Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

Look me in the face and tell me that I needed to be transferred: Defining the criteria for transferring patients with isolated facial injuries

OBJECTIVES

Despite the known burden of inappropriate overtriage of patients with facial injuries on the health care system, no comprehensive guidelines for the transfer of these patients exist. The aim of this study was to define guidelines regarding which patients with isolated craniomaxillofacial trauma require transfer to higher levels of care.

METHODS

We performed a 5-year review at a Level I trauma center (2017-2021). We included all transferred patients with isolated facial fractures. Patients were stratified into appropriate (those who received any emergency [taken directly to operating room] or urgent intervention [intervention in same admission] for facial injuries or were admitted to the ward for observation) and potentially inappropriate (patients who did not require any emergent or urgent intervention or admission to the facial trauma service [FTS]) transfers. Three independent experts reviewed the reason for the transfer and required interventions during the hospitalization and defined if the transfer was appropriate.

RESULTS

We identified 511 patients transferred to our Level I trauma center with isolated facial injuries. Over half (n = 259, 51%) of these transfers were potentially unnecessary, as these patients did not require intervention or admission. Overall, FTS was consulted for 89% of patients. A total of 252 patients (49%) were identified as appropriate transfers, of which 54% were admitted to the floor, 15% received emergency intervention, and 79% underwent urgent intervention. Eighty-two percent of potentially inappropriate transfers received an FTS consultation, and 81% were discharged from ED with a median length of stay of 6 hours. After a review of patient's hospitalization events, the Facial Injury Guidelines were defined.

CONCLUSION

More than half of the patients with isolated facial fractures did not require any intervention or admission. The proposed guidelines could significantly reduce unnecessary transfers and health care costs for patients with isolated craniomaxillofacial trauma. Prospective validation of the Facial Injury Guidelines is warranted before it could be considered for implementation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

A Rare Case of Traumatic Orbital Pseudomeningocele

A traumatic orbital pseudomeningocele is a rare complication of orbital trauma associated with orbital roof fractures and is underreported in the literature. Clinical signs may include proptosis, ophthalmoplegia, and diplopia, and when severe, there can be additional periorbital swelling from the anterior subcutaneous extension of the pseudomeningocele. We present a rare case of an orbital roof fracture resulting in an orbital pseudomeningocele with periorbital extension. CT is the preferred imaging modality for detecting orbital and other maxillofacial fractures, and it is sensitive to structural complications of this nature. In most cases, surgical repair is necessary. Our case emphasizes the significance of diagnostic imaging and collaborative care for optimal patient outcomes.

Transoral Penetrating Foreign Body Into the Foramen Magnum: A Case Report

In this paper, we present the case of a four-year-old boy with a penetrating transoral injury caused by a foreign object directed toward the foramen magnum. Head angiotomography revealed that the object's pathway was in close contact with the vertebral artery, without apparent involvement of the meninges. We discuss the clinical presentation, diagnostic approach, and treatment in this case.

Endoscopic Endonasal Repair and Reconstruction of Traumatic Anterior Skull Base Defects

Eighty percent of cerebrospinal fluid leaks (CSF) occur following trauma and complicate 12 to 13% percent of all basilar skull fractures (Prosser, Vender, and Solares, 2011). An endoscopic endonasal approach (EEA) is often the preferred method of repair with greater than 90% success rates (Prosser, Vender, and Solares, 2011). We report a case of a 37-year-old man who presented to our regional level 1 trauma centre with multiple facial injuries. Initial cross-sectional imaging revealed multiple, continuous anterior skull base fractures with associated pneumocephalus. Though initially managed conservatively, the patient represented five days later with unilateral left-sided rhinorrhoea. An endoscopic endonasal repair with a multilayer fat, tensor fascia lata, free mucosal graft, and vascularised local flap reconstruction was undertaken. This case highlights the importance of maintaining a high level of suspicion for delayed CSF leak in traumatic base of skull injury. The EEA enables meticulous dissection and thorough inspection of the skull base, facilitating multilayered repair and reconstruction of defects.

Reducing Risks for Midface and Mandible Fracture Repair

The midface skeleton provides structural scaffolding to the middle third of the face. Complications associated with fracture repair in these regions can result from incomplete, inaccurate, or delayed assessment, poor initial and subsequent reduction and fixation, infection, uncontrolled hemorrhage, hardware failure and associated soft tissue injuries. A systematic approach to managing the patient with facial trauma that includes Acute Trauma Life Support principles, early reconstruction, and precise reduction and fixation is essential to reducing the short-term and long-term risks of complications.

