Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.
ABSTRACT The management of persistent, post-traumatic cerebrospinal fluid (CSF) rhinorrhea and otorrhea remains a surgical challenge. Repair of CSF leaks has evolved from that of an intracranial approach to one that is primarily extracranial and endoscopic. The purpose of this retrospective analysis is to determine the incidence of persistent CSF rhinorrhea and otorrhea and assess the clinical outcomes of patients presenting to a level 1 trauma center with posttraumatic CSF leaks who were managed by both surgical and nonsurgical means.
The records of all patients with basilar skull fractures and/or severe facial trauma presenting to a major level 1 trauma center from 1991 to 2001 were reviewed. Patients diagnosed with CSF otorrhea or rhinorrhea, who had not undergone an intracranial procedure, elevation of depressed skull fractures, or received a ventriculostomy, were identified and their demographics recorded. For purposes of statistical comparison, patients were divided into 2 groups: "leak" and "no leak." All patients in the leak group were initially observed for a period of 7 to 10 days. Persistent CSF leaks were managed by CSF diversion via lumber drainage for 5 to 7 days. Extracranial repair was performed only if lumbar drainage failed to resolve the leak.
Seven hundred thirty-five patients were identified who met the criteria for inclusion in the study. Thirty-four patients (incidence, 4.6%) were identified with CSF leak presenting as otorrhea (n = 25 [75.8%]) or rhinorrhea (n = 9 [26.5%]), which was diagnosed by clinical, laboratory, or radiographic examination (average age, 28.2 years; age range, 2 to 80 years; 23 males and 11 females). All patients in this study experienced successful resolution of CSF otorrhea or rhinorrhea by using a variable combination of observation, CSF diversion, and extracranial repair. There were no complications or cases of meningitis. Twenty-eight patients (84.6%) experienced uncomplicated resolution of the leak without treatment in 2 to 10 days. Persistent CSF leak, defined by drainage greater than 7 days after injury, was identified in 6 patients (incidence, 0.8%), all except 1 who underwent CSF diversion via a lumbar drain for a period of 5 to 10 days. Two of these patients were treated successfully; the remaining 4 patients required surgical procedures.
Post-traumatic CSF leaks are uncommon and will usually resolve without surgical intervention. Successful management in refractory cases often involves a combination of observation, CSF diversion, and/or extracranial and intracranial procedures.
- [Show abstract] [Hide abstract]
ABSTRACT: Bei der Versorgung von Frontobasisverletzungen ist die Bedeutung des HNO-Chirurgen in den letzten Jahren in den Vordergrund gerückt. Endoskopische transnasale Operationstechniken sowie die Einbindung der intraoperativen Navigation ermöglichen bei einem hohen Prozentsatz der Patienten einen minimal-invasiven Zugang, ohne die bei typischen neurochirurgischen subfrontalen Zugängen begleitende Morbidität. Die wesentliche Ursache frontobasaler Verletzungen sind Verkehrsunfälle, Sportunfälle und iatrogene Perforationen im Rahmen der Nasennebenhöhlenchirurgie. Aufgrund des zunehmenden weltweiten Terrorismus und asymmetrischer Kriege wie in Afghanistan und im Irak gewinnen penetrierende Verletzungen durch Schusswaffen oder Sprengfallen zunehmend an Bedeutung. Bei komplexen Verletzungen mit Beteiligung des Mittelgesichts und/oder des Hirnschädels empfiehlt sich ein interdisziplinärer Therapieansatz, der Mund-Kiefer-Gesichtschirurgen sowie Neurochirurgen miteinbezieht. Die Kooperation dieser Fachgebiete innerhalb einer Kopfklinik, die zusätzlich über eine traumatologisch ausgerichtete Augenklinik und eine interventionelle Neuroradiologie verfügt, bietet optimale Vorraussetzungen für eine suffiziente Versorgung komplexer Schädelbasisverletzungen. In der vorliegenden Arbeit wird ein an der Kopfklinik des Bundeswehrkrankenhauses Ulm etabliertes Konzept für die Versorgung von Frontobasisverletzungen vorgestellt. The role of ENT surgery in the management of anterior skull base defects has become increasingly important in recent years. Transnasal endoscopic surgical techniques and intraoperative navigation enable a minimally invasive approach in a large proportion of patients, thus helping to avoid morbidity typically associated with neurosurgical subfrontal approaches. Whereas traffic accidents and sport injuries are the main causes of anterior skull base trauma in the civilian setting, penetrating injuries caused by gunshots and improvised explosive devices (IEDs) play an increasing role in the military arena and terroristic attacks. Minor injuries to the anterior skull base are usually managed by ENT surgeons. Major injuries, involving the midface or neurocranium, require an interdisciplinary approach including maxillofacial surgeons and neurosurgeons. A centre for head and neck medicine and surgery is an ideal setting for such interdisciplinary teams to provide appropriate care for patients with complex skull base trauma in cooperation with ophthalmologists and interventional neuoradiologists. The present article describes concepts for the treatment of anterior skull base trauma established at the head, neck and skull base center at the Ulm military hospital in Germany. SchlüsselwörterFrontobasisverletzungen–Rhinoliquorrhö–Mittelgesichtsverletzungen–Schuss- und Splitterverletzungen–Duraplastik KeywordsFrontobasal injury–Cerebrospinal fluid rhinorrhoea–Midfacial trauma–Gunshot and splinter wounds–Dura transplantHNO 01/2011; 59(8):791-799. · 0.42 Impact Factor
Article: Traumatic cerebrospinal fluid leaks.[Show abstract] [Hide abstract]
ABSTRACT: This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.Otolaryngologic Clinics of North America 08/2011; 44(4):857-73, vii. · 1.46 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: We report the case of an eighteen-month-old child who suffered a tympanic membrane perforation caused by a digital thermometer. This injury led to a CSF leak. The patient was followed conservatively with no surgical intervention or prophylactic antibiotic therapy and developed pneumococcal meningitis 7 days later. He was then treated with Ceftriaxone for 12 days with full recovery, from a short and long term perspective. Issues concerning the management of CSF leak will be discussed along with review of the literature. This is the first report of post-traumatic meningitis as a result of mild trauma not involving maxillofacial or basilar fractures. The aim of our report is to raise awareness to this cause of meningitis and to stress the importance of immunizing against Streptococcal pneumoniae, a measure which may have prevented the sequelae in our case.Central European Journal of Medicine 8(2). · 0.26 Impact Factor