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: Maxillofacial fractures are often associated with blunt head injuries, of which skull base trauma is a common component. However, most oral and maxillofacial surgeons do not provide definitive management of temporal bone fractures involving the skull base and their sequelae. Persistent cerebrospinal fluid (CSF) leakage that is refractory to conservative measures usually requires surgical closure to decrease the risk of meningitis. In general, reduction of the displaced fragment of the skull base in temporal bone fractures is not considered a priority. We describe an unusual case of craniomaxillofacial injury exhibiting CSF otorrhea because of a temporal bone fracture with a fragment that included the zygomatic arch. The persistent traumatic leakage was stopped after C-arm-guided reduction of the depressed zygomatic arch. This technique facilitated minimal and only necessary manipulation, without overcorrection, thereby avoiding additional damage to the surrounding tissues. The present case illustrates the definitive contribution of therapeutic measures based on maxillofacial surgery as part of an interdisciplinary approach to the management of the complications of severe head injuries; more invasive neurosurgery was thus avoided.International Journal of Oral and Maxillofacial Surgery 03/2014; · 1.52 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Skull-base fractures involve one or more of the cribriform plate of the ethmoid bone, orbital plate of the frontal bone, sphenoid bone, occipital bone, and petrous or temporal bone. Although the fractures themselves only require reduction and reconstruction when the skull base is severely comminuted and altered, even small fractures and the traumatic shear forces can create tears in the meninges and thus predispose to cerebrospinal fluid leaks. This article explores the preoperative, intraoperative, and postoperative management of skull-base fractures, which most commonly involves resolution of the cerebrospinal fluid leak and the prevention of future leaks or meningoencephaloceles.Otolaryngologic Clinics of North America 10/2013; 46(5):749-57. · 1.46 Impact Factor
- Journal of Maxillofacial and Oral Surgery. 01/2014;