Anterior Cranial Base Reconstruction in Complex Craniomaxillofacial Trauma: An Algorithmic Approach and Single-Surgeon's Experience

Management of traumatic skull base fractures and associated complications pose a unique reconstructive challenge. The goals of skull base reconstruction include structural support for the brain and orbit, separation of the central nervous system from the aerodigestive tract, volume to decrease dead space, and restoration of the three-dimensional appearance of the face and cranium with bone and soft tissues. An open bicoronal approach is the most commonly used technique for craniofacial disassembly of the bifrontal region, with evacuation of intracranial hemorrhage and dural repair performed prior to reconstruction. Depending on the defect size and underlying patient and operative factors, reconstruction may involve bony reconstruction using autografts, allografts, or prosthetics in addition to soft tissue reconstruction using vascularized local or distant tissues. The vast majority of traumatic anterior cranial fossa (ACF) injuries resulting in smaller defects of the cranial base itself can be successfully reconstructed using local pedicled pericranial or galeal flaps. Compared with historical nonvascularized ACF reconstructive options, vascularized reconstruction using pericranial and/or galeal flaps has decreased the rate of cerebrospinal fluid (CSF) leak from 25 to 6.5%. We review the existing literature on this uncommon entity and present our case series of n  = 6 patients undergoing traumatic reconstruction of the ACF at an urban Level 1 trauma center from 2016 to 2018. There were no postoperative CSF leaks, mucoceles, episodes of meningitis, or deaths during the study follow-up period. In conclusion, use of pericranial, galeal, and free flaps, as indicated, can provide reliable and durable reconstruction of a wide variety of injuries.

A Case of Penetrating Brain Injury Followed by Delayed Cerebrospinal Fluid Leakage

Although penetrating brain injury is rare, it is associated with high morbidity and mortality. In several studies, even if very few patients arrive at the hospital alive, half of them eventually die, and the other half have significant neurological sequelae. Cerebrospinal fluid (CSF) leakage caused by traumatic brain injury is common. Therefore, we should be aware of the complications, prognosis, and follow-up strategies of penetrating brain injuries. A 55-year-old man was brought to our hospital with diffuse cerebral contusion and skull fracture. Three weeks after successful surgery, the patient returned with a large amount of pneumocephalus and pneumoventricle caused by delayed CSF leakage. Fortunately, the patient was discharged without neurological deficits after reoperation. In the urgent situation of penetrating brain injury, the treatment and prognosis vary depending on the initial actions and clinical factors. In addition, we should be aware that a variety of complications, as well as CSF leakage, can occur in patients with penetrating brain injuries.

Management of Maxillofacial Trauma in Attempt Suicide Patients During COVID-19 Pandemic

The maxillofacial surgeon trained well to face the surgical challenges. In case of dealing with self-inflicted trauma, the surgeon must face the surgical as well as the psychological status of the patients. Five patients received in the emergency room suffering from maxillofacial trauma resulted from suicidal attempts. Unfortunately, 1 patient died, the other patients managed by providing surgical and psychological support. The cornerstone of managing such type of trauma needs appropriate communication between the family, surgical team, and the psychiatric.

Reconstruction of Anterior Skull Base Fracture Using Autologous Fractured Fragments: A Simple Stitching-Up Technique

Objective

A displaced fracture in the anterior cranial base may be complicated by cerebrospinal fluid (CSF) rhinorrhea and enophthalmos. This study introduces a reconstruction technique with direct dural repair and reduction and fixation of the autologous fractured fragments.

Methods

Displaced fractures in the anterior cranial base were reconstructed using a stitching-up technique: A bicoronal scalp incision and frontal craniotomy was performed and the displaced bone was withdrawn. The lacerated dura was repaired primarily using a graft. Small holes were created in the intact cranial bones and the displaced harvest bone. Black silk was passed through the holes and the displaced bone was repositioned on tying the silk. Lumbar drain was not placed in any of the cases. The feasibility and outcome were evaluated.

Results

Five patients with displaced skull fractures of the anterior cranial base were included. All cases were men who had a direct impact on the forehead and/or eye. All the displaced fractures occurred in the orbital roof, and ethmoid bone fractures were present in 4 cases. Dural laceration was involved in 4 cases and repaired by placing artificial dura in 3 cases and a pericranial graft in 1 case. Following surgery, all cases were uneventful, and the anterior cranial fossa was well reconstructed. CSF leakage or enophthalmos did not occur in any of the cases.

Conclusion

Direct dural repair and autologous stitching-up reconstruction using the fractured fragment could be an effective method to prevent CSF leakage and enophthalmos in displaced fractures of the anterior cranial base.

