital rim. Due to pre!ious %ranialization o the rontal
sinus, a ormal %raniotomy 5as #one to prote%t the #ura.
The supraorbital rim 5as re%onstru%te# 5ith ull thi%0ness %ranial bone ta0en rom the posterior part o the
s0ull.
Fostoperati!e 3$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<. Operatie 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 preerre# 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
grating.
4rontal sinus en#os%opi% surgi%al te%hni2ues are among the most #ii%ult en#os%opi% sinus pro%e#ures an#
shoul# only be attempte# by those %omortable #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 Reeren%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 ineriorly. 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 perorme# 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 inerome#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 saely 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 #eormity
,lobe %ompression an# #eormity
<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 #eormity has
also impro!e# signii%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 let ethmoi#e%tomy an# #rainage o the mu%o%ele.
=.ote/ Septal peroration seen on "T s%an 5as present prior to en#os%opi% mu%o%ele #e%ompression.