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

Maxillofacial trauma and cerebrospinal fluid leak: a retrospective clinical study

Objectives

To determine the prevalence of maxillofacial fractures associated with persistent CSF leak, and to assess its bearing on clinical outcomes of consecutive patients managed at our centre.

Methods

This was a retrospective cross-sectional study. The medical records of patients over 11-year period were analysed for age, gender, etiology of injuries, duration between injury and presentation to the hospital, types of facial fracture and their treatments, treatment done to control CSF leak, and complication(s). Descriptive and bivariate statistics were computed.

Results

Overall, 1473 patients were evaluated, 66 (4.5%) presented with craniofacial injuries associated with persistent CSF leak after 5 days of non-surgical treatment. Males (92.5%, P= 0.0000) and those in the 21 to 30 years age group (59.1 %, P=0.01) were predominant. The most common (68.2%) type of fracture combination was Le Fort I, II and III, NOE, zygomatic complex and mandible. The commonest clinical presentation of CSF leak was rhinorrhea only, in 66.7% of patients (P= 0.001).

Conclusions

This study shows that the prevalence of maxillofacial fractures associated with persistent CSF leak was low, which was 4.5% of patients that presented with persistent CSF leak and 84.9% of the cases resolved after treatment of the various maxillofacial fractures.

Case report: regression of aspiration pneumonitis after nasal endoscopic repair of traumatic cerebrospinal fluid nasal leak

Aspiration pneumonitis is an inflammatory lung disease caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria. Accurate diagnosis of aspiration pneumonitis can be challenging, and cerebrospinal fluid (CSF) rhinorrhea is often overlooked as a rare cause of aspiration. In this case report, we present the case of a 48-year-old male patient who experienced right-sided nasal flow of clear watery secretions for 6 months, accompanied by a dry cough as the major symptom. Through comprehensive assessment of clinical symptoms, sinus imaging, nasal endoscopy, and relevant laboratory testing, a presumptive diagnosis of traumatic cribriform plate fracture with CSF rhinorrhea was made. Chest imaging revealed flocculent ground glass shadows in the bilateral lungs. After ruling out viral pneumonia, nasal endoscopic repair of the skull base defect was performed. The patient's dry cough and rhinorrhea symptoms resolved within 1 week after surgery, and the pneumonia showed significant improvement and complete resolution within 2 weeks postoperatively. Despite the absence of characteristic symptoms and evident inhalation factors, chronic CSF rhinorrhea caused by the cribriform plate fracture was ultimately identified as the primary etiology of the patient's aspiration pneumonitis. This rare case highlights the importance of considering traumatic CSF rhinorrhea as an uncommon cause of aspiration, which can enhance physicians' awareness and focus on the less-common etiologies of aspiration. Such awareness can contribute to more accurate diagnosis and early operative intervention, particularly in the context of the coronavirus disease 2019 pandemic.

A comparative analysis of the CP and CG using 2D and 3D visualisation approaches

Investigations on the structural variations in the cribriform plate (CP), olfactory foramina and the Crista Galli showcase the benefits of using 3D imaging on smaller structures. These techniques reveal accurate details about bone morphology and density. Comparing different techniques, this project aims to examine the correlation between the CP, olfactory foramina, and Crista Galli. Computed tomography was used to translate and apply the findings acquired from the samples in radiographic studies on CPs for potential clinical significance. The findings show that the surface area measurements were significantly larger when using 3D imaging techniques in comparison with the 2D counterpart. Using 2D imaging, the maximum surface area of the CPs was 239.54 mm², however, paired 3D samples showed the maximum surface area was 355.51 mm². The findings show that Crista Galli's dimensions varied greatly, with length ranging from 15 to 26 mm, height ranging from 5 to 18 mm, and width ranging from 2 to 7 mm. The 3D imaging allowed for surface area measurements on the Crista Galli, and the surface area ranged from 130 to 390 mm². When 3D imaging was used, significant correlations were found between the surface area of the CP and the length of the Crista Galli (p = 0.001). The findings show that measurements on the Crista Galli using 2D and 3D reconstructed radiographic imaging reflect similar ranges of dimensions to 3D imaging measurements. The findings also suggest that the Crista Galli may increase in length with the CP to support the latter and olfactory bulb during trauma which may be used by clinicians alongside 2D CT scans for optimal diagnosis.

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

Cerebrospinal fluid leak management in anterior basal skull fractures secondary to head trauma

OBJECTIVE

To summarize the presentation, diagnosis, and management of cerebrospinal fluid (CSF) leaks in the setting of traumatic anterior skull base fracture.

METHODS

Wide literature research has been performed as well as the authors' own clinical experience has been summarized.

RESULTS

Articles from the most recent 30 years have been reviewed and a typical case of our own has been presented. Based on the most updated evidence, a treatment algorithm for CSF leaks has been proposed.

CONCLUSION

Anterior skull base fracture accounts for about 4% of all head injuries and CSF leaks is a complication that commonly presents with clear fluid emanating from the nasal passage. A positive beta-2-transferrin study is highly specific for diagnosis, while thin-slice CT scanning and MRI cisternography are also useful tools. The majority of the CSF leaks tend to be resolved spontaneously, and conservative management is attempted first with or without the augmentation of a lumbar drain. Surgical management mainly includes open surgery and endoscopic surgery, which have their own pros and cons.