CT of Skull Base Fractures: Classification Systems, Complications, and Management

As advances in prehospital and early hospital care improve survival of the head-injured patient, radiologists are increasingly charged with understanding the myriad skull base fracture management implications conferred by CT. Successfully parlaying knowledge of skull base anatomy and fracture patterns into precise actionable clinical recommendations is a challenging task. The authors aim to provide a pragmatic overview of CT for skull base fractures within the broader context of diagnostic and treatment planning algorithms. Laterobasal, frontobasal, and posterior basal fracture patterns are emphasized. CT often plays a complementary, supportive, or confirmatory role in management of skull base fractures in conjunction with results of physical examination, laboratory testing, and neurosensory evaluation. CT provides prognostic information about short- and long-term risk of cerebrospinal fluid (CSF) leak, encephalocele, meningitis, facial nerve paralysis, hearing and vision loss, cholesteatoma, vascular injuries, and various cranial nerve palsies and syndromes. The radiologist should leverage understanding of specific strengths and limitations of CT to anticipate next steps in the skull base fracture management plan. Additional imaging is warranted to clarify ambiguity (particularly for potential sources of CSF leak); in other cases, clinical and CT criteria alone are sufficient to determine the need for intervention and the choice of surgical approach. The radiologist should be able to envision stepping into a multidisciplinary planning discussion and engaging neurotologists, neuro-ophthalmologists, neurosurgeons, neurointerventionalists, and facial reconstructive surgeons to help synthesize an optimal management plan after reviewing the skull base CT findings at hand. Online supplemental material is available for this article. ^©RSNA, 2021.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.

Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.

Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.

Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Split hypoglossal facial anastomosis for facial nerve palsy due to skull base fractures: A case report

Introduction

Traumatic brain injury (TBI) is the most prevalent causes of morbidity and mortality worldwide. The biomechanics of primary TBI involve a direct impact, practically extended to the base of the skull, and most of the skull base fractures (SBF) are identified in anterior and medial cranial fossa. Furthermore, those predicted in the medial area are related to fissures from temporal bones.

Presentation of case

We report two cases of right facial nerve palsy initiated by SBF's, which were diagnosed and treated at our institution. The 3D CT evaluation in our first case showed a longitudinal fracture of the right petrosal bone, which was longitudinal and transverse for the second case. Two cases of facial nerve palsy were managed with split hypoglossal facial anastomosis to restore functional reanimation. All patients were adequately achieved after the procedure, and the hypoglossal nerve function was preserved.

Conclusion

Split hypoglossal facial anastomosis technique was used to treat patients with facial nerve paralysis resulting from SBF's. This was to achieve good recovery outcome, in terms of facial reanimation and preservation of tongue function.

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A skull base fracture (SBF) is about 4% of all cases Traumatic brain injury (TBI).

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SBF which frequently occurs in the petrous part of the temporal bone, is implicated in facial nerve palsy.

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Split hypoglossal facial anastomosis technique showed good recovery of facial reanimation with HB scale assessment.

Laryngeal adductor function following potassium titanyl phosphate laser welding of the recurrent laryngeal nerve

OBJECTIVES/HYPOTHESIS

Recurrent laryngeal nerve (RLN) transection injuries may occur during thyroidectomy and other surgical procedures. Laser nerve welding has been shown to cause less technique-related axonal damage than the traditional suture method. We compared functional adductor results using these two methods of RLN repair.

STUDY DESIGN

Animal model.

METHODS

Canine hemilarynges underwent pretreatment testing of laryngeal adductor function, followed by RLN transection and repair using potassium titanyl phosphate (KTP) laser welding (n = 8) or microneural suture (n = 16) techniques. Six months later, adductor function was measured again and expressed as a proportion of the pretreatment value.

RESULTS

The mean laryngeal adductor pressure ratios were 82.4% (95% confidence interval [CI]: 72.8%-92.0%) for the laser repair group and 55.5% (95% CI: 49.4%-61.6%) for the suture control group, with a difference of 26.9% (95% CI: 15.3%-38.5%). Both spontaneous and stimulated glottic closure was observed in the laser welding and microsuture repair groups.

CONCLUSIONS

Laser nerve welding resulted in greater strength of adduction than suture repair of an acutely transected RLN. Suture anastomosis may traumatize more axons than the laser. Stronger vocal fold adduction is associated clinically with better protection from aspiration and improved voice outcomes. KTP laser welding should be considered for anastomosis of the RLN and other nerves.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1764-1769, 2020.

Frontal Sinus Fractures: Evolving Clinical Considerations and Surgical Approaches

Frontal sinus fractures are an uncommon injury of the maxillofacial skeleton, and account for 5-15% of all maxillofacial fractures. As the force of impact increases, fractures may extend beyond the anterior table to involve adjacent skull, posterior table and frontal sinus outflow tract (FSOT). Fractures at these subsites should be evaluated independently to assess the need for and type of operative intervention. Historically, these fractures were managed aggressively with open techniques resulting in obliteration or cranialization. With significant injuries, these approaches are still indispensable. However, the treatment of frontal sinus fractures has changed dramatically over the past half-century, and recent case series have demonstrated favorable outcomes with conservative management. Concurrently, there has been an increasing role of minimally invasive endoscopic techniques, both for primary and expectant management, with a focus on sinus preservation. Here, we review the diagnosis and management of frontal sinus fractures, with an emphasis on subsite evaluation. Following a detailed assessment, an appropriate treatment strategy is selected from a variety of open and minimally invasive approaches available in the surgeon's armamentarium.